A Randomized Controlled Trial of High-Flow Nasal Oxygen (Optiflow) as Part of an Enhanced Recovery Program After Lung Resection Surgery

New Insight into Laryngo-Tracheal Surgery: High-Flow Oxygen Therapy to Prevent Early Complications after Surgery

BACKGROUND

Early post-operative airway management after laryngo-tracheal surgery is crucial. Acute respiratory failure due to glottis' edema may occur, requiring reintubation. This can prolong ventilatory assistance, jeopardizing anastomosis. To date, only judicious steroid administration and fluid management are available to avoid more invasive procedures. High-flow oxygen therapy (HFOT) is a noninvasive O2 support method providing humidification, warmed air, and Positive End-Expiratory Pressure (AIRVO2). No data about HFOT use to prevent early complications after laryngo-tracheal surgery are reported in the literature.

METHODS

Between September 2020 and September 2022, 107 consecutive patients who underwent laryngo-tracheal surgery received HFOT (Group A). Data and long-term results were compared with those of 80 patients operated between September 2018 and August 2020 (Group B), when HFOT was not available. All patients were operated in a single center. No pre- or post-operative settings changed, except for HFOT introduction. We analyzed and compared the risk for "delayed" reintubation (unexpected reintubation within the first 24-48 h after extubating/laryngeal mask removal) in the two groups.

RESULTS

No patients reported HFOT-related adverse events. The control group (B) presented "delayed" reintubation in 37% (p = 0.027), intensive care unit admission in 67% (p = 0.005) and longer hospital stay (p = 0.001) compared to the HFOT group (A). The minor complications' rate was 3% in both group and overall mortality was 0%. Re-stenosis was described in 4.6% of the HFOT group, without a statistically significant difference (p = 0.7006).

CONCLUSIONS

Our study is the first to investigate HFOT use in patients undergoing laryngo-tracheal surgery, potentially representing a consistent innovation in the peri-operative management of these patients. With the limitation of a retrospective series, we would suggest HFOT use for preventing post-operative reintubation rate, possibly reducing ICU admissions and hospital stays.

Personalized Noninvasive Respiratory Support in the Perioperative Setting: State of the Art and Future Perspectives

Background: Noninvasive respiratory support (NRS), including high-flow nasal oxygen therapy (HFNOT), noninvasive ventilation (NIV) and continuous positive airway pressure (CPAP), are routinely used in the perioperative period. Objectives: This narrative review provides an overview on the perioperative use of NRS. Preoperative, intraoperative, and postoperative respiratory support is discussed, along with potential future areas of research. Results: During induction of anesthesia, in selected patients at high risk of difficult intubation, NIV is associated with improved gas exchange and reduced risk of postoperative respiratory complications. HFNOT demonstrated an improvement in oxygenation. Evidence on the intraoperative use of NRS is limited. Compared with conventional oxygenation, HFNOT is associated with a reduced risk of hypoxemia during procedural sedation, and recent data indicate a possible role for HFNOT for intraoperative apneic oxygenation in specific surgical contexts. After extubation, "preemptive" NIV and HFNOT in unselected cohorts do not affect clinical outcome. Postoperative "curative" NIV in high-risk patients and among those exhibiting signs of respiratory failure can reduce reintubation rate, especially after abdominal surgery. Data on postoperative "curative" HFNOT are limited. Conclusions: There is increasing evidence on the perioperative use of NRS. Use of NRS should be tailored based on the patient's specific characteristics and type of surgery, aimed at a personalized cost-effective approach.

ERS Clinical Practice Guidelines: High-flow nasal cannula in acute respiratory failure

BACKGROUND

High-flow nasal cannula (HFNC) has become a frequently used non-invasive form of respiratory support in acute settings, however evidence supporting its use has only recently emerged. These guidelines provide evidence-based recommendations for the use of HFNC alongside other noninvasive forms of respiratory support in adults with acute respiratory failure (ARF).

MATERIALS AND METHODOLOGY

The European Respiratory Society Task Force panel included expert clinicians and methodologists in pulmonology and intensive care medicine. The Task Force used the GRADE (Grading of Recommendations, Assessment, Development, and Evaluations) methods to summarize evidence and develop clinical recommendations for the use of HFNC alongside conventional oxygen therapy (COT) and non-invasive ventilation (NIV) for the management of adults in acute settings with ARF.

RESULTS

The Task Force developed 8 conditional recommendations, suggesting using: 1) HFNC over COT in hypoxemic ARF, 2) HFNC over NIV in hypoxemic ARF, 3)HFNC over COT during breaks from NIV, 4) either HFNC or COT in post-operative patients at low risk of pulmonary complications, 5) either HFNC or NIV in post-operative patients at high risk of pulmonary complications, 6) HFNC over COT in non-surgical patients at low risk of extubation failure, 7) NIV over HFNC for patients at high risk of extubation failure unless there are relative or absolute contraindications to NIV, 8) trialling NIV prior to use of HFNC in patients with chronic obstructive pulmonary disease (COPD) and hypercapnic ARF.

CONCLUSIONS

HFNC is a valuable intervention in adults with ARF. These conditional recommendations can assist clinicians in choosing the most appropriate form of non-invasive respiratory support to provide to patients in different acute settings.

High flow nasal cannula versus conventional oxygen therapy in postoperative patients at high risk for pulmonary complications: A systematic review and meta-analysis

BACKGROUND

The effects of high flow nasal cannula (HFNC) on postoperative patients at high risk for pulmonary complications(PC) are controversial. We aimed to further determine the effectiveness of HFNC in postoperative patients at high risk for PC by comparison to conventional oxygen therapy (COT).

