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(Chest. 2005;128:2688-2695.)
© 2005 American College of Chest Physicians

Outcomes of Patients With Acute Respiratory Failure After Abdominal Surgery Treated With Noninvasive Positive Pressure Ventilation*

Samir Jaber, MD, PhD; Jean-Marc Delay, MD; Gérald Chanques, MD; Mustapha Sebbane, MD; Eric Jacquet, MD; Bruno Souche, MD; Pierre-François Perrigault, MD and Jean-Jacques Eledjam, MD, PhD

* From the Department of Anesthesiology, Intensive Care and Transplantation Unit (DAR B) [Drs. Jaber, Delay, Chanques, Sebbane, Souche, Perrigault, and Eledjam], and Department of Surgery (Dr. Jacquet), Saint Eloi Hospital, University Hospital of Montpellier, Montpellier, France.

Correspondence to: Samir Jaber, MD, PhD, Unité de Réanimation et de Transplantation-Département d’Anesthésie-Réanimation "B," Chu de Montpellier Hopital, Saint Eloi 80, Avenue Augustin Fliche, 34295 Montpellier Cedex, France; e-mail: s-jaber{at}chu-montpellier.fr


   Abstract
TOP
 Abstract
Introduction
 Materials and Methods
 Results
 Discussion
 Conclusion
 References
 
Objectives: Little is known about the physiologic and clinical effects of noninvasive positive pressure ventilation (NPPV) in patients who have acute respiratory failure (ARF) after abdominal surgery. We evaluated our clinical experience with the use of NPPV in the treatment of ARF after abdominal surgery.

Methods: We prospectively evaluated NPPV use during a 2-year period in a medical-surgical ICU of a university hospital. We documented demographic and diagnostic data, gas exchange, and clinical outcomes. We compared patients who were not intubated to those who were intubated after a trial of NPPV.

Results: Of 72 patients with ARF after abdominal surgery who were treated with NPPV, 48 patients avoided intubation (67%). Patients in the intubated and nonintubated groups had similar demographic characteristics, and similar American Society of Anesthesiologists physical status and simplified acute physiology score II scores at admission. The intubated group had a significantly lower PaO2/fraction of inspired oxygen (FIO2) ratio (123 ± 62 mm Hg vs 194 ± 76 mm Hg, p < 0.01) and more extended bilateral alveolar infiltrates (67% vs 31%, p < 0.01) than the nonintubated group. Within the first NPPV observation period, the PaO2/FIO2 increased (+ 36 ± 29% [± SD], p = 0.04) and the respiratory rate decreased (28.2 ± 3.4 breaths/min vs 23.1 ± 3.8 breaths/min, p < 0.01) significantly only in the nonintubated group. The nonintubated group had significantly lower length of ICU stay (17.3 ± 10.9 days vs 34.1 ± 28.5 days, p < 0.01) and mortality rate (6% vs 29%, p < 0.01).

Conclusion: NPPV may be an alternative to conventional ventilation in selected patients with ARF after abdominal surgery who require ventilatory support.

Key Words: atelectasis • endotracheal intubation • extubation • noninvasive ventilation • postoperative complications


   Introduction
TOP
 Abstract
 Introduction
Materials and Methods
 Results
 Discussion
 Conclusion
 References
 
Acute respiratory failure (ARF) is a common complication after abdominal surgery and is associated with significant morbidity and mortality.123 Indeed, patients undergoing abdominal surgery, especially of the upper abdomen, commonly have reductions in lung volumes, elevation of both hemidiaphragms, and lower-lobe atelectasis.3456 Dysfunction of the diaphragm is suggested by decreases in tidal swings in transdiaphragmatic pressure and decreases in the ratio of abdominal to rib cage diameter.3456 The reduction in diaphragmatic activity contributes to lower-lobe atelectasis and other respiratory complications.7

