REVIEW URRENT C OPINION
Preventive and therapeutic noninvasive ventilation in cardiovascular surgery Luca Cabrini, Alberto Zangrillo, and Giovanni Landoni
Purpose of review Postoperative pulmonary complications are common after cardiac and vascular surgery, and they are associated with a marked worsening in hospital survival and length of stay. Noninvasive ventilation (NIV) has been successfully applied in the prevention and treatment of postoperative acute respiratory failure (ARF), including the cardiovascular setting. Recent findings Recent findings confirm that ARF is still highly associated with reintubation and ICU readmission, affecting hospital and long-term mortality. The most recent studies suggest that NIV can be effective both in early and in severe ARF, both in ICU and in surgical ward; on the contrary, NIV efficacy, when applied as a preventive tool in unselected patients, is not demonstrated. Limited but promising data are available on NIV use in pediatric patients and in ancillary procedures like coronarography and transesophageal echocardiography. Summary NIV seems effective when applied to treat postoperative ARF. Its role as a preventive tool is still controversial, and probably should be limited to high-risk patients. Promising findings were reported for NIV application in pediatric patients and in ancillary procedures. So far, a cautious approach should be applied, as NIV failure is associated with poor outcomes if not quickly detected. Keywords acute respiratory failure, cardiac surgery, anesthesia, intensive care, noninvasive ventilation, postoperative, vascular surgery
INTRODUCTION Postoperative pulmonary dysfunction is quite common after cardiac and vascular surgery, ranging from mild hypoxemia to acute respiratory failure (ARF) [1,2,3 ]. Common postoperative pulmonary complications (PPCs) include atelectasis, pleural effusion, diaphragmatic dysfunction, and pneumonia. Several preoperative, intraoperative, and postoperative risk factors associated with PPCs have been identified [1,2]. PPCs are associated with a marked worsening in hospital survival and length of stay [4,5]. Noninvasive ventilation (NIV) has been successfully applied in ARF [6]; recently it has been evaluated in the prevention and treatment of postoperative ARF, including the cardiovascular setting [7 ,8,9 ,10,11]. In this area, NIV is expected to improve lung volumes (in particular, reopening the atelectasis) and ventilation, finally improving gas exchange and reducing the risk of pneumonia in the atelectatic regions [7 ,12,13]. NIV has been &&
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identified as one of the few treatments that proved effective in reducing mortality in the perioperative setting [14,15]. In the present review, we will offer an update of the available data on NIV in cardiovascular surgery, focusing on the most recent findings and new fields of application and research.
REINTUBATION AND ICU READMISSION AFTER CARDIOVASCULAR SURGERY The risk factors for reintubation after cardiovascular surgery were recently evaluated. Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy Correspondence to Giovanni Landoni, Professor, Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, Milan 20132, Italy. Tel: +39 02 26433737; fax: +39 02 26432200; e-mail: [email protected] Curr Opin Anesthesiol 2015, 28:67–72 DOI:10.1097/ACO.0000000000000148
0952-7907 Copyright ß 2015 Wolters Kluwer Health, Inc. All rights reserved.
www.co-anesthesiology.com
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Cardiovascular anesthesia
KEY POINTS Postoperative ARF is still a major cause of prolonged hospital stay and increased mortality in cardiovascular surgery. NIV improves survival when applied to treat postoperative ARF; its efficacy is at its best with early ARF. Its role as a preventive tool is still controversial, and probably should be limited to patients at high risk for postoperative ARF. Promising results were reported from NIV use in pediatric patients. Frail patients undergoing ancillary procedure like coronarography and transesophageal echocardiography, or intraoperative procedures, seem to benefit from NIV. NIV use on the surgical ward is reportedly a growing phenomenon. In any case, a skilled staff is required. NIV failure should be promptly detected and tracheal intubation performed if indicated.
