Continuous positive airway pressure (CPAP) after lung resection: a randomized clinical trial

Clinical guide to perioperative management for videothoracoscopy lung resection (Section of Cardiac, Vascular and Thoracic Anesthesia, SEDAR; Spanish Society of Thoracic Surgery, SECT; Spanish Society of Physiotherapy)

The introduction of video-assisted thoracoscopic (VATS) techniques has led to a new approach in thoracic surgery. VATS is performed by inserting a thoracoscope through a small incisions in the chest wall, thus maximizing the preservation of muscle and tissue. Because of its low rate of morbidity and mortality, VATS is currently the technique of choice in most thoracic procedures. Lung resection by VATS reduces prolonged air leaks, arrhythmia, pneumonia, postoperative pain and inflammatory markers. This reduction in postoperative complications shortens hospital length of stay, and is particularly beneficial in high-risk patients with low tolerance to thoracotomy. Compared with conventional thoracotomy, the oncological results of VATS surgery are similar or even superior to those of open surgery. This aim of this multidisciplinary position statement produced by the thoracic surgery working group of the Spanish Society of Anesthesiology and Reanimation (SEDAR), the Spanish Society of Thoracic Surgery (SECT), and the Spanish Association of Physiotherapy (AEF) is to standardize and disseminate a series of perioperative anaesthesia management guidelines for patients undergoing VATS lung resection surgery. Each recommendation is based on an in-depth review of the available literature by the authors. In this document, the care of patients undergoing VATS surgery is organized in sections, starting with the surgical approach, and followed by the three pillars of anaesthesia management: preoperative, intraoperative, and postoperative anaesthesia.

Non-Invasive Ventilation in a Non-Standard Setting – Is it Safe to Ventilate Outside the ICU?

Non-invasive ventilation (NIV) is considered a fundamental method in treating patients with various disorders, requiring respiratory support. Often the lack of beds in the intensive care unit (ICU) and the concomitant medical conditions, which refer patients as unsuitable for aggressive treatment in the ICU, highlight the need of NIV application in general non-monitored wards and unusual settings – most commonly emergency departments, high-dependency units, pulmonary wards, and even ambulances. Recent studies suggest faster improvement of all physiological variables, reduced intubation rates, postoperative pulmonary complications and hospital mortality with better outcome and quality of life by early well-monitored ward-based NIV compared to standard medical therapy in patients with exacerbation of a chronic obstructive pulmonary disease, after a surgical procedure or acute hypoxemic respiratory failure in hematologic malignancies. NIV is a ceiling of treatment and a comfort measure in many patients with do-not-intubate orders due to terminal illnesses. NIV is beneficial only by proper administration with appropriate monitoring and screening for early NIV failure. Successful NIV application in a ward requires a well-equipped area and adequately trained multidisciplinary team. It could be initiated not only by attending physicians, respiratory technicians, and nurses but also by medical emergency teams. Ward-based NIV is supposed to be more cost-effective than NIV in the ICU, but further investigation is required to establish the safety and efficacy in hospital wards with a low nurse to patient ratio.

Use of lung expansion techniques on drained and non-drained pleural effusion: survey with 232 physiotherapists

Abstract Introduction: Techniques for lung expansion seem to benefit patients with drained and undrained pleural effusion, but there is a lack of evidence to indicate which technique is best in each situation. Currently, the therapeutic choices of respiratory physiotherapists serving this population are not known. Objective: To know which lung expansion techniques are chosen by chest physiotherapists who assist patients with drained and non-drained pleural effusion. Method: Through the announcement of the Federal Council, 232 physiotherapists who work in hospitals in Brazil were questioned about which techniques they apply to patients with drained and non-drained effusion. Results: Initially, 512 were questioned but 232 (45.3%) answered. The physiotherapists associate more than one technique of lung expansion in both types of patients, besides walking. Deep breathing is the most used technique in patients with drained (92%) and non-drained (77%) pleural effusion. Positive pressure exercises in the airways are chosen by 60% of the physiotherapists to treat patients with drained pleural effusion and by 34% to treat patients with non-drained pleural effusion. Yet the incentive spirometry are used with 66% of patients with drained pleural effusion and 42% with non-drained ones. Conclusion: Deep breathing is the most applied lung expansion technique in the treatment of patients with drained and non-drained pleural effusion by chest physiotherapists. In addition, there is association between greatest degree and time of professional performance and the chosen techniques.

