Continuous positive airway pressure effect on functional residual capacity, vital capacity and its subdivisions. Development and Validation of a Multifactorial Risk Index for Predicting Postoperative Pneumonia after Major Noncardiac Surgery Predictors of postoperative pulmonary complications following abdominal surgery. Incidence and hospital stay for cardiac and pulmonary complications after abdominal surgery Effect of oxygen treatment on heart rate after abdominal surgery. Prophylactic nasal continuous positive airway pressure after major vascular surgery: results of a prospective randomized trial Effects of continuous (CPAP) and bi-level positive airway pressure (BiPAP) on extravascular lung water after extubation of the trachea in patients following coronary artery bypass grafting Can postoperative continuous positive airway pressure (CPAP) prevent pulmonary complications after abdominal surgery? Pressure Support Ventilation versus Continuous Positive Airway Pressure with the Laryngeal Mask Airway: A Randomized Crossover Study of Anesthetized Adult Patients Temporal patterns of postoperative complications. A randomized controlled trial comparing periodic mask CPAP with physiotherapy after abdominal surgery. Effect of preoperative smoking intervention on postoperative complications: a randomised clinical trial Effects of periodic positive airway pressure by mask on postoperative pulmonary function. Continuous positive airway pressure for treatment of postoperative hypoxemia: a randomized controlled trial. Three different mask physiotherapy regimens for prevention of post-operative pulmonary complications after heart and pulmonary surgery Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major Noncardiac Surgery [Weaning postoperative artificial respiration in cardiac surgery patients, CPAP versus ZEEP]. Randomized clinical study of the prevention of pulmonary complications after thoracoabdominal resection by two different breathing techniques Does noninvasive ventilation reduce the ICU nosocomial infection risk? A prospective clinical survey Randomized controlled trial of prophylactic chest physiotherapy in major abdominal surgery Effects of conventional physiotherapy, continuous positive airway pressure and non‐invasive ventilatory support with bilevel positive airway pressure after coronary artery bypass grafting Use of a nasal continuous positive airway pressure mask in the treatment of postoperative atelectasis in aortocoronary bypass surgery. Automatic CPAP Compared with Conventional Treatment for Episodic Hypoxemia and Sleep Disturbance after Major Abdominal Surgery Intraoperative Modulation of Alveolar Macrophage Function during Isoflurane and Propofol Anesthesia A controlled trial of intermittent positive pressure breathing, incentive spirometry, and deep breathing exercises in preventing pulmonary complications after abdominal surgery. [Effects of three types of respiratory assistance (continuous positive pressure, intermittent positive pressure, classical respiratory physiotherapy) on PaO2 and PaCO2 in patients undergoing digestive tract surgery]. [The effect of intraoperative PEEP ventilation and postoperative CPAP breathing on postoperative lung function following upper abdominal surgery]. Postoperative spontaneous breathing with CPAP to normalize late postoperative oxygenation Continuous positive airway pressure by mask in patients after coronary surgery Comparison of continuous positive airway pressure, incentive spirometry, and conservative therapy after cardiac operations Respiratory insufficiency after abdominal surgery. Continuous Positive Airway Pressure Versus Noninvasive Pressure Support Ventilation to Treat Atelectasis After Cardiac Surgery Effect of failed extubation on the outcome of mechanical ventilation.
Thirty-four otherwise healthy patients having to undergo elective upper abdominal surgery were r and omly assigned to two equal groups . In the treatment group , constant positive airway pressure ( CPAP ) with an expiratory pressure of 12 cm H2O was applied at one hour following extubation , and at daily intervals for the first five days following surgery for a continuous period of three hours . The control group received no CPAP treatment . All patients were given postoperative physiotherapy . In patients who received postoperative CPAP with an end-expiratory pressure of 12 cm H2O , marked normalization of pulmonary function was noted Postoperative pulmonary complications are associated with substantial morbidity and mortality . It has been estimated that nearly one fourth of deaths occurring within 6 days of surgery are related to postoperative pulmonary complications ( 1 ) . Postoperative infections are also a major source of the morbidity and mortality associated with undergoing surgery . Pneumonia is the most serious postoperative complication that is included in both of these categories . Pneumonia ranks as the third most common postoperative infection , behind urinary tract and wound infection ( 2 ) . According to the National Nosocomial Infection Surveillance system , pneumonia occurred in 18 % of patients after surgery ( 3 ) . Postoperative pneumonia occurs in 9 % to 40 % of patients , and the associated mortality rate is 30 % to 46 % , depending on the type of surgery ( 1 , 4 ) . Previous studies of risk factors used various definitions of postoperative pulmonary complications . Atelectasis ( 1 , 47 ) , postoperative pneumonia ( 12 , 46 , 811 ) , the acute respiratory distress syndrome ( 9 , 12 ) , and postoperative respiratory failure ( 6 , 9 , 11 , 13 ) have been classified as postoperative pulmonary complications . Although the clinical significance of each of these complications varies greatly , they were grouped together as a single outcome in previous studies ( 6 ) . Some studies were limited to examination of risk factors in patients undergoing abdominal or thoracic procedures or in patients with specific medical conditions , such as chronic obstructive pulmonary disease ( 2 , 4 , 6 , 1012 , 14 ) . These studies were often based on a small sample from one institution , and studies of independent sample s did not vali date their findings ( 15 , 16 ) . Although clinicians have used preoperative cardiac risk indexes for more than 20 years ( 17 ) , previous studies have not produced a vali date d risk index that predicts risk for pneumonia ( 18 ) . Our main objective was to develop and vali date a multifactorial risk index for predicting postoperative pneumonia . Preoperative risk factors for postoperative pneumonia were determined in a large multicenter observational cohort of patients undergoing various major noncardiac operations . Specific goals included identification of predictors that are easily obtained and commonly accessible to care providers before surgery . Using these predictors , we developed and vali date d a risk assessment model and scoring system for predicting postoperative pneumonia , analogous to risk assessment models for predicting cardiac complications ( 17 , 19 , 20 ) . Methods Patients were selected from the Department of Veterans Affairs National Surgical Quality Improvement Program ( NSQIP ) . A detailed description of the study methods is published elsewhere and is summarized briefly here ( 13 , 2123 ) . Participating Hospitals Our study includes patients enrolled between 1 September 1995 and 31 August 1999 at 100 Veterans Affairs