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Standard treatment
Lung resections were performed according to standard techniques. Anesthesia procedure do
not include placement of gastric tube. Routine operative and post-operative care was to avoid
high tidal volume use and to maintain a negative fluid balance. All patients were extubated
early (“fast trach extubation”), i.e. either in the theatre at the end of the operation or shortly
(less than 30 minutes) after in the recovery room.
Perioperative antimicrobial prophylaxis with amoxicillin/clavulanate, 2 g q8h for 24h, or
Cefamandol 750 mg q6h for 48h was administered routinely. Continuous negative pressure (10 to - 20 cm H2O) was applied to the pleural drainage system (Pleurevac; DSP Worldwide)
except for pneumonectomy where no suction was applied. Chest tube was withdrawn on day 2
after pneumonectomy and in between days 3 and 5 after other lung resections. All patients
received oxygen supplementation to achieve a SaO2 value above 90% (or above 92% in case
of coronary heart disease), aerosolised bronchodilatators, and chest physiotherapy. Prevention
of venous thromboembolism included low molecular weight heparin and graduating
compression stocking. Postoperative pain was assessed with a visual analogy scale, and
achieved with continuous intravenous or epidural Patient Controlled Analgesia (PCA). No
patients received peri-dural anesthesia. Oral re-alimentation was started on postoperative day
2 after pneumonectomy and on postoperative day 1 for all other types of surgical procedures.
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Noninvasive ventilation modalities:
Noninvasive ventilation was explained to the patient before application.
Non Colloid dressings (Duoderm°) were applied on pressure points (nasal) to avoid the risk of
local injuries by either nasal (PROFILETMLITE Ref 1006317 Respironics®, Murrysfield,
USA), or facial masks (Performa TrackTMSE Ref 1012641 Respironics®, Murrysfield, USA).
Positive inspiratory pressure was delivered by the following ventilators according to
the physician choice and availability: EVITA 2 ou 4 (Dräger® Lübeck, Germany) or Bipap
Vision (Respironics®, Murrysfield, USA), using two modes of ventilation according to the
ventilator used. Pressure support mode was used on EVITA 2 or 4 (Dräger® Lübeck,
Germany) ventilators, and Pressure support ventilation on Bipap Vision ventilator
(Respironics®, Murrysfield, USA) with a backup respiratory rate of 10 mn-1. In patients
ventilated with BiPAP Vision, we used the disposable circuit (single patient use), including a
disposable exhalation port and a calibrate exhaust vent Ref 582072, Respironics®,
Murrysfield, USA Careful attention was made to minimize air leaks around the mask and
reassure the patient during NIV. NIV was actually administered at least 8 hours a day, but this
duration was modulated according to the patient’s clinical status and gas exchange data: if
clinical status or gas exchange deterioration occurred during the NIV-free interval, patients
were returned to NIV. Altogether, NIV was applied as long as necessary to obtain a
respiratory rate < 25/mn and SaO2>90% between NIV periods.
2
Definitions:
Initial NIV positive response was defined by clinical and arterial blood gas (ABG) exchange
improvement after the initial NIV attempt, within the first 6 hours. Clinical improvement
included reduction of respiratory rate, reduction in the use of accessory muscle, hypercapnic
signs disappearance, and good tolerance. ABG improvement was defined as SaO2>92% with
Venturi mask FiO2<45%, and a decreased in PaCO2 greater than 5mmHg associated with
improvement in pH value.
Pneumonia was diagnosed by the presence of new and/or progressive pulmonary infiltrates on
chest radiography, plus two or more of the following criteria: fever (> 38°C), leukocytosis (>
12x109/L), purulent sputum, or isolation of pathogen in respiratory secretions (≥107/ml in
sputum, ≥105 in aspiration, ≥104 in BAL ≥103 in PSB). When pulmonary infiltrates were
present, sputum was collected whenever possible. When no sputum could be recovered,
bronchoscopy was systematically performed during NIV-free period or during NIV with a
special mask.
