Chest
Volume 117, Issue 4, April 2000, Pages 1106-1111
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Clinical Investigations in Critical Care
Nasal Continuous Positive Airway Pressure: A Method to Avoid Endotracheal Reintubation in Postoperative High-risk Patients With Severe Nonhypercapnic Oxygenation Failure

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Objectives

To study whether nasal continuous positive airway pressure (nCPAP) improves pulmonary oxygen transfer and avoids reintubation in patients with severe nonhypercapnic oxygenation failure after major cardiac, vascular, or abdominal surgery.

Design

Prospective interventional study.

Setting

Surgical ICU of a university hospital.

Patients

Twenty consecutive patients after thoracic, abdominal, or combined thoracoabdominal operations, in whom pulmonary oxygen transfer deteriorated continuously following elective extubation after initial mechanical ventilation. Respiratory failure was due to atelectasis and/or left heart failure, and all patients met predefined criteria for reintubation.

Interventions

nCPAP therapy (8 to 10 cm H2O) was initiated if Pao2 had decreased to < 80 mm Hg despite application of 100% oxygen (flow, 25 L/min), intermittent mask continuous positive airway pressure, and maximum conventional therapy.

Measurements and results

nCPAP treatment was started 24.1 ± 3.4 h after elective extubation. Pao2 was < 80 mm Hg in all patients, in 13 patients it was < 60 mm Hg, and in 3 patients it was < 50 mm Hg. Mean Pao2/fraction of inspired oxygen (Fio2) ratio had decreased to 60 ± 2.6, and increased within the first hour of nCPAP to 136 ± 12 (p < 0.001). The clinical condition in all patients improved further, and after 35.2 ± 6.3 h, all patients were well oxygenated by face mask at ambient pressure (Pao2/Fio2 ratio, 146 ± 14). Two patients were reintubated for reasons unrelated to oxygenation or ventilation (data are presented as mean ± SEM).

Conclusions

nCPAP is safe, easy to apply, and effective to improve arterial blood oxygenation in < 1 h in postoperative patients with severe nonhypercapnic oxygenation failure. In these patients, who otherwise would have been reintubated, nCPAP can avoid endotracheal reintubation and mechanical ventilation.

Section snippets

Materials and Methods

Patients were recruited prospectively for this study and entered the ICU following thoracic, abdominal, or combined thoracoabdominal procedures. Postoperatively, they received MV until criteria for extubation were fulfilled: Pao2> 70 mm Hg, with fraction of inspired oxygen (Fio2) < 0.35 and positive end-expiratory pressure ≤ 5 cm H2O; normocapnia, with pressure support ≤ 5 cm H2O; rectal temperature > 36.6°C, and a stable cardiovascular system (ie, systolic BP > 100 mm Hg, heart rate < 120

Results

Demographic data, body mass index, operative procedures, acute physiology and chronic health evaluation II score, and mortality data are shown in Table 1 . Mean Paco2 before nCPAP was 43.0 ± 2.0 mm Hg, and did not change with nCPAP (43.0 ± 1.5 mm Hg). No patient had hypercapnic respiratory failure. Ten patients received dobutamine (9.7 ± 1.02 μg/kg/min1), the dosages of which did not change significantly during the first 3 h of nCPAP.

Deterioration of pulmonary oxygen transfer was from severe

Discussion

We showed that nCPAP can substantially improve pulmonary oxygen transfer and avoid the need for EI and MV in patients after major surgery who developed—after an interval of well being—severe and progressive nonhypercapnic respiratory failure.

Following extended cardiac, vascular, or abdominal surgery, patients may develop pulmonary complications, such as atelectasis,14 consolidation of lung areas, or pneumonia.15 Pulmonary gas exchange can additionally be impaired by left heart failure following

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