medical centers that perform major surgery . Patients enrolled at 97 medical centers between 1 September 1997 and 31 August 1999 were used to develop the model , and patients enrolled at 100 medical centers between 1 September 1995 and 31 August 1997 were used to vali date the model . Selection of Patients All noncardiac operations performed under general , spinal , epidural , local , or monitored anesthesia were eligible for inclusion as index operations . All eligible operations were included at low-volume hospitals ( < 140 eligible operations per month ) . At 5 high-volume hospitals ( 140 eligible operations per month ) , the first 36 consecutive eligible operations were entered in each consecutive 8-day period , beginning with a different day each period . On the basis of a review of operative mortality rates from the Veterans Affairs administrative discharge data base for 1988 and 1989 , selected operations with very low mortality rates were excluded from the NSQIP . Major transplantation procedures and patients entered into the study within the previous 30 days were also excluded . Patients were defined as having postoperative pneumonia if they met the Centers for Disease Control and Prevention definition of nosocomial pneumonia after surgery ( Table 1 ) ( 24 ) . We excluded patients who were ventilator dependent before surgery and those who had preoperative pneumonia . Patients who experienced postoperative respiratory failure or unplanned intubation before postoperative pneumonia was diagnosed were also excluded . Table 1 . Definition of Postoperative Pneumonia Data Collection A surgical risk- assessment nurse was assigned at each center to collect the data . All variables were defined before data collection ( 21 ) . The nurses completed in-depth training on all study definitions and conduct of the protocol . Annual meetings and regular conference calls were conducted , and two traveling nurse coordinators performed site visits to maintain data reliability . Generic preoperative , intraoperative , and postoperative variables were chosen on the basis of clinical relevance , reliability of data collection , and availability of data . Preoperative data were obtained by the study nurse from the medical chart or a surgical risk- assessment profile that was completed by the surgical resident caring for the patient and later verified by the study nurse from the medical record . Preoperative laboratory values within 30 days of the index operation and closest to the time of operation were acquired automatically from the laboratory software in each center 's computer system . Intraoperative variables were collected from the operative log and anesthesia record for the index operation . The index operation was defined as the first eligible operation performed on the patient . Other operations performed under the same anesthetic by the same or different surgical team were also recorded . The type of surgery was primarily classified by the anatomic location of the surgical incision ( 13 ) . On the 30th postoperative day , the study nurse obtained outcome information by chart review , interviews with care providers , reports from morbidity and mortality conferences , and communication with each patient by letter or by telephone .  Postoperative mortality was defined as death from any cause inside or outside the hospital within 30 days of surgery . The nurse entered all data into a surgical risk assessment module in each center 's computer system . A summary of each patient data record was forwarded to the chief of the surgical service 30 days after surgery for inspection . No later than 45 days after surgery , the patient records were transmitted automatically to the statistical coordinating center for editing and analysis . Missing Data Data were more than 92 % complete , except for preoperative laboratory variables ; the completeness of these depended on whether the specific laboratory tests had been ordered . Patients with missing data for tests that were not ordered more than 8 % of the time were excluded from the development and validation data sets . Twelve percent of blood urea nitrogen and 9 % of creatinine values were missing ; thus , patients for whom these values were missing were excluded from the development and validation data sets . Statistical Analysis Data were analyzed by using two software packages ( SAS for UNIX [ SAS Institute , Inc. , Cary , North Carolina ] and Stata statistical software , version 7.0 for Windows [ Stata Corp. , College Station , Texas ] ) . Using patients from the development set ( enrolled between 1 September 1997 and 31 August 1999 ) , we used the chi-square test for categorical variables and the Student t-test for continuous variables to test the relationship between each potential risk factor and postoperative pneumonia . All potential risk factors were entered into a logistic regression model with postoperative pneumonia as the dependent variable and the potential risk factors as the independent variables . Blood urea nitrogen was categorized into ranges suggested by its U-shaped relationship to postoperative pneumonia in univariate analyses . Indicator variables created for each range were included in the logistic regression model . Potential risk factors that were not statistically significant ( P < 0.05 ) were sequentially deleted from the full model . Excluded variables were reintroduced at various stages of model development until only statistically significant risk factors remained . Two-way interaction between recent smoking and history of chronic obstructive pulmonary disease was analyzed and found to be statistically nonsignificant . Robust variance estimates were calculated by using the HuberWhite method to account for the effect of clustering of patients within hospitals ( 25 ) . Development of a Scoring System By using the methods of Le Gall and colleagues ( 26 ) , point values were assigned to each risk factor by multiplying the -coefficients from the logistic regression model by 10 and rounding off to the nearest integer . The point total for each patient was design ated the postoperative pneumonia risk index and was used in a multiple logistic regression equation design ed to convert the risk index to the probability of developing postoperative pneumonia . Because the risk index scores were highly skewed , a shrinking power transformation , ln ( postoperative pneumonia risk index score + 25 ) , where ln indicates the natural logarithm , was incorporated into the model for improved calibration ( 26 ) . Evaluation of Model Performance Formal goodness-of-fit ( HosmerLemeshow ) tests ( 27 ) were performed by using data on patients from the development cohort , the validation cohort , and 10 r and om sets of five hospitals to assess model calibration . The C-statistic was used to evaluate discrimination in model development and validation ( 28 ) . Results Patient Characteristics and Postoperative Pneumonia Rates Of the 206 434 patients enrolled between 1 September 1997 and 31 August 1999 , 5395 patients ( 2.6 % ) with preoperative pneumonia or dependence on a ventilator were excluded . An additional 729 patients were excluded because STUDY OBJECTIVE To determine how risk factors could be combined to best predict the development of a  postoperative pulmonary complication ( PPC ) following abdominal surgery .  