[Pulmonary rehabilitation and non-invasive ventilation before lung surgery in very high-risk patients]. / Réhabilitation et VNI avant exérèse pulmonaire chez les patients à haut risque opératoire.

INTRODUCTION: The benefits of a rehabilitation program before surgical lung cancer resection remain to be defined. The purpose of this prospective observational study was to assess the effects of rehabilitation together with the use of noninvasive ventilation (NIV) in patients who were at a high operative risk. METHODS: Between January 2010 and June 2011, 20 consecutive patients (16 males, four females, mean age: 66 years [44-79]) with a clinical N0 non-small cell lung cancer were included. Eligibility criteria were predicted post-operative respiratory function (FEV1, VO2 max) below the guideline thresholds for eligibility for surgical resection and/or associated with severe co-morbidities. The protocol included a cardiorespiratory rehabilitation program and 3 hours of NIV each day. Functional tests were repeated after 3 weeks of therapy. RESULTS: Participants displayed a significant increase in their FEV1 and VO2 max, which allowed surgical resection to go ahead in all patients (lobectomy, n=15; pneumonectomy, n=3; bilobectomy, n=2). The morbidity rate was 20% (acute renal failure, n=2; pneumonia, n=1; haemothorax, n=1). The mortality rate was 5% (myocardial infarction, n=1). Further postoperative rehabilitation allowed a return at home in 19 patients after a mean hospital stay of 11 days. CONCLUSION: Pulmonary rehabilitation associated with a period of preoperative NIV allows surgery to be performed in patients who are not initially eligible for resection. An evaluation of long-term outcomes survival in comparison to non-surgical therapies is necessary.

Noninvasive ventilation using a mouthpiece in patients with chronic obstructive pulmonary disease and acute respiratory failure.

BACKGROUND: Noninvasive positive pressure ventilation (NPPV) delivered via a mouthpiece (mNPPV) has been successfully used in stable chronic restrictive respiratory insufficiency, but not in patients with chronic obstructive pulmonary disease (COPD) and acute respiratory failure (ARF). OBJECTIVES: The purpose of this matched case-control study was to compare the usefulness of mNPPV to noninvasive ventilation using a nasal or oronasal mask (nNPPV) or standard medical treatment (SMT) in COPD patients with ARF. METHODS: Twenty-nine patients receiving mNPPV were matched with 29 patients receiving nNPPV and 29 patients receiving SMT regarding age, SAPSII, admission PaCO(2) and pH. RESULTS: In the mNPPV group, admission PaCO(2) and pH were 78.6 +/- 12 mm Hg and 7.30 +/- 0.04, respectively. mNPPV and nNPPV avoided the need for endotracheal intubation in 27 and 25 patients, respectively (nonsignificant) whereas SMT resulted in a higher mechanical ventilation rate (13 patients). At the end of the treatment protocol, PaCO(2) was lower in the mNPPV group (62.2 +/- 9.6 mm Hg) than in the SMT group (72.4 +/- 20.4 mm Hg, p < 0.018) leading to a significantly higher pH. No significant differences were observed between the mNPPV and nNPPV groups. CONCLUSIONS: In case of moderate respiratory acidosis, noninvasive ventilation using a mouthpiece significantly reduces the endotracheal intubation rate in comparison with SMT and therefore appears to be a second-line alternative to noninvasive ventilation delivered via a mask, especially when poorly tolerated.