Effect of oxygenation modalities among patients with postoperative respiratory failure: a pairwise and network meta-analysis of randomized controlled trials

New Treatment Modality for Burn Injury-Related Acute Respiratory Distress Syndrome: High-Flow Nasal Oxygen Therapy in Major Burns

Pulmonary insufficiency is the primary cause of death in cases of major burns accompanied by inhalation damage. It is important to consider the impact on the face and neck in flame burns. Early implementation of bronchial hygiene measures and oxygenation treatment in inhalation injury can reduce mortality. This case series presents the effects of high-flow nasal oxygen (HFNO) application on patient outcomes in major burns and inhalation injury. This report discusses 3 different patients. One patient, a 29-year-old male with 35% TBSA burns, received HFNO treatment for inhalation injury on the sixth day after the trauma. After 72 hours of HFNO application, the patient's pulmonary symptoms improved. The second patient had 60% TBSA burns and developed respiratory distress symptoms on the fifth day after the trauma. After 7 days of HFNO application, all symptoms and findings of acute respiratory distress syndrome (ARDS) were resolved. HFNO has been used for the treatment of ARDS related to major burn (60% of burned TBSA) in a 28-year-old patient, and improvement was achieved. The use of HFNO in pulmonary insufficiency among burn patients has not been reported previously. This series of patient cases demonstrates the successful application of HFNO in treating inhalation injury and burn-related ARDS. However, further clinical studies are necessary to increase its clinical utilization.

Effects of non-invasive respiratory support in post-operative patients: a systematic review and network meta-analysis

BACKGROUND

Re-intubation secondary to post-extubation respiratory failure in post-operative patients is associated with increased patient morbidity and mortality. Non-invasive respiratory support (NRS) alternative to conventional oxygen therapy (COT), i.e., high-flow nasal oxygen, continuous positive airway pressure, and non-invasive ventilation (NIV), has been proposed to prevent or treat post-extubation respiratory failure. Aim of the present study is assessing the effects of NRS application, compared to COT, on the re-intubation rate (primary outcome), and time to re-intubation, incidence of nosocomial pneumonia, patient discomfort, intensive care unit (ICU) and hospital length of stay, and mortality (secondary outcomes) in adult patients extubated after surgery.

METHODS

A systematic review and network meta-analysis of randomized and non-randomized controlled trials. A search from Medline, Embase, Scopus, Cochrane Central Register of Controlled Trials, and Web of Science from inception until February 2, 2024 was performed.

RESULTS

Thirty-three studies (11,292 patients) were included. Among all NRS modalities, only NIV reduced the re-intubation rate, compared to COT (odds ratio 0.49, 95% confidence interval 0.28; 0.87, p = 0.015, I2 = 60.5%, low certainty of evidence). In particular, this effect was observed in patients receiving NIV for treatment, while not for prevention, of post-extubation respiratory failure, and in patients at high, while not low, risk of post-extubation respiratory failure. NIV reduced the rate of nosocomial pneumonia, ICU length of stay, and ICU, hospital, and long-term mortality, while not worsening patient discomfort.

CONCLUSIONS

In post-operative patients receiving NRS after extubation, NIV reduced the rate of re-intubation, compared to COT, when used for treatment of post-extubation respiratory failure and in patients at high risk of post-extubation respiratory failure.

Noninvasive respiratory support in the perioperative setting: a narrative review

The application of preoperative noninvasive respiratory support (NRS) has been expanding with increasing recognition of its potential role in this setting as a physiological optimization for patients with a high risk of developing atelectasis and postoperative pulmonary complications (PPC). The increased availability of high-performance anesthesia ventilator machines providing an easy way for NRS support in patients with reduced lung function should not be under-evaluated. This support can reduce hypoxia, restore lung volumes and theoretically reduce atelectasis formation after general anesthesia. Therapeutic purposes should also be considered in the perioperative setting, such as preoperative NRS to optimize treatment of patients' pre-existing diseases, e.g., sleep-disordered breathing. Finally, the recent guidelines for airway management suggest preoperative NRS application before anesthesia induction in difficult airway management to prolong the time needed to secure the airway with an orotracheal tube. This narrative review aims to revise all these aspects and to provide some practical notes to maximize the efficacy of perioperative noninvasive respiratory support.

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.

[The perioperative role of high-flow cannula oxygen (HFNO)]

High-flow nasal cannula oxygen (HFNO) is commonly used during the perioperative period. Its numerous physiological benefits, satisfactory tolerance and ease of use have led to its widespread application in intensive care and post-anesthesia care units. HFNO is also used in the operating theater in multiple indications: as oxygen supplementation (associated with pressurization) prior to orotracheal intubation; in digestive and bronchial endoscopies, especially in patients at risk of hypoxemia; and in intraoperative surgery requiring spontaneous ventilation (ENT, thoracic surgery…). During the postoperative period, HFNO can be used in a curative strategy for respiratory failure or in a prophylactic strategy to prevent reintubation. In a curative approach, HFNO seems of interest following cardiac or thoracic surgery but has not been evaluated in respiratory failure subsequent to abdominal surgery, in which case noninvasive ventilation remains the gold standard. The risk of respiratory complications depends on type of surgery and on patient comorbidities. As prophylaxis, HFNO is currently preferred to conventional oxygen therapy after cardiac or thoracic surgery, especially in patients at high risk of respiratory complications. For the clinician, it is important to acknowledge the limits of HFNO and to closely monitor patients receiving HFNO, the objective being to avoid delays in intubation that could lead to increased mortality.

