Abstract
Objective: Our study aimed to evaluate if an extubation protocol for all post-operative cardiac patients in the cardiothoracic intensive care unit using intermittent bilevel positive airway pressure (BiPAP) could reduce the rate of re-intubation.Methods: A total of 1,718 patients undergoing cardiac surgery from May 2012 to April 2016 were analyzed. Patients from May 2014 to April 2016 were included in a post-extubation BiPAP therapy protocol that included one hour of BiPAP followed by three hours of a nasal cannula for 24 hours after extubation in the cardiothoracic intensive care unit. The protocol cohort was retrospectively compared to a control group (nasal cannula only) from May 2012 to April 2014. All demographic and outcome data were analyzed from our institution’s Society of Thoracic Surgeons (STS) Cardiac Database.Results: There was no statistical difference in the rate of re-intubation between the BiPAP group (n = 35; 4.07%) and the control group (n = 34; 3.96%; p = 0.9022). Sub-group analysis of the 69 re-intubated patients identified several significant risk factors: prior valve surgery (p = 0.028), chronic lung disease (p = 0.0343), emergent operation (p = 0.0016), longer operating room time (p = 0.0109), cardiopulmonary bypass time (p = 0.0086), higher STS predicted risk of mortality score (p = 0.0015). Re-intubation was associated with higher 30-day mortality rates (p = 0.0026), prolonged cardiothoracic intensive care unit length of stay (p < 0.0001), and hospital length of stay (p < 0.0001).Conclusion: While a BiPAP protocol did not show a significant difference in re-intubation rates after cardiac surgery, the subgroup analysis of re-intubated patients showed several significant risk factors for re-intubation. Early identification of these risk factors when considering extubation may help teams avoid associated morbidity and mortality outcomes.
Highlights
Acute respiratory failure and pulmonary dysfunction is a significant cause of morbidity and mortality following cardiac surgery [1,2]
While a Bilevel positive airway pressure (BiPAP) protocol did not show a significant difference in re-intubation rates after cardiac surgery, the subgroup analysis of re-intubated patients showed several significant risk factors for reintubation
Pulmonary function tests were performed on 95.93% of the patients in the BiPAP group, compared to 94.88% in the control group (p = 0.2999)
Summary
Acute respiratory failure and pulmonary dysfunction is a significant cause of morbidity and mortality following cardiac surgery [1,2]. This pulmonary dysfunction stems from impairment of gas exchange and lung mechanics secondary to multiple factors including use of cardiopulmonary bypass, activation of the inflammatory cascade, atelectasis, decreased thoracic compliance, pleural effusions, postoperative pain, and diaphragmatic dysfunction. Many studies have looked at different methods of NPPV, including BiPAP to prevent and treat respiratory failure following cardiac surgery [7,8,9]. There is not much evidence on the use of BiPAP in preventing re-intubation following cardiac surgery [8,11]
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