Failure of noninvasive ventilation after lung surgery: a comprehensive analysis of incidence and possible risk factors

The role of ultrasound in predicting non-invasive ventilation outcomes: a systematic review

Purpose

To systematically review and compare ultrasonographic methods and their utility in predicting non-invasive ventilation (NIV) outcomes.

Methods

A systematic review was performed using the PubMed, Medline, Embase, and Cochrane databases from January 2015 to March 2023. The search terms included the following: ultrasound, diaphragm, lung, prediction, non-invasive, ventilation, and outcomes. The inclusion criteria were prospective cohort studies on adult patients requiring non-invasive ventilation in the emergency department or inpatient setting.

Results

Fifteen studies were analyzed, which comprised of 1,307 patients (n = 942 for lung ultrasound score studies; n = 365 patients for diaphragm dysfunction studies). Lung ultrasound scores (LUS) greater than 18 were associated with NIV failure with a sensitivity 62-90.5% and specificity 60-91.9%. Similarly, a diaphragm thickening fraction (DTF) of less than 20% was also associated with NIV failure with a sensitivity 80-84.6% and specificity 76.3-91.5%.

Conclusion

Predicting NIV failure can be difficult by routine initial clinical impression and diagnostic work up. This systematic review emphasizes the importance of using lung and diaphragm ultrasound, in particular the lung ultrasound score and diaphragm thickening fraction respectively, to accurately predict NIV failure, including the need for ICU-level of care, requiring invasive mechanical ventilation, and resulting in higher rates of mortality.

[Efficacy Analysis of High-flow Nasal Oxygen Therapy in Patients Accepting Single-port Video-assisted Thoracoscopic Lobectomy]

BACKGROUND

Patients who underwent lobectomy resection are prone to hypoxemia, and the vast majority present with type I respiratory failure. Thus, improvement of hypoxemia is one of the most important factors to facilitate postoperative recovery of patients. In this study, the superiority-inferiority of different oxygen inhalation methods were compared with high-flow nasal oxygen therapy (HFNO), noninvasive mechanical ventilation (NIMV) and nasal oxygen breath (NOB) in patients with hypoxemia after single-port video-assisted thoracoscopic (VATS) lobectomy, and the clinical efficacy of HFNO in these patients was further investigated.

METHODS

A total of 180 patients from the Second Affiliated Hospital of Soochow University in China with hypoxemia who accepting single-port VATS lobectomy from June 2021 to March 2022 were randomly divided into three groups (n=60), which were treated with HFNO, NIMV and NOB, respectively. The results of arterial blood gas analysis, patient's comfort score and incidence of complications were observed before, 1 h, 6 h-12 h and after use. Statistical analyses were conducted using statistical program for social sciences 25.0 (SPSS 25.0), and P<0.05 was considered as statistical significance.

RESULTS

For patients with hypoxemia after accepting single-port VATS lobectomy, HFNO was no less effective than NIMV (P=0.333), and both of whom could fast increase patients' partial pressure of oxygen/fraction of inspiration O₂ (PaO₂/FiO₂) compared to NOB (P<0.001). Besides, HFNO shows a great advantage in comfort degree and stay length (P<0.001, P=0.004), and incidence of complications were slightly lower than other groups (P=0.232). But it is worthy to note that HFNO is still slightly less effective than NIMV in patients with postoperative hypoxemia accompanied by elevated partial pressure of carbon dioxide (PaCO₂).

CONCLUSIONS

For patients with hypoxemia who accepting single-port VATS lobectomy, HFNO can be used as the first choice. However, for patients with postoperative hypoxemia accompanied by elevated PaCO₂, NIMV is still recommended to improve oxygenation.

Neuromuscular Blockade Monitoring in Acute Respiratory Distress Syndrome: Randomized Controlled Trial of Clinical Assessment Alone or With Peripheral Nerve Stimulation

BACKGROUND

Whether train-of-four (TOF) monitoring is more effective than clinical monitoring to guide neuromuscular blockade (NMB) in patients with acute respiratory distress syndrome (ARDS) is unclear. We compared clinical monitoring alone or with TOF monitoring to guide atracurium dosage adjustment with respect to drug dose and respiratory parameters.

