Highlights on…

Peri-operative NIV

JF Muir, C Gounane (F) & G Laier-Groeneveld (G)

Disclosures

• Grants, invitations, board participations and

consulting honorarium from Breas, Philips,

Resmed, Invacare

Agenda

• Introduction JFM 5’

• Review JFM 20’

• Specific conditions (1) : Obesity JFM 15’

• Specific conditions (2) : NMD, COPD GLG 30’

• Conclusions GLG 10’

• Questions/answers All 10 ’

At the bedside

• Pulmonary/extra pulmonary surgery

• Video/ robotic surgery

• At risk surgery or not

• Emergency situation or not

• Comorbidities / age

• Respiratory chronic illness & previous resp. assistance

• Obesity

� NIV or not ?

Peri-operative NIV: Why ?

• Major impact of surgery on respiratory function.

• Up to 60% post operative resp. complications(Chiumello, Int Care Med 2011).

• 30-50% post operative hypoxemia and 8-10% need for intubation(Arozullah , Ann Surg 2000).

JABER S, Anesthesiology 2010, 112,453.

An evaluation of diaphragmatic movement by M-

mode sonography as a predictor of pulmonary

dysfunction after upper abdominal surgery.

Soo Hwan Kim. Anesth Analg 2010 (110):5;1349-54

• Prospective study.

• 35 non smoking patients.

• Abdominal surgery (liver).

• Aim: echographic evaluation of pre/post

diaphragmatic function

Major and prolonged alteration of post-operative

respiratory function (non linked to pain)

Major and prolonged alteration of post-operative

respiratory function (non linked to pain)

So what?

PERI-OPERATIVE NIV: AIMS

• Preop

– To prevent post op complications in at risk or frail pts

– To teach the pt about use of NIV which may be

necessary after surgery

• Postop

– Avoid ARF

– Improve the resp comfort of the patient

– Synergy with physiotherapy

Post operative NIV• Aim:

– To provide preventive respiratory assistance adapted to possible post op ARF

• Benefits :

– To avoid morbidities linked to ETI

– No sedation

• Drawbacks :

– To delay ETI when needed

– To delay surgical re-intervention when ARF is the emergency signal (suture leak, infection)

Post operative complication prevention

BONNET F, MAPAR 2013

NIV

V

NIV

V

2011

Which surgery?

NIV and thoracic surgery

- Randomized, prospective study

- Aim: evaluation of NIV 7 days before and 3 days after

carcinologic surgery.

- 39 patients (FEV1 < 70%)

Prophylactic use of noninvasive ventilation in patients

undergoing lung resectional surgery.

PERRIN C., Respiratory Medicine (2007) 101,1572-1578.

- Improvement of PaO2,

FVC, FEV1.

- Reduction of

hospitalisation.

Rehab. and NIV before pulmonary resection in high

operative risk patients

BAGAN Rev Mal Resp 2013,30,414.

• Aim: evaluation of pulm. rehab. + 3 hrs-preop VNI

• 20 patients with lung adenocarcinoma and low FEV1

& VO2max

Results

- Significant increment of FEV1 and VO2max under PR which permits

surgery

- Post op mortality 5%.

- Home discharge after 11 day (average).

Parameters Before preop-rehab After preop-rehab p

ppo FEV1 36,1 (4,3) 49,6 (9) <0,0001

ppo VO2max 42,4 (14,-7) 53,8 (17,5) <0,0001

ppo: predicted post op

Noninvasive ventilation reduces mortality in acute

respiratory failure following lung resection.AURIANT , AJRCCM 2001.

• Prospective, monocentric study.

• 48 post operative ARF episodes (lobectomy or

pneumonectomy).

• 2 groups: NIV vs conventional management.

Results

NIV

Control •Reduction of mortality

•Reduction of % ETI

•Improvement of oxygenation ≥

2nd hrs.

•No difference about comorbidites.

PreONIV study (F)

Design of preONIV study

• Prospective, randomized, controlled, multicentric.

• Endpoint :

– efficiency of preop NIV (≥ 7 days) before thoracic resection surgery on prevention of post-op pulm and CV complications.

PreONIV Study

Inclusion criteria:

• Age> 18 yrs

• Elective pulmonary resection (lobectomy/segmentectomy) for lung carcinoma

• Preop restrictive or obstructive pattern

• Hypercapnic RF in the year before surgery

• LTO

• Obesity (BMI>30)

• Chronic card. failure

ABG

PFT

V1D-30 à D-7

V3Hospital

dischargeD-15 à D-7

Phone

call

V4D+30

Surgery

ABG

PFTPFT

Home treatment Follow up

Randomisation

NIV

No NIV

ABG

Gazométrie

VEMS

CVF

V5D+90

Follow up of compliance to NIV by home care service NIV started in week hospital

PreONIV study

NIV and abdominal surgery

Ford et al., Am Rev Respir Dis 1983 ;127(4):431-6

• Major impact of abdominal

surgery on respiratory

function

• 30-50% post op.

hypoxemic episodes and 8-

10% intubation

(Arozullah , Ann Surg 2000)

Impact on pulmonary function

Outcomes of patients with acute respiratory failure

after abdominal surgery treated with noninvasive

positive pressure ventilation.

JABER S., Chest 2005

• 72 post laparotomy ARF

• Systematic bilevel pressure ventilation in first line when:

– Respiratory fight signs

– SpO2 < 92%

– PaO2 < 80 mmHg under 10L/min

– No need for intubation : 67% (48/72)

– No difference for post-op complications

– Reduction of LOS and mortality

Continuous positive airway pressure for

treatment of postoperative hypoxemia.

