No 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; $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.

BACKGROUND: Noninvasive ventilation (NIV) is standard of care for chronic hypercapnic respiratory failure, but indications, devices, and ventilatory modes are in constant evolution.RESEARCH QUESTION: To describe changes in prevalence and indications for NIV over a 15-year period; to provide a comprehensive report of characteristics of the population treated (age, comorbidities, and anthropometric data), mode of implementation and follow-up, devices, modes and settings used, physiological data, compliance, and data from ventilator software. STUDY DESIGN AND METHODS:Cross-sectional observational study designed to include all subjects under NIV followed by all structures involved in NIV in the Cantons of Geneva and Vaud (1,288,378 inhabitants).RESULTS: A total of 489 patients under NIV were included. Prevalence increased 2.5-fold since 2000 reaching 38 per 100,000 inhabitants. Median age was 71 years, with 31% being > 75 years of age. Patients had been under NIV for a median of 39 months and had an average of 3 AE 1.8 comorbidities; 55% were obese. COPD (including overlap syndrome) was the most important patient group, followed by obesity hypoventilation syndrome (OHS) (26%). Daytime PaCO 2 was most often normalized. Adherence to treatment was satisfactory, with 8% only using their device < 3.5 h/d. Bilevel positive pressure ventilators in spontaneous/timed mode was the default mode (86%), with a low use of autotitrating modes. NIV was initiated electively in 50% of the population, in a hospital setting in 82%, and as outpatients in 15%.INTERPRETATION: Use of NIV is increasing rapidly in this area, and the population treated is aging, comorbid, and frequently obese. COPD is presently the leading indication followed by OHS.

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 >or=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 H(2)O 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 (Pao(2)/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.