METHODS

We performed a comprehensive search that compared HFNC with COT in postoperative patients at high risk for PC. The main outcomes were length of hospital stay (hospital LOS) and respiratory complications.

RESULTS

Six trials with a total of 733 patients were pooled in our final studies. Except for Hospital LOS (I²  = 53%, χ²  = 8.51, P = .07) and rate of intubation or non-invasive ventilation (NIV) for respiratory failure (RF) (I²  = 49%, χ²  = 1.97, P = .16) between HFNC and COT, no significant heterogeneity was found in outcome measures. Compared with COT, HFNC was associated with a lower rate of intubation or NIV for RF (RR 0.23, 95% CI 0.08-0.66, P = .006) and rate of hypercapnia (RR 0.37, 95% CI 0.20-0.68, P = .002). As for the Hospital LOS, ICU LOS, rate of requirement of O2 after discontinuous and hypoxemia, HFNC did not show any advantage over COT. Trial Sequential Analysis (TSA) for Hospital LOS showed that monitoring boundaries were finally not surpassed and required information size (RIS) was not met.

CONCLUSIONS

The available randomised controlled trials (RCTs) suggest that, among the postoperative patients at high risk for PC, HFNC therapy compared with the COT significantly reduces rate of incubation or NIV for RF and rate of hypercapnia, meanwhile is safely administered. Further large-scale, multicenter, randomised and controlled studies are needed to confirm our results.

Guidelines on enhanced recovery after pulmonary lobectomy

OBJECTIVE

To establish recommendations for optimisation of the management of patients undergoing pulmonary lobectomy, particularly Enhanced Recovery After Surgery (ERAS).

DESIGN

A consensus committee of 13 experts from the French Society of Anaesthesia and Intensive Care Medicine (Soci,t, franOaise d'anesth,sie et de r,animation, SFAR) and the French Society of Thoracic and Cardiovascular Surgery (Soci,t, franOaise de chirurgie thoracique et cardiovasculaire, SFCTCV) was convened. A formal conflict-of-interest policy was developed at the onset of the process and enforced throughout. The entire guidelines process was conducted independently of any industry funding. The authors were advised to follow the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to guide assessment of quality of evidence.

METHODS

Five domains were defined: 1) patient pathway and patient information; 2) preoperative management and rehabilitation; 3) anaesthesia and analgesia for lobectomy; 4) surgical strategy for lobectomy; and 5) enhanced recovery after surgery. For each domain, the objective of the recommendations was to address a number of questions formulated according to the PICO model (Population, Intervention, Comparison, Outcome). An extensive literature search on these questions was carried out and analysed using the GRADE® methodology. Recommendations were formulated according to the GRADE® methodology, and were then voted by all experts according to the GRADE grid method.

RESULTS

The SFAR/SFCTCV guideline panel provided 32 recommendations on the management of patients undergoing pulmonary lobectomy. After two voting rounds and several amendments, a strong consensus was reached for 31 of the 32 recommendations and a moderate consensus was reached for the last recommendation. Seven of these recommendations present a high level of evidence (GRADE 1+), 23 have a moderate level of evidence (18 GRADE 2+ and 5 GRADE 2-), and 2 correspond to expert opinions. Finally, no recommendation was provided for 2 of the questions.

CONCLUSIONS

A strong consensus was expressed by the experts to provide recommendations to optimise the whole perioperative management of patients undergoing pulmonary lobectomy.

Prevent deterioration and long-term ventilation: intensive care following thoracic surgery

PURPOSE OF REVIEW

Patients with indication for lung surgery besides the pulmonary pathology often suffer from independent comorbidities affecting several other organ systems. Preventing patients from harmful complications due to decompensation of underlying organ insufficiencies perioperatively is pivotal. This review draws attention to the peri- and postoperative responsibility of the anaesthetist and intensivist to prevent patients undergoing lung surgery deterioration.

RECENT FINDINGS

During the last decades we had to accept that 'traditional' intensive care medicine implying deep sedation, controlled ventilation, liberal fluid therapy, and broad-spectrum antimicrobial therapy because of several side-effects resulted in prolongation of hospital length of stay and a decline in quality of life. Modern therapy therefore should focus on the convalescence of the patient and earliest possible reintegration in the 'life-before.' Avoidance of sedative and anticholinergic drugs, early extubation, prophylactic noninvasive ventilation and high-flow nasal oxygen therapy, early mobilization, well-adjusted fluid balance and reasonable use of antibiotics are the keystones of success.

SUMMARY

A perioperative interprofessional approach and a change in paradigms are the prerequisites to improve outcome and provide treatment for elder and comorbid patients with an indication for thoracic surgery.

The role for high flow nasal cannula as a respiratory support strategy in adults: a clinical practice guideline

Purpose

High flow nasal cannula (HFNC) is a relatively recent respiratory support technique which delivers high flow, heated and humidified controlled concentration of oxygen via the nasal route. Recently, its use has increased for a variety of clinical indications. To guide clinical practice, we developed evidence-based recommendations regarding use of HFNC in various clinical settings.

Methods

We formed a guideline panel composed of clinicians, methodologists and experts in respiratory medicine. Using GRADE, the panel developed recommendations for four actionable questions.

Results

The guideline panel made a strong recommendation for HFNC in hypoxemic respiratory failure compared to conventional oxygen therapy (COT) (moderate certainty), a conditional recommendation for HFNC following extubation (moderate certainty), no recommendation regarding HFNC in the peri-intubation period (moderate certainty), and a conditional recommendation for postoperative HFNC in high risk and/or obese patients following cardiac or thoracic surgery (moderate certainty).