Most often, the management of ARF in patients after abdominal surgery admitted to the ICU requires endotracheal intubation and mechanical ventilation (MV). Furthermore, ARF with the need of endotracheal intubation and MV are independent predictors of hospital mortality.3 Noninvasive positive pressure ventilation (NPPV) by facemask refers to the delivery of assisted MV without the need for an invasive artificial airway. NPPV, which consists of delivery of pressure support ventilation (PSV) plus positive end-expiratory pressure (PEEP) via facemask, has emerged as a significant advance in the management of respiratory failure,89 particularly in patients with an acute exacerbation of COPD910 and cardiogenic pulmonary edema.11 It has already been shown that not only patients with decompensated COPD but also patients with ARF due to other causes111213 can benefit from NPPV. NPPV is used in ARF with the aim of decreasing inspiratory effort and improving gas exchange. When NPPV is effective in avoiding endotracheal intubation in ARF, morbidity and mortality associated with MV are reduced.89111314 A reduction in the number of infectious complications is a particular advantage of NPPV.15 NPPV is safe and as efficient as invasive MV in improving gas exchange in patients with various patterns of ARF.91112131617 Several studies have provided supporting evidence for the selected application of NPPV in hypoxemic ARF, including immunocompromised patients13 and thoracic surgery.18 The clinical experience reported in abdominal postsurgical patients is limited to the use of PEEP alone without positive inspiratory PSV (ie, continuous positive airway pressure [CPAP]).19202122 Moreover, in these studies19202122 CPAP was used to prevent ARF after surgery (prophylactic use, ie, immediately following extubation, not waiting for respiratory distress to develop) but not to treat ARF when it developed (curative use). Only, one study23 reported that the application of prophylactic NPPV used during the first 24 h following surgery allows a significant reduction in the magnitude of the postoperative pulmonary restrictive syndrome in obese patients undergoing gastroplasty. However, no study reported the outcome of postoperative patients with ARF after abdominal surgery treated with NPPV. For this reason, we describe our experience with the management of ARF by NPPV in patients admitted to the ICU after abdominal surgery.


   Materials and Methods
TOP
 Abstract
 Introduction
 Materials and Methods
Results
 Discussion
 Conclusion
 References
 
Patient Selection and Exclusion
This study was conducted in a 12-bed surgical ICU during a 24-month period (January 1, 2000, to January 1, 2002). All patients who received NPPV for ARF after abdominal surgery were prospectively included. The study was approved by the ethics committee of the hospital. The requirement for obtaining written informed consent was waived, as this was an observational study and all procedures were considered to be routine clinical practice.

Patients were included and NPPV was performed if at least two of following clinical criteria and one of the hypoxemia criteria for ARF were present: severe respiratory distress with dyspnea, respiratory rate > 25 breaths/min, contraction of accessory inspiratory muscles, paradoxical abdominal motion, peripheral oxygen saturation < 92% while breathing at least 10 L/min oxygen, or PaO2 < 60 mm Hg on air or < 80 mm Hg while breathing any supplemental oxygen. Exclusion criteria were as follows: respiratory arrest, unable to protect airway, excessive secretions, uncooperative or agitated, or unable to fit mask. Esophageal and GI surgery were not contraindications in the present study.

NPPV Technique
NPPV was administered in a semirecumbent position with a ventilator designed for the ICU (Servo-Ventilator 300; Siemens; Elema, Sweden; or Evita 4; Dräger Medical; Lübeck, Germany). PSV was employed with a peak inspiratory pressure set above PEEP to obtain an expiratory tidal volume from 8 to 10 mL/kg. The first level of PSV was set at 5 to 8 cm H2O, and we increased progressively the level by 2 to 3 cm H2O until we obtained respiratory comfort with a tidal volume from 8 to 10 mL/kg. The inspiratory trigger was set at its minimal value to detect minimal inspiratory effort while avoiding autotriggering. The fraction of inspired oxygen (FIO2) was adjusted to obtain a percutaneous oxygen saturation > 92%, and we used a PEEP of 4 to 8 cm H2O. All NPPV attempts were performed with a facemask. Air leaks were reduced by carefully fitting the mask on the patient, focusing on leaks around nasogastric tube. All patients received nasogastric suction except for those who had hepatectomy. In most patients, nasogastric tubes were placed during surgery and were maintained by surgeons. Inspired gases were heated and humidified by a conventional heated humidifier (MR 730; Fisher & Paykel; Panmure, New Zealand).24

