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(BQ) Part 2 book Noninvasive mechanical ventilation and difficult weaning in critical care has contents: Post extubation failure and use of non invasive mechanical ventilation, non invasive mechanical ventilation and decannulation in tracheostomized patients, discharge ventilator depend patients,... and other contents.
Use of Noninvasive Mechanical Ventilation in Lung Transplantation 27 Ana Hernandez Voth, Pedro Benavides Mañas, and Javier Sayas Catalán Abbreviations CF COPD CPAP ETI FEV1 ICU ILD LT NIV 27.1 Cystic fibrosis Chronic obstructive pulmonary disease Continuous positive airway pressure Endotracheal intubation Flow expiratory volume in the first second Intensive care unit Interstitial lung disease Lung transplantation Noninvasive mechanical ventilation Introduction Lung transplantation (LT) is a consolidated therapeutic strategy in cases of end-stage pulmonary diseases such as chronic obstructive pulmonary disease (COPD), diffuse interstitial diseases, or vascular diseases Noninvasive mechanical ventilation (NIV) is one of the ventilatory support techniques that has achieved greater use in recent years, becoming available at most hospitals and being successfully implemented in intensive care units (ICUs), intermediate care units, and recovery units In this chapter, the role of NIV in the management of lung transplant patients in the pretransplant period, in the early postoperative period, and with LT complications, or to carry out diagnostic and therapeutic techniques in transplant patients, is reviewed A Hernandez Voth, MD (*) • P Benavides Mas, MD • J Sayas Catalan, MD Pulmonology Service, Hospital Universitario 12 de Octubre, Madrid, Spain e-mail: anahvoth@gmail.com; pedrobenavides79@yahoo.es; jsayascat@gmail.com © Springer International Publishing Switzerland 2016 A.M Esquinas (ed.), Noninvasive Mechanical Ventilation and Difficult Weaning in Critical Care: Key Topics and Practical Approaches, DOI 10.1007/978-3-319-04259-6_27 213 214 27.2 A Hernandez Voth et al Discussion and Analysis 27.2.1 NIV in LT Indication Diseases Many candidates for LT have a chronic domiciliary NIV indication as part of their underlying lung disease treatment There is evidence of NIV benefit as a bridge to LT in two obstructive pathologies: COPD and cystic fibrosis (CF) COPD exacerbation is a situation where the use of NIV has a higher degree of evidence, particularly in severe exacerbations that develop respiratory acidosis These exacerbations are frequent in patients with COPD on the waiting list for LT, and NIV can decrease mortality in up to 50 % cases of COPD exacerbation with respiratory acidosis when compared with standard treatment [1] This impact on survival is much higher than that obtained from any of pharmacological treatments used in COPD exacerbations, and it has a high degree of evidence to be recommended NIV usefulness in stable COPD is more controversial In patients with chronic hypercapnic respiratory failure, several studies with contradictory results have been published Some of them show a slight increase in survival of patients with COPD with hypercapnic respiratory insufficiency, whereas others have not found any differences in terms of exacerbations or survival Nevertheless, although there is no conclusive scientific evidence about its usefulness in stable COPD, it is one of the main indications of chronic domiciliary NIV in Europe Regarding the use of NIV in COPD as bridge to LT, an improvement in a pulmonary function parameter (an increase of 0.20 ± 0.18 l (liters) in FEV1) has been described, along with a small increase in survival while on the waiting list for LT [2] However, these are limited data because of the absence of a control group and the presence of important selection bias in their results Functional improvement has been achieved in very severe COPD by using NIV prior to an oncologic thoracic surgery, which can be extrapolated to very severe COPD patients on the waiting list for LT NIV in CF patients has shown short-term improvement in oxygen saturation and in pCO2 levels, as well as a decrease in the work of breathing, alveolar ventilation and exercise tolerance improvement, and pulmonary function stabilization during rehabilitation [3, 4] When these patients have a severe exacerbation that requires ventilatory support, invasive mechanical ventilation has a bad prognosis associated with infectious complications from frequent bronchial