Adding positive airway pressure to mobilisation and respiratory techniques hastens pleural drainage: a randomised trial

QUESTIONS

In patients with a collection of fluid in the pleural space, do mobilisation and respiratory techniques: shorten the drainage period and length of hospital stay; improve respiratory function and oxygenation; and prevent pulmonary complications? Does the addition of positive airway pressure to this regimen further improve the effects?

DESIGN

Randomised controlled trial with three intervention arms, concealed allocation, intention-to-treat analysis and blinded assessment.

PARTICIPANTS

One hundred and fifty-six inpatients with a fluid collection in the pleural space and with chest drainage in situ.

INTERVENTION

Participants received usual care and were randomly assigned to: a control group that also received sham positive airway pressure (4 cmH₂O) only (Con); an experimental group that received incentive spirometry, airway clearance, mobilisation and the same sham positive pressure (Exp1); or an experimental group that received the Exp1 regimen except that the positive airway pressure was 15 cmH₂O (Exp2). Treatments were provided three times per day for 7 days.

OUTCOME MEASURES

Days of chest tube drainage, length of hospital stay, pulmonary complications and adverse events were recorded until hospital discharge. Costs in each group were estimated.

RESULTS

The Exp2 group had shorter duration of chest tube drainage and length of hospital stay compared with the Exp1 and Con groups. In addition, the Exp2 group had less antibiotic use (18% versus 43% versus 55%) and pneumonia incidence (0% versus 16% versus 20%) compared with the Exp1 and Con groups (all p < 0.01). The groups had similar rates of adverse events (10% versus 2% versus 6%, p > 0.05). Total treatment costs were lower in the Exp2 group than in the Exp1 and Con groups.

CONCLUSIONS

In patients with a fluid collection in the pleural space, the addition of positive pressure to mobilisation and respiratory techniques decreased the duration of thoracic drainage, length of hospital stay, pulmonary complications, antibiotic use and treatment costs.

REGISTRATION

ClinicalTrials.govNCT02246946.

Non-invasive positive pressure ventilation for prevention of complications after pulmonary resection in lung cancer patients

BACKGROUND

Pulmonary complications are often seen during the postoperative period following lung resection for patients with lung cancer. Some situations such as intubation, a long stay in the intensive care unit, the high cost of antibiotics and mortality may be avoided with the prevention of postoperative pulmonary complications. Non-invasive positive pressure ventilation (NIPPV) is widely used in hospitals, and is thought to reduce the number of pulmonary complications and mortality after this type of surgery. Therefore, a systematic review is needed to critically assess the benefits and harms of NIPPV for patients undergoing lung resection. This is an update of a Cochrane review first published in 2015.

OBJECTIVES

To assess the effectiveness and safety of NIPPV for preventing complications in patients following pulmonary resection for lung cancer.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, LILACS and PEDro until 21 December 2018, to identify potentially eligible trials. We did not use any date or language restrictions in the electronic searches. We searched the reference lists of relevant papers and contacted experts in the field for information about additional published and unpublished studies. We also searched the Register of Controlled Trials (www.controlled-trials.com) and ClinicalTrials.gov (clinicaltrials.gov) to identify ongoing studies.

SELECTION CRITERIA

We considered randomised or quasi-randomised clinical trials that compared NIPPV in the immediate postoperative period after pulmonary resection with no intervention or conventional respiratory therapy.