Squadrone, JAMA. 2005;293:589-595

• Prospective, multicentric, randomized study.

• Aim: CPAP interest for treatment of post-op. ARF

• 209 patients (CPAP vs O2).

Reduction of:

• intubation

• LOS in Intensive Care Unit

• Infection rate

Results

10%

0

2

4

6

8

10

12

Pneumopathie Sepsis Mortalité

no

mb

re d

e p

ati

en

ts (

%)

Contrôle CPAP

p = 0.03

p = 0.12

p = 0.02

NIV and cardiac surgery

Prophylactic nasal continuous positive airway

pressure following cardiac surgery protects from

postoperative pulmonary complications.

ZARBOCK A. Chest 2009;135:1252-1259

• Randomized study.

• 500 patients.

• CPAP 10 cmH2O > 6 h vs O2 + CPAP 10 min/4 hrs.

• No difference on hemodynamics parameters.

• Improvement of oxygenation and reduction of pulmonary

complications and readmission in ICU.

Results

How ?

• A team affair with nurses physiotherapists

• Common respirators providing NIV may be

used (ICU respirators or not)

• Common masks

• Cope with tube problems source of vent. leaks

(naso gastric tubes)

Present challenges: Obesity

Morbid obesity and postoperative pulmonary atelectasis: an

underestimated problem.

Eichenberger Anesth Analg 2002; 95: 1788-92.

• 15 patients /group

• BMI> 35 vs <30

• Gastric Bypass by laparotomy

Results

The effect of bi-level positive airway pressure on

postoperative pulmonary function following gastric surgery

for obesity.

EBEO Respir Med 2002; 96: 672-676.

• 27 patients

• BMI> 40

• Gastric bypass

• Bi-level pressure ventilation during 12-24 hrs (N=14) vs O2 (N=13)

Results

OSA and POST-OP. COMPLICATIONS

• 40000 operated�471 pts with VPG�282 OSA

• During post op. period, OSA pts presented with increment of:

– Hypoxia (OR 7.9)

– Complications (OR 6.9) (1/3 with ARF)

– ICU transfer (OR 4.43)

– LOS(OR 1.65)

Kaw Chest 2012

Preop. recommandations

• Clinical diagnosis with the help of risk scores

• Nocturnal recording if doubt

• « Preoperative initiation of CPAP should be

considered, particularly if OSA is severe…. »ASA report for the perioperative management of patients

with OSA. Anesthesiology, 2006)

Preop resp assessment in bariatric

surgery

Caractéristiques N = 198 patients

Age

(années + écart type) 37,6 + 10

Femmes / hommes (%) 92,5 / 7,5

Poids moyen

(kg + écart type) 121,3 + 19

IMC

(kg/m2 / écart type) 45 + 6,7

SAS initialement sous PPC 1,5%

Oxymétrie nocturne

pathologique

51 %

Polygraphie ventilatoire

IAH > 5/h

55 %

45%

32%

11%12%

Polygraphie ventilatoire

IAH < 5/h 5<IAH<15 15<IAH<30 IAH>30

27 had preop CPAP for severe OSA(14,6 %)

89% de novo diagnosis (Morice, Muir in prep.)

RESULTS

• PaO2 11,8 ± 1,58 kPa

• PaCO2 4,99 ± 0,47 kPa

• CVF 84,8 ± 6,41 %Th

• VEMS/CVF 102 ± 14,99 %

• Epworth > 10 17%

81% pts could stop nCPAP in the year after bariatric surgery

� 49 % de perte d’excès de poids.

� - 27 % du poids initial

� -34 kg

� 49 % de perte d’excès de poids.

� - 27 % du poids initial

� -34 kg

BARIATRIC SURGERY:

RESP ASSESSMENT ALGORITHM

Obesity

Bariatric surgery discussed (network)

Resp. assessment

(clinical, PFT, ABG, NPG)

Severe OSA (IAH ≥≥≥≥ 30) No OSA

Preop CPAP during 2 months

Bariatric surgery Bariatric surgery

6 to 8 months with nCPAP

NPG.

Persistent OSA No more OSA

n CPAP No n CPAP

OBESITY AND SURGERY

• Very common situation

• Beware of OSAS � screening with VPG and

treat if it is present

• Beware of OHS� Screen also and treat ny NIV

• Increasing use of bariatric surgery:

– Cure of OSA in a majority of cases

– To be discussed to treat some young OHS pts

Conclusions

• Periop NIV is efficient to prevent ETI and reduce postop ARF

mortality.

• Interest in preventive post op pulm. complications is under

investigation.

• Problem : not to delay surgical re-intervention or post – op.

ETI.

• Need +++ for further studies

Agenda

• Introduction JFM 5’

• Review JFM 20’

• Specific conditions (1) : Obesity JFM 15’

• Specific conditions (2) : NMD, COPD GLG 30’

• Conclusions GLG 10’

• Questions/answers All 10 ’

A ajouter

• Photo NIV

• Appareils

• Interfaces et pb de sonds digestive montage

• Effets escomptés de la VNI

:desencombrement peep education reduction

de la dyspnee

Plan

• Introduction JFM (pulm extrapulm surg niv

dependent or not failure after surg) 5’

• Obesity JFM 15’

• Literature JFM 20’

• Specific situations (COPD NMD…) GLG 30’

• Conclusion GLG 10’

• Questions All 10’