Abstract
BackgroundPostoperative respiratory failure is associated with increased perioperative complications. Our aim is to compare outcomes between non-invasive ventilation (NIV), high-flow nasal cannula (HFNC), and standard oxygen in patients at high-risk for or with established postoperative respiratory failure.MethodsElectronic databases including PubMed, Embase, and the Cochrane Library were reviewed from inception to September 2019. We included only randomized controlled trials (RCTs) that compared NIV, HFNC, and standard oxygen in patients at high risk for or with established postoperative respiratory failure. We performed a Bayesian network meta-analysis to calculate the odds ratio (OR) and Bayesian 95% credible intervals (CrIs).ResultsNine RCTs representing 1865 patients were included (the mean age was 61.6 ± 10.2 and 64.4% were males). In comparison with standard oxygen, NIV was associated with a significant reduction in intubation rate (OR 0.23; 95% Cr.I. 0.10–0.46), mortality (OR 0.45; 95% Cr.I. 0.27–0.71), and intensive care unit (ICU)-acquired infections (OR 0.43, 95% Cr.I. 0.25–0.70). Compared to standard oxygen, HFNC was associated with a significant reduction in intubation rate (OR 0.28, 95% Cr.I. 0.08–0.76) and ICU-acquired infections (OR 0.41; 95% Cr.I. 0.20–0.80), but not mortality (OR 0.58; 95% Cr.I. 0.26–1.22). There were no significant differences between HFNC and NIV regarding different outcomes. In a subgroup analysis, we observed a mortality benefit with NIV over standard oxygen in patients undergoing cardiothoracic surgeries but not in abdominal surgeries. Furthermore, in comparison with standard oxygen, NIV and HFNC were associated with lower intubation rates following cardiothoracic surgeries while only NIV reduced the intubation rates following abdominal surgeries.ConclusionsAmong patients with post-operative respiratory failure, HFNC and NIV were associated with significantly reduced rates of intubation and ICU-acquired infections compared with standard oxygen. Moreover, NIV was associated with reduced mortality in comparison with standard oxygen.
Highlights
Postoperative respiratory failure is associated with increased perioperative complications such as reintubation, invasive mechanical ventilation, and healthcareassociated infections, which can lead to increases in mortality, intensive care unit (ICU) and hospital length of stay, delays in hospital discharges, and higher healthcare resource utilization [1,2,3,4].Several post-operative pulmonary complications may result in post-operative hypoxemic respiratory failure, including pneumonia, atelectasis, bronchospasm, pneumothorax, and pleural effusion
Non-invasive ventilation (NIV) was the most commonly used treatment (41.2% of patients), high-flow nasal cannula (HFNC) was used in 31.6% of cases, and 27.2% of patients were treated with standard oxygen therapy
In an exploratory meta-regression analysis, we found that higher PaCO2 was associated with lower risk for intubation when NIV was compared to standard oxygen therapy (P < 0.05) (Supplementary Figure 3)
Summary
Several post-operative pulmonary complications may result in post-operative hypoxemic respiratory failure, including pneumonia, atelectasis, bronchospasm, pneumothorax, and pleural effusion. The incidence of these complications is variable and ranges between 5 and 40% according to the type of surgery, as well as other risk factors including anesthetic technique, duration of surgery, and severity of illness [5,6,7,8,9]. Our aim is to compare outcomes between non-invasive ventilation (NIV), high-flow nasal cannula (HFNC), and standard oxygen in patients at high-risk for or with established postoperative respiratory failure
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