Screening and Perioperative Management of Obesity Hypoventilation Syndrome.

Obesity hypoventilation syndrome (OHS) can often be underdiagnosed or misdiagnosed and has been shown to pose significant risks in perioperative situations. Patients with OHS have a higher prevalence of baseline morbid conditions like hypertension, congestive heart failure (CHF), diabetes mellitus, atrial fibrillation, and pulmonary hypertension (PH), which contribute to adverse postoperative outcomes. The potential challenges include difficult intubation and loss of airway, postoperative respiratory failure, worsening heart failure, pulmonary hypertensive crisis, and opioid-induced respiratory depression (OIRD). It is, therefore, important to screen all obese patients for obstructive sleep apnea (OSA) and OHS before elective surgical procedures. The aim of this review is to discuss the preoperative screening and evaluation and safe anesthetic and up-to-date ventilatory management of this complex group of patients. This review also intends to increase the awareness of OHS in the adult population among hospitalists, surgeons, and cardiologists who may find themselves taking care of these patients in complex multidisciplinary settings.

Evaluation and Management of Perioperative Pulmonary Complications.

Pulmonary complications are very common after noncardiac surgery and can be easily overlooked. If not properly screened for or evaluated these can in many instances lead to postoperative respiratory failure or even death. Decisions regarding ambulatory versus inpatient surgery, modality of anesthesia, protective ventilation and method of weaning, type of analgesia, and postoperative monitoring can be crucial to avoid such complications.

Pulmonary function testing in preoperative high-risk patients.

BACKGROUND: Postoperative respiratory failure is the most frequent complication in postsurgical patients. The purpose of this study is to assess whether pulmonary function testing in high-risk patients during preoperative assessment detects previously unknown respiratory impairments which may influence patient outcomes. METHODS: A targeted patient screening by spirometry and the measurement of the diffusing capacity of the lung for carbon monoxide (DLCO) was implemented in the anesthesia department of a tertiary university hospital. Patients of all surgical disciplines who were at least 75 years old or exhibited reduced exercise tolerance with the metabolic equivalent of task less than four (MET < 4) were examined. Clinical characteristics, history of lung diseases, and smoking status were also recorded. The statistical analysis entailed t-tests, one-way ANOVA, and multiple linear regression with backward elimination for group comparisons. RESULTS: Among 256 included patients, 230 fulfilled the test quality criteria. Eighty-one (35.2%) patients presented obstructive ventilatory disorders, out of which 65 were previously unknown. 38 of the newly diagnosed obstructive disorders were mild, 18 moderate, and 9 severe. One hundred forty-five DLCO measurements revealed 40 (27.6%) previously unknown gas exchange impairments; 21 were mild, 17 moderate, and 2 severe. The pulmonary function parameters of forced vital capacity (FVC), forced expiratory volume in 1 s (FEV1), and DLCO were significantly lower than the international reference values of a healthy population. Patients with a lower ASA class and no history of smoking exhibited higher FVC, FEV1, and DLCO values. Reduced exercise tolerance with MET < 4 was strongly associated with lower spirometry values. CONCLUSIONS: Our screening program detected a relevant number of patients with previously unknown obstructive ventilatory disorders and impaired pulmonary gas exchange. This newly discovered sickness is associated with low metabolic equivalents and may influence perioperative outcomes. Whether optimized management of patients with previously unknown impaired lung function leads to a better outcome should be evaluated in multicenter studies. TRIAL REGISTRATION: German Registry of Clinical Studies (DRKS00029337), registered on: June 22nd, 2022.

Pre- and intra-operative risk factors predict postoperative respiratory failure after minimally invasive oesophagectomy.