METHODS

From 2015 to 2016, we conducted a randomized controlled trial comparing clinical assessments every 2 hours with or without corrugator supercilii TOF monitoring every 4 hours in patients who developed ARDS (Pao2/Fio2 <150 mm Hg) in a cardiothoracic intensive care unit. The primary outcome was the cumulative atracurium dose (mg/kg/h). Secondary outcomes included respiratory parameters during the neuromuscular blockade.

RESULTS

A total of 38 patients in the clinical + TOF (C + TOF) group and 39 patients in the clinical (C) group were included in an intention-to-treat (ITT) analysis. The cumulative atracurium dose was higher in the C + TOF group (1.06 [0.75-1.30] vs 0.65 [0.60-0.89] mg/kg/h in the C group; P < .001) compared to C group, as well as the atracurium daily dose (C + TOF - C group mean difference = 0.256 mg/kg/h [95% confidence interval {CI}, 0.099-0.416], P = .026). Driving pressures during neuromuscular blocking agent (NMBA) administration did not differ between groups (P = .653). Intensive care unit (ICU) mortality was 22% in the C group and 27% in the C + TOF group (P = .786). Days on ventilation were 17 (8-26) in the C group and 16 (10-35) in the C + TOF group.

CONCLUSIONS

In patients with ARDS, adding TOF to clinical monitoring of neuromuscular blockade did not change ICU mortality or days on mechanical ventilation (MV) but did increase atracurium consumption when compared to clinical assessment alone. TOF monitoring may not be needed in all patients who receive neuromuscular blockade for ARDS.

Recommendations from the Italian intersociety consensus on Perioperative Anesthesa Care in Thoracic surgery (PACTS) part 2: intraoperative and postoperative care

Introduction

Anesthetic care in patients undergoing thoracic surgery presents specific challenges that require a multidisciplinary approach to management. There remains a need for standardized, evidence-based, continuously updated guidelines for perioperative care in these patients.

Methods

A multidisciplinary expert group, the Perioperative Anesthesia in Thoracic Surgery (PACTS) group, was established to develop recommendations for anesthesia practice in patients undergoing elective lung resection for lung cancer. The project addressed three key areas: preoperative patient assessment and preparation, intraoperative management (surgical and anesthesiologic care), and postoperative care and discharge. A series of clinical questions was developed, and literature searches were performed to inform discussions around these areas, leading to the development of 69 recommendations. The quality of evidence and strength of recommendations were graded using the United States Preventive Services Task Force criteria.

Results

Recommendations for intraoperative care focus on airway management, and monitoring of vital signs, hemodynamics, blood gases, neuromuscular blockade, and depth of anesthesia. Recommendations for postoperative care focus on the provision of multimodal analgesia, intensive care unit (ICU) care, and specific measures such as chest drainage, mobilization, noninvasive ventilation, and atrial fibrillation prophylaxis.

Conclusions

These recommendations should help clinicians to improve intraoperative and postoperative management, and thereby achieve better postoperative outcomes in thoracic surgery patients. Further refinement of the recommendations can be anticipated as the literature continues to evolve.

Predictive Factors for Failure of Noninvasive Ventilation in Adult Intensive Care Unit: A Retrospective Clinical Study

Background

Noninvasive ventilation (NIV) has been reported to be beneficial for patients with acute respiratory failure in intensive care unit (ICU); however, factors that influence the clinical outcome of NIV were unclarified. We aim to determine the factors that predict the failure of NIV in critically ill patients with acute respiratory failure (ARF). Setting. Adult mixed ICU in a medical university affiliated hospital. Patients and Methods. A retrospective clinical study using data from critical adult patients with initial NIV admitted to ICU in the period August 2016 to November 2017. Failure of NIV was regarded as patients needing invasive ventilation. Logistic regression was employed to determine the risk factor(s) for NIV, and a predictive model for NIV outcome was set up using risk factors.

Results

Of 101 included patients, 50 were unsuccessful. Although more than 20 variables were associated with NIV failure, multivariate logistic regression demonstrated that only ideal body weight (IBW) (OR 1.110 (95%1.027-1.201), P=0.009), the maximal heart rate during NIV period (HR-MAX) (OR 1.024 (1.004-1.046), P=0.021), the minimal respiratory rate during NIV period (RR-MIN) (OR 1.198(1.051-1.365), P=0.007), and the highest body temperature during NIV period (T-MAX) (OR 1.838(1.038-3.252), P=0.037) were independent risk factors for NIV failure. We set up a predictive model based on these independent risk factors, whose area under the receiver operating characteristic curve (AUROC) was 0.783 (95% CI: 0.676-0.899, P < 0.001), and the sensitivity and specificity of model were 68.75% and 71.43%, respectively, with the optimal cut-off value of 0.4863.