colonization, as ventilator-associated pneumonia As a bridge to LT, NIV in CF can reduce mortality from this cause 27.2.2 NIV in the LT Early Postoperative Period Generally, after thoracic surgery there are strong effects on respiratory function that relate to postoperative prolonged mechanical ventilation requirements In the particular case of LT, there are also other associated factors: the usual myopathy that terminal respiratory insufficiency patients present, functional alterations due to clamshell incision in bilateral LT, and postoperative diaphragm involvement due to phrenic nerve damage 27 Use of Noninvasive Mechanical Ventilation in Lung Transplantation 215 NIV use has been considered in the LT early postoperative period with three major objectives: to facilitate early extubation, to prevent reintubation due to postsurgery ventilatory failure, and to treat ventilatory failure once it is established [5] 27.2.2.1 NIV as a Tool in Early Extubation Early extubation is of particular interest in immunosuppressed patients to avoid infectious consequences of prolonged mechanical ventilation, but also to avoid airway complications Prolonged mechanical ventilation can lead to barotrauma on the sutures associated with air leakage, modifying pulmonary defense mechanisms and leading to bronchial anastomosis infection Consequences of reintubation due to postsurgical ventilatory failure may result in a remarkable increase of mortality Hypoxemia, hypercapnia and muscle fatigue due to an increase in breathing work are the most common causes of failed extubation Furthermore, at the time of extubation, there is a loss of the intrathoracic positive pressure maintained so far This induces hemodynamic changes, increasing venous return to the right ventricle, left cardiac septum displacement, and a possible increase in pulmonary artery pressure and pulmonary capillary wedge pressure All these events can result in the development of interstitial pulmonary edema and in a higher expiratory work Pressure support associated with some degree of positive end-expiratory pressure can offset these effects, even applying ventilation in the noninvasive mode NIV can represent a helpful tool in extubation of patients who not succeed a T-tube trial Thus, early weaning protocols have been developed in LT including epidural analgesia, early seating position, intensive physiotherapy, and NIV [6] In our experience, we have reviewed retrospectively NIV use in the early postoperative period of 54 lung transplant patients for three consecutive years Postextubation NIV was indicated in case of high levels of pCO2 during a T-piece trial or after extubation, ventilatory mechanisms alterations, or moderate respiratory acidosis A major indication for LT was COPD (48 %), and the other indications were interstitial lung disease (ILD) (26 %), pulmonary arterial hypertension (11 %), CF (7 %), and others (6 %) Three patients had chronic domiciliary NIV as a bridge to LT (two had COPD, the other one had ILD) Fourteen patients (26 %) constituted a NIV group having five endotracheal reintubations (three of them ended in tracheostomy), whereas in the non-NIV group there were three endotracheal reintubations (all of them ended in tracheostomy) There were no complications observed in the NIV group related to NIV, as well as fewer hours of endotracheal intubation (ETI) and shorter length of stay in the ICU compared with non-NIV group (Table 27.1) In our study, NIV was a useful tool in the LT early postoperative period, and it was associated with absence of airway complications, less ETI time, and shorter length of stay on the ICU Another circumstance that frequently motivates a prolonged time spent on invasive mechanical ventilation and prolonged ICU length of stay is postsurgical phrenic paralysis In these cases, NIV use can reduce time spent on invasive mechanical ventilation and, hence, length of stay on the ICU 216 A Hernandez Voth et al Table 27.1 Variables analyzed in the early postoperative period in lung transplant patients Hospital Universitario 12 de Octubre Variable Arterial blood gases (early postoperative period) [pH/PCO2 (mean)] Time spent in endotracheal intubation (mean) Length of stay (mean) Non-NIV group (N = 39) 7.36/45.9 NIV group (N = 14) 7.33/49.5 53.52 h 10.53 days 43.68 h 7.10 days NIV noninvasive mechanical ventilation, ICU intensive care unit, PCO2 carbon dioxide partial pressure in blood 27.2.2.2 NIV as Prevention of Post-extubation