Conclusions

This clinical practice guideline synthesizes current best-evidence into four recommendations for HFNC use in patients with hypoxemic respiratory failure, following extubation, in the peri-intubation period, and postoperatively for bedside clinicians.

Electronic supplementary material

The online version of this article (10.1007/s00134-020-06312-y) contains supplementary material, which is available to authorized users.

Does an enhanced recovery after surgery protocol affect perioperative surgical outcomes in stage III tubercular empyema? A comparative analysis of 243 patients

BACKGROUND

Enhanced recovery after surgery protocols in tuberculous empyema surgery have the potential for improved outcomes, but have not been studied widely. This study aimed to analyze the outcomes after implementation of an enhanced recovery after surgery protocol in patients undergoing surgery for tubercular empyema.

METHODS

A retrospective analysis of patients who underwent surgery for tuberculous empyema in a dedicated thoracic surgery center from March 2012 to March 2019 was performed. The control group included patients operated on between March 2012 and March 2016. The enhanced recovery after surgery protocol was strictly introduced into our practice from April 2016. The study group included patients operated on between April 2016 and March 2019. All perioperative outcomes were measured, documented, analyzed, and compared between the two groups. There were 166 patients in the control group and 77 in the study group.

RESULTS

Intraoperative blood loss (p = 0.0001), prolonged air leak (p = 0.04), chest tube duration (p = 0.005), and length of stay (p = 0.003) were significantly reduced in the study group. Overall rates of postoperative complications (p = 0.04) including wound infection (p = 0.01) were also significantly lower in the study group.

CONCLUSIONS

Implementation of an enhanced recovery after surgery protocol in patients undergoing surgery for tuberculous empyema is feasible and effective. Application of such a protocol leads to less intraoperative blood loss, shorter hospital stay and duration of chest drainage, and fewer complications. Application of enhanced recovery after surgery protocols are strongly recommended in tubercular empyema surgery.

Efficiency of High-Flow Nasal Cannula on Pulmonary Rehabilitation in COPD Patients: A Meta-Analysis

Introduction

The clinical benefit of high-flow nasal cannula (HFNC) on factors related to pulmonary rehabilitation in chronic obstructive pulmonary disease (COPD) patients remains unclear. This meta-analysis aimed at synthesizing the available evidence on the efficacy of HFNC on exercise capacity, lung function, and other factors related to pulmonary rehabilitation in COPD patients.

Methods

Electronic databases (MEDLINE, Embase, Cochrane Central Register of Controlled Trials, Web of Science) were searched for randomized trials comparing with conventional oxygen therapy (COT) or noninvasive ventilation (NIV). Primary outcomes were respiratory rate, FEV1, tidal volume, oxygen partial pressure, total score of St. George's respiratory questionnaire, 6-minute walk test, and exercise endurance time.

Results

Ten trials met the criteria for inclusion. Combined data from six studies showed that HFNC showed a lower respiratory rate in COPD patients [mean difference -1.27 (95% CI: -1.65–(-0.89)]. Combined data from three studies showed a lower forced expiratory volume in one second (FEV1) in the group of HFNC. No difference in tidal volume was showed between the HFNC and control groups in COPD patients. No significant oxygen improvement between the HFNC groups and control groups. The total score of St. George's respiratory questionnaire was improved by the subgroup analysis of HFNC versus COT but no NIV. Two multicenter RCTs showed the six-minute walk test, and statistical results showed that the length of the six-minute walk capacity was increased after usage of HFNC compared to the control group [mean difference -8.65 (95% CI: -9.12–(-8.19)]. No increase of exercise capacity after usage of HFNC (mean difference -12.65).

Conclusion

In the first meta-analysis of the area, the current evidence did not show so much positive effect on tidal volume or oxygen improvement in COPD patients. Length of the six-minute walk capacity was increased after using HFNC, while other pulmonary rehabilitation parameters, namely, the score of St. George's respiratory questionnaire and exercise capacity show no increase in the group of HFNC. The variance in the quality of the evidence included in this meta-analysis highlights the need for this evidence to be followed up with further high-quality and more randomized trials.

Nasal High Flow Versus Conventional Oxygen Therapy for Postoperative Cardiothoracic Surgery Patients

BACKGROUND

Reintubation and complications in postoperative cardiothoracic patients remain high despite medical advancements. A 2-year retrospective, observational study was conducted in postextubated cardiothoracic patients to assess the effectiveness of the current standard-conventional oxygen therapy (COT) compared with a nasal high flow (NHF) therapy.

OBJECTIVES

The objective of this study was to understand whether NHF therapy would reduce the need for reintubation and improve clinical outcomes after surgery.

METHOD

All consecutive postoperative patients who had same-day elective cardiothoracic surgery in a tertiary hospital were included. The 2013 data were from patients' charts who received COT, and the 2014 data were from patients' charts after the implementation of NHF therapy post extubation as a standard of care.

RESULTS

A total of 400 patient charts were analyzed: 221 and 179 patients in the COT and NHF, respectively. No significant difference was seen in the frequency of reintubation (P = .48). Despite both cohorts having the same length of stay (P = .10), patients treated with NHF required less time on supplemental oxygen (P = .001). Day 1 postoperative chest x-ray results did not show any significant differences between groups, whereas day 2 x-rays showed worsening results in the COT cohort (P < .001). Furthermore, the incidence of ventilator-associated pneumonia (VAP) post extubation was significantly higher in the COT cohort, with zero VAP episodes reported in the NHF cohort (P = .02).

DISCUSSION

Although this study was not able to demonstrate the reduction in reintubation between groups, the use of NHF compared with COT seems to reduce the time spent on oxygen therapy and decrease the rate of VAP. Further evidence including randomized controlled trials is required to determine the impact of NHF on reintubation and complications in postoperative cardiothoracic surgery.