DATA COLLECTION AND ANALYSIS

Two authors collected data and assessed trial risk of bias. Where possible, we pooled data from the individual studies using a fixed-effect model (quantitative synthesis), but where this was not possible we tabulated or presented the data in the main text (qualitative synthesis). Where substantial heterogeneity existed, we applied a random-effects model.

MAIN RESULTS

Of the 190 references retrieved from the searches, 7 randomised clinical trials (RCTs) (1 identified with the new search) and 1 quasi-randomised trial fulfilled the eligibility criteria for this review, including a total of 486 patients. Five studies described quantitative measures of pulmonary complications, with pooled data showing no difference between NIPPV compared with no intervention (RR 1.03; 95% CI 0.72 to 1.47). Three studies reported intubation rates and there was no significant difference between the intervention and control groups (RR 0.55; 95% CI 0.25 to 1.20). Five studies reported measures of mortality on completion of the intervention period. There was no statistical difference between the groups for this outcome (RR 0.60; 95% CI 0.24 to 1.53). Similar results were observed in the subgroup analysis considering ventilatory mode (bi-level versus continuous positive airway pressure (CPAP). No study evaluated the postoperative use of antibiotics. Two studies reported the length of intensive care unit stay and there was no significant difference between the intervention and control groups (MD -0.75; 95% CI -3.93 to 2.43). Four studies reported the length of hospital stay and there was no significant difference between the intervention and control groups (MD -0.12; 95% CI -6.15 to 5.90). None of the studies described any complications related to NIPPV. Of the seven included studies, four studies were considered as 'low risk of bias' in all domains, two studies were considered 'high risk of bias' for the allocation concealment domain, and one of these was also considered 'high risk of bias' for random sequence generation. One other study was considered 'high risk of bias' for including participants with more severe disease. The new study identified could not be included in the meta-analysis as its intervention differed from the other studies (use of pre and postoperative NIPPV in the same population).

AUTHORS' CONCLUSIONS

This review demonstrated that there was no additional benefit of using NIPPV in the postoperative period after pulmonary resection for all outcomes analysed (pulmonary complications, rate of intubation, mortality, postoperative consumption of antibiotics, length of intensive care unit stay, length of hospital stay and adverse effects related to NIPPV). However, the quality of evidence is 'very low', 'low' and 'moderate' since there were few studies, with small sample size and low frequency of outcomes. New well-designed and well-conducted randomised trials are needed to answer the questions of this review with greater certainty.

Comparison of an expiratory flow accelerator device versus positive expiratory pressure for tracheobronchial airway clearance after lung cancer lobectomy: a preliminary study

OBJECTIVE

A new type of device has recently been introduced in chest physiotherapy as an aid to tracheo-bronchial airway clearance: expiratory flow accelerator (EFA). It promotes mucus clearance without generating any pressure gradient, allowing patients to breathe at tidal volume against no resistance.

DESIGN

Pilot randomized controlled study.

SETTING

Tertiary hospital.

PARTICIPANTS

Fifty adult patients who underwent lung cancer lobectomy were randomized to undergo chest physiotherapy with EFA (n=26) or PEP (n=24).

INTERVENTIONS

EFA; PEP bottle.

MAIN OUTCOMES

Incidence of postoperative pulmonary complications (PPC) and length of stay.

SECONDARY OUTCOMES

trends in inspiratory capacity, respiratory rate, oxygen saturation, and dyspnoea. Patients rated user-friendliness of the two devices on a 5-point Likert scale.

RESULTS

A slightly different incidence of PPCs was observed between the EFA and PEP group. Nevertheless, the length of stay was similar in the two groups. No substantial differences were seen in trends of inspiratory capacity, respiratory rate, oxygen saturation, dyspnoea between the two groups. Patient-reported user-friendliness of the two devices did not differ significantly, although the use of the EFA device appeared less strenuous.