Ventilatory Failure Reintubation due to ventilatory failure is associated with high mortality, mainly because of its association with infectious events, which increases prophylactic use of NIV in patients at risk of reintubation We not provide concrete evidence in LT, but there are several studies on intubated patients at risk of post-extubation ventilatory failure in comparable circumstances to lung transplant patients’ conditions that have shown a decrease in post-extubation ventilatory failure rate in patients using NIV after extubation, trying to maintain NIV as long as possible in the first 24 h, compared with patients who received standard treatment [7] Along with this, early use of NIV could be considered in lung transplant patients who not pass a T-piece trial or have hypercapnia during this trial, looking for a protective effect on further development of ventilatory failure 27.2.2.3 NIV as a Treatment of Ventilatory Failure In post-extubation ventilatory failure, the use of NIV seems attractive as a way to avoid the need for reintubation However, in this case, there are dissenting opinions about its safety and usefulness Once ventilatory failure is established, NIV may not be as useful as we think; it can even have a deleterious effect on survival because it may delay a needed intubation, increasing the overall mortality However, in some studies performed in ventilatory failure in the postoperative period in thoracic surgery, NIV allowed a reduction in the rate of respiratory complications and its associated mortality in a relevant way 27.2.3 NIV in LT Complications That Present Ventilatory Failure A major cause of readmission to the ICU in the late postoperative period of LT is respiratory failure This might be due to many circumstances, most commonly infection, cardiogenic acute pulmonary edema, drug side effects, and acute rejection These situations with higher ventilatory requirements are often worsened by different circumstances related to LT: myopathy due to steroid use and ventilatory mechanics alterations due to surgery Thus, it is known that lung transplant patients who require invasive mechanical ventilation have a worse prognosis than patients admitted to the ICU due to diseases not derived from surgery [8] 27 Use of Noninvasive Mechanical Ventilation in Lung Transplantation 217 Moreover, NIV has demonstrated its usefulness in treating patients with hypoxemic respiratory failure of different etiologies, reducing the need for ETI and thereby decreasing infectious complications from it (nosocomial pneumonia and septic shock) and decreasing global mortality [9] Along with the evidence that NIV is safe and may be beneficial in hypoxemic failure, this technique also has utility in ventilatory failure management in immunosuppressed patients In these patients, when ventilatory failure requires ETI, mortality increases significantly, but NIV use enables to reduce reintubation rate and mortality, compared with reintubated patients Particularly in lung transplant patients it has demonstrated an improvement in physiological parameters (arterial blood gases analysis, breathing rate, etc.) after introducing NIV as acute respiratory failure treatment However, these results derive from a descriptive study without a control group, so we can only conclude that the NIV option is safe and may be beneficial to these patients [10] 27.2.4 NIV in Diagnostic and Therapeutic Techniques in Lung Transplant Patients Frequently, lung transplant patients require performance of diagnostic or therapeutic techniques in the airway, particularly bronchoscopy Bronchoscopy can reduce tracheal lumen in 10–15 % of patients and increases work of breathing, generating a relevant hypoxemia Procedures like bronchoalveolar lavage can cause a greater decline of oxygenation, and aspiration of bronchial secretions during bronchoscopy performance may produce a pressure drop at the end of expiration that facilitates alveolar collapse Frequently, these techniques should be performed in patients with severe hypoxemia, making it necessary to assure adequate oxygenation NIV use can allow the performance of these procedures, avoiding the need for intubation and invasive ventilation Bronchoscopy performance has been described under continuous positive airway pressure (CPAP), a particularly useful nonmechanical CPAP system designed by Boussignac, or the “helmet,” but there are no randomized studies that compare bronchoscopy performance under