Ventilatory support after extubation in critically ill patients

The periextubation period represents a crucial moment in the management of critically ill patients. Extubation failure, defined as the need for reintubation within 2-7 days after a planned extubation, is associated with prolonged mechanical ventilation, increased incidence of ventilator-associated pneumonia, longer intensive care unit and hospital stays, and increased mortality. Conventional oxygen therapy is commonly used after extubation. Additional methods of non-invasive respiratory support, such as non-invasive ventilation and high-flow nasal therapy, can be used to avoid reintubation. The aim of this Review is to describe the pathophysiological mechanisms of postextubation respiratory failure and the available techniques and strategies of respiratory support to avoid reintubation. We summarise and discuss the available evidence supporting the use of these strategies to achieve a tailored therapy for an individual patient at the bedside.

The effects of high-flow nasal cannula on intubation and re-intubation in critically ill patients: a systematic review, meta-analysis and trial sequential analysis

Objective

To evaluate the efficacy of high-flow nasal cannula in the prevention of intubation and re-intubation in critically ill patients compared to conventional oxygen therapy or noninvasive ventilation.

Methods

This systematic review was performed through an electronic database search of articles published from 1966 to April 2018. The primary outcome was the need for intubation or re-intubation. The secondary outcomes were therapy escalation, mortality at the longest follow-up, hospital mortality and the need for noninvasive ventilation.

Results

Seventeen studies involving 3,978 patients were included. There was no reduction in the need for intubation or re-intubation with high-flow nasal cannula (OR 0.72; 95%CI 0.52 - 1.01; p = 0.056). There was no difference in the need for therapy escalation (OR 0.80, 95% CI 0.59 - 1.08, p = 0.144), mortality at the longest follow-up (OR 0.94; 95%CI 0.70 - 1.25; p = 0.667), hospital mortality (OR 0.84; 95%CI 0.56 - 1.26; p = 0.391) or noninvasive ventilation (OR 0.64, 95%CI 0.39 - 1.05, p = 0.075). In the trial sequential analysis, the number of events included was lower than the optimal information size with a global type I error > 0.05.

Conclusion

In the present study and setting, high-flow nasal cannula was not associated with a reduction of the need for intubation or re-intubation in critically ill patients.

Association between anaesthetic technique and unplanned admission to intensive care after thoracic lung resection surgery: the second Association of Cardiothoracic Anaesthesia and Critical Care (ACTACC) National Audit

Unplanned intensive care admission is a devastating complication of lung resection and is associated with significantly increased mortality. We carried out a two-year retrospective national multicentre cohort study to investigate the influence of anaesthetic and analgesic technique on the need for unplanned postoperative intensive care admission. All patients undergoing lung resection surgery in 16 thoracic surgical centres in the UK in the calendar years 2013 and 2014 were included. We defined critical care admission as the unplanned need for either tracheal intubation and mechanical ventilation or renal replacement therapy, and sought an association between mode of anaesthesia (total intravenous anaesthesia vs. volatile) and analgesic technique (epidural vs. paravertebral) and need for intensive care admission. A total of 253 out of 11,208 patients undergoing lung resection in the study period had an unplanned admission to intensive care in the postoperative period, giving an incidence of intensive care unit admission of 2.3% (95%CI 2.0-2.6%). Patients who had an unplanned admission to intensive care unit had a higher mortality (29.00% vs. 0.03%, p < 0.001), and hospital length of stay was increased (26 vs. 6 days, p < 0.001). Across univariate, complete case and multiple imputation (multivariate) models, there was a strong and significant effect of both anaesthetic and analgesic technique on the need for intensive care admission. Patients receiving total intravenous anaesthesia (OR 0.50 (95%CI 0.34-0.70)), and patients receiving epidural analgesia (OR 0.56 (95%CI 0.41-0.78)) were less likely to have an unplanned admission to intensive care after thoracic surgery. This large retrospective study suggests a significant effect of both anaesthetic and analgesic technique on outcome in patients undergoing lung resection. We must emphasise that the observed association does not directly imply causation, and suggest that well-conducted, large-scale randomised controlled trials are required to address these fundamental questions.

An individualised versus a conventional pneumoperitoneum pressure strategy during colorectal laparoscopic surgery: rationale and study protocol for a multicentre randomised clinical study

Background

A recent study shows that a multifaceted strategy using an individualised intra-abdominal pressure titration strategy during colorectal laparoscopic surgery results in an acceptable workspace at low intra-abdominal pressure in most patients. The multifaceted strategy, focused on lower to individualised intra-abdominal pressures, includes prestretching the abdominal wall during initial insufflation, deep neuromuscular blockade, low tidal volume ventilation settings and a modified lithotomy position. The study presented here tests the hypothesis that this strategy improves outcomes of patients scheduled for colorectal laparoscopic surgery.

Methods

The Individualized Pneumoperitoneum Pressure in Colorectal Laparoscopic Surgery versus Standard Therapy (IPPCollapse-II) study is a multicentre, two-arm, parallel-group, single-blinded randomised 1:1 clinical study that runs in four academic hospitals in Spain. Patients scheduled for colorectal laparoscopic surgery with American Society of Anesthesiologists classification I to III who are aged > 18 years and are without cognitive deficits are randomised to an individualised pneumoperitoneum pressure strategy (the intervention group) or to a conventional pneumoperitoneum pressure strategy (the control group). The primary outcome is recovery assessed with the Post-operative Quality of Recovery Scale (PQRS) at postoperative day 1. Secondary outcomes include PQRS score in the post anaesthesia care unit and at postoperative day 3, postoperative complications until postoperative day 28, hospital length of stay and process-related outcomes.

