Prophylactic continuous positive airway pressure after pulmonary lobectomy: a randomized controlled trial

Prophylactic non-invasive positive pressure ventilation reduces complications and length of hospital stay after invasive thoracic procedures: a systematic review

QUESTION

In patients undergoing invasive thoracic procedures, what are the effects of prophylactic non-invasive positive pressure ventilation (NIV)?

DESIGN

Systematic review with meta-analysis of randomised trials. Methodological quality was assessed using the PEDro scale and the certainty of evidence with the GRADE approach.

PARTICIPANTS

Patients undergoing invasive thoracic procedures.

INTERVENTION

Continuous positive airway pressure (CPAP) or bi-level positive airway pressure (BiPAP).

OUTCOME MEASURES

Length of hospital stay, postoperative pulmonary complications, need for tracheal intubation, mortality, hypoxaemia, pulmonary function and adverse events. Meta-analysis was performed for all outcomes. Subgroup analyses estimated the effects of CPAP and BIPAP independently.

RESULTS

Sixteen trials with 1,814 participants were included. The average quality of the included studies was fair. Moderate certainty evidence indicated that NIV reduces postoperative pulmonary complications (RD -0.09, 95% CI -0.15 to -0.04) without increasing the rate of adverse events (RD 0.01, 95% CI -0.02 to 0.04). Low certainty evidence indicated that NIV reduces length of hospital stay (MD -1.4 days, 95% CI -2.2 to -0.5) compared with usual care. The effects on intubation and mortality rates were very close to no effect, indicating that NIV is safe. Subgroup analyses showed that the evidence for CPAP had more precise estimates that that for BiPAP.

CONCLUSION

NIV reduces postoperative pulmonary complications and length of stay after invasive chest procedures without increasing the risk of adverse events.

REGISTRATION

PROSPERO CRD42015019004.

Use of continuous positive airway pressure in drainage of pleural effusion: Educational intervention for evidence-based practice

OBJECTIVE

To create an educational intervention for health professionals and test its effectiveness in implementing the use of CPAP in hospitalized patients with pleural effusion undergoing thoracic drainage.

METHODS

This implementation study was developed in 5 hospitals in Brazil and one in Belgium within four phases: (I) Situational diagnosis (professionals and patients' knowledge about CPAP usage for drained pleural effusion and checking medical records for the last 6 months); (II) Education and training of professionals; (III) New situational diagnosis (equal to phase I); (IV) Follow-up for two years.

RESULTS

65 professionals, 117 patients' medical records, and 64 patients were enrolled in this study. Initially, only 72% of medical records presented a description of interventions. CPAP usage was mentioned in only one patient with a chest tube. After phase III, the number of professionals who used CPAP for their patients with drained pleural effusion increased from 28.8% to 66.7%, p < 0.001. Similarly, the acceptability of this therapy for this clinical situation also increased among professionals from 6.4 ± 1.3 to 7.8 ± 1.4, p < 0.001. However, before the implementation, only one medical record described the use of CPAP in one patient with drained pleural effusion. After two years, the use of CPAP therapy by healthcare professionals for patients with drained thoracic drainage was sustained in 3 hospitals.

CONCLUSIONS

The educational intervention for the use of CPAP in patients with drained pleural effusion was effective for health professionals. Results were sustained after two years in three of the six hospitals.

The role of prophylactic administration of CPAP in general surgical wards after open visceral surgery in reducing postoperative pneumonia-a retrospective cohort study

BACKGROUND

Postoperative pneumonia is a main adverse event that causes increased postoperative morbidity and prolonged length of hospital stay leading to high postoperative mortality. Continuous positive airway pressure (CPAP) is a type of non-invasive ventilation for the delivery of a positive airway pressure during respiration. In this study, we evaluated the impact of postoperative prophylactic CPAP on prevention of pneumonia in patients after open visceral surgery.