CONCLUSIONS

Results of this pilot study point to the use of EFA as an alternative treatment option rather than as a replacement for the PEP bottle in chest physiotherapy following lung cancer lobectomy. EFA may be preferable for weaker patients and/or with airway leakages in whom PEP has limited indications. Further investigation in a larger sample is required to statistically confirm the findings. Clinical Trial Registration Number ChiCTR-ONC-17013255.

External validation in an intermediate unit of a respiratory decompensation model trained in an intensive care unit

BACKGROUND

Preventing urgent intubation and upgrade in level of care in patients with subclinical deterioration could be of great utility in hospitalized patients. Early detection should result in decreased mortality, duration of stay, and/or resource use. The goal of this study was to externally validate a previously developed, vital sign-based, intensive care unit, respiratory instability model on a separate population, intermediate care patients.

METHODS

From May 2014 to May 2016, the model calculated relative risk of adverse events every 15 minutes (n = 373,271 observations) for 2,050 patients in a surgical intermediate care unit.

RESULTS

We identified 167 upgrades and 57 intubations. The performance of the model for predicting upgrades within 12 hours was highly significant with an area under the curve of 0.693 (95% confidence interval, 0.658-0.724). The model was well calibrated with relative risks in the highest and lowest deciles of 2.99 and 0.45, respectively (a 6.6-fold increase). The model was effective at predicting intubation, with a demonstrated area under the curve within 12 hours of the event of 0.748 (95% confidence interval, 0.685-0.800). The highest and lowest deciles of observed relative risk were 3.91 and 0.39, respectively (a 10.1-fold increase). Univariate analysis of vital signs showed that transfer upgrades were associated, in order of importance, with rising respiration rate, rising heart rate, and falling pulse-oxygen saturation level.

CONCLUSION

The respiratory instability model developed previously is valid in intermediate care patients to predict both urgent intubations and requirements for upgrade in level of care to an intensive care unit.

Postoperative Noninvasive Ventilation Following Cardiothoracic Surgery

Postoperative pulmonary complications following cardiac and thoracic surgery are common and associated with significant morbidity and mortality. Noninvasive ventilation has emerged as a successful and well-validated strategy to treat various acute medical conditions. More recently, noninvasive ventilation has been studied in selective surgical patient populations with the goal of preventing postoperative complications and treating acute respiratory failure. In this clinical review, we will briefly examine the incidence of pulmonary complications following cardiothoracic surgery and the physiology and mechanics of acute respiratory failure and noninvasive ventilation. We then present a systematic review of the indications, patient selection, and current literature investigating the specific use of noninvasive ventilation in this population.

Non-invasive positive pressure ventilation for prevention of complications after pulmonary resection in lung cancer patients

BACKGROUND

Pulmonary complications are often observed during the postoperative period of lung resection for patients with lung cancer. Some conditions such as intubation, a long stay in the intensive care unit, the high cost of antibiotics and mortality may be avoided with the prevention of postoperative pulmonary complications. Non-invasive positive pressure ventilation (NIPPV) is widely accepted and often used in hospitals, and may reduce the number of pulmonary complications and mortality after this type of surgery. Therefore, a systematic review is required to map and critically assess the benefits and harms of NIPPV for patients undergoing lung resection.

OBJECTIVES

To assess the efficacy and safety of NIPPV for preventing complications in patients who underwent pulmonary resection for lung cancer.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, LILACS and PEDro, to identify potentially eligible trials. We did not use any date or language restrictions in the electronic searches. The databases were last searched on 17 March 2015. We searched the reference lists of relevant papers and contacted experts in the field for information about additional published and unpublished studies. We also searched the Register of Controlled Trials (www.controlled-trials.com) and ClinicalTrials.gov (clinicaltrials.gov) to identify ongoing studies.

SELECTION CRITERIA

We considered randomised or quasi-randomised clinical trials that compared NIPPV in the immediate postoperative period after pulmonary resection with no intervention or conventional respiratory therapy.