During the first 24 h, for the majority of the patients, NPPV was applied for approximately 30 to 45 min at 2- to 4-h intervals, depending on the patient’s clinical condition. Some patients were treated during the initial period with NPPV for 60 to 90 min at 2- to 3-h intervals (range, 8 to 12 h/d). Between the periods of NPPV, the patients breathed through a Venturi mask. The length of NPPV cycles was progressively reduced and was withdrawn completely as blood gas values and clinical condition improved. NPPV success was defined as avoidance of endotracheal intubation and invasive MV. NPPV failure was defined as the requirement for endotracheal intubation. The decision to perform endotracheal intubation was made by the attending physician, according to the usual criteria used in the ICU,2425 ie, cardiac arrest, respiratory arrest, respiratory pauses with loss of consciousness, severe encephalopathy, agitation uncontrollable by sedation, shock, and gas exchange deterioration. All patients also received daily physiotherapy, and transient lateral or prone positioning in case of lobar or pulmonary atelectasis.26 Mucolytics and/or bronchodilators were administered if required.

Data Collection
The following data were collected: demographic data, American Society of Anesthesiologists (ASA) physical status score, simplified acute physiology score (SAPS) II,27 associated comorbidities (cardiovascular, respiratory, and renal), and underlying respiratory status. Body mass index (BMI) was calculated by dividing the weight in kilograms by the square of height in meters, and obesity was defined as a BMI > 30 kg/m2. We also evaluated the presence and the severity of pleural effusion, atelectasis, and alveolar infiltrates.26 Arterial blood gases, heart rate, systolic and diastolic BPs, and respiratory rate preceding and following the institution of NPPV were analyzed. Physiologic and arterial blood gas measurements were recorded as close to before the institution of NPPV as possible and after 0.5 ± 3 h (± SD) [0.5 ± 1 h whenever available] of NPPV. The PaO2/FIO2 ratio was computed for each arterial blood gas measurement. For spontaneously breathing patients, each liter of oxygen was assumed to add 3% oxygen to room air.28 Mean duration of each NPPV sequence and total NPPV use (from the initiation of NPPV until weaned or endotracheal intubation) were recorded. We also evaluated the following NPPV complications: gastric distension (clinically evaluated by the physician), nasal bridge erythema or ulceration, agitation (frequent movements of head, arms, or legs that persisted despite attempts of staff to calm the patient), and major air leaks (air leaks interfering with the ability to ventilate). Outcomes were evaluated for intubation rate, length of ICU and hospital stay, and mortality.

Statistical Analysis
Data are expressed as frequency for nominal variables and as mean ± SD for continuous variables. Patients requiring intubation for reasons other than worsening of respiratory failure (ie, surgical complications requiring a new surgical procedure) were excluded from the statistical analysis. When a patient received more than one NPPV treatment (ie, more than one ARF episode treated by NPPV treatment), only the first one was included for analysis. For categorical variables, the comparisons were performed using the {chi}2 test or Fisher Exact Test, as appropriate. For continuous variables, the comparisons were performed using the unpaired Student t test or the Mann-Whitney U test if the distribution of the continuous variables was not normal. The analysis was made with a nonparametric paired Wilcoxon test to compare data obtained before and after NPPV for each patient. A p value of < 0.05 was considered statistically significant. All statistical analysis was performed using statistical software (SAS version 6.12; SAS Institute; Cary, NC).


   Results
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
Discussion
 Conclusion
 References
 
Over the 2-year period of the study, 627 patients were admitted to the unit. Among these, 463 patients were admitted for postoperative care (372 were intubated). ARF occurred in 96 patients after extubation. Eighteen patients required immediate intubation without trying to perform NPPV, and 6 patients were reintubated for surgical complications requiring a new surgical procedure. Seventy-two patients received NPPV for postoperative ARF and were included in the study. Of the 72 included patients who were treated with NPPV, 48 were not intubated (67%).

