Interact CardioVasc Thorac Surg 2008;7:1152-1154. doi:10.1510/icvts.2008.188334
© 2008 European Association of Cardio-Thoracic Surgery
Best evidence topic - Thoracic general |
Does non-invasive ventilation associated with chest physiotherapy improve outcome after lung resection?
Anne Freynet and
Pierre-Emmanuel Falcoz*
Department of Thoracic and Cardiovascular Surgery, Jean-Minjoz University Hospital, Besançon, France
Received 14 July 2008;
received in revised form 29 August 2008;
accepted 1 September 2008
Corresponding author. Department of Thoracic and Cardiovascular Surgery, Hôpital Jean-Minjoz, Boulevard Fleming, 25000 Besançon, France. Tel.: +33-3-81668664; fax: +33-3-81668661.
E-mail address: pierre-emmanuel.falcoz{at}wanadoo.fr (P.-E. Falcoz).
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Abstract
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A best evidence topic was constructed according to a structured protocol. The question addressed was whether the use of non-invasive ventilation (NIV) associated with chest physiotherapy (CPT) is effective in preventing respiratory complications in patients undergoing lung resection surgery. Of the 172 papers found using a report search, five presented the best evidence to answer the clinical question. The authors, journal, date and country of publication, study type, group studied, relevant outcomes and results of these papers are given. We conclude that, on the whole, the five studies were all in favor of NIV as an adjuvant to CPT for improving outcome after lung resection surgery. Indeed, the interest and benefit has been shown not only in the treatment of postoperative acute respiratory failure, but also in the prevention and treatment of respiratory complications (atelectasis, pneumonia and bronchial congestion). Hence, current evidence shows NIV associated with acute CPT management to be safe and effective in reducing postoperative complications and in improving patient recovery, thus enhancing the choice of available medical care and bettering outcome in lung resection surgery.
Key Words: Non-invasive ventilation; Chest physiotherapy; Lung resection surgery; Respiratory complications
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1. Introduction
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A best evidence topic was constructed according to a structured protocol. This is fully described in the ICVTS [1].
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2. Three-part question
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In [patients undergoing lung resection surgery] is [non-invasive ventilation associated with chest physiotherapy] superior to [chest physiotherapy alone] in [preventing respiratory complications]?
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3. Clinical scenario
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Four days after a right lower lobectomy for squamous cell carcinoma, you see a 65-year-old patient with a smoking history of 40 cigarettes a day for 30 years and a weight loss of 10 kg over the past three months. He had a right middle lobe pneumonia diagnosed on postoperative day 3. He is currently tired, breathless and presents with severe bronchial congestion. In view of the situation – particularly the fatigue – you wonder if non-invasive ventilation (NIV) might be a relevant adjuvant to chest physiotherapy (CPT). You propose this therapeutic option to the patient, who argues that it would probably make things worse. You therefore decide to look up the evidence in the literature.
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4. Search strategy
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Medline 1988 – May 2008, using the OVID interface, with results limited to human subjects and English language articles: [thoracic surgery] AND [non-invasive ventilation].
The Centre for Evidence-Based Physiotherapy (CEBP) – developed to give rapid access to bibliographic details and abstracts of randomized controlled trials, systematic reviews and evidence-based clinical practice guide-lines in physiotherapy; http://www.pedro.fhs.usyd.edu.au/index.html – was also searched. Finally, a hand search was used to follow-up references from the retrieved studies.
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5. Search outcome
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A total of 172 abstracts were found, from which five papers were selected for providing the best evidence on the topic. These papers are documented in Table 1.
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6. Results
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Three prospective randomized controlled trials, one non-systematic review and one systematic review emanating from an international consensus conference were identified; all investigated the effect of NIV with CPT in improving outcome in patients undergoing lung resection surgery.
Aguilo et al. [2] designed a prospective, randomized, controlled and parallel trial to investigate the short-term effects of NIV on pulmonary gas exchange, ventilatory pattern, systemic hemodynamics and pleural air leaks in 19 patients submitted to elective lung resection. Medical therapy – including CPT – was standardized for all patients. Ten subjects received NIV with a nasal ventilator support system (BiPAP for 1 h=study group). The remaining nine individuals constituted the control group. In the study group, NIV significantly increased PaO2 and also significantly decreased alveolar to arterial oxygen pressure gradient (P[A-a]O2). By contrast, PaO2 and P[A-a]O2 remained unchanged throughout the study. PaCO2, the ventilatory pattern and systemic hemodynamics did not change significantly throughout the study in any group. NIV did not increase dead space to tidal volume ratio or significantly worsen pleural air leaks.
Recommendations concerning NIV for surgical patients with acute respiratory failure were given by the International Consensus Conference in Intensive Care Medicine in 2000 [3]. NIV associated with CPT demonstrated short-term physiologic benefits on gas exchange without significant hemodynamic effects. NIV was well tolerated, but no clinical endpoints were investigated. Further investigations on its clinical relevance in the postoperative period of thoracic surgery are needed.