METHODS

In this observational cohort study, we compared the rates of postoperative pneumonia in patients who underwent open major visceral surgery from January 2018 till August 2020 in the study and control group. The study group had postoperative prophylactic sessions of CPAP for 15 min, 3-5 times a day and a repeated spirometer training was also performed in the general surgical ward. The control group received only the postoperative spirometer training as a prophylactic measure against postoperative pneumonia. The chi-square test was used to measure the relationships between categorical variables, and a binary regression analysis determined the correlation between independent and dependent variables.

RESULTS

A total of 258 patients met the inclusion criteria who had open visceral surgery for various clinical illnesses. There were 146 men (56.6%) and 112 women with a mean age of 68.62 years. As many as 142 patients received prophylactic CPAP and they were grouped into the study group, whereas 116 patients without prophylactic CPAP were placed in the control group. Overall, the rate of postoperative pneumonia was significantly less in the study group (5.6% vs. 25.9% in the control group; p-value < 0.0001), which could be confirmed by the regression analysis (OR 0.118, CI 95% 0.047-0.295, p < 0.001).

CONCLUSION

Postoperative intermittent CPAP after open visceral surgery can be performed in a general surgical ward. Our study showed a significant association with a low rate of postoperative pneumonia, especially in high-risk patients. This leads to a significantly shorter postoperative hospital stay especially in high-risk patients after upper gastrointestinal surgery.

TRIAL REGISTRATION NUMBER

DRKS00028988, 04.05.2022, retrospectively registered.

Recommendations of the Society of Thoracic Surgery and the Section of Cardiothoracic and Vascular Surgery of the Spanish Society of Anesthesia, Resuscitation and Pain Therapy, for patients undergoing lung surgery included in an intensified recovery program

In recent years, multidisciplinary programs have been implemented that include different actions during the pre, intra and postoperative period, aimed at reducing perioperative stress and therefore improving the results of patients undergoing surgical interventions. Initially, these programs were developed for colorectal surgery and from there they have been extended to other surgeries. Thoracic surgery, considered highly complex, like other surgeries with a high postoperative morbidity and mortality rate, may be one of the specialties that most benefit from the implementation of these programs. This review presents the recommendations made by different specialties involved in the perioperative care of patients who require resection of a lung tumor. Meta-analyzes, systematic reviews, randomized and non-randomized controlled studies, and retrospective studies conducted in patients undergoing this type of intervention have been taken into account in preparing the recommendations presented in this guide. The GRADE scale has been used to classify the recommendations, assessing on the one hand the level of evidence published on each specific aspect and, on the other hand, the strength of the recommendation with which the authors propose its application. The recommendations considered most important for this type of surgery are those that refer to pre-habilitation, minimization of surgical aggression, excellence in the management of perioperative pain and postoperative care aimed at providing rapid postoperative rehabilitation.

Routine postoperative noninvasive respiratory support and pneumonia after elective surgery: a systematic review and meta-analysis of randomised trials

BACKGROUND

Postoperative pulmonary complications, including pneumonia, are a substantial cause of morbidity. We hypothesised that routine noninvasive respiratory support was associated with a lower incidence of pneumonia after surgery.

METHODS

Systematic review and meta-analysis of RCTs comparing the routine use of continuous positive airway pressure (CPAP), noninvasive ventilation (NIV), or high-flow nasal oxygen (HFNO) against standard postoperative care in the adult population. We searched MEDLINE (PubMed), EMBASE, and CENTRAL from the start of indexing to July 27, 2021. Articles were reviewed and data extracted in duplicate, with discrepancies resolved by a senior investigator. The primary outcome was pneumonia, and the secondary outcome was postoperative pulmonary complications. We calculated risk difference (RD) with 95% confidence intervals using DerSimonian and Laird random effects models. We assessed risk of bias using the Cochrane risk of bias tool.