Conclusion

IBW, HR-MAX, RR-MIN, and T-MAX were associated with NIV failure in patients with ARF. A predictive model based on the risk factors could help to discriminate patients who are vulnerable to NIV failure.

Efficacy of early passive tilting in minimizing ICU-acquired weakness: A randomized controlled trial

Purpose

To investigate whether passive tilting added to a standardized rehabilitation therapy improved strength at Intensive Care Unit (ICU) discharge.

Material and methods

This single-center trial included patients admitted to an adult surgical ICU and ventilated for at least 3 days. Patients were randomized to daily standardized rehabilitation therapy alone or with tilting on a table for at least 1 h. The primary outcome was the Medical Research Council (MRC) sum score at ICU discharge. Muscular recovery was a secondary outcome.

Results

Of 145 included patients, 125 received mobilization, 65 in the Tilt group and 60 in the Control group. Total mobilization duration (median [25th–75th percentiles]) in the Tilt group was 1020 [580–1695] versus 1340 [536–2775] minutes in the Control group (p = 0.313). MRC sum scores at ICU discharge were not significantly different between groups (Tilt, 50 [45–56] versus 48 [45–54]; p = 0.555). However, the number of patients with weakness was higher in the Tilt group at baseline (Tilt: 60/65 versus 48/60, p = 0.045) and muscular recovery was better in the Tilt group (p = 0.004).

Conclusions

Passive tilting added to a standardized rehabilitation therapy did not improve muscle strength at ICU discharge in surgical patients even if a faster recovery with tilting is suggested.

Fiber optic bronchoscopy and remifentanil target-controlled infusion in critically ill patients with acute hypoxaemic respiratory failure: A descriptive study

INTRODUCTION

Sedation optimizes patient comfort and ease of execution during fiber optic bronchoscopy (FOB). Our objective was to describe the safety and efficacy of remifentanil-TCI during FOB in non-intubated, hypoxaemic, thoracic surgery ICU patients.

METHODS

Consecutive spontaneously breathing adults requiring FOB after thoracic surgery were included if they had hypoxaemia (PaO₂/FiO₂<300mmHg or need for non-invasive ventilation [NIV]) and prior FOB failure under topical anaesthesia. The remifentanil initial target was chosen at 1ng/mL brain effect-site concentration (Cet), then titrated to 0.5ng/mL Cet increments according to patient comfort and coughing. Outcomes were patient-reported pain and discomfort (Visual Analogue Scale scores), ventilatory support intensification within 24hours after bronchoscopy, and ease of FOB execution.

RESULTS

Thirty-nine patients were included; all had a successful FOB. Their median PO₂/FiO₂ before starting FOB was 187±84mmHg and 24 patients received NIV. Median [interquartile range] pain scores were not different before and after FOB (1.0 [0.0-3.0] and 0.0 [0.0-2.0], respectively). Discomfort was reported as absent or minimal by 27 patients (69%; 95% confidence interval [95% CI], 54-81%) and as bothersome but tolerable by 12 patients (31%; 95% CI, 19-46%). Mean FiO₂ returned to baseline within 2hours after FOB in 30 patients; the remaining 9 patients (23%; 95% CI, 13-38%) received ventilatory support intensification. Ease of execution was good or very good in 34 patients (87%; 95% CI, 73-94%), acceptable in 4 patients, and poor in 1 patient (persistent cough).

CONCLUSION

Sedation with remifentanil-TCI during FOB with prior failure under topical anaesthesia alone was effective and acceptably safe in non-intubated hypoxaemic thoracic surgery patients.

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.

[The patient with lung cancer in intensive care]

In Western countries, lung cancer (LC) is the most common cause of cancer death. It is present in 15-20% of patients admitted to the ICU with a neoplastic condition. The purpose of this article is to review the causes of admission to ICU of patients with LC, their prognosis and the results of different life-support techniques. Most studies include mixed populations of non-small cell (NSCLC) and small-cell lung cancers (SCLC). However, there is preponderance of NSCLC (70%) and LC of advanced or metastatic stages, reflecting the distribution in the general population of LC. The cause of admission of LC patients to ICU is most often of respiratory origin. The ICU mortality rate currently ranges from 13 to 47% and the hospital mortality rate from 24 to 65%. The predictors of in-hospital mortality are mainly severity scores, organ dysfunction, general condition (performance status), respiratory distress and the need for mechanical ventilation or vasopressor drugs. When considering the long-term mortality, it is the features of the cancer (presence of metastases, cancer progression) that are important predictive factors.

