Nasal continuous positive airway pressure - A method to avoid endotrachealreintubation in postoperative high-risk patients with severe nonhypercapnic oxygenation failure

Objectives: To study whether nasal continuous positive airway pressure (nCP AP) improves pulmonary oxygen transfer and avoids reintubation in patients with severe nonhypercapnic oxygenation failure after major cardiac, vascula r, or abdominal surgery. Design: Prospective international study. Setting: Surgical ICU of a university hospital, Patients: Twenty consecutive patients after thoracic, abdominal, or combine d thoracoabdominal operations, in whom pulmonary oxygen transfer deteriorat ed continuously following elective extubation after initial mechanical vent ilation, Respiratory failure was due to atelectasis and/or left heart failu re, and all patients met predefined criteria for reintubation. Interventions: nCPAP therapy (8 to 10 cm H2O) was initiated if PaO2 had dec reased to < 80 mm Hg despite application of 100% oxygen (flow, 25 L/min), i ntermittent mask continuous positive airway pressure, and maximum conventio nal therapy. Measurements and results: nCPAP treatment was started 24.1 +/- 3.4 h after elective extubation, PaO2 was < 80 mm Hg in all patients, in 13 patients it was < 60 mm Hg, and in 3 patients it was < 50 mm Hg. Mean PaO2/fraction of inspired oxygen (FIO2) ratio had decreased to 60 +/- 2.6, and increased wi thin the first hour of nCPAP to 136 +/- 12 (p < 0.001). The clinical condit ion in all patients improved further, and after 35.2 +/- 6.3 h, all patient s were well oxygenated by face mask at ambient pressure (PaO2/FIO2 ratio, 1 46 +/- 14). Two patients were reintubated for reasons unrelated to oxygenat ion or ventilation (data are presented as mean +/- SEM). Conclusions: nCPAP is safe, easy to apply, and effective to improve arteria l blood oxygenation in <1 h in postoperative patients with sec ere nonhyper capnic oxygenation failure. In these patients, who otherwise would have bee n reintubated, nCPAP can avoid endotracheal reintubation and mechanical ven tilation.