OBJECTIVES: Severe pulmonary complications such as postoperative respiratory failure can occur after minimally invasive oesophagectomy. However, the risk factors have not been well identified. The goal of this study was to develop a predictive model for the occurrence of postoperative respiratory failure with a large sample. METHODS: We collected data from patients with oesophageal cancer who had a minimally invasive oesophagectomy at Shanghai Chest Hospital from 2019 to 2022. Univariable and backward stepwise logistic regression analysis of 19 pre- and intra-operative factors was used before model fitting, and its performance was evaluated with the receiver operating characteristic curve. Internal validation was assessed with a calibration plot, decision curve analysis and area under the curve with 95% confidence intervals, obtained from 1000 resamples set by the bootstrap method. RESULTS: This study enrolled 2,386 patients, 57 (2.4%) of whom developed postoperative respiratory failure. Backward stepwise logistic regression analysis revealed that age, body mass index, cardiovascular disease, diabetes, diffusion capacity of the lungs for carbon monoxide, tumour location and duration of chest surgery ≥101.5 min were predictive factors. A predictive model was constructed and showed acceptable performance (area under the curve: 0.755). The internal validation with the bootstrap method proves the good agreement for prediction and reality. CONCLUSIONS: Obesity, severe diffusion dysfunction and upper segment oesophageal cancer were strong predictive factors. The established predictive model has acceptable predictive validity for postoperative respiratory failure after minimally invasive oesophagectomy, which may improve the identification of high-risk patients and enable health-care professionals to perform risk assessment for postoperative respiratory failure at the initial consultation.

Development of an automated, general-purpose prediction tool for postoperative respiratory failure using machine learning: A retrospective cohort study.

STUDY OBJECTIVE: Postoperative respiratory failure is a major surgical complication and key quality metric. Existing prediction tools underperform, are limited to specific populations, and necessitate manual calculation. This limits their implementation. We aimed to create an improved, machine learning powered prediction tool with ideal characteristics for automated calculation. DESIGN, SETTING, AND PATIENTS: We retrospectively reviewed 101,455 anesthetic procedures from 1/2018 to 6/2021. The primary outcome was the Standardized Endpoints in Perioperative Medicine consensus definition for postoperative respiratory failure. Secondary outcomes were respiratory quality metrics from the National Surgery Quality Improvement Sample, Society of Thoracic Surgeons, and CMS. We abstracted from the electronic health record 26 procedural and physiologic variables previously identified as respiratory failure risk factors. We randomly split the cohort and used the Random Forest method to predict the composite outcome in the training cohort. We coined this the RESPIRE model and measured its accuracy in the validation cohort using area under the receiver operating curve (AUROC) analysis, among other measures, and compared this with ARISCAT and SPORC-1, two leading prediction tools. We compared performance in a validation cohort using score cut-offs determined in a separate test cohort. MAIN RESULTS: The RESPIRE model exhibited superior accuracy with an AUROC of 0.93 (95% CI, 0.92-0.95) compared to 0.82 for both ARISCAT and SPORC-1 (P-for-difference < 0.0001 for both). At comparable 80-90% sensitivities, RESPIRE had higher positive predictive value (11%, 95% CI: 10-12%) and lower false positive rate (12%, 95% CI: 12-13%) compared to 4% and 37% for both ARISCAT and SPORC-1. The RESPIRE model also better predicted the established quality metrics for postoperative respiratory failure. CONCLUSIONS: We developed a general-purpose, machine learning powered prediction tool with superior performance for research and quality-based definitions of postoperative respiratory failure.

Intensity of one-lung ventilation and postoperative respiratory failure: A hospital registry study.

BACKGROUND: Studies linked a high intensity of mechanical ventilation, measured as high mechanical power (MP) to postoperative respiratory failure (PRF) in the setting of two-lung ventilation. We investigated whether a higher MP during one-lung ventilation (OLV) is associated with PRF. METHODS: In this registry-based study, adult patients who underwent general anesthesia with OLV for thoracic surgeries between 2006 and 2020 at a New England tertiary healthcare network were included. The association between MP during OLV and PRF (emergency non-invasive ventilation or reintubation within seven days) was assessed in a cohort weighted through a generalized propensity score conditional on a priori defined preoperative and intraoperative factors. Dominance of components of MP and intensity of OLV versus two-lung ventilation in predicting PRF was investigated. RESULTS: Out of 878 included patients, 106 (12.1%) developed PRF. The median (IQR) MP during OLV was 9.8 J/min (7.5-11.8) and 8.3 J/min (6.6-10.2) in patients with and without PRF respectively. A higher MP during OLV was associated with PRF (ORadj 1.22 per 1 J/min increase; 95%CI 1.13-1.31; p < 0.001) and characterized by a U-shaped dose-response curve, with the lowest probability of PRF (7.5%) at 6.4 J/min. Dominance analysis of PRF predictors showed a stronger contribution of driving pressure over respiratory rate and tidal volume, the dynamic over the static component of MP, and MP during OLV over two-lung ventilation (contribution to Pseudo-R2: 0.017, 0.021, and 0.036, respectively). CONCLUSION: A higher intensity of OLV, mainly driven by driving pressure, is dose-dependently associated with PRF and might constitute a target for mechanical ventilation.