DESIGN Prospect i ve model-building study . Logistic regression models were developed using significant risk factors identified in the univariate analysis . SETTING Four midwestern hospitals . PATIENTS Convenience sample of 400 patients who underwent abdominal surgical procedures between January 1993 and August 1995 . MEASUREMENTS AND RESULTS Multi criteria outcome for postoperative pulmonary complication used to collectively assess atelectasis and pneumonia . Twenty-three risk factors were assessed . Six risk factors were identified as independent by logistic regression : age > or = 60 years ( adjusted odds ratio [ Adj OR ] , 1.89 ) ; impaired preoperative cognitive function ( Adj OR , 5.93 ) ; smoking history within the past 8 weeks ( Adj OR , 2.27 ) ; body mass index > or = 27 ( Adj OR , 2.82 ) ; history of cancer ( Adj OR , 2.23 ) ; and incision site-upper abdominal or both upper/lower abdominal incision ( Adj OR 2.30 ) . CONCLUSIONS These results provide a framework for identifying patients at risk of developing a  PPC following abdominal surgery .  A reliable and valid risk index could be used clinical ly to guide preoperative and postoperative pulmonary care and target limited re sources for patients at risk OBJECTIVE : Internists frequently evaluate preoperative cardiopulmonary risk and comanage cardiac and pulmonary complications , but the comparative incidence and clinical importance of these complications are not clearly delineated . This study evaluated incidence and length of stay for both cardiac and pulmonary complications after  elective laparotomy .  DESIGN : Nested case-control . SETTING : University-affiliated Department of Veterans Affairs Hospital . PATIENTS : Computerized registry of all 2,291 patients undergoing elective abdominal operations from 1982 to 1991.MEASUREMENT AND MAIN RESULTS : Strategy for ascertainment and verification of complications was systematic and explicit . The charts of all 116 patients identified by the registry as having complications and 412 ( 19 % ) r and omly selected from 2,175 remaining patients were review ed to verify presence or absence of cardiac or pulmonary complications , using explicit criteria and independent abstract ion of pre- and postoperative components of charts . From these 528 vali date d cases and controls ( 23 % of the cohort ) , 96 cases and 96 controls were matched by operation type and age within ten years . Hospital and intensive care unit stays were significantly longer ( p<0.0001 ) for the cases than for the controls ( 24.1 vs 10.3 and 5.8 vs 1.5 days , respectively ) . All 19 deaths occurred among the cases . Among the cases , pulmonary complications occurred significantly more often than cardiac complications ( p<0.00001 ) and were associated with significantly longer hospital stays ( 22.7 vs 10.4 days , p=0.001 ) . Combined cardiopulmonary complications occurred among 26 % of the cases . Misclassification-corrected incidence rates for the entire cohort were 9.6 % ( 95 % CI 7.2–12.0 ) for pulmonary and 5.7 % ( 95 % CI 3.8–7.7 ) for cardiac complications . CONCLUSIONS : For noncardiac surgery , previous research has focused on cardiac risk . In this study , pulmonary complications were more frequent , were associated with longer hospital stay , and occurred in combination with cardiac complications in a substantial proportion of cases . These results suggest that further research is needed to fully characterize the clinical epidemiology of postoperative cardiac and pulmonary complications and better guide preoperative risk assessment BACKGROUND Cardiac complications are common during the postoperative period and may be associated with hypoxemia and tachycardia . Preliminary studies in high-risk patients after operation have shown a possible beneficial effect of oxygen therapy on arterial oxygen saturation and heart rate . METHODS The authors studied the effect of oxygen therapy on arterial oxygen saturation and heart rate in 100 consecutive unselected patients r and omly and double blindly allocated to receive air or oxygen therapy between the first and fourth day after major abdominal surgery . RESULTS The median arterial oxygen saturation rate increased significantly from 96 % to 99 % ( P < 0.0001 ) and the heart rate decreased significantly from 85 beats/min to 81 beats/min ( P < 0.0001 ) during oxygen supplementation compared with air administered by a binasal catheter . The greatest decrease in heart rate occurred in patients with the lowest oxygen saturation or the highest heart rate values before oxygen supplementation . Overall , 73 % of this unselected group of patients responded with decreased heart rate during supplemental oxygen therapy . No significant differences in changes in heart rate after oxygen supplementation were found between patients with or without an epidural catheter or between the postoperative day studied . CONCLUSION Postoperative oxygen therapy increased arterial oxygen saturation and decreased heart rate after uncomplicated abdominal surgery in a consecutive unselected group of patients who received routine postoperative care Abstract . Background : The efficacy of nasal continuous positive airway pressure ( nCPAP ) as a prophylactic method for preventing cardiopulmonary complications after major vascular surgery has not been investigated . Patients / methods : In a prospect i ve r and omized trial , 204 patients undergoing elective midline laparotomy for vascular surgery were r and omized to receive st and ard therapy ( n=105 ) or additional prophylactic nCPAP ( n=99 ) for the first postoperative night . Postoperative oxygenation , incidence of severe cardiac , and pulmonary complications , length of intensive care surveillance and length of total postoperative hospital stay ( LOS ) were compared . Results : Prophylactic nCPAP significantly reduced the number of patients with severe oxygenation disturbances defined as paO2<70 mmHg with FiO2≥ 0.7 ( 5 versus 17 , P=.01 ) . There were no differences with respect to death , cardiac and pulmonary complications , length of intensive care surveillance or LOS . Conclusion : Prophylactic 12 h nCPAP significantly reduces the occurrence of postoperative oxygenation disturbances but has no effect on cardiac or pulmonary complications , need for intensive care , LOS or mortality after major vascular surgery Objective To evaluate the effects of continuous positive airway pressure ( CPAP ) and bilevel positive airway pressure ( BiPAP ) on extravascular lung water during weaning from mechanical ventilation in patients following coronary artery bypass grafting . Design Prospect i ve , r and omized clinical study . Setting Intensive care unit at a university hospital . Patients Seventy-five patients following coronary artery bypass grafting . Interventions After extubation of the trachea , patients were treated for 30 min with CPAP via face mask ( n=25 ) , with nasal BiPAP ( n=25 ) , or with oxygen administration via nasal cannula combined with routine chest physiotherapy ( RCP ) for 10 min ( n=25 ) . Measurements and results Extravascular lung water ( EVLW ) , pulmonary blood volume index ( PBVI ) and cardiac index ( CI ) were obtained during mechanical ventilation ( T1 ) , T-piece breathing ( T2 ) , interventions ( T3 ) , spontaneous breathing 60 min ( T4 ) and 90 min ( T5 ) after extubation of the trachea using a combined dye-thermal dilution method . Changing from mechanical ventilation to