Direct extubation onto high-flow nasal cannulae post-cardiac surgery versus standard treatment in patients with a BMI ≥30: a randomised controlled trial
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Patients with a body mass index (BMI) ≥30 kg/m2 experience more severe atelectasis following cardiac surgery than those with normal BMI and its resolution is slower. This study aimed to compare extubation of patients post-cardiac surgery with a BMI ≥30 kg/m2 onto high-flow nasal cannulae (HFNC) with standard care to determine whether HFNC could assist in minimising post-operative atelectasis and improve respiratory function.
In this randomised controlled trial, patients received HFNC or standard oxygen therapy post-extubation. The primary outcome was atelectasis on chest X-ray. Secondary outcomes included oxygenation, respiratory rate (RR), subjective dyspnoea, and failure of allocated treatment.
One hundred and fifty-five patients were randomised, 74 to control, 81 to HFNC. No difference was seen between groups in atelectasis scores on Days 1 or 5 (median scores = 2, p = 0.70 and p = 0.15, respectively). In the 24-h post-extubation, there was no difference in mean PaO2/FiO2 ratio (HFNC 227.9, control 253.3, p = 0.08), or RR (HFNC 17.2, control 16.7, p = 0.17). However, low dyspnoea levels were observed in each group at 8 h post-extubation, median (IQR) scores were 0 (0–1) for control and 1 (0–3) for HFNC (p = 0.008). Five patients failed allocated treatment in the control group compared with three in the treatment group [Odds ratio 0.53, (95 % CI 0.11, 2.24), p = 0.40].
In this study, prophylactic extubation onto HFNC post-cardiac surgery in patients with a BMI ≥30 kg/m2 did not lead to improvements in respiratory function. Larger studies assessing the role of HFNC in preventing worsening of respiratory function and intubation are required.
KeywordsCardiac surgery Endotracheal extubation Oxygen therapy Intensive care
We would like to thank Drs Rachael O’Rourke and Johnny Ayres for scoring the chest X-rays. We would also like to gratefully acknowledge the assistance and enthusiasm of the ICU staff, without whom this study would not have been possible. Prof Fraser acknowledges support through his Health Research Fellowship from the Office of Health and Medical Research, Queensland Health.
Conflicts of interest
John F. Fraser has received an unrestricted grant from Fisher and Paykel Healthcare Ltd in support of the current study totalling NZ$50 000. Fisher and Paykel Healthcare Ltd had no part in study design, data collection, data analysis, or creation of the manuscript. John F. Fraser has received assistance from Fisher and Paykel Healthcare Ltd to support travel and accommodation costs to attend research meetings totalling approximately NZ$15.000; Amanda Corley has received assistance from Fisher and Paykel Healthcare Ltd to support travel and accommodation costs to attend two research meetings totalling NZ$3000. Authors Taressa Bull, Amy J. Spooner and Adrian G. Barnett declare that they have no conflict of interest.
- 4.Zarbock A, Mueller E, Netzer S, Gabriel A, Feindt P, Kindgen-Milles D (2009) Prophylactic nasal continuous positive airway pressure following cardiac surgery protects from postoperative pulmonary complications: a prospective, randomized, controlled trial in 500 patients. Chest 135:1252–1259CrossRefPubMedGoogle Scholar
- 7.World Health Organisation(2014) Obesity and overweight. http://www.who.int/mediacentre/factsheets/fs311/en/. Accessed 29 Sept 2014
- 11.Al Jaaly E, Fiorentino F, Reeves BC, Ind PW, Angelini GD, Kemp S, Shiner RJ (2013) Effect of adding postoperative noninvasive ventilation to usual care to prevent pulmonary complications in patients undergoing coronary artery bypass grafting: a randomized controlled trial. J Thorac Cardiovasc Surg 146:912–918CrossRefPubMedGoogle Scholar
- 14.Gregoretti C, Confalonieri M, Navalesi P, Squadrone V, Frigerio P, Beltrame F, Carbone G, Conti G, Gamna F, Nava S, Calderini E, Skrobik Y, Antonelli M (2002) Evaluation of patient skin breakdown and comfort with a new face mask for non-invasive ventilation: a multi-center study. Intensive Care Med 28:278–284CrossRefPubMedGoogle Scholar
- 22.Maggiore SM, Idone FA, Vaschetto R, Festa R, Cataldo A, Antonicelli F, Montini L, De Gaetano A, Navalesi P, Antonelli M (2014) Nasal high-flow versus Venturi mask oxygen therapy after extubation. Effects on oxygenation, comfort, and clinical outcome. Am J Respir Crit Care Med 190:282–288CrossRefPubMedGoogle Scholar
- 26.Schwabbauer N, Berg B, Blumenstock G, Haap M, Hetzel J, Riessen R (2014) Nasal high-flow oxygen therapy in patients with hypoxic respiratory failure: effect on functional and subjective respiratory parameters compared to conventional oxygen therapy and non-invasive ventilation (NIV). BMC Anesth 14:66CrossRefGoogle Scholar
- 30.Bozbas SS, Dedekarginoglu BE, Cakir S, Karakayali FY, Eyuboglu FO (2012) Effects of use of Boussignac CPAP on development of post-operative atelectasis. Euro Resp J 40:2060Google Scholar
- 32.Treschan TA, Kaisers W, Schaefer MS, Bastin B, Schmalz U, Wania V, Eisenberger CF, Saleh A, Weiss M, Schmitz A, Kienbaum P, Sessler DI, Pannen B, Beiderlinden M (2012) Ventilation with low tidal volumes during upper abdominal surgery does not improve postoperative lung function. Br J Anaesth 109:263–271CrossRefPubMedGoogle Scholar
- 33.Pierce LNB (2007) Management of the mechanically ventilated patient. Saunders Elsevier, St LouisGoogle Scholar