Timing of noninvasive ventilation failure: causes, risk factors, and potential remedies

Background

Identifying the predictors of noninvasive ventilation (NIV) failure has attracted significant interest because of the strong link between failure and poor outcomes. However, very little attention has been paid to the timing of the failure. This narrative review focuses on the causes of NIV failure and risk factors and potential remedies for NIV failure, based on the timing factor.

Results

The possible causes of immediate failure (within minutes to <1 h) are a weak cough reflex, excessive secretions, hypercapnic encephalopathy, intolerance, agitation, and patient-ventilator asynchrony. The major potential interventions include chest physiotherapeutic techniques, early fiberoptic bronchoscopy, changing ventilator settings, and judicious sedation. The risk factors for early failure (within 1 to 48 h) may differ for hypercapnic and hypoxemic respiratory failure. However, most cases of early failure are due to poor arterial blood gas (ABGs) and an inability to promptly correct them, increased severity of illness, and the persistence of a high respiratory rate. Despite a satisfactory initial response, late failure (48 h after NIV) can occur and may be related to sleep disturbance.

Conclusions

Every clinician dealing with NIV should be aware of these risk factors and the predicted parameters of NIV failure that may change during the application of NIV. Close monitoring is required to detect early and late signs of deterioration, thereby preventing unavoidable delays in intubation.

Pulmonary endarterectomy: outcomes in patients aged >70

OBJECTIVES

Advanced age is not a barrier to cardiac surgery, with reports demonstrating excellent outcomes, but the effect of age on more complex surgery has not been studied. We assessed the outcomes of pulmonary endarterectomy (PEA) surgery in patients aged >70.

METHODS

A retrospective review of consecutive patients who underwent PEA between January 2006 and March 2011 at a national referral centre. The total cohort was dichotomized according to age on the day of surgery, either below or above 70 years. Outcomes were in-hospital mortality, overall survival and the length of ICU and hospital stays.

RESULTS

Four hundred and eleven patients underwent PEA during the 5-year period. The mean age was 56.9 years (range, 17-84 years). The in-hospital mortality was 14 of 308 (4.6%) for patients <70 years compared with 8 of 103 (7.8%) for patients ≥70 years (P = 0.21). The overall survival at 1, 2 and 3 years was 91.4, 89.9 and 87.7% in the <70-year old group and 85.9, 84.1 and 84.1% in the >70-year old group (log-rank test, P = 0.07), respectively. The length of ICU and in-hospital stays was longer in the >70-year old group, by 1 and 2 days, respectively (P = 0.005 and 0.001).

CONCLUSIONS

PEA surgery in patients ≥70 years is safe and carries a comparable risk of early mortality in younger patients, but there is an increase in resource use due to longer ICU and hospital stays. Advanced age should be taken into consideration when assessing suitability for PEA, but age per se should not be a contraindication to surgery.

Lung physiology and obesity: anesthetic implications for thoracic procedures

Obesity is a worldwide health problem affecting 34% of the American population. As a result, more patients requiring anesthesia for thoracic surgery will be overweight or obese. Changes in static and dynamic respiratory mechanics, upper airway anatomy, as well as multiple preoperative comorbidities and altered drug metabolism, characterize obese patients and affect the anesthetic plan at multiple levels. During the preoperative evaluation, patients should be assessed to identify who is at risk for difficult ventilation and intubation, and postoperative complications. The analgesia plan should be executed starting in the preoperative area, to increase the success of extubation at the end of the case and prevent reintubation. Intraoperative ventilatory settings should be customized to the changes in respiratory mechanics for the specific patient and procedure, to minimize the risk of lung damage. Several non invasive ventilatory modalities are available to increase the success rate of extubation at the end of the case and to prevent reintubation. The goal of this review is to evaluate the physiological and anatomical changes associated with obesity and how they affect the multiple components of the anesthetic management for thoracic procedures.