Postoperative Respiratory Failure and Advanced Ventilator Settings.

Postoperative respiratory failure has a multifactorial etiology, of which atelectasis is the most common mechanism. Its injurious effects are magnified by surgical inflammation, high driving pressures, and postoperative pain. Chest physiotherapy and noninvasive ventilation are good options to prevent progression of respiratory failure. Acute respiratory disease syndrome is a late and severe finding, which is associated with high morbidity and mortality. If present, proning is a safe, effective, and underutilized therapy. Extracorporeal membrane oxygenation is an option only when traditional supportive measures have failed.

Predictive factors for respiratory failure and in-hospital mortality after surgery for spinal metastasis.

PURPOSE: Spinal metastasis surgeries carry substantial risk of complications. PRF is among complications that significantly increase mortality rate and length of hospital stay. The risk factor of PRF after spinal metastasis surgery has not been investigated. This study aims to identify the predictors of postoperative respiratory failure (PRF) and in-hospital death after spinal metastasis surgery. METHODS: We retrospectively reviewed consecutive patients with spinal metastasis surgically treated between 2008 and 2018. PRF was defined as mechanical ventilator dependence > 48 h postoperatively (MVD) or unplanned postoperative intubation (UPI). Collected data include demographics, laboratory data, radiographic and operative data, and postoperative complications. Stepwise logistic regression analysis was used to determine predictors independently associated with PRFs and in-hospital death. RESULTS: This study included 236 patients (average age 57 ± 14 years, 126 males). MVD and UPI occurred in 13 (5.5%) patients and 13 (5.5%) patients, respectively. During admission, 14 (5.9%) patients had died postoperatively. Multivariate logistic regression analysis revealed significant predictors of MVD included intraoperative blood loss > 2000 mL (odds ratio [OR] 12.28, 95% confidence interval [CI] 2.88-52.36), surgery involving cervical spine (OR 9.58, 95% CI 1.94-47.25), and ASA classification ≥ 4 (OR 6.59, 95% CI 1.85-23.42). The predictive factors of UPI included postoperative sepsis (OR 20.48, 95% CI 3.47-120.86), central nervous system (CNS) metastasis (OR 10.21, 95% CI 1.42-73.18), lung metastasis (OR 7.18, 95% CI 1.09-47.4), and postoperative pulmonary complications (OR 6.85, 95% CI 1.44-32.52). The predictive factors of in-hospital death included postoperative sepsis (OR 13.15, 95% CI 2.92-59.26), CNS metastasis (OR 10.55, 95% CI 1.54-72.05), and postoperative pulmonary complications (OR 9.87, 95% CI 2.35-41.45). CONCLUSION: PRFs and in-hospital death are not uncommon after spinal metastasis surgery. Predictive factors for PRFs included preoperative comorbidities, intraoperative massive blood loss, and postoperative complications. Identification of risk factors may help guide therapeutic decision-making and patient counseling.

Risks of postoperative respiratory failure in elderly patients after hip surgery: a retrospective study.