T-piece breathing did not show any significant differences in EVLW between the three groups , but a significant increase in PBVI from 155±5 ml/m2 to 170±4 ml/m2 could be observed in all groups ( p<0.05 ) . After extubation of the trachea and treatment with BiPAP , PBVI decreased significantly to 134±6 ml/m2 ( p<0.05 ) . After treatment with CPAP or BiPAP , EVLW did not change significantly in these groups ( 5.5±0.3 ml/kg vs 5.0±0.4 ml/kg and 5.1±0.4 ml/kg vs 5.7±0.4 ml/kg ) . In the RCP-treated group , however , EVLW increased significantly from 5.8±0.3 ml/kg to 7.1±0.4 ml/kg ( p<0.05 ) . Sixty and 90 min after extubation , EVLW stayed at a significantly higher level in the RCP-treated group ( 7.5±0.5 ml/kg and 7.4±0.5 ml/kg ) than in the CPAP-(5.6±0.3 ml/kg and 5.9±0.4 ml/kg ) . No significant differences in CI could be observed within the three groups during the time period from mechanical ventilation to 90 min after extubation of the trachea . Conclusions Mask CPAP and nasal BiPAP after extubation of the trachea prevent the increase in extravascular lung water during weaning from mechanical ventilation . This effect is seen for at least 1 h after the discontinuation of CPAP or BiPAP treatment . Fuether studies have to evaluate the clinical relavance of this phenomenon Twenty-four patients underwent elective cholecystectomy .  They were r and omized into two groups , one consisting of 13 patients having CPAP * by face-mask for 4 h after surgery and the other , consisting of 11 patients , serving as control . The patients were all given intravenous anesthesia and were manually ventilated during anesthesia without using PEEP . The groups were comparable as concerns sex , age , weight , smoking-habits , preoperative pulmonary status , type of surgery and anesthesia-time . The study showed that both groups had a reduction in VC and PaO2 and a high percentage of them developed chest X-ray changes . In none of the variables mentioned was there any significant difference between the groups after surgery . Hypoxemia after abdominal surgery can thus not be prevented by only using CPAP for 4 h postoperatively Background The authors tested the hypothesis that pressure support ventilation ( PSV ) provides more effective gas exchange than does unassisted ventilation with continuous positive airway pressure ( CPAP ) in anesthetized adult patients treated using the laryngeal mask airway . Methods Forty patients were r and omized to two equal-sized crossover groups , and data were collected before surgery . In group 1 , patients underwent CPAP , PSV , and CPAP in sequence . In group 2 , patients underwent PSV , CPAP , and PSV in sequence . PSV comprised positive end expiratory pressure set at 5 cm H2O and inspiratory pressure support set at 5 cm H2O above positive end expiratory pressure . CPAP was set at 5 cm H2O . Each ventilatory mode was maintained for 10 min . The following data were recorded every minute for the last 5 min of each ventilatory mode and the average reading taken : end tidal carbon dioxide , oxygen saturation , expired tidal volume , leak fraction , respiratory rate , noninvasive mean arterial pressure , and heart rate . Results In both groups , PSV showed lower end tidal carbon dioxide ( P < 0.001 ) , higher oxygen saturation , ( P < 0.001 ) , and higher expired tidal volume ( P < 0.001 ) compared with CPAP . In both groups , PSV had similar leak fraction , respiratory rate , mean arterial pressure , and heart rate compared with CPAP . In group 1 , measurements for CPAP were similar before and after PSV . In group 2 , measurements for PSV were similar before and after CPAP . Conclusion The authors concluded that PSV provides more effective gas exchange than does unassisted ventilation with CPAP during LMA anesthesia while preserving leak fraction and hemodynamic homeostasis HYPOTHESIS A variety of major complications occur after  intra-abdominal operations . Knowledge of when specific complications occur during the postoperative period would be useful in their diagnosis , prevention , and management . Our aim was to determine the incidence of major complications during specific postoperative intervals . DESIGN One thous and twenty-one patients undergoing intra-abdominal operations  were studied postoperatively as part of a r and omized clinical trial . Thirteen defined major complications were sought at the following specific intervals : less than 1 , 1 through 3 , 4 through 7 , and 8 through 30 days after the operation . SETTING Cooperative trial from 15 Veterans Affairs medical centers . INTERVENTIONS Intra-abdominal aortic , gastric , biliary , and colonic procedures . MAIN OUTCOME MEASUREMENTS Major postoperative complications . RESULTS Four hundred thirty-five major complications were diagnosed within 30 days of the patients ' being operated on . Seventy-four ( 17 % ) occurred within 1 day , 185 ( 43 % ) between 1 and 3 days , 72 ( 17 % ) between 4 and 7 days , and 104 ( 24 % ) between 8 and 30 days . Three deaths ( 8 % ) occurred within 1 day , 3 ( 8 % ) in 1 through 3 days , 4 ( 11 % ) in 4 through 7 days , and 27 ( 73 % ) in 8 through 30 days . The greatest risk of hypotension ( 43 % ) , myocardial infa rct ion ( 47 % ) , and respiratory depression ( 55 % ) was within 1 day . The highest incidence of congestive heart failure ( 46 % ) , pulmonary embolus ( 50 % ) , and respiratory failure ( 76 % ) occurred at 1 through 3 days . Pneumonia ( 38 % ) was most common at 4 through 7 days . Cerebrovascular accident ( 53 % ) and sepsis ( 71 % ) occurred preponderantly at 8 through 30 days . Renal failure had a bimodal distribution with maxima at 1 through 3 days ( 31 % ) and 8 through 30 days ( 56 % ) . The risk of cardiac arrhythmia and gastrointestinal tract bleeding was similar throughout all intervals . CONCLUSIONS While major complications occur throughout the postoperative period , the highest incidence is 1 through 3 days after the operation . However , specific complications occur in the following distinct temporal patterns : early postoperative , several days after the operation , throughout the postoperative period , and in the late postoperative period . Knowledge of these patterns should aid clinical management BACKGROUND AND PURPOSE Physiotherapists use a variety of techniques aim ed at improving lung volumes and secretion clearance in patients after surgery .  Periodic continuous positive airway pressure ( PCPAP ) is used to treat patients following elective upper abdominal surgery . However , the optimal method of application has not been identified , more specifically , the dosage of application of PCPAP . The present r and omized controlled trial compared the effects of two dosages of PCPAP application and ' traditional ' physiotherapy upon functional residual capacity ( FRC ) , vital capacity ( VC ) , oxyhaemoglobin saturation ( SpO2 ) , incidence of post-operative pulmonary complications and length of stay with a control group receiving ' traditional ' physiotherapy only . METHOD Fifty-seven subjects were r and omly allocated to one of three groups . All groups received ' traditional ' physiotherapy twice daily for a minimum of three post-operative days . In addition , two groups received PCPAP for 15 or 30 minutes , four times per day , for three days . RESULTS Fifty subjects ( 39 male ; 11 female ) completed the study . There were no significant differences in any variables between the three groups . The overall incidence of post-operative pulmonary complications was 22 % in the control group , 11 % and 6 % in the PCPAP 15-minute and PCPAP 30-minute groups , respectively . Length of hospital stay was not significantly different between the groups but for subjects who developed post-operative pulmonary complications , the length of stay was significantly greater ( Z = -2.32 ; p = 0.021 ) . CONCLUSIONS The addition of PCPAP to a traditional physiotherapy post-operative treatment regimen after upper abdominal surgery did not significantly affect physiological or clinical outcomes BACKGROUND Smokers are at higher risk of cardiopulmonary and wound-related postoperative complications than non-smokers . Our aim was to investigate the effect of preoperative smoking intervention on the frequency of postoperative complications in patients undergoing hip and knee replacement . METHODS We did a r and omised trial in three hospitals in Denmark . 