Discussion

The IPPCollapse-II study will be the first randomised clinical study that assesses the impact of an individualised pneumoperitoneum pressure strategy focused on working with the lowest intra-abdominal pressure during colorectal laparoscopic surgery on relevant patient-centred outcomes. The results of this large study, to be disseminated through conference presentations and publications in international peer-reviewed journals, are of ultimate importance for optimising the care and safety of laparoscopic abdominal surgery. Selection of patient-reported outcomes as the primary outcome of this study facilitates the translation into clinical practice. Access to source data will be made available through anonymised datasets upon request and after agreement of the Steering Committee of the IPPCollapse-II study.

Trial registration

ClinicalTrials.gov, NCT02773173. Registered on 16 May 2016. EudraCT, 2016-001693-15. Registered on 8 August 2016.

Electronic supplementary material

The online version of this article (10.1186/s13063-019-3255-1) contains supplementary material, which is available to authorized users.

Early nasal high-flow versus Venturi mask oxygen therapy after lung resection: a randomized trial

Background

Data on high-flow nasal oxygen after thoracic surgery are limited and confined to the comparison with low-flow oxygen. Different from low-flow oxygen, Venturi masks provide higher gas flow at a predetermined fraction of inspired oxygen (FiO₂). We conducted a randomized trial to determine whether preemptive high-flow nasal oxygen reduces the incidence of postoperative hypoxemia after lung resection, as compared to Venturi mask oxygen therapy.

Methods

In this single-center, randomized trial conducted in a teaching hospital in Italy, consecutive adult patients undergoing thoracotomic lung resection, who were not on long-term oxygen therapy, were randomly assigned to receive high-flow nasal or Venturi mask oxygen after extubation continuously for two postoperative days. The primary outcome was the incidence of postoperative hypoxemia (i.e., ratio of the partial pressure of arterial oxygen to FiO₂ (PaO₂/FiO₂) lower than 300 mmHg) within four postoperative days.

Results

Between September 2015 and April 2018, 96 patients were enrolled; 95 patients were analyzed (47 in high-flow group and 48 in Venturi mask group). In both groups, 38 patients (81% in the high-flow group and 79% in the Venturi mask group) developed postoperative hypoxemia, with an unadjusted odds ratio (OR) for the high-flow group of 1.11 [95% confidence interval (CI) 0.41–3] (p = 0.84). No inter-group differences were found in the degree of dyspnea nor in the proportion of patients needing oxygen therapy after treatment discontinuation (OR 1.34 [95% CI 0.60–3]), experiencing pulmonary complications (OR 1.29 [95% CI 0.51–3.25]) or requiring ventilatory support (OR 0.67 [95% CI 0.11–4.18]). Post hoc analyses revealed that PaO₂/FiO₂ during the study was not different between groups (p = 0.92), but patients receiving high-flow nasal oxygen had lower arterial pressure of carbon dioxide, with a mean inter-group difference of 2 mmHg [95% CI 0.5–3.4] (p = 0.009), and were burdened by a lower risk of postoperative hypercapnia (adjusted OR 0.18 [95% CI 0.06–0.54], p = 0.002).

Conclusions

When compared to Venturi mask after thoracotomic lung resection, preemptive high-flow nasal oxygen did not reduce the incidence of postoperative hypoxemia nor improved other analyzed outcomes. Further adequately powered investigations in this setting are warranted to establish whether high-flow nasal oxygen may yield clinical benefit on carbon dioxide clearance.

Trial registration

ClinicalTrials.gov, NCT02544477. Registered 9 September 2015.

Electronic supplementary material

The online version of this article (10.1186/s13054-019-2361-5) contains supplementary material, which is available to authorized users.

The Effect of High-Flow Nasal Oxygen Therapy on Postoperative Pulmonary Complications and Hospital Length of Stay in Postoperative Patients: A Systematic Review and Meta-Analysis

OBJECTIVE

To evaluate the effect of high-flow nasal cannula oxygen (HFNO) therapy on hospital length of stay (LOS) and postoperative pulmonary complications (PPCs) in adult postoperative patients.

DATA SOURCES

PubMed, Embase, the Cochrane Library, Web of Science of Studies, China National Knowledge Index, and Wan Fang databases were searched until July 2018.

STUDY SELECTION

Randomized controlled trials (RCTs) comparing HFNO with conventional oxygen therapy or noninvasive mechanical ventilation in adult postoperative patients were included. The primary outcomes were hospital LOS and PPCs; short-term mortality (defined as intensive care unit, hospital, or 28-day mortality) and intubation rate were the secondary outcomes.

DATA EXTRACTION

Demographic variables, high-flow oxygen therapy application, effects, and side effects were retrieved. Data were analyzed by the methods recommended by the Cochrane Collaboration. The strength of evidence was assessed by the Grading of Recommendations Assessment, Development and Evaluation. Random errors were evaluated with trial sequential analysis.

DATA SYNTHESIS

Fourteen studies (2568 patients) met the inclusion criteria and were included. Compared to the control group, the pooled effect showed that HFNO was significantly associated with a shorter hospital stay (mean difference: -0.81; 95% confidence interval [CI]: -1.34 to -0.29, P = .002), but not mortality (risk ratio [RR]: 1.0, 95% CI: 0.63 to 1.59, P = 1.0). Weak evidence of a reduction in reintubation rate (RR: 0.76, 95% CI: 0.57-1.01, P = .06) and PPC rate (RR: 0.89, 95% CI: 0.75-1.06, P = .18) with HFNO versus control group was recorded.