RESULTS

From 18 513 records, we included 38 trials consisting of 9782 patients. Pneumonia occurred in 214/4403 (4.9%) patients receiving noninvasive respiratory support compared with 216/3937 (5.5%) receiving standard care (RD -0.01 [95% confidence interval: -0.02 to 0.00]; I²=8%; P=0.23). Postoperative pulmonary complications occurred in 393/1379 (28%) patients receiving noninvasive respiratory support compared with 280/902 (31%) receiving standard care (RD -0.11 [-0.23 to 0.01]; I²=79%; P=0.07). Subgroup analyses did not identify a benefit of CPAP, NIV, or HFNO in preventing pneumonia. Tests for publication bias suggest six unreported trials.

CONCLUSION

The results of this evidence synthesis do not support the routine use of postoperative CPAP, NIV, or HFNO to prevent pneumonia after surgery in adults.

CLINICAL TRIAL REGISTRATION

PROSPERO: CRD42019156741.

Recommendations of the Society of Thoracic Surgery and the Section of Cardiothoracic and Vascular Surgery of the Spanish Society of Anesthesia, Resuscitation and Pain Therapy, for patients undergoing lung surgery included in an intensified recovery program

In recent years, multidisciplinary programs have been implemented that include different actions during the pre, intra and postoperative period, aimed at reducing perioperative stress and therefore improving the results of patients undergoing surgical interventions. Initially, these programs were developed for colorectal surgery and from there they have been extended to other surgeries. Thoracic surgery, considered highly complex, like other surgeries with a high postoperative morbidity and mortality rate, may be one of the specialties that most benefit from the implementation of these programs. This review presents the recommendations made by different specialties involved in the perioperative care of patients who require resection of a lung tumor. Meta-analyses, systematic reviews, randomized and non-randomized controlled studies, and retrospective studies conducted in patients undergoing this type of intervention have been taken into account in preparing the recommendations presented in this guide. The GRADE scale has been used to classify the recommendations, assessing on the one hand the level of evidence published on each specific aspect and, on the other hand, the strength of the recommendation with which the authors propose its application. The recommendations considered most important for this type of surgery are those that refer to pre-habilitation, minimization of surgical aggression, excellence in the management of perioperative pain and postoperative care aimed at providing rapid postoperative rehabilitation.

The effect of immediate postoperative Boussignac CPAP on adverse pulmonary events after thoracic surgery: A multicentre, randomised controlled trial

BACKGROUND

The effectiveness of prophylactic continuous positive pressure ventilation (CPAP) after thoracic surgery is not clearly established.

OBJECTIVE

The aim of this study was to assess the effectiveness of CPAP immediately after lung resection either by thoracotomy or thoracoscopy in preventing atelectasis and pneumonia.

DESIGN

A multicentre, randomised, controlled, open-label trial.

SETTINGS

Four large University hospitals at Madrid (Spain) from March 2014 to December 2016.

PATIENTS

Immunocompetent patients scheduled for lung resection, without previous diagnosis of sleep-apnoea syndrome or severe bullous emphysema. Four hundred and sixty-four patients were assessed, 426 were randomised and 422 were finally analysed.

INTERVENTION

Six hours of continuous CPAP through a Boussignac system versus standard care.

MAIN OUTCOME MEASURES

Primary outcome: incidence of the composite endpoint 'atelectasis + pneumonia'. Secondary outcome: incidence of the composite endpoint 'persistent air leak + pneumothorax'.

RESULTS

The primary outcome occurred in 35 patients (17%) of the CPAP group and in 58 (27%) of the control group [adjusted relative risk (ARR) 0.53, 95% CI 0.30 to 0.93]. The secondary outcome occurred in 33 patients (16%) of the CPAP group and in 29 (14%) of the control group [ARR 0.92, 95% CI 0.51 to 1.65].

CONCLUSION

Prophylactic CPAP decreased the incidence of the composite endpoint 'postoperative atelectasis + pneumonia' without increasing the incidence of the endpoint 'postoperative persistent air leaks + pneumothorax'.