120 patients were r and omly assigned 6 - 8 weeks before scheduled surgery to either the  control ( n=60 ) or smoking intervention ( 60 ) group .  Smoking intervention was counselling and nicotine replacement therapy , and either smoking cessation or at least 50 % smoking reduction . An assessor , who was masked to the intervention , registered the occurrence of cardiopulmonary , renal , neurological , or surgical complications and duration of hospital admittance . The main analysis was by intention to treat . FINDINGS Eight controls and four patients from the intervention group were excluded from the final analysis because their operations were either postponed or cancelled . Thus , 52 and 56 patients , respectively , were analysed for outcome . The overall complication rate was 18 % in the smoking intervention group and 52 % in controls ( p=0.0003 ) . The most significant effects of intervention were seen for wound-related complications ( 5 % vs 31 % , p=0.001 ) , cardiovascular complications ( 0 % vs 10 % , p=0.08 ) , and secondary surgery ( 4 % vs 15 % , p=0.07 ) . The median length of stay was 11 days ( range 7 - 55 ) in the intervention group and 13 days ( 8 - 65 ) in the control group . INTERPRETATION An effective smoking intervention programme 6 - 8 weeks before surgery reduces postoperative morbidity , and we recommend , on the basis of our results , this programme be adopted Postoperative pulmonary complications , alveolar-arteriolar oxygen difference ( [A-a]O2-diff ) , peak expiratory flow ( PEF ) and forced vital capacity ( FVC ) were compared in patients using continuous positive airway pressure ( CPAP ) and positive expiratory pressure ( PEP ) administered  by face mask  against those of a control  group using  a deep-breathing device ( Triflo ) .  Forty-three consecutive , r and omized patients undergoing elective upper abdominal surgery were included .  CPAP , PEP and Triflo were administered for 30 consecutive breaths in every waking hour for three days postoperatively . The (A-a)O2-difference increased equally and significantly in the three groups after surgery , reaching a maximum on the first postoperative day . After this day , however , (A-a)O2-diff decreased in the CPAP and PEP groups , being significantly lower in the PEP group compared to the control group , two days postoperatively ( p less than 0.05 ) and significantly lower in both the PEP and CPAP groups three days postoperatively ( p less than 0.001 and p less than 0.05 , respectively . ) PEF did not differ significantly between the groups before or after surgery , while FVC was significantly higher in the PEP and CPAP groups , compared to control , on the third postoperative day ( p less than 0.05 ) . Atelectatic consolidation was observed in six of 15 patients in the control group three days postoperatively , the incidence being significantly lower in both the PEP group ( 0 of 15 , p less than 0.001 ) and the CPAP group ( one of 13 , p less than 0.05 ) . We concluded that periodic face mask administration of CPAP and PEP are superior to deep breathing exercises with respect to gas exchange , preservation of lung volumes and development of atelectasis after upper abdominal surgery . We also conclude that the simple and commercially available PEP mask is as effective as the more complicated CPAP system CONTEXT Hypoxemia complicates the recovery of 30 % to 50 % of patients after abdominal surgery ; endotracheal intubation and mechanical ventilation may be required in 8 % to 10 % of cases , increasing morbidity and mortality and prolonging intensive care unit and hospital stay . OBJECTIVE To determine the effectiveness of continuous positive airway pressure compared with st and ard treatment in preventing the need for intubation and mechanical ventilation in patients who develop acute hypoxemia after elective major abdominal surgery . DESIGN AND SETTING R and omized , controlled , unblinded study with concealed allocation conducted between June 2002 and November 2003 at 15 intensive care units of the Piedmont Intensive Care Units Network in Italy . PATIENTS Consecutive patients who developed severe hypoxemia after major elective abdominal surgery . The trial was stopped for efficacy after 209 patients had been enrolled . INTERVENTIONS Patients were r and omly assigned to receive oxygen ( n = 104 ) or oxygen plus continuous positive airway pressure ( n = 105 ) . MAIN OUTCOME MEASURES The primary end point was incidence of endotracheal intubation ; secondary end points were intensive care unit and hospital lengths of stay , incidence of pneumonia , infection and sepsis , and hospital mortality . RESULTS Patients who received oxygen plus continuous positive airway pressure had a lower intubation rate ( 1 % vs 10 % ; P = .005 ; relative risk [ RR ] , 0.099 ; 95 % confidence interval [ CI ] , 0.01 - 0.76 ) and had a lower occurrence rate of pneumonia ( 2 % vs 10 % , RR , 0.19 ; 95 % CI , 0.04 - 0.88 ; P = .02 ) , infection ( 3 % vs 10 % , RR , 0.27 ; 95 % CI , 0.07 - 0.94 ; P = .03 ) , and sepsis ( 2 % vs 9 % ; RR , 0.22 ; 95 % CI , 0.04 - 0.99 ; P = .03 ) than did patients treated with oxygen alone . Patients who received oxygen plus continuous positive airway pressure also spent fewer mean ( SD ) days in the intensive care unit ( 1.4 [ 1.6 ] vs 2.6 [ 4.2 ] , P = .09 ) than patients treated with oxygen alone . The treatments did not affect the mean ( SD ) days that patients spent in the hospital ( 15 [ 13 ] vs 17 [ 15 ] , respectively ; P = .10 ) . None of those treated with oxygen plus continuous positive airway pressure died in the hospital while 3 deaths occurred among those treated with oxygen alone ( P = .12 ) . CONCLUSION Continuous positive airway pressure may decrease the incidence of endotracheal intubation and other severe complications in patients who develop hypoxemia after elective major abdominal surgery Objective An investigation into the incidence of post-operative complications after thoracic surgery with  3 different physiotherapy masks . Design A prospect i ve , consecutive , r and omized comparison . Setting Department of Thoracic and Heart Surgery at a University Hospital . The treatments were performed by experienced and specially trained physiotherapists . Patients 160 patients were evaluated . 