Impact of non-invasive ventilation immediately after extubation on clinical and functional outcomes in patients submitted to coronary artery bypass grafting: a clinical trial
Background: The use of non-invasive ventilation (NIV) after coronary artery bypass grafting (CABG) may help reduce loss of functional capacity and complications in patients. However, the evidence regarding its immediate versus conventional use is controversial.
Aim: The aim of the study was to assess the impact of immediate NIV after extubation on oxygenation and the functional capacity of patients undergoing CABG.
Methods: This study was a randomized clinical trial involving patients of both sexes, aged 18 years or older, who have undergone elective CABG with median sternotomy and cardiopulmonary bypass. Patients were assessed before and after surgery using the Functional Independence Measure (FIM), 6-min walk test (6MWT), and the Medical Research Council (MRC) scale for peripheral muscle strength. On the 1st day after the surgery, two groups were formed: immediate NIV (NIVI) and conventional NIV (NIVC). Hemogasometry was performed before and after NIV, and complication rates were assessed. NIVI was administered 1 h after orotracheal extubation, while NIVC was performed on the first post-operative day, 24 h after extubation. After discharge, the above variables were re-evaluated.
Results: A total of 79 patients were evaluated; 46 (58.22%) were men, with a mean age of 65 ± 9 years. NIVI reduced the reintubation rate in one patient (3%) compared to NIVC with five patients (12%) (p = 0.01). In the post-intervention period, the inspired oxygen fraction (FIO2) was 0.43 ± 0.07 in the NIVC group and 0.30 ± 0.10 in the NIVI group (p = 0.01). The post-intervention PaO2/FIO2 ratio was 191 ± 45 in the NIVC group and 266 ± 29 in the NIVI group (p < 0.001); the ratio one day later was 210 ± 39 in the NIVC group and 279 ± 37 in the NIVI group (p < 0.001). From the 6MWT, the INVI group reported a reduction of 51 ± 36 m compared to a reduction of 95 ± 40 m in the NIVC group (p < 0.01).
Conclusion: NIVI after extubation of patients undergoing CABG reduced the loss of functional capacity, improved blood gas levels, and decreased the rate of reintubation.
Relevance for Patients: This study suggests that the use of NIVI after extubation in patients undergoing CABG may improve recovery, preserve lung function, and reduce complications such as reintubation.
[1] Daltro FMS, De Seixas Rocha M, Oliveira L. Effectiveness of positive expiratory pressure on the vital capacity of patients undergoing myocardial revascularization. Rev Bras Fisioter. 2010;14(S1):450.
[2] Lawton JS, Tamis-Holland JE, Bangalore S, Bates ER,Beckie TM, Bischoff JM, et al. 2021 ACC/AHA/SCAI guideline for coronary artery revascularization: Executive summary: A report of the American college of cardiology/ American heart association joint committee on clinical practice guidelines. Circulation 2022;145:e4-e17.doi: 10.1161/CIR.0000000000001039. Erratum in: Circulation 2022;145:e771.
[3] Renault JA, Costa-Val R, Rossetti MB. Respiratory physiotherapy in the pulmonary dysfunction after cardiac surgery. Rev Bras Cir Cardiovasc 2008;23:562-9.doi: 10.1590/s0102-76382008000400018 [Article in English, Portuguese].
[4] Smith J, Jones M, Brown L. Muscle strength and pulmonary function decline post-cardiac surgery: A longitudinal study. J Cardiothorac Surg 2019;14:45.
[5] Pieczkoski SM, Margarites AGF, Sbruzzi G. Noninvasive ventilation during immediate postoperative period in cardiac surgery patients: Systematic review and meta- analysis. Braz J Cardiovasc Surg 2017;32:301-311.
doi: 10.21470/1678-9741-2017-0032
[6] Borges DL, Nina VJS, Costa MAG, Baldez TE,Santos NP, Lima IM, et al. Effects of different PEEP levels on respiratory mechanics and oxygenation after coronary artery bypass grafting. Braz J Cardiovasc Surg 2013;28:380-385.
doi: 10.5935/1678-9741.20130058
[7] Ferreira LL, Souza NMD, Vitor ALR, Bernardo AFB,Valenti VE, Vanderlei LCM. Ventilação mecânica não-invasiva no pós-operatório de cirurgia cardíaca: Atualização da literatura. Braz J Cardiovasc Surg 2012;27:446-52.
doi: 10.5935/1678-9741.20120074
[8] Esquinas AM, Gill H, Mina B. Postoperative noninvasive ventilation in patients undergoing coronary artery bypass grafting: A small step with great repercussions. J Thorac Cardiovasc Surg 2013;146:1299.
doi: 10.1016/j.jtcvs.2013.06.053
[9] Méndez VMF, Oliveira MF, Baião ADN, Xavier PA,Gun C, Sperandio PA, et al. Hemodynamics and tissue oxygenation effects after increased in positive end- expiratory pressure in coronary artery bypass surgery. Arch Physiother 2017;7:2.
doi: 10.1186/s40945-016-0030-4
[10] Esquinas AM, De Santo LS. Noninvasive ventilation after surgical myocardial revascularization for left- ventricular dysfunction: A hypothesis-generating study.Respir Care 2019;64:115-6.
doi: 10.4187/respcare.06510
[11] Guizilini S, Viceconte M, Esperança GT, Bolzan DW,Vidotto M, Moreira RS, et al. Pleural subxyphoid drain confers better pulmonary function and clinical outcomes in chronic obstructive pulmonary disease after off-pump coronary artery bypass grafting: A randomized controlled trial. Rev Bras Cir Cardiovasc 2014;29:588-94.