Guidelines on enhanced recovery after pulmonary lobectomy

OBJECTIVE

To establish recommendations for optimisation of the management of patients undergoing pulmonary lobectomy, particularly Enhanced Recovery After Surgery (ERAS).

DESIGN

A consensus committee of 13 experts from the French Society of Anaesthesia and Intensive Care Medicine (Soci,t, franOaise d'anesth,sie et de r,animation, SFAR) and the French Society of Thoracic and Cardiovascular Surgery (Soci,t, franOaise de chirurgie thoracique et cardiovasculaire, SFCTCV) was convened. A formal conflict-of-interest policy was developed at the onset of the process and enforced throughout. The entire guidelines process was conducted independently of any industry funding. The authors were advised to follow the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to guide assessment of quality of evidence.

METHODS

Five domains were defined: 1) patient pathway and patient information; 2) preoperative management and rehabilitation; 3) anaesthesia and analgesia for lobectomy; 4) surgical strategy for lobectomy; and 5) enhanced recovery after surgery. For each domain, the objective of the recommendations was to address a number of questions formulated according to the PICO model (Population, Intervention, Comparison, Outcome). An extensive literature search on these questions was carried out and analysed using the GRADE® methodology. Recommendations were formulated according to the GRADE® methodology, and were then voted by all experts according to the GRADE grid method.

RESULTS

The SFAR/SFCTCV guideline panel provided 32 recommendations on the management of patients undergoing pulmonary lobectomy. After two voting rounds and several amendments, a strong consensus was reached for 31 of the 32 recommendations and a moderate consensus was reached for the last recommendation. Seven of these recommendations present a high level of evidence (GRADE 1+), 23 have a moderate level of evidence (18 GRADE 2+ and 5 GRADE 2-), and 2 correspond to expert opinions. Finally, no recommendation was provided for 2 of the questions.

CONCLUSIONS

A strong consensus was expressed by the experts to provide recommendations to optimise the whole perioperative management of patients undergoing pulmonary lobectomy.

Predicting prolonged length of stay after endoscopic transsphenoidal surgery for pituitary adenoma

BACKGROUND

Endoscopic transsphenoidal surgery (ETS) for the resection of pituitary adenoma has become more common throughout the past decade. Although most patients have a short postoperative hospitalization, others require a more prolonged stay. We aimed to identify predictors for prolonged hospitalization in the setting of ETS for pituitary adenomas.

METHODS

A retrospective chart review as performed on 658 patients undergoing ETS for pituitary adenoma at a single tertiary care academic center from 2005 to 2019. Length of stay (LoS) was defined as date of surgery to date of discharge. Patients with LoS in the top 10th percentile (prolonged LoS [PLS] >4 days, N = 72) were compared with the remainder (standard LoS [SLS], N = 586).

RESULTS

The average age was 54 years and 52.5% were male. The mean LoS was 2.1 days vs 7.5 days (SLS vs PLS). On univariate analysis, atrial fibrillation (p = 0.002), hypertension (p = 0.033), partial tumor resection (p < 0.001), apoplexy (p = 0.020), intraoperative cerebrospinal fluid (ioCSF) leak (p = 0.001), nasoseptal flap (p = 0.049), postoperative diabetes insipidus (DI) (p = 0.010), and readmission within 30 days (p = 0.025) were significantly associated with PLS. Preoperative continuous positive airway pressure (CPAP) (odds ratio, 15.144; 95% confidence interval, 2.596-88.346; p = 0.003) and presence of an ioCSF leak (OR, 10.362; 95% CI, 2.143-50.104; p = 0.004) remained significant on multivariable analysis.

CONCLUSION

For patients undergoing ETS for pituitary adenomas, an ioCSF leak or preoperative use of CPAP predicted PLS. Additional common reasons for PLS included postoperative CSF leak (10 of 72), management of DI or hypopituitarism (15 of 72), or reoperation due to surgical or medical complications (14 of 72).