60 patients undergoing heart surgery , 59 patients having pulmonary resection , and 41 patients with exploratory thoractomy . Interventions In each operative category the patients were treated with one of three face mask systems used in addition to routine chest physiotherapy . These were either continuous positive airway pressure ( CPAP ) , positive expiratory pressure ( PEP ) , or inspiratory resistance — positive expiratory pressure ( IR-PEP ) . Measurements and results Post-operative pulmonary complications were assessed by forced vital capacity ( FVC ) , arterial oxygen tension ( PaO2 ) , and chest X-ray examination , all measured pre-operatively and on the fourth and ninth post-operative day . The patients filled in a question naire expressing their opinion about their mask treatment . There was an equal decrease in FVC , FVC% , and PaO2 , and equal frequency of atelectasis in the 3 mask treatments . More patients with the PEP mask favoured their system than did those with the other 2 systems . Conclusion There was no statistically significant difference between the treatments : continuous positive airway pressure ( CPAP ) , positive expiratory pressure ( PEP ) , and inspiratory resistance — positive expiratory pressure ( IR-PEP ) on post-operative complications . Any of the three treatments may be used as supplement to st and ard chest physiotherapy Objective To develop and vali date a preoperative risk index for predicting  postoperative respiratory failure ( PRF ) .  Summary Background Data Respiratory failure is an important postoperative complication . Method Based on a prospect i ve cohort study , cases from 44 Veterans Affairs Medical Centers ( n = 81,719 ) were used to develop the models . Cases from 132 Veterans Affairs Medical Centers ( n = 99,390 ) were used as a validation sample . PRF was defined as mechanical ventilation for more than 48 hours after surgery or reintubation and mechanical ventilation after postoperative extubation . Ventilator-dependent , comatose , do not resuscitate , and female patients were excluded . Results PRF developed in 2,746 patients ( 3.4 % ) . The respiratory failure risk index was developed from a simplified logistic regression model and included abdominal aortic aneurysm repair , thoracic surgery , neurosurgery , upper abdominal surgery , peripheral vascular surgery , neck surgery , emergency surgery , albumin level less than 30 g/L , blood urea nitrogen level more than 30 mg/dL , dependent functional status , chronic obstructive pulmonary disease , and age . Conclusions The respiratory failure risk index is a vali date d model for identifying patients at risk for developing PRF and may be useful for guiding perioperative respiratory care Pulmonary lesions following extracorporeal circulation ( ECC ) are said to be responsible for decreased functional residual capacity ( FRC ) . Weaning from controlled mechanical ventilation ( CMV ) in the postoperative period is commonly performed by a CPAP system in order to restore the impaired oxygen exchange . Testing the superiority of CPAP against insufflation at atmospheric pressure ( ZEEP ) , 33 patients after coronary bypass grafting ( CABG ) underwent from the end of CMV till extubation either CPAP  or ZEEP in a r and omized distribution . Data sampling included respiratory rate , paO2 , paCO2 and AaDO2-Quotient ( gas exchange ) , as well as HR , MAP , CVP and LAP ( hemodynamics ) . None of the obtained data showed statistical significant differences between the CPAP and the ZEEP group . Therefore there appears to be no necessity for CPAP when weaning CABG patients , due to the absence of previous lung damage and the short time range of intubation and CMV Pulmonary complications are frequently seen after thoracoabdominal resection of the oesophagus . The aim of this study was to compare the effects of two different breathing exercise regimens applied in the immediate postoperative period on the risk of pulmonary insufficiency after thoracoabdominal resection Objective : To observe the nosocomial infection ( NI ) distribution in ventilated patients of a single intensive care unit ( ICU ) according to the kind of control of the upper airways :  noninvasive positive pressure ventilation ( NPPV ) versus endotracheal intubation ( ETI ) . Setting : ICU of a general hospital . Design : Prospect i ve clinical and epidemiologic survey . Patients : In the period December 1994–March 1997 , 761 patients were included who needed mechanical ventilation for more than 48 h : 129 were ventilated by NPPV ( NPPV group ) , 607 were intubated ( ETI group ) and 25 required intubation after a period of NPPV ( NPPV-ETI group ) . Measurements and results : The data used were prospect ively collected according to the NI epidemiologic surveillance protocol of “ C. CLIN Sud Est , Réa Sud Est ” , France . NI included a ventilator-associated pneumonia ( VAP ) , catheter-related infection , urinary tract infection and bacteremia . Occurrence of NI was estimated by the density of incidence . Covariate-adjusted NI and VAP risk factors were assessed by the Cox model . The incidence density of total NI was lower for NPPV than for ETI ( 14.2 versus 30.3 per 1000 patient-days , p < 0.01 ) . The Cox model showed that the use of noninvasive ventilation , adjusted to the severity of illness ( SAPS II ) , reduced not only the VAP risk ( hazard ratio ( HR ) = 4.07 ) but also the NI risk ( HR = 1.95 ) . Conclusion : The use of NPPV reduces the risk of VAP and NI , compared to ETI , irrespective of the severity of the patient 's illness Introduction This r and omized controlled study evaluated the clinical benefit and physiological effects of prophylactic chest physiotherapy in open major abdominal surgery Background : Coronary artery bypass graft ( CABG ) surgery with the use of mammary arteries is associated with severe alteration of lung function parameters . The purpose of the present study was to compare the effect on lung function tests of conventional physiotherapy using incentive spirometry ( IS ) with non‐invasive ventilation on continuous positive airway pressure ( CPAP ) and with non‐invasive ventilation on bilevel positive airway pressure ( BiPAP or NIV‐2P ) Pulmonary oxygen transfer , defined by PaO2/FIO2 , and radiologic presence of atelectasis were measured pre- , intra- , and postoperatively to postoperative day 9 in elective cardiac aortocoronary bypass surgical patients , who were r and omly allocated either to receive 18 h PEEP while on the ventilator followed by 12 h of nasal continuous positive airway pressure ( nasal CPAP ) or  to  be control subjects .  The two groups were comparable in age , sex , forced expiratory volume in 1 sec ( FEV1 ) , the ratio of FEV1 over forced vital capacity ( FVC ) , time on pump , units of blood transfused , New York Heart Association grading , and cardiac performance indices . The PaO2/FIO2 was significantly ( p less than .05 ) better from half an hour after extubation until 24 h postextubation in the nasal CPAP group , but was decreased for the remainder of the study in both groups . Incidence of atelectasis/consolidation was not different in both groups during the study period . We conclude that nasal CPAP is well tolerated as a treatment of hypoxemia in the immediate postoperative period of aortocoronary bypass patients . CPAP does not change the course of postoperative atelectasis Background After major surgery , analgesia with opioids can cause obstructive apnea and intermittent hypoxemia , probably from loss of upper airway control . Since this resembles the obstructive sleep apnea syndrome , we tested the possibility that nasal continuous positive airway pressure ( nCPAP ) would reduce episodes of reduced oxygen saturation and sleep disruption . Because oxygen therapy is frequent after surgery , we also assessed the effect of oxygen on sleep disruption . Methods We recruited 48 patients about to have major abdominal surgery . We present data for 34 patients : 27 who received patient-controlled intravenous morphine and 7 who received epidural opioid .  