Jian et al. [16] retrospectively analyzed their data about reintubation for ARF after coronary artery bypass grafting (CABG) over an 8-year period. The incidence of reintubation was 7.8%; reintubation occurred most commonly on the second day after extubation; cardiogenic pulmonary edema and hypoxemia due to pulmonary disease (particularly atelectasis) were the most common causes. Patients in the reintubation group had longer length of stay and higher hospital mortality (9.3 vs. 1.4%). The authors concluded suggesting that NIV application after extubation should be considered to improve oxygenation. Wang et al. [17], in a retrospective study, analyzed data on risk factors for hypoxemia (defined as PaO2/FiO2
Preventive and therapeutic noninvasive ventilation in cardiovascular surgery Luca Cabrini, Alberto Zangrillo, and Giovanni Landoni
Purpose of review Postoperative pulmonary complications are common after cardiac and vascular surgery, and they are associated with a marked worsening in hospital survival and length of stay. Noninvasive ventilation (NIV) has been successfully applied in the prevention and treatment of postoperative acute respiratory failure (ARF), including the cardiovascular setting. Recent findings Recent findings confirm that ARF is still highly associated with reintubation and ICU readmission, affecting hospital and long-term mortality. The most recent studies suggest that NIV can be effective both in early and in severe ARF, both in ICU and in surgical ward; on the contrary, NIV efficacy, when applied as a preventive tool in unselected patients, is not demonstrated. Limited but promising data are available on NIV use in pediatric patients and in ancillary procedures like coronarography and transesophageal echocardiography. Summary NIV seems effective when applied to treat postoperative ARF. Its role as a preventive tool is still controversial, and probably should be limited to high-risk patients. Promising findings were reported for NIV application in pediatric patients and in ancillary procedures. So far, a cautious approach should be applied, as NIV failure is associated with poor outcomes if not quickly detected. Keywords acute respiratory failure, cardiac surgery, anesthesia, intensive care, noninvasive ventilation, postoperative, vascular surgery
INTRODUCTION Postoperative pulmonary dysfunction is quite common after cardiac and vascular surgery, ranging from mild hypoxemia to acute respiratory failure (ARF) [1,2,3 ]. Common postoperative pulmonary complications (PPCs) include atelectasis, pleural effusion, diaphragmatic dysfunction, and pneumonia. Several preoperative, intraoperative, and postoperative risk factors associated with PPCs have been identified [1,2]. PPCs are associated with a marked worsening in hospital survival and length of stay [4,5]. Noninvasive ventilation (NIV) has been successfully applied in ARF [6]; recently it has been evaluated in the prevention and treatment of postoperative ARF, including the cardiovascular setting [7 ,8,9 ,10,11]. In this area, NIV is expected to improve lung volumes (in particular, reopening the atelectasis) and ventilation, finally improving gas exchange and reducing the risk of pneumonia in the atelectatic regions [7 ,12,13]. NIV has been &&
&&
&&
&&
identified as one of the few treatments that proved effective in reducing mortality in the perioperative setting [14,15]. In the present review, we will offer an update of the available data on NIV in cardiovascular surgery, focusing on the most recent findings and new fields of application and research.
REINTUBATION AND ICU READMISSION AFTER CARDIOVASCULAR SURGERY The risk factors for reintubation after cardiovascular surgery were recently evaluated. Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy Correspondence to Giovanni Landoni, Professor, Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, Milan 20132, Italy. Tel: +39 02 26433737; fax: +39 02 26432200; e-mail: [email protected] Curr Opin Anesthesiol 2015, 28:67–72 DOI:10.1097/ACO.0000000000000148
0952-7907 Copyright ß 2015 Wolters Kluwer Health, Inc. All rights reserved.
www.co-anesthesiology.com
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Cardiovascular anesthesia
KEY POINTS Postoperative ARF is still a major cause of prolonged hospital stay and increased mortality in cardiovascular surgery. NIV improves survival when applied to treat postoperative ARF; its efficacy is at its best with early ARF. Its role as a preventive tool is still controversial, and probably should be limited to patients at high risk for postoperative ARF. Promising results were reported from NIV use in pediatric patients. Frail patients undergoing ancillary procedure like coronarography and transesophageal echocardiography, or intraoperative procedures, seem to benefit from NIV. NIV use on the surgical ward is reportedly a growing phenomenon. In any case, a skilled staff is required. NIV failure should be promptly detected and tracheal intubation performed if indicated.
Jian et al. [16] retrospectively analyzed their data about reintubation for ARF after coronary artery bypass grafting (CABG) over an 8-year period. The incidence of reintubation was 7.8%; reintubation occurred most commonly on the second day after extubation; cardiogenic pulmonary edema and hypoxemia due to pulmonary disease (particularly atelectasis) were the most common causes. Patients in the reintubation group had longer length of stay and higher hospital mortality (9.3 vs. 1.4%). The authors concluded suggesting that NIV application after extubation should be considered to improve oxygenation. Wang et al. [17], in a retrospective study, analyzed data on risk factors for hypoxemia (defined as PaO2/FiO2
