Effects of Preoxygenation With Intratracheal Suctioning During Extubation: An Alternating Cluster-Controlled Trial (INtratracheal suctioning and oxygenation AT Extubation [INNOVATE])

Extubation is a critical event for patients in the ICU. Preoxygenation and intratracheal suctioning during extubation may contribute to atelectasis. However, evidence concerning extubation procedures and their impact on patient outcomes is limited. This study aimed to compare two extubation strategies: one using preoxygenation with 100% Fio2 combined with intratracheal suctioning, and the other using a low Fio2 (35%) without suctioning. A single-center, alternating cluster-controlled trial. Tertiary level interdisciplinary adult ICU. A total of 3,675 patients were randomized into two groups: 1) Fio2 100% with suctioning (n = 1,877, 51.1%) and 2) Fio2 35% without suctioning (n = 1,798, 48.9%). Comparison of two extubation strategies: Fio2 100% with suctioning vs. Fio2 35% without suctioning. The primary outcome was a composite of reintubation and/or noninvasive ventilation within 48 hours after extubation. Secondary outcomes included the components of the primary endpoint, the need for nasal high-flow oxygenation or changes in the ratio of arterial oxygen partial pressure to fractional inspired oxygen (P/F ratio) after extubation. Differences in outcomes were assessed via adjusted logistic or linear regression models. The low Fio2/no suctioning strategy resulted in a 23% reduction in the primary outcome (odds ratio 0.77; 95% CI, 0.60-0.98; p = 0.032) compared with the high Fio2/suctioning group. In addition, the P/F ratio in the low Fio2/no suctioning group was significantly higher, with an estimated mean difference of 4.72 kPa (95% CI, 4.12-5.32; p < 0.001). Extubation with a low-inspired oxygen fraction and without suctioning appears safe and may improve patient-relevant outcomes. Further research is necessary to optimize Fio2 settings and secretion management during extubation in critically ill patients.