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J Thorac Cardiovasc Surg 2009;137:342-346
© 2009 The American Association for Thoracic Surgery

Acquired Cardiovascular Disease

Noninvasive positive-pressure ventilation for extubation failure after cardiac surgery: Pilot safety evaluation

^a University of Foggia School of Medicine, Foggia, Italy
^b Department of Cardiothoracic and Respiratory Sciences, Second University of Naples, V. Monaldi Hospital, Naples, Italy
^c Department of Cardiovascular Surgery and Transplantation, V. Monaldi Hospital, Naples, Italy

Received for publication October 24, 2007; revisions received February 4, 2008; accepted for publication July 5, 2008.

^_* Address for reprints: Luca S. De Santo, MD, Department of Cardiothoracic and Respiratory Sciences, Second University of Naples, V. Monaldi Hospital, Via L. Bianchi, 80131 Naples, Italy. (Email: lucas.desanto{at}ospedalemonaldi.it).

Objective: Extubation failure is a serious complication after cardiac surgery. The role of noninvasive positive-pressure ventilation for acute respiratory failure in patients undergoing cardiac surgery is unknown. This study aimed to assess the safety of implementing noninvasive positive-pressure ventilation in this setting and its impact on lung function and operative outcomes.

Methods: In a 6-month pilot prospective survey, the study population comprised 43 patients (32were male with a mean age of 65.73 ± 9 years; 3 heart transplantations, 18 coronary artery bypass grafts, 5 aortic dissections, and 17 valvular procedures; 34 active smokers, 25 with medically treated chronic obstructive pulmonary disease, 21 emergency/urgency procedures) who required noninvasive positive-pressure ventilation for acute respiratory failure after initial weaning from a respirator. The cause of acute respiratory failure (classified as post-cardiopulmonary bypass lung injury in 48.8% [21 patients], cardiogenic edema in 30.2% [13 patients], and pneumonia in 21% [9 patients]), length of noninvasive positive-pressure ventilation support, respiratory ratios (arterial oxygen tension/fraction of inspired oxygen assessed immediately before noninvasive positive-pressure ventilation, and every 6 hours after institution of pressure ventilation), and need for reintubation along with a set of predefined safety parameters were recorded.

Results: The mean length of noninvasive positive-pressure ventilation support was 33.8 ± 24.04 hours. Plotting respiratory ratios with length of noninvasive positive-pressure ventilation supports a significant improvement was already evident within the first 6-hour frame (133.6 ± 39.5 vs 205 ± 65.7; P < .001) for all causes. Noninvasive positive-pressure ventilation prevented intubation in 74.4% of the patients, with satisfactory recovery for post-cardiopulmonary bypass lung injury and cardiogenic dysfunction (90.5% and 69.2%, respectively) and poor results (55% reintubated) in those treated for pneumonia. Noninvasive positive-pressure ventilation safety approached 97.7%.

Conclusion: In appropriate candidates, noninvasive positive-pressure ventilation exerts favorable effects on lung function, preventing reintubation. The cost-effectiveness of its systematic use in this setting should be assessed.