NIV versus ETI In general, it is described that NIV can significantly improve oxygenation during bronchoscopy performance in patients with refractory hypoxemia compared with conventional oxygen therapy Nevertheless, it may present some disadvantages, particularly in hemodynamically unstable patients, severely acidotic patients (pH < 7.20), or patients with no possibility of airway isolation with bronchoaspiration or gastric distension as associated complications Conclusion NIV is a useful tool in lung transplant patients, where avoiding intubation is crucial It can also improve work of breathing, gas exchange, oxygenation, and exercise tolerance Its applications include all the range of complications that may be present in the pretransplant and post-transplant period (early and late ones) 218 A Hernandez Voth et al In addition, NIV presents obvious advantages over invasive mechanical ventilation, especially related to the lack of infectious complications associated with the latter It also allows patient feeding, talking, and expectorating, can be used intermittently, and its withdrawal or its restart is easy However, its use is not free of risk, as with the delay of a necessary intubation, and may have implications in prognosis, which is why it is recommended that it be used under close surveillance and with skilled staff trained in its application Key Major Recommendations • NIV use in diseases that may require LT is clear Numerous candidates for LT have an indication of chronic domiciliary NIV as part of the underlying disease treatment There is evidence of NIV’s benefit as a transition aid to LT in two obstructive pathologies: COPD and CF • NIV use in the early postoperative period after LT has three major objectives: to facilitate early extubation, to prevent reintubation due to postsurgery ventilatory failure, and to treat ventilatory failure once it is established In our experience, NIV can decrease the number of reintubations and length of stay in the ICU compared with patients in whom NIV has not been used during their stay on the ICU • NIV is safe and may be beneficial in hypoxemic failure It is very useful in ventilatory failure management of immunosuppressed patients Particularly in lung transplant patients, an improvement of physiological parameters (arterial blood gases, breathing rate, etc.) has been observed after introduction of NIV as acute respiratory failure treatment in the late postoperative period • NIV can significantly improve oxygenation during diagnostic and therapeutic procedures in lung transplant patients, including bronchoscopy performance in patients with refractory hypoxemia to isolated oxygen therapy References Rabe KF, et al Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: GOLD executive summary Am J Respir Crit Care Med 2007;176(6):532–55 Wiebel M, et al Noninvasive self-ventilation–successful transition aid in the waiting period before lung transplantation? Med Klin (Munich) 1995;90(1 Suppl 1):32–4 Fauroux B, et al Long-term noninvasive ventilation in patients with cystic fibrosis Respiration 2008;76(2):168–74 Serra A, et al Non-invasive proportional assist and pressure support ventilation in patients with cystic fibrosis and chronic respiratory failure Thorax 2002;57(1):50–4 Feltracco P, et al Noninvasive ventilation in postoperative care of lung transplant recipients Transplant Proc 2009;41(4):1339–44 27 Use of Noninvasive Mechanical Ventilation in Lung Transplantation 219 Rocca GD, et al Is very early extubation after lung transplantation feasible? J Cardiothorac Vasc Anesth 2003;17(1):29–35 Ferrer M, et al Noninvasive ventilation during persistent weaning failure: a randomized controlled trial Am J Respir Crit Care Med 2003;168(1):70–6 Hadjiliadis D, et al Outcome of lung transplant patients admitted to the medical ICU Chest 2004;125(3):1040–5 Ferrer M, et al Noninvasive ventilation in severe hypoxemic respiratory failure: a randomized clinical trial Am J Respir Crit Care Med 2003;168(12):1438–44 10 Rocco M, et al Non-invasive pressure support ventilation in patients with acute respiratory failure after bilateral lung transplantation Intensive Care Med 2001;27(10):1622–6 Noninvasive Mechanical Ventilation in Postoperative Spinal Surgery 28 Eren Fatma Akcil, Ozlem Korkmaz Dilmen, and Yusuf Tunali 28.1 Introduction Noninvasive mechanical ventilation (NIMV) is widely used in the treatment of acute respiratory failure (ARF), and it is particularly effective in the treatment