The patient characteristics on admission to the ICU are shown in Table 1 . On admission to the ICU, there were no statically significant differences between intubated and nonintubated patients in terms of age, gender, weight, BMI, comorbidities, ASA physical status, severity of illness evaluated by SAPS II, and type of surgery. The two study groups were similar in duration of initial period of MV (4.6 ± 4.9 days vs 5.2 ± 4.8 days, not significant [NS]) and time from extubation to ARF (26.9 ± 28.3 h vs 27.7 ± 23.0 h, NS). Among the 11 obese patients studied, 5 were intubated.


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  		Table 1. Patient Characteristics Upon Admission to the ICU*

 
Changes in physiologic parameters and arterial blood gases obtained before and after NPPV are presented in Table 2 . For the two studied groups, no hemodynamic repercussions of NPPV was observed. Blood arterial gas values were collected from 37 patients in nonintubated group and 18 patients in the intubated group. Figure 1 shows the PaO2/FIO2 ratio obtained before and after NPPV for both intubated and nonintubated patients. The intubated group had a significantly lower PaO2/FIO2 ratio (123 ± 62 mm Hg vs 194 ± 76 mm Hg, p < 0.01) than the nonintubated group. However, within the first NPPV observation period, the PaO2/FIO2 increased (36 ± 29% vs 21 ± 34%, p = 0.04) and respiratory rate decreased (28.2 ± 3.4 breaths/min vs 23.1 ± 3.8 breaths/min, p < 0.01) significantly only in the nonintubated group.


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  		Table 2. Changes in Physiologic Parameters and Arterial Blood Gases Obtained Before and After NPPV*

 


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  		Figure 1. PaO2/FIO2 ratio obtained before and after NPPV for both nonintubated and intubated groups. The intubated group had a significantly lower PaO2/FIO2 ratio than the nonintubated group. However, within the first NPPV observation period, the PaO2/FIO2 ratio increased significantly only in the nonintubated group.

 
The site of surgical incision, severity and presence of atelectasis, pleural effusion, and alveolar infiltrates are shown in Table 3 . Atelectasis developed in the majority of the studied patients, with no significant difference between nonintubated and intubated patients (88% vs 92%, NS). All abdominal surgeries were performed under laparotomy, except for two under laparoscopy. The intubated group had significantly more bilateral alveolar infiltrates (67% vs 31%, p < 0.01).


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  		Table 3. Thoracic and Abdominal Characteristics*

 
Table 4 gives the characteristics of NPPV use and final outcome. The mean level of PSV was 14 ± 2 cm H2O, the mean level of PEEP was 6 ± 3 cm H2O, and FIO2 was adjusted to 55 ± 10% with no significant difference between nonintubated and intubated patients. No significant difference was observed between the two groups for tolerance and complication of NPPV (Table 4). The median duration of NPPV was 3.1 days (range, 2 to 7 days) for the nonintubated group. The 24 patients who failed to respond to NPPV were intubated after a mean time of 41 ± 23 h, and most of the patients had undergone only a small number of NPPV trials. Figure 1 shows the individual distribution of the delay of intubation after the start of NPPV for the 24 patients. The nonintubated group had significantly lower length of ICU stay (17.3 ± 10.9 days vs 34.1 ± 28.5 days, p < 0.01) and mortality (6% vs 29%, p < 0.01). The cause of death was myocardial infarction for one patient and sepsis with multiple organ failure for six of the seven patients in the intubated group, and acute pulmonary embolism for one patient and intractable heart failure for the two other patients in the intubated group.


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  		Table 4. Characteristics of NPPV Use and Outcome*

 

   Discussion
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
Conclusion
 References
 
This study demonstrates the feasibility and clinically efficacy of NPPV applied in selected patients with ARF after abdominal surgery in the daily practice of a surgical ICU, with an overall success rate of 67%. The role of NPPV in the treatment of hypoxemic ARF is recognized and becoming more widespread.8917 To our knowledge, no previous studies have evaluated NPPV for the treatment of ARF occurring after abdominal surgery.