Lower respiratory tract infection was defined as the presence of purulent tracheobronchial
secretions plus two or more of the following criteria: fever (>38°C), leukocytosis
(>12x109/L), or significant bacteriologic counts in respiratory secretions, without new
pulmonary infiltrates on the chest radiography.
Sputum retention was defined as an inability to expectorate in a patient with ARF while
auscultation found marked bronchial rales
Atelectasis was defined by reduction in lung volume, loss of aeration and displacement in
interlobar fissures on chest radiography, with a rapid improvement after Fiberoptic
bronchoscopy and/or chest physiotherapy and/or mechanical ventilation.
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Wound infection was defined as a reddened, painful, and indurated wound not necessary
associated with bacteria isolation.
Alveolar hypoventilation was defined based on a PaCO2>50mmHg with a low respiratory
rate (<12/min).
Empyema was defined as the presence of purulent fluid in the pleural drainage or as the
isolation of pathogens from the pleural cavity.
Pleural air leaks were defined by prolonged air leaks> 4 days, and/or air leaks interfering with
the ability to ventilate correctly.
Gastric distension was clinically evaluated by the clinician and confirmed by abdominal
radiography, and acute colonic pseudo-obstruction (ACPO) is defined by abdominal
distension with massive dilation of the colon in the absence of mechanical obstruction.
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Table1: Characteristics of the patients admitted in the medical or surgical ICU
Characteristics
Medical ICU
N = 63 (70.7%)
61.4 + 11
Surgical ICU
N = 26 (29.2%)
61.5 + 10.7
P value
Age, yr, mean + SD
Total population
N = 89
61.4 + 10.8
Male gender, No (%)
79 (88.7%)
56 (88.8)
23 (88.4)
0.95
28.9 + 9
28.2 + 9.7
30.5 + 7.1
0.27
ASA III + IV, No (%)
56 (62.9%)
42 (66.6)
14 (53.8)
0.25
CCI score, mean + SD
1.69 + 1.38
1.79 + 1.35
1.46 + 1.44
0.30
COPD, No (%)
51 (57.3%)
36 (57.1)
15 (57.6)
0.84
FEV1, ml, mean + SD
2135 + 8.8
2047 +798
2365 + 808
0.1
FEV1,%ref, mean + SD
70.3 + 22.4
68.7 + 23
74 +19
0.35
FEV1/FVC (%)
65 + 20
60 + 19
67 + 22
0.3
Preoperative PaCO2
38 + 5.3
38 + 3.9
38 + 9
0.96
Cardiac disease, No (%)
40 (44.9%)
32 (50.7)
8 (30.7)
0.08
Diabete mellitus, No (%)
13 (14.6%)
9 (14.2)
4 (15.3)
0.89
Extent of resection, n (%)
Pneumonectomy
Lobe/ bilobectomy
Segmentectomy
Lung volume reduction
Others
11 (12.3%)
57 (64%)
11 (12.3%)
5 (5.6%)
5 (5.6%)
6 (9.5%)
39 (61.9%)
8 (12.6%)
5 (7.9%)
5 (7.9%)
5 (19.2%)
18 (69.2%)
3 (11.5%)
0
0
SAPSII at ICU admission,
0.94
mean + SD
(mmHg), mean + SD
0.33
SAPS, Simplified Acute Physiologic score; ASA, American Society of Anesthesiologists;
CCI, Charlson comorbidity index; COPD, Chronic obstructive pulmonary disease; FEV1,
forced expiratory volume
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Table 2: Complications observed during NIV:
Complications
Total
Infectious complications
Pneumonia
Lower respiratory tract infection
N ( %)
33 (37%)
17 (19.1%)
11 (12.3%)
2 (2.2%)
Empyema
1
Bacteremia
1
Severe sepsis with other sources
2
Non infectious complications :
16 (17.9%)
Gastric distension
3 (3.3%)
ACPO
4 (4.4%)
Supraventricular arrhythmia
3 (3.3%)
Acute pulmonary edema
3 (3.3%)
Persistent pleural air leak
1
NIV intolerance
1
Skin ulceration
1
ACPO, Acute colonic pseudo obstruction
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