BACKGROUND: The purpose of this retrospective study was to investigate the determinants of postoperative respiratory failure in elderly patients with hip fracture. METHODS: The subjects of this study were 663 elderly patients who had hip fracture and had been treated with total hip arthroplasty at our hospital from January 2014 to May 2020. According to the occurrence of postoperative respiratory failure, 626 patients with no respiratory failure were retrospectively included in the control group, and 37 cases combined with respiratory failure were enrolled in the PRF group. The clinical and surgical data of the two groups were collected and analyzed to evaluate the determinants of respiratory failure by logistic regression analysis. RESULTS: There were no significant differences in the demographics and baseline variables including age, gender, fracture type and location between the groups (P > 0.05). All patients received hip surgery including total hip arthroplasty (THA), hemiarthroplasty (HA) and internal fixation with PFNA (proximal femoral nail anti-rotation). There were no significant differences in operative time and intraoperative blood loss between the groups (P > 0.05). However, close associations were found between pulmonary hypertension (univariate analysis: OR = 3.792, 95% CI = 1.421-10.203; multivariate analysis: OR = 1.132, 95% CI = 1.003-1.251), obstructive pulmonary disease (OR = 1.119, 95% CI = 1.009-1.238; multivariate analysis: OR = 13.298, 95% CI = 4.021-43.298), bronchiectasis and emphysema (OR = 4.949, 95% CI = 1.919-9.873; multivariate analysis: OR = 11.231, 95% CI = 187.87), and history of respiratory failure (OR = 6.098, 95% CI = 2.012-12.198; multivariate analysis: OR = 8.389, 95% CI = 2.391-21.982) with postoperative respiratory failure (P < 0.05). CONCLUSION: Pulmonary hypertension, abnormal lung texture, obstructive pulmonary disease, bronchiectasis, emphysema, history of respiratory failure, and hypoproteinemia may be risk factors for postoperative respiratory failure in elderly patients with hip fracture.

Postoperative Respiratory Failure After Elective Abdominal Surgery: A Case-Control Study.

INTRODUCTION: Postoperative respiratory failure (PRF) contributes significantly to morbidity and mortality. We sought to identify patient characteristics and perioperative risk factors associated with PRF in patients undergoing elective abdominal surgery to improve patient outcomes. METHODS: We retrospectively reviewed patients undergoing elective abdominal surgery from 2011 to 2016 at our institution. An experimental group consisting of adult patients with the Patient Safety Indicator 11 diagnosis of PRF was compared with a time-matched control group. RESULTS: Each group consisted of 233 patients. Comorbidities associated with PRF included ascites, coronary artery disease, chronic kidney disease, chronic obstructive pulmonary disease, diabetes mellitus type II, hypertension, and hypoalbuminemia (P < 0.05). American Society of Anesthesiologists score IV (20.2% versus 3.95%; P < 0.001), operative time (4.13 versus 2.55 h; P < 0.001), laparotomy with open operation (77.7% versus 45.5%; P < 0.001), and net intraoperative fluid balance (3635 versus 2410 mL; P < 0.001) were higher in patients with PRF. On multivariate analysis, age, American Society of Anesthesiologists score, chronic obstructive pulmonary disease, diabetes mellitus type II, laparotomy, and net intraoperative fluid balance maintained significance (P < 0.05). CONCLUSIONS: We identified contributing pre- and intra-operative risk factors for PRF undergoing elective abdominal surgery. These findings may help identify those at increased risk for respiratory failure and mitigate complications.

[Effectiveness and safety evaluation of a cough stimulation device in early postoperative respiratory rehabilitation in cardiac surgery patients]. / Otsenka effektivnosti i bezopasnosti apparatnoi stimulyatsii kashlya pri rannei posleoperatsionnoi respiratornoi reabilitatsii u kardiokhirurgicheskikh patsientov.

