Prospective evaluation of noninvasive positive pressure ventilation (NPPV) in acute hypoxemic respiratory failure (AHRF) following lung resection

The mortality associated with AHRF after lung resection may reach 50% mainly in relationship with complication of endotracheal intubation and mechanical ventilation. We compared NPPV and conventional therapy in avoiding endotracheal intubation in patients with AHRF after lung resection.

Methods

On 2280 patients who had undergone thoracic surgery between May 1999 and July 2000, those who had pulmonary resection and experienced AHRF were prospectively recruited. Patients were enrolled if they met at least three of the following criteria: dyspnea at rest defined by a respiratory rate of 25 breaths/min or more, active contraction of the accessory respiratory muscles or abdominal paradox, a ratio PaO₂/FiO₂ < 200 and radiologic lesions on the chest radiograph. They were randomly assigned to receive either conventional therapy or conventional therapy and noninvasive positive pressure ventilation (NPPV) through a nasal mask. NPPV was provided with the BiPAP^® Vision Ventilator System (Respironics Inc., Murrysville, PA, USA). The primary end point of the study was 'need for endotracheal intubation'. Secondary endpoints included: in-hospital mortality, the length of stay in the ICU, length of stay in the hospital, and the need for fiberoptic bronchoscopy. An interim analysis was designed at the middle of the study.

Results

Over this 16 month period, 912 patients were admitted to the Intensive Care Unit. Forty-eight patients were enrolled.

Conclusion

Because endotracheal intubation is the most important predisposing factor for ventilator associated pneumonia, bronchial stump disruption and bronchopleural fistula, postoperative re-intubation must be avoided. This is the first prospective, randomized study which demonstrates an improvement in survival and in avoiding endotracheal intubation in the postoperative care of patients undergoing lung resection surgery.

Table 1