Elsevier

Anesthesiology Clinics

Volume 30, Issue 3, September 2012, Pages 495-511
Anesthesiology Clinics

Postoperative Noninvasive Ventilation

https://doi.org/10.1016/j.anclin.2012.07.002Get rights and content

Introduction

General anesthesia is associated with significant changes in the shape of the chest, the orientation of the diaphragm, and alveolar gas content. This process results in significant loss of lung volume, airway closure, mucus trapping, ventilation-perfusion mismatch, and shunt, further compounded by surgeries of the upper abdomen and chest.1 The major impact of these changes is atelectasis and increased work of breathing, which elevates the risk for reintubation, mechanical ventilation, and nosocomial pneumonia, all resulting in prolonged hospital stay.

Noninvasive positive pressure ventilation (NIPPV Box 1), a term that covers continuous positive airway pressure (CPAP) and noninvasive pressure support ventilation (NIV/bilevel positive airway pressure [BiPAP]), is widely used in the postanesthesia care unit (PACU), intensive care unit (ICU), and high-dependency care unit (HDU) to both treat and prevent postoperative respiratory failure. This review initially addresses the basic physiology of gas-exchange abnormalities under anesthesia, and looks at NIPPV delivery systems and the evidence to support their use in the postoperative setting. Finally, a stepwise clinical approach to the patient with acute respiratory distress in the PACU is discussed.

Section snippets

Anesthesia: Atelectasis and Ventilation-Perfusion Mismatch

Ventilation-perfusion mismatch occurs in all patients who undergo general anesthesia and major surgery,2 and occurs whether or not the patient breathes spontaneously or whether the patient is maintained on volatile or intravenous anesthetic.3 Immediately following induction of anesthesia there is a 16% to 20% reduction in functional residual capacity (FRC),4 and this continues to decrease over the next 5 or 10 minutes.5, 6 The reduction in FRC is correlated with age and chest-wall elastance,7

Noninvasive positive pressure ventilation in the PACU

Noninvasive positive pressure ventilation (NIPPV) includes CPAP and pressure support ventilation/BiPAP, henceforth described as noninvasive ventilation (NIV). CPAP refers to elevated baseline airway pressure, applied throughout the respiratory cycle, but delivered principally at end expiration. It has 3 effects. (1) By restricting outward movement of gas from the alveoli, lung units are stented open, preventing end-expiratory atelectasis (Fig. 1B). (2) By increasing the gradient between the

Clinical use of NIV in the PACU

NIV has been widely used in the recovery room in various settings, both prophylactic and therapeutic (Box 2). Although there have been several clinical studies that have evaluated postoperative NIPPV, most of these are small studies, few are randomized, and the majority look only at short-term outcomes. The literature can be neatly divided into studies that have addressed prophylactic NIPPV for patients who are at elevated risk for pulmonary complications, and rescue NIPPV for patients with

Prevention of pulmonary complications (prophylactic NIV)

Patients who undergo upper abdominal, cardiac, thoracic, and bariatric surgery are at elevated risk for postoperative respiratory failure. For these patients prevention and reversal of atelectasis using NIPPV is an attractive proposition. Several studies have addressed this issue.

Therapeutic NIPPV in patients with postoperative respiratory failure

In patients who develop acute postoperative respiratory failure in the PACU/ICU, NIPPV has the potential to reduce the length of stay in ICU and development of further complications by preventing reintubation.

Respiratory failure following thoracic surgery is associated with very poor outcomes. Auriant and colleagues58 compared NIV versus medical therapy for respiratory failure following lung resection. Five of the 24 patients (20.8%) randomly assigned to the NIPPV group versus 12 of the 24

Clinical approach

The decision to use NIPPV in the PACU for prophylactic therapy in high-risk patients is usually taken preoperatively, based on sleep studies (for OSA) or on assessment of risk. There is no evidence that NIV is superior to CPAP in these situations. The applied airway pressure will depend on the patient's body habitus (higher body mass index will require greater amounts of positive pressure) and intraoperative oxygenation. For morbidly obese patients (body mass index >40 kg/m2), CPAP of 10 cm H2O

Summary

NIPPV is a useful tool that may be used for select patients in the PACU. NIPPV can be used to prevent and treat postoperative respiratory failure. This approach may reduce the number of patients being reintubated in the PACU as well as the burden on ICU beds, the length of stay in hospital, and morbidity.

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    The author has no conflicts of interest to disclose.

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