Postoperative respiratory complications in cardiac surgery patients occur in 22-30% of cases, mostly associated with ineffective cough and evacuation of bronchial secretion. OBJECTIVE: To evaluate the effectiveness and safety of cough stimulation using the mechanical in- and exsufflator in the early postoperative period in cardiac surgery patients. MATERIAL AND METHODS: The study included 37 patients; mean age was 57±12.3 years. Inclusion criteria: age over 18 years; post-extubation spontaneous breathing; fully conscious and cooperative; adequate gas exchange with oxygen therapy; adequate pain control (2 points or less on 10-point visual analogue scale). Exclusion criteria: need for re-intubation and mechanical ventilation; noninvasive mask ventilation; high-flow oxygen therapy; acute cerebrovascular event; uncontrolled bleeding; heart failure (inotropic score over 10); shock; need of extracorporeal blood purification; neuromuscular disease; pneumothorax, hydro- or hemothorax. Cough stimulation was performed using the mechanical in- and exsufflator Comfort Cough Plus («Seoil Pacific Corporation¼, Republic of Korea). The device provides cough stimulation after high-frequency vibrations transmitted through a special vest and lung tissue recruiting by changing the airways pressure of the gas mixture, delivered through the anesthesia face mask. RESULTS: Cough stimulation device use was associated with an increase in the cough effectiveness; the number of patients with productive cough increased 8-fold, from 4 (10.8%) to 32 (86.4%), p=0.0000. The increase of blood oxygen saturation (SpO2) on room air from 92% to 96% (p=0.000001) and inspiratory capacity (IC) from 750 mL to 1200 mL (p=0.000002) was observed. The number of patients with IC of 1200-1500 mL increased 3-fold, and those with an IC over 1500 mL increased 2.6-fold. The proportion of patients with low oxygenation (SpO2 less than 92%) decreased 5-fold after the procedure (p=0.0011). Good tolerability and no side effects of the procedure were noted in all patients. CONCLUSION: Impaired sputum expectoration early after cardiac surgery is observed in most patients and may cause low oxygenation. The main effects of the cough stimulation device were improvement of sputum expectoration and an increase in oxygenation. An increase in blood oxygen saturation and inspiratory capacity after a single procedure with this device was demonstrated. It resulted in a significantly decreased proportion of patients with respiratory insufficiency. No adverse effects of the procedure were observed.

Novel application of respiratory muscle index obtained from chest computed tomography to predict postoperative respiratory failure after major non-cardiothoracic surgery.

BACKGROUND: Postoperative respiratory failure (PRF) is a serious complication associated with significant morbidity and mortality. We propose a new method to predict PRF by utilizing computed tomography (CT) of the chest to assess degree of respiratory muscle wasting prior to surgery. METHODS: Patients who received a chest CT and required invasive mechanical ventilation (MV) after major non-cardiothoracic surgery were included. Exclusion criteria included cardiothoracic surgery. Respiratory muscle index (RMI) was calculated at the T6 vertebra measured on Slice-O-Matic® software. RESULTS: Thirty three patients met inclusion with a mean (±SD) age, BMI, and APACHE II score of 62.2 years (±12.1), 28.1 kg/m2 (±7.8), and 14.1 (±4.7). Most patients were female (n = 22 [67%]). Eleven patients (33%) developed PRF with a mean of 6.0 (±10.7) initial ventilation days. There was no difference in baseline demographics between groups. RMI values for the PRF group were significantly lower when compared to the non-PRF group: 22.7 cm2/m2 (±5.3) vs. 28.5 cm2/m2 (±5.9) (p = 0.008). CONCLUSION: Presence of respiratory muscle wasting prior to surgery was found to be associated with postoperative respiratory failure.

Prolonged Postoperative Mechanical Ventilation (PPMV) in children undergoing abdominal operations: An analysis of the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database.

BACKGROUND: Prolonged postoperative mechanical ventilation (PPMV) increases length of stay, hospitalization costs, and postoperative complications. Independent risk factors associated with PPMV are not well-known for children. METHOD: We identified children (<18 years) in the ACS NSQIP-P database who underwent a general surgical abdominal operation. We excluded children with preoperative ventilator dependence and mortality within 48 h of surgery. PPMV was defined as cumulative postoperative mechanical ventilation exceeding 72 h. A multivariable logistic regression model identified independent predictors of PPMV. RESULTS: We identified 108,392 children who underwent a general surgical abdominal operation in the ACS NSQIP-P database from 2012 to 2017. We randomly divided the population into a derivation cohort of 75,874(70%) and a validation cohort of 32,518(30%). In the derivation cohort, we identified PPMV in 1,643(2.2%). In the multivariable model, the strongest independent predictor of PPMV was neonatal age (OR:20.66; 95%CI:16.44-25.97). Other independent risk factors for PPMV were preoperative inotropic support (OR:10.56; 95%CI:7.56-14.77), an operative time longer than 150 min (OR:4.30; 95%CI:3.72-4.52), and an American Society of Anesthesiologists classification >3 (OR:12.16; 95%CI:10.75-13.75). CONCLUSION: Independent preoperative risk factors for PPMV in children undergoing a general surgical operation were neonatal age, preoperative ionotropic support, duration of operation, and ASA classification >3.