CONCLUSIONS

The available RCTs suggest that, among the adult postoperative patients, HFNO therapy compared to the control group significantly reduces hospital LOS.

Enhanced recovery after pulmonary surgery

The concept of surgical recovery encompasses the entire perioperative phase of the patient, beginning with the preoperative baseline and culminating in the long-term rehabilitation of the patient in the post-operative phase. Enhanced recovery pathways (ERPs) aim to encompass all phase of the patient trajectory, including the preoperative, perioperative, and postoperative management of surgical patients. While significant literature exists on standardizing and optimizing the perioperative phase, standardizing the pre and post-operative phases remains a topic of debate. Furthermore, with regards to pulmonary surgery, the available data on enhanced recovery remains limited, with no consensus on which components to include within the ERP. The difficulty in identifying specific factors to include within a pathway is in part due to the lack of representative metrics of recovery. Secondly, the strength of ERPs usually lies in the agglomeration of multiple components rather than the individual components themselves. This review provides a brief review on current developments in ERPs in pulmonary surgery, emphasizing novel components in the pre and post-operative care of patients. Furthermore, we discuss the limitations of current metrics used to study recovery, and what steps can be taken to direct future studies that aim to enhance patient recovery after pulmonary surgery.

Interventions to avoid pulmonary complications after lung cancer resection

Surgical resection of lung cancer is the preferred treatment for early-stage disease in medically fit patients. The rates of postoperative pulmonary complications (PPCs) such as pneumonia, empyema and atelectasis are as high as 10% in contemporary series. A review of the literature was performed to identify the best evidence supporting interventions to identify, prevent and treat PPCs. The use of patient risk scores, appropriate choice of antibiotic prophylaxis, intraoperative ventilatory strategies, chest physiotherapy, sputum management and non-invasive ventilatory support were specifically discussed, as was the relevant supporting data. Recommendations to guide best practice and inform future research questions are outlined.

High-flow nasal cannula in adults with acute respiratory failure and after extubation: a systematic review and meta-analysis

Background

High-flow nasal cannula (HFNC) can be used as an initial support strategy for patients with acute respiratory failure (ARF) and after extubation. However, no clear evidence exists to support or oppose HFNC use in clinical practice. We summarized the effects of HFNC, compared to conventional oxygen therapy (COT) and noninvasive ventilation (NIV), on important outcomes including treatment failure and intubation/reintubation rates in adult patients with ARF and after extubation.

Methods

We searched 4 electronic databases (Pubmed, EMBASE, Scopus, and Web of Science) to identify randomized controlled trials (RCTs) comparing the effects of HFNC with either COT or NIV on rates of 1) treatment failure and 2) intubation/reintubation in adult critically ill patients.

Results

We identified 18 RCTs (n = 4251 patients) in pooled analyses. As a primary mode of support, HFNC treatment reduced the risk of treatment failure [Odds Ratio (OR) 0.65; 95% confidence interval (CI) 0.43–0.98; p = 0.04; I² = 32%] but had no effect on preventing intubation (OR, 0.74; 95%CI 0.45–1.21; p = 0.23; I² = 0%) compared to COT. When used after extubation, HFNC (vs. COT) treatment significantly decreased reintubation rate (OR 0.46; 95%CI 0.33–0.63; p < 0.00001; I² = 30%) and extubation failure (OR 0.43; 95%CI 0.25–0.73; p = 0.002; I² = 66%). Compared to NIV, HFNC significantly reduced intubation rate (OR 0.57; 95%CI 0.36–0.92; p = 0.02; I² = 0%) when used as initial support, but did no favorably impact clinical outcomes post extubation in few trials.

Conclusions

HFNC was superior to COT in reducing treatment failure when used as a primary support strategy and in reducing rates of extubation failure and reintubation when used after extubation. In few trials, HFNC reduced intubation rate compared to NIV when used as initial support but demonstrated no beneficial effects after extubation.

Electronic supplementary material

The online version of this article (10.1186/s12931-018-0908-7) contains supplementary material, which is available to authorized users.

High-flow nasal therapy vs standard oxygen during breaks off noninvasive ventilation for acute respiratory failure: A pilot randomized controlled trial

PURPOSE

To assess the role of high-flow nasal therapy (HFNT) compared to standard oxygen (SO) as complementary therapy to non-invasive ventilation (NIV).

METHODS

Multicenter trial including patients (n = 54) anticipated to receive NIV for ≥24 h due to acute or acute-on-chronic respiratory failure. Subjects were randomized (1:1) to SO or HFNT during breaks off NIV. Primary outcome was total time on and off NIV. Secondary outcomes were comfort and dyspnea, respiratory rate (RR), oxygen saturation (S_pO₂), tolerance and side effects.

RESULTS

Total time per patient on NIV (1315 vs 1441 min) and breaks (1362 vs 1196 min), and mean duration of each break (520 vs 370 min) were similar in the HFNT and SO arms (p > .05). Comfort score was higher on HFNT than on SO (8.3 ± 2.7 vs 6.9 ± 2.3, p = .001). Dyspnea, RR and S_pO₂ were similar in the two arms, but the increase in RR and dyspnea seen with SO during breaks did not occur with HFNT.

CONCLUSION

Compared to SO, HFNT did not reduce time on NIV. However, it was more comfortable and the increase in RR and dyspnea seen with SO did not occur with HFNT. Therefore, HFNT could be a suitable alternative to SO during breaks off NIV.

Effect of high-flow nasal cannula oxygen therapy vs conventional oxygen therapy on adult postcardiothoracic operation: A meta-analysis

INTRODUCTION

The effect of high-flow nasal cannula (HFNC) on adult post cardiothoracic operation remains controversial. We conducted a meta-analysis of randomized controlled trials to evaluate the effect of HFNC and conventional oxygen therapy (COT) on postcardiothoracic surgery.

