Patrick Pasquina

Prophylactic respiratory physiotherapy after cardiac surgery: systematic review

Abstract Objective To assess whether respiratory physiotherapy prevents pulmonary complications after cardiac surgery. Data sources Searches through Medline, Embase, Cinahl, the Cochrane library, and bibliographies, for randomised trials comparing any type of prophylactic respiratory physiotherapy with another type or no intervention after cardiac surgery, with a follow up of at least two days, and reporting on respiratory outcomes. Review methods Investigators assessed trial validity independently. Information on study design, population, interventions, and end points was abstracted by one investigator and checked by the others. Results 18 trials (1457 patients) were identified. Most were of low quality. They tested physical therapy (13 trials), incentive spirometry (eight), continuous positive airway pressure (five), and intermittent positive pressure breathing (three). The maximum follow up was six days. Four trials only had a no intervention control; none showed any significant benefit of physiotherapy. Across all trials and interventions, average values postoperatively were: incidence of atelectasis, 15-98%; incidence of pneumonia, 0-20%; partial pressure of arterial oxygen per inspired oxygen fraction, 212-329 mm Hg; vital capacity, 37-72% of preoperative values; and forced expiratory volume in one second, 34-72%. No intervention showed superiority for any end point. For the most labour intensive intervention, continuous positive airway pressure, the average cost of labour for each patient day was €27 (£19;

Continuous Positive Airway Pressure Versus Noninvasive Pressure Support Ventilation to Treat Atelectasis After Cardiac Surgery

32). Conclusions The usefulness of respiratory physiotherapy for the prevention of pulmonary complications after cardiac surgery remains unproved. Large randomised trials are needed with no intervention controls, clinically relevant end points, and reasonable follow up periods.

What Does Built-In Software of Home Ventilators Tell Us? An Observational Study of 150 Patients on Home Ventilation

Atelectasis is common after cardiac surgery and may result in impaired gas exchange. Continuous positive airway pressure (CPAP) is often used to prevent or treat postoperative atelectasis. We hypothesized that noninvasive pressure support ventilation (NIPSV) by increasing tidal volume could improve the evolution of atelectasis more than CPAP. One-hundred-fifty patients admitted to our surgical intensive care unit (SICU) with a Radiological Atelectasis Score ≥2 after cardiac surgery were randomly assigned to receive either CPAP or NIPSV four times a day for 30 min. Positive end-expiratory pressure was set at 5 cm H2O in both groups. In the NIPSV group, pressure support was set to provide a tidal volume of 8–10 mL/kg. At SICU discharge, we observed an improvement of the Radiological Atelectasis Score in 60% of the patients with NIPSV versus 40% of those receiving CPAP (P = 0.02). There was no difference in oxygenation (Pao2/fraction of inspired oxygen at SICU discharge: 280 ± 38 in the CPAP group versus 301 ± 40 in the NIPSV group), pulmonary function tests, or length of stay. Minor complications, such as gastric distensions, were similar in the two groups. NIPSV was superior to CPAP regarding the improvement of atelectasis based on radiological score but did not confer any additional clinical benefit, raising the question of its usefulness for altering outcome.

Contribution of Back-Up Respiratory Rate Setting in Noninvasive Ventilation

Background: Recent home ventilators are equipped with built-in software which provides data such as compliance, estimations of leaks, tidal volume, minute ventilation, respiratory rate, apnea and apnea-hypopnea indexes, and percentage of inspirations triggered by the patient (or ventilator). However, for many of these variables, there is neither consensus nor documentation as to what is to be expected in a population of stable patients under noninvasive ventilation (NIV). Objectives: To document the values and distribution of specific items downloaded from ventilator monitoring software, by diagnostic category. Methods: Analysis of data downloaded from home ventilators in clinically stable patients under long-term NIV, during elective home visits by specialized nurses. Results: Data were collected from home ventilators of 150 patients with chronic obstructive pulmonary disease (n = 32), overlap syndrome (n = 29), obesity-hypoventilation (n = 38), neuromuscular disorders (n = 19), restrictive disorders (n = 21), and central sleep apnea syndrome (n = 11). On average, leaks were low, being lowest in patients with facial masks (vs. nasal masks), and increased with older age. Compliance was excellent in all groups. Patients with neuromuscular diseases triggered their ventilators less and tended to be ‘captured’, while other groups triggered at least half of inspiratory cycles. Most patients had a respiratory rate just slightly above the back-up rate. Residual apneas and hypopneas were highest in patients with central apneas. Conclusions: Built-in software of home ventilators provides the clinician with new parameters, some of which are a useful adjunct to recommended tools for monitoring NIV and may contribute to a better understanding of residual hypoventilation and/or desaturations. However, an independent validation of the accuracy of this information is mandatory.

Development and validation of a simple tool for the assessment of home NIV: the S3-NIV questionnaire

Few studies have specifically addressed the role of back-up respiratory rate (BURR) in noninvasive ventilation (NIV), and clinical practice is often empirical. There are potentially complex interactions between BURR settings and respiratory centers: absence of BURR may be associated with central respiratory events and can contribute to upper airway instability in patients prone to obstructive hypopnea or apnea. Conversely, use of a BURR can contribute to improved efficacy of NIV and arterial blood gases in obesity-hypoventilation and is strongly recommended in patients with neuromuscular disorders.

Software for Home Ventilators and Leak Compensation: Key Technical and Practical Applications

Patient-centred outcomes are significantly modified by long-term home noninvasive ventilation (NIV), but a short, self-administered, specific tool for routine clinical assessment is lacking. The aim of this study was to develop and validate the S3-NIV questionnaire, a short questionnaire to measure respiratory symptoms, sleep quality and NIV-related side effects. Patients with stable disease who were under long-term home NIV were recruited from three outpatient NIV services. Questionnaire development consisted of a selection of core items for analysis, followed by item reduction, validation and test–retest reliability. 338 patients completed a 22-item questionnaire. 11 items were removed because of non-scalability (n=2), redundancy (n=8) and lack of fit (n=1). The final version of the S3-NIV questionnaire consisted of 11 items covering two dimensions: “respiratory symptoms” (Cronbachs α=0.84) and “sleep & NIV-related side effects” (Cronbachs α=0.77). Convergent validity was high between the “respiratory symptoms” subscale of the S3-NIV questionnaire and the St Georges Respiratory Questionnaire (rho= −0.76, p<0.001), and between the “sleep & NIV-related side effects” subscale and the Quebec Sleep Questionnaire (rho=0.51, p<0.001). The S3-NIV questionnaire had good test–retest reliability after 4 weeks (intraclass correlation coefficient=0.72). The S3-NIV questionnaire is a short, valid and repeatable self-completed tool for the routine clinical assessment of patients undergoing home NIV. The S3-NIV questionnaire provides clinicians and patients with a simple and reliable tool to assess important domains (symptoms, sleep quality and NIV-related side effects) as a complement to physiological monitoring http://ow.ly/rR8e30mKGCG

Respiratory physiotherapy to prevent pulmonary complications after abdominal surgery: a systematic review.

Home ventilators with built-in software provide substantial information for monitoring home noninvasive ventilation, such as compliance, pattern of ventilator use, leaks, respiratory rate, percentage of respiratory cycles triggered and cycled by the device, and apnea-hypopnea index. Certain values are reliable and useful, however, reliability of data is not equivalent between all ventilators. The clinician should thus not rely only on these data for adjusting ventilator settings.