DATA COLLECTION AND ANALYSIS

Two authors collected data and assessed trial risk of bias. Where possible, we pooled data from the individual studies using a fixed-effect model (quantitative synthesis), but where this was not possible we tabulated or presented the data in the main text (qualitative synthesis). Where substantial heterogeneity existed, we applied a random-effects model.

MAIN RESULTS

Of the 155 references retrieved from searches, 6 randomised clinical trials (RCTs) and 1 quasi-randomised trial fulfilled the eligibility criteria for this review, including a total of 436 patients. Five studies described quantitative measures of pulmonary complications, with pooled data showing no difference between NIPPV compared with no intervention (RR 1.03; 95% CI 0.72 to 1.47). Three studies reported intubation rates and there was no significant difference between the intervention and control groups (RR 0.55; 95% CI 0.25 to 1.20). Five studies reported measures of mortality on completion of the intervention period. There was no statistical difference between the groups for this outcome (RR 0.60; 95% CI 0.24 to 1.53). Similar results were observed in the subgroup analysis considering ventilatory mode (bi-level versus continuous positive airway pressure (CPAP). No study evaluated the postoperative consumption of antibiotics. Two studies reported the length of intensive care unit stay and there was no significant difference between the intervention and control groups (MD -0.75; 95% CI -3.93 to 2.43). Four studies reported the length of hospital stay and there was no significant difference between the intervention and control groups (MD -0.12; 95% CI -6.15 to 5.90). None of the studies described any complications related to NIPPV. Of the seven included studies, four studies were considered as 'low risk of bias' in all domains, two studies were considered 'high risk of bias' for the allocation concealment domain, and one of these was also considered 'high risk of bias' for random sequence generation. One other study was considered 'high risk of bias' for including participants with more severe disease.

AUTHORS' CONCLUSIONS

This review demonstrated that there was no additional benefit of using NIPPV in postoperative pulmonary resection for all outcomes analysed (pulmonary complications, rate of intubation, mortality, rate of non-pulmonary complications, postoperative consumption of antibiotics, length of intensive care unit stay, length of hospital stay and adverse effects related to NIPPV). However, the quality of evidence is 'very low', 'low' and 'moderate' since there were few studies, with small sample size and low frequency of outcomes. New well-designed and well-conducted randomised trials are needed to answer the questions of this review with greater certainty.

The effect of non-invasive positive airway pressure therapy following thoracic surgical procedures: protocol for a systematic review

BACKGROUND

Thoracic surgical procedures impair respiratory function, decreasing ventilation and oxygenation and increasing the risk of acute respiratory failure and pulmonary complications. To prevent these clinical repercussions, positive airway pressure therapy is widely used to increase pulmonary ventilation, decrease muscle overload, and ensure adequate oxygenation; however, the benefit of this therapy remains unclear.

METHODS/DESIGN

A systematic search of the literature including PubMed, CINAHL, AMED, PsycINFO, LILACS, Scielo, Scopus, PEDro, and the Cochrane Library will identify the randomized and quasi-randomized trials that used CPAP, Bilevel, or IPPB compared with a control without intervention, a sham treatment or other lung expansion techniques following thoracic surgical procedures. From these trials, we will extract data on a predefined list of outcomes, including oxygenation, ventilation, respiratory failure, pulmonary complications, and time of resolution of the clinical condition. The methodological quality of each trial included will be assessed using the PEDro scale. The strength of the recommendations will be summarized using the GRADE scale. Meta-analyses will be performed, if appropriate.

DISCUSSION

This review aims to promote greater knowledge regarding the efficiency of the use of non-invasive positive airway pressure on recovery of respiratory function and on prevention of pulmonary complications following thoracic surgical procedures. This review could help health professionals improve the care for patients undergoing thoracic surgical procedures.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42015019004.