METHODS

A search was conducted in Embase, MEDLINE, Ovid, and Cochrane databases until December, 2017 for all the controlled study to compare HFNC with COT in adult postcardiothoracic surgery. Two authors extracted data and assessed the quality of each study independently. The meta-analysis was performed by using RevMan 5.3. The primary outcome was the rate of escalation of respiratory support rate and pulmonary complications; secondary outcome included the length of intensive care unit (ICU) stay and length of hospital stay and the rate of intubation.

RESULTS

Four studies that involved 649 patients were included in the analysis. No significant heterogeneity was found in outcome measures. Compared with COT, HFNC were associated with a significant reduction in the escalation of respiratory support (odds ratio [OR] = 0.44, 95% confidence interval [CI] = 0.29-0.66, P < .001) and pulmonary complications (OR = 0.28, 95% CI = 0.13-0.6, P = .001). There were no significant differences in the reintubation rate (OR = 0.33, 95% CI = 0.02-5.39, P = .43), length of ICU stay (weighted mean difference = 0.11; 95% CI = -0.44 -0.26, P = .14) or length of hospital stay (weighted mean difference = -0.15, 95% CI = -0.46 -0.17, P = .36) between the 2 groups. No severe complications were reported in either group.

CONCLUSION

The HFNC could reduce respiratory support and pulmonary complications, and it could be safely administered for adult postcardiothoracic surgery. Further large-scale, randomized, and controlled trials are needed to update this finding.

Enhanced recovery for thoracic surgery in the elderly

PURPOSE OF REVIEW

Both surgical workload and the age of those patients being considered for radial pulmonary resection are increasing. Enhanced recovery programmes are now well established in most surgical disciplines and are increasingly reported in thoracic procedures. This review will discuss the relevant principles of these programmes as applied to an increasing elderly population.

RECENT FINDINGS

Elderly patients undergoing less radial surgical resections without lymphadenectomy have comparable outcomes to those undergoing classical curative treatment. Patients require careful assessment and self-reported quality of life metrics or function may be a better marker of outcome than static measures such as lung function. Hypotension, low values for bispectral index and low anaesthetic gas mean alveolar concentration values are common and independent predictors of mortality in the elderly. Paravertebral blockade is preferred to epidural anaesthesia because of a more favourable side-effect profile and comparable efficacy. As yet no robust work has examined the efficacy of an integrated enhanced recovery programme in thoracic surgery.

SUMMARY

Elderly patients are suitable for enhanced recovery programmes but these must be tailored to individual circumstance. Further work is required to comprehensively assess their value in a modern healthcare setting.

Validation of a revised Mandarin Chinese language version of the Postoperative Quality of Recovery Scale

The aim of the study was to validate a revised Mandarin version of the Postoperative Quality of Recovery Scale (PostopQRS) and to apply the revised version in a Chinese population. In a prospective design, bilingual volunteers completed the scale at baseline, day one, day seven, and day 14 in both languages, with the order of language and parallel forms randomised. In addition, lung cancer patients undergoing open or video-assisted thoracoscopic surgery (VATS) completed the Mandarin version prior to surgery, day one, day three, day seven, day 14, one month, and three months postoperatively. Sixty-eight volunteers participated in the validation part of the study and in the clinical application, 93 lung cancer patients were included. The scores in the Mandarin version were equal to the English version in all domains at all timepoints including the word generation task, when the Mandarin morpheme was included in any part of the Mandarin word. However, Mandarin scores were lower in the word generation task if the morpheme was only included in the first part of the word. In addition, the Mandarin version was able to identify lower rates of overall recovery (<i>P</i> <0.01), nociceptive (<i>P</i> <0.01), emotive (<i>P</i> <0.01), and activities of daily living recovery (<i>P</i>=0.02) after open surgery compared to after VATS. The revised Mandarin version is equivalent to the English version for the cognitive domain, if morpheme substitution for the word generation task is allowed as any part of the word, and it is able to discriminate quality of recovery in Chinese patients.

High-flow oxygen therapy in immunocompromised patients with acute respiratory failure: A review and meta-analysis

PURPOSE

Acute respiratory failure remains a common hazardous complication in immunocompromised patients and is associated with increased mortality rates when endotracheal intubation is need. We aimed to evaluate the effect of high-flow nasal cannula oxygen therapy (HFNC) compared with other oxygen technique for this patient population.

METHODS

We searched Cochrane library, Embase, PubMed databases before Aug. 15, 2017 for eligible articles. A meta-analysis was performed for measuring short-term mortality (defined as ICU, hospital or 28-days mortality) and intubation rate as the primary outcomes, and length of stay in ICU as the secondary outcome.

RESULTS

We included seven studies involving 667 patients. Use of HFNC was significantly association with a reduction in short-term mortality (RR 0.66; 95% CI, 0.52 to 0.84, p=0.0007) and intubation rate (RR 0.76, 95% CI 0.64 to 0.90; p=0.002). In addition, HFNC did not significant increase length of stay in ICU (MD 0.15days; 95% CI, -2.08 to 2.39; p=0.89).

CONCLUSIONS

The results of current meta-analysis suggest that use of HFNC significantly improve outcomes of acute respiratory failure in immunocompromised patients. Owing to the quality of the included studies, further adequately powered randomized controlled trials are needed to confirm our results.

Outcomes after implementing the enhanced recovery after surgery protocol for patients undergoing tuberculous empyema operations

BACKGROUND

Enhanced recovery after surgery (ERAS) protocols provide recommendations for care in various surgical fields. However, there is scarce information on the application of these protocols in tuberculous empyema surgery. The purpose of this research is to evaluate the outcomes of ERAS recommendations for patients who received tuberculous empyema surgery.