Auriant et al. [4] conducted a randomized prospective trial to compare standard therapy with and without NIV in 48 patients with acute hypoxemic respiratory insufficiency after lung resection. Standard therapy consisted of oxygen supplementation to achieve an SaO2 above 90%, bronchodilatators, patient controlled analgesia, and CPT. The primary outcome variable was the need for endotracheal mechanical ventilation (ETMV) and the secondary outcome variables were in-hospital and 120-day mortality rates, duration of stay in the intensive care unit and duration of in-hospital stay. Twelve of the 24 patients (50%) randomly assigned to the no NIV group required ETMV, versus only five (20.8%) in the NIV group (P=0.035). Of the 17 patients who required ETMV, nine in the no NIV group and one in the NIV group were started on ETMV during the first 48 h after lung resection. Nine patients in the no NIV group died (37.5%) compared to three (12.5%) in the NIV group (P=0.045). The other secondary outcomes were similar in the two groups.
Conti et al. [5] performed a non-systematic review on the indications and clinical results of NIV in the framework of postoperative acute respiratory failure in thoracic and abdominal surgery. They found two quality papers (prospective studies) in thoracic surgery, one within the framework of lung resection surgery and the other, lung transplantation. From these, they concluded that NIV associated with CPT in thoracic surgery results in improved management of postoperative acute respiratory failure and reduction in postoperative complications. However, further studies are needed to confirm these good initial results.
Perrin et al. [6] examined the prophylactic use of NIV administered pre- and postoperatively associated with CPT for reducing postoperative pulmonary function impairment. Thirty-nine patients with a preoperative FEV1 <70% of the predicted value scheduled for elective lobectomy related to lung cancer were enrolled. Seven patients were excluded after enrollment. A randomized, controlled and parallel trial was designed. Patients were required to follow standard treatment without (control group, n=18) or with NIV (study group, n=14) for seven days preoperatively at home and for three days postoperatively in hospital. Standard treatment included CPT, performed with the same regimen during the pre- and postoperative period, twice a day. NIV was provided via a facial mask, in the spontaneous mode, for one hour five times a day. The primary outcome variable was the change in arterial blood gases on room air. Pulmonary function testing, lobar or supra-lobar atelectasis requiring a fiberoptic bronchoscopy and duration of in-hospital stay were also recorded. Regarding the pre- and postoperative periods and, as compared to the control group, the use of NIV significantly improved the overall evolution of the arterial blood gas values on room air in the study group with NIV: pH (P=0.0003); PaO2 (P=0.0006); PaCO2 (P=0.04), FVC (P=0.03) and FEV1 (P=0.02). The hospital stay was significantly longer in the control group with no NIV than in the study group with NIV (respectively 19±3 days vs. 12±1 days; P=0.04). The incidence of major atelectasis was 14.2% in the NIV group and 38.9% in the no NIV group (P=0.15).
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7. Clinical bottom line
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On the whole, of the five studies presented, all were in favor of NIV as an adjuvant to CPT for improving outcome after lung resection surgery. Indeed, the interest and benefit has been shown not only in the treatment of postoperative acute respiratory failure, but also in the prevention and treatment of respiratory complications (atelectasis, pneumonia and bronchial congestion).
Hence, current evidence shows NIV associated with acute CPT management to be safe and effective in reducing postoperative complications and in improving patient recovery, thus enhancing the choice of available medical care and bettering outcome in lung resection surgery.
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Acknowledgements
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The authors thank Nancy Richardson-Peuteuil for her editorial assistance.
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References
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- Dunning J, Prendergast B, Mackway-Jones K. Towards evidence-based medicine in cardio-thoracic surgery: best BETS. Interact Cardiovasc Thorac Surg 2003;2:405–409.[Abstract/Free Full Text]
- Aguilo R, Togores B, Pons S, Rubi M, Barbe F, Agusti A. Non-invasive ventilatory support after lung resectional surgery. Chest 1997;112:117–121.[CrossRef][Medline]
- Evans TW. International Conferences in intensive care medicin: Non-invasive positive pressure ventilation in acute respiratory failure. Intensive Care Med 2001;27:166–178.[CrossRef][Medline]
- Auriant I, Jallot A, Hervé P, Cerrina J, Le Roy Ladurie F, Lamet Fournier J, Lescot B, Parquin F. Non-invasive ventilation reduces mortality in acute respiratory failure following lung resection. Am J Respir Crit Care Med 2001;164:1231–1235.[Abstract/Free Full Text]
- Conti G, Costa R, Spinazzola G. Non-invasive ventilation (NIV) in surgical patients with post-operative acute respiratory failure. Current Anaesth Critic Care 2006;17:329–332.[CrossRef]
- Perrin C, Jullien V, Vénissac N, Berthier F, Padovani B, Guillot F, Coussement A, Mouroux J. Prophylactic use of non-invasive ventilation in patients undergoing lung resectional surgery. Respiratory Med 2007;101:1572–1578.[CrossRef]
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Abstract
1. Introduction