Review: Continuous Positive Airway Pressure for Treatment of Postoperative Hypoxemia

Abstract

Context Hypoxemia complicates the recovery of 30% to 50% of patients after ab- dominal surgery; endotracheal intubation and mechanical ventilation may be re- quired in 8% to 10% of cases, increasing morbidity and mortality and prolonging in- tensive care unit and hospital stay. Objective To determine the effectiveness of continuous positive airway pressure com- pared with standard treatment in preventing the need for intubation and mechanical ventilation in patients who develop acute hypoxemia after elective major abdominal surgery. Design and Setting Randomized, controlled, unblinded study with concealed al- location 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 elec- tive abdominal surgery. The trial was stopped for efficacy after 209 patients had been enrolled. Interventions Patients were randomly assigned to receive oxygen (n=104) or oxy- gen plus continuous positive airway pressure (n=105). Main OutcomeMeasures 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 pa- tients 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 en- dotracheal intubation and other severe complications in patients who develop hypox- emia after elective major abdominal surgery.