Treatment was r and omized to either nCPAP or conventional therapy with an oxygen mask . Alternate periods of administration of air and 35 % oxygen were used in both groups . If the oxygen saturation as measured by pulse oximetry was consistently < 90 % on air , the patient was withdrawn from the study . We measured sleep , arousals , oxygenation , episodes of desaturation , and disturbances of respiration . Values are given as median and quartiles . Results The median proportion of time awake was 65 % ( 45–79 % ) among control patients and 74 % ( 55–87 % ) among those undergoing nCPAP . Oxygen administration did not affect the sleep pattern . The median frequency of arousals per hour of sleep was very similar in each group : during air breathing from nCPAP , 125 ( 76–187 ) , and during air breathing by mask , 116 ( 84–187 ) . Oxygen therapy had no effect . Oxygenation and hypoxemic events were not improved by nCPAP . Oxygen therapy improved oxygenation and reduced but did not eliminate episodes of desaturation . Conclusions Nasal CPAP does not improve sleep and oxygenation or reduce hypoxemic events in the first night after major abdominal surgery Background Alveolar macrophages are a critical part of the defense against pulmonary infection . Thus the authors determined time‐dependent changes in alveolar macrophage functions in patients having surgery who were anesthetized with isoflurane or propofol .  Methods Patients anesthetized with propofol ( n = 30 ) or isoflurane ( n = 30 ) during orthopedic surgery were studied . Alveolar macrophages were harvested by bronchoalveolar lavage immediately , and 2 , 4 , and 6 h after induction anesthesia and at the end of surgery . The fraction of aggregated and nonviable macrophages was determined . Then phagocytosis was measured by ingestion of opsonized and unopsonized particles . Finally , microbicidal activity was determined as the ability of the macrophages to kill Listeria monocytogenes directly . Results Demographic and morphometric characteristics of the patients given propofol and isoflurane were similar , as were their levels of pulmonary function and hemodynamic responses . The fraction of alveolar macrophages ingesting opsonized and unopsonized particles , and the number of particles ingested , decreased significantly over time , with the decrease slightly but significantly greater during isoflurane anesthesia . Microbicidal function decreased progressively during anesthesia and surgery , with the decrease almost twice as great during isoflurane compared with propofol anesthesia . The fraction of aggregated macrophages and recovered neutrophils increased over time in the patients given each anesthetic . Conclusions Pulmonary immunologic function changed progressively during anesthesia and surgery . The data from this study suggest that pulmonary defenses are modulated by the type of anesthesia and by the duration of anesthesia and surgery Controversy exists regarding the routine use of aids to lung expansion in the prevention of pulmonary complications after abdominal surgery . We prospect ively r and omized 172 patients into 1 of 4 groups : the  control group ( 44 patients ) received no respiratory treatment  , the IPPB  group ( 45 patients ) received intermittent positive pressure breathing therapy for 15 min 4 times daily , the IS group ( 42 patients ) was treated with incentive spirometry 4 times daily , and the DBE group ( 41 patients ) carried out deep breathing exercises under supervision for 15 min 4 times daily . Roentgenographic changes , observed 24 h after surgery , were comparable in the 4 groups ( 20.5 to 36.6 % ) . Pulmonary complications were defined as the development of 3 or more of 6 new findings : cough , phlegm , dyspnea , chest pain , temperature greater than 38 degrees C , pulse rate more than 100 beats/min . The frequency of development of pulmonary complications was 48 % in the control group , 22 % in the IPPB group ( p less than 0.05 ) , 21 % in the IS group ( p less than 0.05 ) , and 22 % in the DBE group ( p less than 0.05 ) . Side effects of respiratory treatment were observed only in the IPPB group ( 18 % ; p less than 0.05 ) . Hospital stay in patients undergoing upper abdominal surgery was significantly shorter in the IS group ( mean + /- SD , 8.6 + /- 3 days ) than in the control group ( 13 + /- 5 days ) . This difference was not observed for the other 2 treatment groups . ( ABSTRACT TRUNCATED AT 250 WORDS Two hundred and seventeen patients undergoing digestive tract surgery , either r and omly or non-r and omly allocated in two separate groups , and presenting postoperative hypoxemia , were studied during intensive care : 77 were ventilated by continuous positive pressure ( CPP ) , 70 by intermittent positive pressure ( IPP ) , and 70 were treated by classical respiratory physiotherapy . Results showed that CPP was the method of choice for ventilatory assistance following digestive tract surgery : hematosis was improved in a prolonged manner without modification of CO2 levels . The other procedures had a beneficial effect on PaO2 but at the price of a hyperventilation .  Patients receiving IPP developed hypocapnea and hypoxemia five minutes after the end of the treatment . Physiopathological bases for these differences in gasometric behaviour in patients undergoing digestive tract surgery are analyzed as a function of the characteristics of CPP on the one h and , and IPP and respiratory physiotherapy on the other The problem of how to improve postoperative pulmonary function after upper abdominal surgery was investigated in a r and omized study involving 64 patients who were subjected to various treatment regimens design ed to increase airway pressure .  Intraoperative ventilation was carried out with either zero or positive end exspiratory pressure , and postoperatively either CPAP or a nasal oxygen catheter were applied . The following groups were formed : 1 . ZEEP /O2-catheter ; 2 . PEEP/O2-catheter ; 3 . ZEEP /CPAP ; 4 . PEEP/CPAP . The typical reduction in vital capacity occurred postoperatively , the lowest value being recorded on the 2nd postoperative day , an alteration in respiratory pattern with reduced tidal volume and increased respiratory rate together with an initially low , later normal alveolar ventilation , and an initial hypoxaemia which was at first associated with a moderate hypercapnia , on the second postoperative day with a normocapnia , were observed . At no point in time could a difference be found between the 4 groups , no measurable improvement in respiratory function being found as a result of the treatment given . Intra- and post-operative increase in airway pressure was however found to be associated with a reduction in the incidence of post-operative pulmonary complications Abstract After intubation for elective upper abdominal surgery 30 patients were r and omized in group