Perioperative diaphragm point-of-care ultrasound as a prediction tool of postoperative respiratory failure in high-risk patients: A feasibility study and case series. / Ecografía diafragmática perioperatoria en el punto de atención como herramienta de predicción de fallo respiratorio postoperatorio en pacientes de alto riesgo: estudio de viabilidad y serie de casos.

INTRODUCTION: Respiratory muscle function in the postoperative period is a key to whether a patient develops Postoperative Respiratory Failure (PRF) or not. PRF occurs when the gas exchange does not meet metabolic needs. Ipsilateral paralysis of the hemidiaphragm after interscalenic brachial plexus block (ISB) causes an acute reduction of respiratory muscle function. This reduction does not cause PRF when the contralateral hemidiaphragm generates enough gas exchange to meet metabolic demands. OBJECTIVES: To study the evolution of hemidiaphragmatic muscle function during the perioperative period with diaphragmatic ultrasound (D-POCUS), and use it as an innovative tool to predict PRF, assessing the contralateral hemidiaphragm in the event of acute hemidiaphragm paralysis. METHODS: Patients considered high risk, scheduled for shoulder surgery with ISB are studied. Both hemidiaphragms were evaluated by ultrasound, before and after the procedure, measuring Thickening Fraction (TF) and Diaphragmatic Excursion (DE). PACU patients with PRF were registered. RESULTS: There was a significant reduction in the TF and DE of the ipsilateral hemidiaphragm in the six patients studied. Only 1/6 patients showed signs of PRF. The evaluation of the contralateral hemidiaphragm during the postoperative period showed that in the five patients without signs of PRF, there were no significant changes in the function of the contralateral hemidiaphragm. The patient, who showed a reduction in contralateral hemidiaphragm function, was the only one who suffered PRF. CONCLUSIONS: In this case series, D-POCUS allows to know the perioperative function of the diaphragm in high-risk patients. All patients suffered an acute reduction of hemidiaphragm function after ISB; however, these patients did not develop PRF when the contralateral hemidiaphragm function was preserved.

Anesthetic management of a 12-year-old child with Kagami-Ogata syndrome for pectus excavatum: a case report.

BACKGROUND: Kagami-Ogata syndrome (KOS) is due to abnormal gene expression in the 14q32.2 imprinted region. Laryngomalacia and bell-shaped thorax of children with KOS can affect airway management of general anesthesia. CASE PRESENTATION: A 12-year-old girl with KOS had a mechanical ventilation history and underwent pectus excavatum repair for cosmetic reasons. Although she had undergone invasive thoracic surgery under general and epidural anesthesia, her respiratory rate and tidal volume were stable with adequate pain control mainly through epidural analgesia at the end of the surgery. We examined her larynx by a bronchoscope. Then, we successfully extubated her after confirming the normal movement of her larynx. CONCLUSIONS: When patients with KOS undergo pectus excavatum repair, anesthesiologists should prevent postoperative respiratory failure by providing adequate postoperative analgesia. Evaluation of airway patency and respiratory pattern before extubation is critical.

Effect of oxygenation modalities among patients with postoperative respiratory failure: a pairwise and network meta-analysis of randomized controlled trials.

BACKGROUND: Postoperative 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. METHODS: Electronic 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). RESULTS: Nine 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. CONCLUSIONS: Among 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.

Bilevel positive airway pressure therapy in a patient with myotonic dystrophy and postoperative respiratory failure: A case report.

Respiratory failure is a common complication in patients with myotonic dystrophy (MD) and might be a presenting symptom in the perioperative setting. We report the case of a 59-year-old woman with MD who underwent open cholecystectomy and developed postoperative respiratory failure. Without reintubation, the patient was successfully managed with bilevel positive airway pressure (BiPAP) and was discharged uneventfully. BiPAP may be considered as an alternative for postoperative respiratory failure in patients with MD. Careful observation of patients' postoperative condition and an earlier application of BiPAP are instrumental in avoiding retracheal intubation, which may cause further serious problems in patients with MD.

Predictors and outcomes of postoperative respiratory failure after cardiac surgery.