doi: 10.5935/1678-9741.20140047
[12] Barbas CV, Isola AM, Farias AM, Cavalcanti AB,Gama AMCD. Diretrizes brasileiras de ventilação mecânica. Associação de medicina intensiva brasileira e sociedade brasileira de pneumologia e tisiologia. Parte 2. J Bras Pneumol São Paulo 2013; 1:1-140.
doi: 10.5935/0103-507X.20140017
[13] ATS Committee on Proficiency Standards for Clinical Pulmonary Function Laboratories. ATS statement: Guidelines for the six-minute walk test. Am J Respir Crit Care Med 2002;166:111-7.
doi: 10.1164/ajrccm.166.1.at1102
[14] Riberto M, Miyazaki MH, Jucá SSH, Sakamoto H, Pinto PPN, Battistela LR. Validation of the Brazilian version of the functional independence measure. Acta Fisiatr 2004;11(2):72-6.
doi: 10.5935/0104-7795.20040003
[15] Medical Research Council. Aids to the Investigation of Peripheral Nerve Injuries. War Memorandum. 2nd ed. London: HMSO; 1943.
[16] De Araújo-Filho AA, De Cerqueira-Neto ML, Cacau LA,Oliveira GU, Cerqueira TC, De Santana-Filho VJ. Effect of prophylactic non-invasive mechanical ventilation on functional capacity after heart valve replacement: A clinical trial. Clinics 2017;72:618-23.
doi: 10.6061/clinics/2017(10)05
[17] Landoni G, Zangrillo A, Cabrini L. Noninvasive ventilation after cardiac and thoracic surgery in adult patients: A review. J Cardiothorac Vasc Anesth 2012;26:917-22.
doi: 10.1053/j.jvca.2011.06.003
[18] Reis HV, Borghi-Silva A, Catai AM, Reis MS. Impact of CPAP on physical exercise tolerance and sympathetic- vagal balance in patients with chronic heart failure. Braz J Phys Ther 2014;18:218-27.
doi: 10.1590/bjpt-rbf.2014.0037
[19] Franco AM, Torres FC, Simon IS, Morales D,Rodrigues AJ. Avaliação da ventilação não-invasiva com dois níveis de pressão positiva nas vias aéreas após cirurgia cardíaca. Rev Bras Cir Cardiovasc 2011;26(4):582-90.
doi: 10.5935/1678-9741.20110048
[20] Gremeaux V, Troisgros O, Benaïm S, Hannequin A,Laurent Y, Casillas JM, et al. Determining the minimal clinically important difference for the six-minute walk test and the 200-meter fast-walk test during cardiac rehabilitation program in coronary artery disease patients after acute coronary syndrome. Arch Phys Med Rehabil 2011;92:611-9.
doi: 10.1016/j.apmr.2010.11.023
[21] Nasrala MLS, Bolzan DW, Lage YG, Prado FS, Arena R,Lima PRL, et al. Extended-time of noninvasive positive pressure ventilation improves tissue perfusion after coronary artery bypass surgery: A randomized clinical trial. Braz J Cardiovasc Surg 2018;33:250-7.
doi: 10.21470/1678-9741-2017-0232
[22] Shoji CY, Figuereido LCD, Calixtre EM, Rodrigues CDA,Falcão ALE, Martins PP, et al. Reintubation of patients undergoing cardiac surgery: A retrospective analysis.Rev Bras Ter Intensiva 2017;29:180-187.
doi: 10.5935/0103-507X.20170028
[23] Wu Q, Xiang G, Song J, Xie L, Wu X, Hao S, et al.Effects of non-invasive ventilation in subjects undergoing cardiac surgery on length of hospital stay and cardiac- pulmonary complications: A systematic review and meta-analysis. J Thorac Dis 2020;12:1507-19.
doi: 10.21037/jtd.2020.02.30
[24] Zarbock A, Mueller E, Netzer S, Gabriel A, Feindt P,Kindgen-Milles D. Prophylactic nasal continuous positive airway pressure following cardiac surgery protects from postoperative pulmonary complications: A prospective, randomized, controlled trial in 500 patients. Chest 2009;135:1252-9.
doi: 10.1378/chest.08-1602
[25] Cordeiro ALL, Gruska CA, Ysla P, Queiroz A,Nogueira SCO, Leite MC, et al. Effect of different levels of peep on oxygenation during non-invasive ventilation in patients submitted to CABG surgery: Randomized clinical trial. Braz J Cardiovasc Surg 2017;32:295-300.
doi: 10.21470/1678-9741-2016-0038
[26] Liu Q, Shan M, Liu J, Cui L, Lan C. Prophylactic noninvasive ventilation versus conventional care in patients after cardiac surgery. J Surg Res 2020;246:384-94.
doi: 10.1016/j.jss.2019.09.008
[27] Laizo A, Delgado FEF, Rocha GM. Complications that increase the length of stay in the intensive care unit in cardiac surgery. Braz J Cardiovasc Surg 2010;25:166-71.
doi: 10.1590/S0102-76382010000200007
[28] Cabrini L, Plumari VP, Nobile L, Olper L, Pasin L,Bocchino S, et al. Non-invasive ventilation in cardiac surgery: A concise review. Heart Lung Vessel 2013;5: 137-41.