METHODS

A retrospective analysis was performed on patients who underwent tuberculous empyema surgery in our hospital from March 2011 to March 2016. The patients were divided into an ERAS group and a conventional control group. The main outcome measure was the postoperative median length of stay (including readmissions). Principles related to ERAS were documented, and the postoperative median hospital stay was analyzed statistically between the two groups.

RESULTS

A total of 92 patients underwent 93 consecutive tuberculous empyema surgical treatments. The postoperative fasting time, chest tube duration, and length of stay were shorter in the ERAS group compared with the control group. The volume of chest tube drainage in the ERAS group was significantly smaller than that of the control group. No statistical differences were observed in the postoperative complications and reasons for readmission between the two groups.

CONCLUSIONS

Application of ERAS recommendations in patients receiving tuberculous empyema operations decreased the length of stay and chest tube drainage compared to the control group.

Nasal high flow therapy: a novel treatment rather than a more expensive oxygen device

Nasal high flow is a promising novel oxygen delivery device, whose mechanisms of action offer some beneficial effects over conventional oxygen systems. The administration of a high flow of heated and humidified gas mixture promotes higher and more stable inspiratory oxygen fraction values, decreases anatomical dead space and generates a positive airway pressure that can reduce the work of breathing and enhance patient comfort and tolerance. Nasal high flow has been used as a prophylactic tool or as a treatment device mostly in patients with acute hypoxaemic respiratory failure, with the majority of studies showing positive results. Recently, its clinical indications have been expanded to post-extubated patients in intensive care or following surgery, for pre- and peri-oxygenation during intubation, during bronchoscopy, in immunocompromised patients and in patients with “do not intubate” status. In the present review, we differentiate studies that suggest an advantage (benefit) from other studies that do not suggest an advantage (no benefit) compared to conventional oxygen devices or noninvasive ventilation, and propose an algorithm in cases of nasal high flow application in patients with acute hypoxaemic respiratory failure of almost any cause.

Use of noninvasive ventilation in immunocompromised patients with acute respiratory failure: a systematic review and meta-analysis

Background

Acute respiratory failure (ARF) remains a common hazardous complication in immunocompromised patients and is associated with increased mortality rates when endotracheal intubation is needed. We aimed to evaluate the effect of early noninvasive ventilation (NIV) compared with oxygen therapy alone in this patient population.

Methods

We searched for relevant studies in MEDLINE, EMBASE, and the Cochrane database up to 25 July 2016. Randomized controlled trials (RCTs) were included if they reported data on any of the predefined outcomes in immunocompromised patients managed with NIV or oxygen therapy alone. Results were expressed as risk ratio (RR) and mean difference (MD) with accompanying 95% confidence interval (CI).

Results

Five RCTs with 592 patients were included. Early NIV significantly reduced short-term mortality (RR 0.62, 95% CI 0.40 to 0.97, p = 0.04) and intubation rate (RR 0.52, 95% CI 0.32 to 0.85, p = 0.01) when compared with oxygen therapy alone, with significant heterogeneity in these two outcomes between the pooled studies. In addition, early NIV was associated with a shorter length of ICU stay (MD −1.71 days, 95% CI −2.98 to 1.44, p = 0.008) but not long-term mortality (RR 0.92, 95% CI 0.74 to 1.15, p = 0.46).

Conclusions

The limited evidence indicates that early use of NIV could reduce short-term mortality in selected immunocompromised patients with ARF. Further studies are needed to identify in which selected patients NIV could be more beneficial, before wider application of this ventilator strategy.

Electronic supplementary material

The online version of this article (doi:10.1186/s13054-016-1586-9) contains supplementary material, which is available to authorized users.

Applications of Nasal High-Flow Oxygen Therapy in Critically ill Adult Patients

The use of nasal high-flow oxygen therapy (NHFOT) has become increasingly common in hospitals across Europe, Asia, and North America. These high utility devices provide an efficient and comfortable access points for providing supplemental oxygen to patients with variety of respiratory disorders. They are relatively easy to set up, and clinicians and patients alike give very positive feedback about their ease of use and comfort for patients in the hospital setting. However, it remains uncertain whether NHFOT improves patient survival or even reduces respiratory complications. Outcome data in adult populations are few and frequently underpowered to guide physicians for their widespread use in hospital setting. In this article, we present a review of the current technology and available studies pertinent to NHFOT.

Design and implementation of an enhanced recovery program in thoracic surgery

Despite significant improvements in perioperative care, major surgery is still associated with major complications. Enhanced recovery after surgery was introduced by the National Health Service in the UK with the aim of improving patient outcomes and reducing length of stay in hospital. The degree of applicability differs between surgical specialties, and in thoracic surgery it has not been developed until recently. We have therefore reviewed recent literature specific to thoracic surgery, and will discuss key elements of the design, implementation and monitoring of an enhanced recovery (ER) program based on our recent experience. The program is divided into several high impact intervention measures that involve the preoperative, intraoperative and postoperative periods. Physical activity promotion and educational programs that provide information about the surgery and the surgical pathway are an essential part of the preoperative strategies. During surgery, an optimal pain control strategy, antibiotic prophylaxis and protective ventilation are important. Minimally invasive surgery and well-planned postoperative care including early drain removal and planned discharge are also important. Overall, we have shown that ER in thoracic surgery can facilitate early discharge from hospital and possibly reduce postoperative complications. Further studies are required to understand the extent of ER benefits when applied to thoracic surgery, and to test individual components in a prospective manner.