BACKGROUND: Postoperative respiratory failure after cardiac surgery (CS-PRF) is a devastating complication and its incidence and predictors vary depending on how it is defined and the patient population. AIMS: This study was conducted to determine the incidence, predictors and outcomes of CS-PRF defined as prolonged mechanical ventilation >48 hours and reintubation. METHODS: This is a retrospective chart review of 1257 patients who underwent cardiac surgery between June 2011 and December 2018. The research questions were addressed through bivariate inferential, descriptive and binary logistic regression. RESULTS: The overall incidence of CS-PRF was 15.9% and significant regression predictors included diabetes mellitus (OR = 1.77, P = .001), preoperative renal replacement therapy (OR = 2.07, P = .033), need for intraoperative transfusion (OR = 2.35, P = .000), combined coronary bypass/valvular surgery (OR = 2.61, P = .001) and intra-aortic balloon pump (OR = 3.60, P = .000). CS-PRF patients had increased postoperative blood transfusions (69.5% vs 27.9%, P = .000), reoperation for bleeding (9.0 vs 0.4%, P = .000), pleural effusion (13.5% vs 4.1%, P = .000), pneumonia (33.5% vs 1.6%, P = .000), acute kidney injury (70.9% vs 39.9%, P = .000), atrial fibrillation (42.5% vs 26.3%, P = .000), coma/encephalopathy (21.5% vs 3.3%, P = .000) and cerebrovascular accident (6.0% vs 1.3%, P = .000). They also had longer intensive care (262.1 vs 97.4 hours, P = .000) and hospital lengths of stay (17 vs 8 days, P = .000), and increased in-hospital mortality (17.5% vs 0.4%, P = .000). Survivors of CS-PRF were less likely to be discharged home (38.0% vs 84.4%, P = .000). CONCLUSIONS: Knowledge of predictors for CS-PRF may help identify patients who are at risk for this complication and who may benefit from preventive measures to promote early extubation and to avert reintubation.

Postoperative respiratory failure: An update on the validity of the Agency for Healthcare Research and Quality Patient Safety Indicator 11 in an era of clinical documentation improvement programs.

BACKGROUND: Administrative data can be used to identify cases of postoperative respiratory failure (PRF). We aimed to determine if recent changes to the Agency for Healthcare Research and Quality Patient Safety Indicator 11 (PSI 11) and adoption of clinical documentation improvement programs have improved the validity of PSI 11. We also analyzed reasons why PSI 11 was falsely triggered. STUDY DESIGN: Cross-sectional study of all eligible discharges using health record data from five academic medical centers between October 1, 2012 and September 30, 2015. RESULTS: Of 437 flagged records, 434 (99.3%) were accurately coded and 414 (94.7%) represented true clinical PRF. None of the false positive records involved respiratory failure present on admission. Most (78.3%) false positive records required airway protection but did not have respiratory failure. CONCLUSION: The validity of PSI 11 has improved with recent changes to the code criterion and adoption of clinical documentation improvement programs.

Successful bilevel positive airway pressure therapy in a patient with amyotrophic lateral sclerosis after emergency laparotomy: A case report.

Patients with amyotrophic lateral sclerosis (ALS) present an increased risk of postoperative respiratory failure after general anesthesia. We report the case of a 71-year-old man with ALS who underwent emergency laparotomy for small bowel strangulation. After surgery, he remained intubated and was transferred to the high care unit under mechanical ventilation, due to unstable hemodynamics requiring inotropic support. On postoperative day (POD) 3, he was extubated under stable hemodynamics and respiratory status. Immediately after extubation, bilevel positive airway pressure (bilevel PAP) was prophylactically applied to prevent postoperative respiratory failure, which may have been caused by respiratory muscle fatigue, attributed to general anesthesia and surgical stress. On POD 7, bilevel PAP was smoothly weaned off because no signs and symptoms of respiratory failure were observed. On POD 10, he achieved 30 m-walk without rest. No postoperative complications were observed up to one month after surgery. Postoperative respiratory failure may lead to death in patients with neuromuscular disorder. Non-invasive ventilation (NIV) reduces respiratory muscle fatigue, resulting in easy sputum expectoration, promoting CO2 washout, and better oxygenation. Consequently, the prophylactic use of NIV to avoid postoperative respiratory insufficiency should be considered in patients with ALS after emergency operation under general anesthesia.