of acute exacerbation of chronic obstructive pulmonary disease (COPD) and cardiogenic pulmonary edema [1] Acute postoperative respiratory failure is another of the application areas of NIMV [2] Postoperative pulmonary complications (PPCs) are critical in the postoperative period because they increase hospital length of stay (LOS), morbidity, and mortality [2, 3] Atelectasis, pneumonia, bronchospasm, pleural effusion, pulmonary edema, pulmonary embolism, and pneumothorax are the clinical forms of PPC that occur most often Many cases of postoperative ARF are short and can be treated successfully with supplemental oxygen, reversal of neuromuscular blocking agents, bronchodilators, deep-breathing exercises, and chest physiotherapy if no intubation or mechanical ventilation is required Postoperative reintubation and invasive mechanical ventilation themselves are also suggested as relating to PPCs Therefore, because it is a noninvasive method, NIMV can be properly used in postoperative ARF [4] 28.2 Discussion The efficacy of NIMV has been demonstrated in postoperative ARF, including cardiac, thoracic, thoracoabdominal, and abdominal surgery [1–5] Various complications may develop following spinal surgery; the most common are cardiac E.F Akcil, MD (*) • O.K Dilmen, MD • Y Tunali, MD Department of Anaesthesiology and Intensive Care Medicine, Istanbul University Cerrahpasa School of Medicine, Istanbul, Turkey e-mail: erenfat@yahoo.com; ozlemkorkmaz1978@mynet.com; ytunali@yahoo.com © Springer International Publishing Switzerland 2016 A.M Esquinas (ed.), Noninvasive Mechanical Ventilation and Difficult Weaning in Critical Care: Key Topics and Practical Approaches, DOI 10.1007/978-3-319-04259-6_28 221 222 E.F Akcil et al complications (3 %), pulmonary complications (1.2 %), and pneumonia (1.2 %) Postoperative complications were reported to increase mortality; advanced age (>65), comorbidities, and complexity of surgical interventions are contributing factors [6, 7] It is obvious that scoliosis, trauma, and oncological spinal surgical interventions are more invasive interventions than degenerative disc disease surgery, with higher perioperative morbidity and mortality rates Moreover, in posterior lumbar fusion operations, mortality is lower than with anterior and thoracic approaches [6] It has been demonstrated that diabetes mellitus (particularly insulin-dependent), obesity, COPD, and steroid use increase complications in lumbar stenosis surgery [7] Thoracic disk surgery is particularly associated with pulmonary complications (6.9 %) [8] In those undergoing anterior/anterolateral decompression and fusion, all complications and pulmonary complications were reported to be greater than in those undergoing posterior/posterolateral decompression and only disc decompression with fusion Although we report high mortality and morbidity rates in scoliosis surgery, surgical interventions are needed to improve the quality of life of these patients and for the correction of the vital functions Irreversibly affected respiratory and cardiac functions may complicate both anesthesia and surgery Spinal deformity progression may cause deteriorated respiratory functions Secondary scoliosis may develop in children with muscular dystrophies and myopathies, and, hence, spinal fusion surgery is required There is alveolar hypoventilation and hypercapnia susceptibility due to respiratory muscle weakness, and inability to cough in scoliosis accompanied by neuromuscular diseases Postoperative pulmonary function is seen to deteriorate further than preoperative function In a case series including eight patients, early pre- and postoperative NIMV applications are effective in protecting the respiratory functions in these children with restrictive respiratory failure [9] Pre- and postoperative biphasic positive airway pressure was performed in children with forced vital capacity (FVC) ≤ L, those undergoing scoliosis surgery, and in a case of desaturation due to hypoventilation during the night, and no difference between preoperative and postoperative respiratory functions was observed [9] When NIMV is used in chronic respiratory failure due to scoliosis, it may improve arterial oxygenation, increase the quality of life, and reduce the hospital LOS Following scoliosis surgery, acute respiratory failure may develop, particularly in patients with poor respiratory functions in the preoperative period Atelectasis, depressant effects of opioids, and pain are