Contrary to thoracic surgery,18293031 there are a few studies that specifically evaluate the feasibility and efficiency of NPPV after abdominal surgery that is prophylactic (ie, immediately following extubation, not waiting for respiratory distress to develop) or curative. Joris et al23 reported that prophylactic NPPV at an inspiratory pressure of 12 cm H2O and PEEP of 4 cm H2O used during the first 24 h following surgery allows a significant reduction in the magnitude of the postoperative pulmonary restrictive syndrome in obese patients undergoing gastroplasty. In our study, 11 obese patients were included: 5 were intubated and 6 were not intubated (Table 1). No significant difference was observed between obese and nonobese patients for NPPV success (45% vs 31%, NS) and clinical outcomes. However, the limited number of studied obese patients limits conclusions about the benefits of NPPV in this population after abdominal surgery. Stock et al19 showed that after abdominal surgery, NPPV with only CPAP increased lung volume rapidly and decreased atelectasis at 72 h postoperatively compared with conventional therapy.

The earlier report by Pennock et al32 found that NPPV avoided reintubation in 73% of 22 patients who had respiratory deteriorations at least 36 h after various types of surgery. Varon et al33 prospectively evaluated the feasibility of NPPV in the treatment of ARF in postoperative cancer patients. Among the 60 included patients, the primary cancer sites were GI for 25 patients; 70% had gradual improvement in their ARF and were successfully weaned from NPPV without the requirement of endotracheal intubation. Most patients required NPPV for < 48 h, and no complications related to the use of NPPV were seen in any of the 60 patients. These results are comparable to those observed in our study.

Antonelli et al12 showed in a controlled randomized trial that in organ transplant recipients with hypoxemic ARF, NPPV reduced the rate of intubation, the incidence of fatal complications, and ICU mortality compared with the provision of supplemental oxygenation alone. Among the 40 included patients, 22 patients underwent liver transplantation—10 patients in the NPPV group and 12 patients in the standard group—with no significant differences in intubation rates and clinical outcomes between the two subgroups. In our present study, no significant difference was observed in the percentage of patients undergoing liver transplantation between the nonintubated and intubated groups (31% vs 42%, NS).

Keenan et al34 reported in a controlled randomized trial that NPPV does not improve outcome in a heterogeneous group of 81 patients with respiratory distress during the first 48 h after extubation. Esteban et al35 showed in a large, multicenter, controlled randomized study that NPPV does not prevent the need for reintubation or reduce mortality in unselected patients who have respiratory failure after extubation. However, in these two last studies,3435 the majority of the ARF etiologies were of medical origin and there was a limited number of abdominal postoperative patients.

Dysfunction of the respiratory muscles due to surgery may lead to a reduction in the vital capacity, tidal volume, and total lung capacity and, thus, insufficient cough.3637 This may cause atelectasis in the basal lung segments and a decrease in functional residual capacity that, in turn, affects the gas exchange properties of the lung by increasing the ventilation/perfusion mismatch.41937

The use of NPPV with PSV and PEEP allows for decreased work of breathing,1038 reduced pulmonary extravascular water,30 and increased lung volume with reexpansion of atelectasis.21 In the present study, 62 of 72 patients had atelectasis with no significant difference between the nonintubated and intubated groups (88% vs 83%, NS). Atelectasis is frequently observed after abdominal surgery especially in patients who had received MV for > 24 h. The successful application of mask CPAP for the treatment of established atelectasis has been reported in uncontrolled studies.1921

Compared with nonintubated NPPV patients, patients who failed NPPV were more hypoxemic, as shown by the significant lower PaO2/FIO2 ratio (194 ± 76 mm Hg vs 123 ± 62 mm Hg, p < 0.01) [Fig 1]. Moreover, improvements in gas exchange and respiratory rate within the first hours of NPPV were observed only in the success group (Table 2). The improvement in oxygenation and the reduction in respiratory rate (Table 2) for patients of the nonintubated group are in accordance with the results of the above cited studies and are classical effects of NPPV in ARF.914 The absence of hemodynamic repercussions of NPPV observed in our study is also a common finding in studies on NPPV in ARF not resulting from acute cardiogenic pulmonary edema (Table 2).