A or B. Both groups had the same anaesthetics and were ventilated with a tidal volume of 12 ml/kg the rate keeping PaCO2 near 40 mm Hg . Group A was ventilated with ZEEP and group B with PEEP 10 cm H2O . Group A was extubated when VC reached 15 ml/kg and PaCO2 did not exceed 50 mm Hg breathing spontaneously . Group B was allowed to breathe spontaneously with CPAP and PEEP 5 cm H2O ( Basel PEEP-WeanerR ) for 3 hours before extubation . Measurements : BP , PAP , RAP , HR , Hb , arterial and mixed-venous blood gases with FIO2=0,21 . Both groups were similar in age , sex , cigarette consumption , preoperative pulmonary pathology , surgical procedure pathology , surgical procedure and time of operation . Results : RAP , PAP , BP , HR , PaCO2 , PaH , Pv−O2 did not show important differences . Mean PaO2 changed as follows : Postoperative chest X-rays showed in Group A a total of 56 negative scores , in Group B 25 . Conclusion : After upper abdominal surgery the well known decrease of FRC with its increased venous admixture can be prevented if the patient is ventilated with PEEP during operation and is breathing spontaneously with CPAP and PEEP for 3 postoperative hours before extubation Thirty patients who underwent coronary artery bypass grafting were r and omized to receive 30 % oxygen by mask either with an ambient airway pressure or with 7.4 mmHg ( 1 kPa ) continuous positive airway pressure ( CPAP ) for 8 h after extubation . Arterial blood oxygen tension ( Pao2 ) decreased remarkably in the control group after extubation ( from 19.2± 5.3 kPa to 12.4 ± 2.7 kPa ) but less in the CPAP group ( from 16.4 ± 3.3 kPa to 14.0 ± 2.1 kPa ) . On the second postoperative morning Pao2 was equally low in both groups ( control : 8.4 ± 1.5 kPa , CPAP : 8.9 ± 1.9 kPa ) . Atelectatic areas were seen with similar frequency in both groups , 17 % ( whole material ) on the first and 50 % on the second postoperative morning . Atelectasis was more common in patients with internal thoracic artery grafting and /or pleural drainage . In conclusion , CPAP therapy was well tolerated , and minimized the decrease in Pao2 after extubation , but could not prevent the poor oxygenation or the late development of atelectatic areas on the second postoperative day Of 38 patients undergoing median sternotomy for cardiac operations all developed profound restrictive defects in pulmonary function during the first 72 h after tracheal extubation . Although decreased lung volumes were refractory to correction by vigorous , aggressive pulmonary therapy during this period , frequent and supervised treatment may prevent further deterioration in pulmonary function . The overall incidence of pneumonia was only 3 % ( 1/38 ) . Continuous positive airway pressure delivered by mask proved to be a nearly effortless form of postoperative respiratory therapy that was less painful than incentive spirometry or coughing and deep breathing , and therefore may be preferable The objective of this study was to define the relationship between respiratory insufficiency ( RI ) and various putative risk factors for patients undergoing abdominal surgery .  A review of 1332 adults undergoing abdominal surgery  was undertaken . Information was collected in a unbiased , prospect i ve and uniform manner with regard to baseline characteristics , perioperative events and adverse outcomes after surgery . Respiratory Insufficiency was defined as either : a PO2 < 60 mm Hg , the performance of a  tracheotomy  , or  endotracheal intubation for more than 24 h. The incidence of RI was 3 % ( 40/1332 ) . A logistic regression analysis only identified an American Society of Anesthesia ( ASA ) classification > 2 ( P < 0.001 ) and the presence of chronic bronchitis ( P ( P < 0.05 ) as significant risk factors . In addition , 33 % ( 8/24 ) of the patients who developed postoperative intraperitoneal sepsis and 30 % ( 14/47 ) of the patients who underwent a reoperation developed RI . It was concluded that patients with a significant systemic disease ( ASA > 2 ) , as well as patients with chronic bronchitis , should be the recipients of intense efforts to prevent pulmonary complications after abdominal surgery 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 r and omly 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 OBJECTIVE To examine medical outcomes associated with reintubation for extubation failure after discontinuation of mechanical ventilation . DESIGN Prospect i ve cohort study of consecutive intubated medical ICU patients who underwent a trial of extubation at a tertiary-care teaching hospital . The failed extubation group consisted of all patients reintubated within 72 h or within 7 days ( if continuous ICU care had been required ) of extubation . All others were considered to be successfully extubated . Study end points included hospital death vs survival , the number of days spent in the ICU and in the hospital after the onset of mechanical ventilation , the likelihood of requiring > or = 7 or > or = 14 days of ICU care after extubation , and the need for transfer to either a long-term care or rehabilitation facility among the survivors . RESULTS Of 289 intubated patients , 247 ( 85 % ) were successfully extubated , and 42 ( 15 % ) required reintubation for failed extubation ( time to reintubation 1.5+/-0.2 days ) . Reintubation for extubation failure result ed in 12 additional days of mechanical ventilation . When compared with successfully extubated patients , reintubated patients were more likely to die in the hospital ( 43 % vs 12 % ; p<0.0001 ) , spend more time in the ICU ( 21.2+/-2.8 days vs 4.5+/-0.6 days ; p<0.001 ) and in the hospital ( 30.5+/-3.3 days vs 16.3+/-1.2 days ; p<0.001 ) after extubation , and require transfer to a long-term care or rehabilitation facility ( 38 % vs 21 % ; p<0.05 ) . Using multiple logistic regression , extubation failure was an independent predictor for death and the need for transfer to a long-term care facility . Compared with those successfully extubated , patients who failed extubation were seven times ( p<0.0001 ) more likely to die , 31 times ( p<0.0001 ) more likely to spend > or = 14 days in the ICU after extubation , and six times ( p<0.001 ) more likely to need transfer to a long-term care or rehabilitation facility if they survived . CONCLUSION After adjusting for severity of illness and comorbid conditions , extubation failure had a significant independent association with increased risk for death , prolonged ICU stay , and transfer to a long-term care or rehabilitation facility . Extubation failure may serve as an additional independent marker of severity of illness . Alternatively , poor outcomes may be etiologically related to extubation failure . If the latter proves to be the case , identifying patients at risk for poor outcomes from extubation failure and instituting alternative care practice s may reduce mortality , duration of ICU stay , and need for transfer to a long-term care facility
OBJECTIVE We evaluated the potential benefit of continuous positive airway pressure ( CPAP ) to prevent postoperative pulmonary complications ( PPCs ) , atelectasis , pneumonia , and intubation in patients undergoing major abdominal surgery .
SUMMARY BACKGROUND DATA PPCs are common during the postoperative period and may be associated with a high morbidity rate .
Efficacy of CPAP to prevent PPCs occurrence is controversial .