B25-13 What Works in High-risk Extubations: Humidified Niv vs Hfnc, a Focused Meta-analysis

Rationale Reducing extubation failure in high-risk adults is fundamental to ICU practice. HFNC and NIV are used prophylactically after planned extubation, but the comparative effect of modern humidified NIV vs HFNC on short-term re-intubation remains uncertain. Objectives To estimate the effect of prophylactic humidified NIV vs HFNC on 7-day re-intubation after planned extubation in high-risk adult ICU patients. Methods We included RCTs of adults undergoing planned extubation that compared immediate humidified NIV (protocolized ≥24-48 h) with heated-humidified HFNC and reported 7-day re-intubation. Trials using alternating or combination strategies, non-prophylactic indications, pediatrics, or phenotype-restricted cohorts (e.g., cardiac surgery only, COPD-only hypercapnia) were excluded from the primary analysis. Risk ratios (RR) were pooled with random effects using REML and Hartung-Knapp confidence intervals (primary); DerSimonian-Laird with classic random-effects confidence intervals was a prespecified sensitivity. Heterogeneity was summarized with I². A related 72-hour RCT was summarized separately. Results Two eligible RCTs enrolled high-risk adults (one very-high-risk cohort; one obesity cohort). N = 326 were analyzed (NIV 164; HFNC 162). Trial-level RRs for 7-day re-intubation were 0.59 (95% CI 0.37-0.93) and 0.71 (0.42-1.20). The primary pooled estimate was RR 0.64 (95% CI 0.20-2.07), I² 0%, heterogeneity p = 0.60. The DL sensitivity yielded RR 0.64 (95% CI 0.45-0.90), p = 0.01. Across pooled trials, re-intubation occurred in 38/164 (23.2%) with NIV vs 59/162 (36.4%) with HFNC, absolute risk difference -13.2% (approximate NNT 8). The 72-hour RCT (shorter NIV dose, different rescue policy) showed RR 0.84 (95% CI 0.62-1.15) and was not pooled with the 7-day endpoint. Conclusions Within a strict and clinically coherent framework for high-risk adults after planned extubation, humidified NIV is associated with fewer 7-day re-intubations than HFNC. The point estimate is stable across models with no observed heterogeneity. Precision is limited with Hartung-Knapp small-k inference, while the DL sensitivity suggests a statistically significant reduction. These findings support protocolized humidified NIV pathways for high-risk extubations and justify a harmonized confirmatory RCT with standardized endpoint windows and rescue policies. This abstract is funded by: None