Practice-Changing Updates in Perioperative Medicine Literature 2020-2021: A Systematic Review

Recent literature published in a variety of multidisciplinary journals has significantly influenced perioperative patient care. Distilling and synthesizing the clinically important literature can be challenging. This review summarizes practice-changing articles in perioperative medicine from the years 2020 and 2021. Embase, Ovid, and EBM reviews databases were queried from January 2020 to December 2021. Inclusion criteria were original research, systematic review, meta-analysis, and important guidelines. Exclusion criteria were conference abstracts, case reports, letters, protocols, pediatric and obstetric articles, and cardiac surgery literature. Two authors reviewed each reference using the Distiller SR systematic review software (Evidence Partners Inc., Ottawa, Ont., Canada). A modified Delphi technique was used to identify 9 practice-changing articles. We identified another 13 articles for tabular summaries, as they were relevant to an internist's perioperative evaluation of a patient. Articles were selected to highlight the clinical implications of new evidence in each field. We have also pointed out limitations of each study and clinical populations where they are not applicable.

Perioperative oxygen therapy: a protocol for an overview of systematic reviews and meta-analyses

BACKGROUND

Oxygen is routinely given to patients during and after surgery. Perioperative oxygen administration has been proposed as a potential strategy to prevent and treat hypoxaemia and reduce complications, such as surgical site infections, pulmonary complications and mortality. However, uncertainty exists as to which strategies in terms of amount, delivery devices and timing are clinically effective. The aim of this overview of systematic reviews and meta-analyses is to answer the research question, 'For which types of surgery, at which stages of care, in which sub-groups of patients and delivered under what conditions are different types of perioperative oxygen therapy clinically effective?'.

METHODS

We will search key electronic databases (MEDLINE, EMBASE, the Cochrane Database of Systematic Reviews, CENTRAL, Epistemonikos, PROSPERO, the INAHTA International HTA Database and DARE archives) for systematic reviews and randomised controlled trials comparing perioperative oxygen strategies. Each review will be mapped according to type of surgery, surgical pathway timepoints and clinical comparison. The highest quality reviews with the most comprehensive and up-to-date coverage of relevant literature will be chosen as anchoring reviews. Standardised data will be extracted from each chosen review, including definition of oxygen therapy, summaries of interventions and comparators, patient population, surgical characteristics and assessment of overall certainty of evidence. For clinical outcomes and adverse events, the overall pooled findings and results of subgroup and sensitivity analyses (where available) will be extracted. Trial-level data will be extracted for surgical site infections, mortality, and potential trial-level effect modifiers such as risk of bias, outcome definition and type of surgery to facilitate quantitative data analysis. This analysis will adopt a multiple indication review approach with panoramic meta-analysis using review-level data and meta-regression using trial-level data. An evidence map will be produced to summarise our findings and highlight any research gaps.

DISCUSSION

There is a need to provide a panoramic overview of systematic reviews and meta-analyses describing peri-operative oxygen practice to both inform clinical practice and identify areas of ongoing uncertainty, where further research may be required. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42021272361.

Non-Invasive Respiratory Support for Management of the Perioperative Patient: A Narrative Review

BACKGROUND

Non-invasive respiratory support including high-flow nasal oxygen (HFNO), continuous positive airway pressure (CPAP) or bilevel positive airway pressure (BiPAP) is routinely used in the perioperative period.

OBJECTIVES

The aim of this narrative review was to discuss some of the existing literature on perioperative non-invasive respiratory support outlining its potential roles in each of the three perioperative periods (pre-, intra- and postoperatively) and to propose the way forward.

RESULTS

During induction of anesthesia, non-invasive ventilation (NIV) was associated with improved ventilatory variables and reduced risk of postoperative respiratory complications. HFNO did not seem to confer an advantage in terms of peri-intubation hypoxemia. Intraoperative data on NIV are scarce. Upper airway obstruction and worsening hypoventilation are two risks associated with its use. Compared with conventional oxygenation, HFNO is associated with a reduced risk of hypoxemia. Postoperative NIV has been associated with improved arterial blood gases and a reduced reintubation rate, but no difference was reported for mortality, hospital length of stay, rate of anastomotic leakage, pneumonia-related complications and sepsis or infections. Head-to-head comparison of HFNO versus BiPAP showed no advantage to either mode of support.

CONCLUSION

In the preoperative setting, NIV seems to be associated with improved clinical outcomes in specific patient subgroups (obesity, pregnancy). In the postoperative setting, both NIV and HFNO were associated with lower reintubation rates. The literature has provided little evidence regarding the use of non-invasive ventilatory support in other patient subgroups or intraoperatively. There is also little literature regarding the appropriateness of combining different modes of support. In the next years, the combination of several modes of respiratory support should be assessed in targeted populations.

Perioperative Noninvasive Ventilation After Adult or Pediatric Surgery: A Comprehensive Review

Postoperative pulmonary complications and acute respiratory failure are among the leading causes of adverse postoperative outcomes. Noninvasive ventilation may safely and effectively prevent acute respiratory failure in high-risk patients after cardiothoracic surgery and after abdominal surgery. Moreover, noninvasive ventilation can be used to treat postoperative hypoxemia, particularly after abdominal surgery. Noninvasive ventilation also can be helpful to prevent or manage intraoperative acute respiratory failure during non-general anesthesia, primarily in patients with poor respiratory function. Finally, noninvasive ventilation is superior to standard preoxygenation in delaying desaturation during intubation in morbidly obese and in critically ill hypoxemic patients. The few available studies in children suggest that noninvasive ventilation could be safe and valuable in treating hypoxemic or hypercapnic acute respiratory failure after cardiac surgery; on the other hand, it could be dangerous after tracheoesophageal correction.