Noninvasive positive pressure ventilation for acute respiratory failure following oesophagectomy: Is it safe? A systematic review of the literature

Abstract

Objective: To find, critically appraise and synthesise all published studies so as to determine the safety and spectrum of use of noninvasive positive pressure ventilation for acute respiratory failure following oesophagectomy. Design: Systematic review. Methods: The MEDLINE and EMBASE databases were searched and the quality of the studies and any bias or confounding were rated according to established protocols. Outcomes extracted included re-intubation, anastomotic leakage, length of intensive care unit stay and mortality. The data were analysed quantitatively and qualitatively. Pooling of outcomes was considered if appropriate. Results: The search identified four papers, demonstrating the understudying/underreporting of the topic. Three were case-series and one was a conference abstract. The overall methodological quality was low. Design-specific biases and confounding were high. Despite this, the included studies conclude that noninvasive positive pressure ventilation is safe and effective and that re-intubation rates, intensive care unit length of stay, mortality and anastomotic dehiscence is lower when it is used. Meta-analysis was deemed to be inappropriate. Conclusions: Despite the conclusions and consensus of the included studies, there is no evidence to definitively conclude that noninvasive positive pressure ventilation is either safe or dangerous following oesophagectomy and the current literary evidence is inadequate. Current practice varies and is based on opinion and consensus. As such, randomised controlled studies are urgently required as current practice may cause undue harm to patients. The incidence of anastomotic leakage with noninvasive positive pressure ventilation use needs to be determined.

Postoperative CPAP after major abdominal surgery – Authors' reply

“…However, the number of these patients was very low, which was probably due to concerns among surgeons about the purported effects of CPAP on the integrity of surgical anastomoses. Evidence from a systematic review 6 suggests that non-invasive ventilation after upper gastrointestinal surgery might reduce the incidence of complications. However, the constituent studies are small and further data are needed on the safety and efficacy of CPAP and non-invasive ventilation in this group of patients.…”

“…However, the constituent studies are small and further data are needed on the safety and efficacy of CPAP and non-invasive ventilation in this group of patients. 6 Tandabany and colleagues 2 also mention evidence from previous small efficacy trials and question whether the absence of effect of postoperative CPAP in reducing postoperative pneumonia, re-intubation, or death in the PRISM trial was due to the duration and timing of CPAP, rather than an absence of efficacy of CPAP per se. Similarly, Hess and Branson 1 question the absence of technical data regarding the equipment used to deliver CPAP.…”

Management of Respiratory Failure Caused by COVID-19 after Thoracoscopic Esophagectomy

“…The patient in the present case received tactics considered controversial for the postoperative period of esophagectomy, especially non-invasive ventilation. Non-invasive ventilation is usually contraindicated due to the potential risk of triggering the dehiscence of esophageal-gastric anastomosis (7). However, as there was a high risk of clinical worsening and the need for invasive mechanical ventilation, this alternative was reconsidered and precautionary measures were taken, such as limiting the positive pressure values in the ventilator.…”

Controversies when using mechanical ventilation in obese patients with and without acute distress respiratory syndrome

“…In abdominal surgery, incentive spirometry and NIV appear to be more effective than no respiratory physical therapy intervention in the prevention of postoperative pulmonary complications [80,81]. There is still concern regarding whether the benefits of incentive spirometry as a post-extubation management strategy could be applied in other surgeries, such as thoracic surgery, due to the risk of suture dehiscence and anastomotic leakage [82]; however, this has not been completely established. Additionally, current practice varies and opinion and consensus differ concerning the use of incentive spirometry in these scenarios.…”