Our success rate of 67% was consistent with rates reported in controlled or uncontrolled clinical trials,12394041 which ranged from 60 to 80% in hypoxemic ARF. It should be noted, however, that NPPV is considered to be contraindicated after esophageal surgery, and many surgeons have concerns about its application after gastric or small intestinal surgery that has disrupted bowel wall integrity. Van de Louw et al42 reported the first case of esophageal perforation associated with NPPV (pressure support level of 15 cm H2O and PEEP of 5 cm H2O) after a surgical procedure (extensive nephrectomy).

In our present study, 10 patients who underwent esophagus and/or gastric surgery were included. No complication were present. The patients received ventilation with pressure support of 11.0 ± 1.4 cm H2O and PEEP of 8.6 ± 2.0 cm H2O. In our practice, we preferentially use a moderate-to-high PEEP (8 to 12 cm H2O) with low-to-moderate pressure support (< 12 cm H2O). Esophageal and gastric surgery are usually considered contraindications to NPPV use. The current study showed that NPPV can be used without adverse effect in patients after esophageal surgery when the insufflation pressure level is < 12 cm H2O. In the study of Joris et al,23 NPPV was applied at an inspiratory pressure of 12 cm H2O and PEEP of 4 cm H2O during the first postoperative 24 h of gastroplasty, and no severe complications such as aspiration or gastric distension were observed. Gastric distension was successfully avoided by the placement of nasogastric tubes prior to the institution of NPPV and by regular decompression of the stomach. Moreover, higher ventilatory pressures were avoided, as they are associated with increased risk of gastric distension, leaks around the face mask, and desynchronization between the patient’s spontaneous breathing and the ventilator, which reduce the tolerance of NPPV.43

In our present study, the majority of the patients who failed NPPV were intubated early after the onset of ARF (Fig 2 ), suggesting that the higher mortality observed in the intubated group is probably not related to delayed intubation. The trial of Wood et al44 is one of the first studies to point out that the use of NPPV may not always be successful because experience may differ from one institution to another. It has been shown that administration of NPPV by an inexperienced health-care team has been associated with a poor prognosis.917 Since 1997, we introduced NPPV use in our medical-surgical ICU as a first-line therapy in patients with various patterns of ARF such as postoperative and acute pancreatitis patients. Motivation of the staff and education of the personnel are essential for the success of the technique, especially when using NPPV in new indications.



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  		Figure 2. Individual distribution of the delay of intubation after the start of NPPV for the 24 patients of the intubated group.

 
There are limitations inherent to the design of this study. The decision to initiate NPPV was not controlled or randomized but relied on the clinical judgment of the attending physicians. We did not observe patients after hospital discharge, and thus we are unaware of post-hospital discharge mortality. This was an observational report of our daily clinical experience without control subjects, and as such we are unable to conclude that patient outcomes were changed by the application of NPPV.


   Conclusion
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
 Conclusion
References
 
NPPV should be considered as an interesting alternative to conventional ventilation in selected patients after abdominal surgery with ARF who require ventilatory support. The results of our descriptive study can be the basis for a larger, prospective, randomized study comparing NPPV with conventional medical treatment.


   Acknowledgements
 
The authors wish to thank the physiotherapists of the unit for their invaluable help, as well as the nurses and the rest of the personnel of the ICUs for their active participation.


   Footnotes
 
Abbreviations: ARF = acute respiratory failure; ASA = American Society of Anesthesiologists; BMI = body mass index; CPAP = continuous positive airway pressure; FIO2 = fraction of inspired oxygen; MV = mechanical ventilation; NPPV = noninvasive positive pressure ventilation; NS = not significant; PEEP = positive end-expiratory pressure; PSV = pressure support ventilation; SAPS = simplified acute physiology score

Received for publication November 14, 2004. Accepted for publication April 18, 2005.


   References
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 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
 Conclusion
 References
 

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