the contributing factors to the risk of postoperative respiratory failure in these patients [10] It is established that the application of mechanically assisted cough and nasal intermittent positive pressure ventilation before and after surgery ensures that extubation will performed successfully and invasive mechanical ventilation will not be required in patients undergoing scoliosis surgery with FVC values of < 40 % before the surgery [11] In a study of 73 patients undergoing scoliosis surgery, NIMV was applied in 28 patients in the perioperative period, and PPC developed less often in this group than in those who did not undergo NIMV [12] In the pulmonary function tests of the children with muscular dystrophy, assuming that the vital capacity decreases by 3–10 % per year and surgery is contraindicated without opening tracheostomy in cases with FVC values of below 40 %, perioperative NIMV application and early surgery seem to be advantageous [13] 28 Noninvasive Mechanical Ventilation in Postoperative Spinal Surgery 223 Respiratory function tests guide us in determining the need of ventilator postoperatively and PPC progression in these patients The use of short-acting anesthetic drugs, methods reducing blood loss, and effective pain control may reduce postoperative ventilator requirements [14] Conclusion Spinal surgery particularly surgery for scoliosis could be complicated by respiratory failure in the perioperative period, and NIMV is essential for its management Key Recommendations • Respiratory function tests should be evaluated in the preoperative period of thoracic spinal and scoliosis surgery • Short-acting anesthetic drugs should be preferred • Postoperative pain management is essential for recovery References Garcia-Delgado M, Navarrete I, Garcia-Palma MJ, et al Postoperative respiratory failure after cardiac surgery: use of noninvasive ventilation J Cardiothorac Vasc Anesth 2012;26:443–7 Pelosi P, Jaber S Noninvasive respiratory support in the perioperative period Curr Opin Anaesthesiol 2010;23:233–8 Chiumello D, Chevallard G, Gregoretti C Non-invasive ventilation in postoperative patients: a systematic review Intensive Care Med 2011;37:918–29 Jaber S, Chanques G, Jung B Postoperative noninvasive ventilation Anesthesiology 2010;112:453–61 Albala MZ, Ferrignio M Short term noninvasive ventilation in the postanesthesia care unit: a case series J Clin Anesth 2005;17:636–9 Pumberger M, Chiu YL, Ma Y, et al Perioperative mortality after lumbar spinal fusion surgery: an analysis of epidemiology and risk factors Eur Spine J 2012;21:1633–9 Deyo RA, Hickam D, Duckard JP, et al Complications after surgery for lumbar stenosis in a veteran population Spine 2013;38:1695–702 Jain A, Menga EN, Hassanzadeh H, et al Thoracic disc disorders with myelopathy Spine 2014;39:1233–8 Gill I, Eagle M, Mehta JS, et al Correction of neuromuscular scoliosis in patients with preexisting respiratory failure Spine 2006;31:2478–83 10 Doherty MJ, Millner PA, Latham M, et al Non-invasive ventilation in the treatment of ventilatory failure following corrective spinal surgery Anaesthesia 2001;56:235–47 11 Bach JR, Sabharwal S High pulmonary risk scoliosis surgery: role of noninvasive ventilation and related techniques J Spinal Disord Tech 2005;18:527–30 12 Chong HS, Padua MRA, Kim JS, et al Usefulness of noninvasive positive-pressure ventilation during surgery of flaccid neuromuscular scoliosis J Spinal Disord Tech 2015 doi:10.1097 BSD.0000000000000234 13 Mills B, Bach JR, Zhao C, et al Posterior spinal fusion in children with flaccid neuromuscular scoliosis: the role of noninvasive positive pressure ventilatory support J Pediatr Orthop 2013;33:488–93 14 Almenrader N, Patel D Spinal fusion surgery in children with non-idiopathic scoliosis: is there a need for routine postoperative ventilation? Br J Anaesth 2006;97(6):851–7 ... Publishing Switzerland 20 16 A.M Esquinas (ed.), Noninvasive Mechanical Ventilation and Difficult Weaning in Critical Care: Key Topics and Practical Approaches, DOI 10.1007/978-3-319-0 425 9-6_31 24 1 24 2... ytunali@yahoo.com © Springer International Publishing Switzerland 20 16 A.M Esquinas (ed.), Noninvasive Mechanical Ventilation and Difficult Weaning in Critical Care: Key Topics and Practical Approaches,... (ed.), Noninvasive Mechanical Ventilation and Difficult Weaning in Critical Care: Key Topics and Practical Approaches, DOI 10.1007/978-3-319-0 425 9-6 _29 22 5 22 6 A.J Morgan and A.J Glossop pneumonitis,