Hypoxemia is common in postoperative patients and is associated with prolonged hospital stays, high costs, and increased mortality. This review discusses the postoperative management of hypoxemia in regard to the use of conventional oxygen therapy, high-flow nasal cannula oxygen therapy, CPAP, and noninvasive ventilation. The recommendations made are based on the currently available evidence.
KhanNA, QuanH, BugarJM, LemaireJB, BrantR, GhaliWA. Association of postoperative complications with hospital costs and length of stay in a tertiary care center. J Gen Intern Med, 2006; 21(2):177-180.
2.
GuptaH, GuptaPK, FangX, MillerWJ, CemajS, ForseRA, et al. Development and validation of a risk calculator predicting postoperative respiratory failure. Chest, 2011; 140(5):1207-1215.
3.
Serpa NetoA, HemmesSNT, BarbasCSV, BeiderlindenM, Fernandez-BustamanteA, FutierE, et al. Incidence of mortality and morbidity related to postoperative lung injury in patients who have undergone abdominal or thoracic surgery: a systematic review and meta-analysis. Lancet Respir Med, 2014; 2(12):1007-1015.
4.
BartelsK, KaizerA, JamesonL, BullardK, DingmannC, Fernandez-BustamanteA. Hypoxemia within the first 3 postoperative days is associated with increased 1-year postoperative mortality after adjusting for perioperative opioids and other confounders. Anesth Analg, 2020; 131(2):555-563.
5.
XueFS, LiBW, ZhangGS, LiaoX, ZhangYM, LiuJH, et al. The influence of surgical sites on early postoperative hypoxemia in adults undergoing elective surgery. Anesth Analg, 1999; 88(1):213-219.
6.
ArozullahAM, DaleyJ, HendersonWG, KhuriSF. Multifactorial risk index for predicting postoperative respiratory failure in men after major noncardiac surgery. The National Veterans Administration Surgical Quality Improvement Program. Ann Surg, 2000; 232(2):242-253.
7.
ChaudhuriD, GrantonD, WangDX, BurnsKEA, HelvizY, EinavS, et al. High-flow nasal cannula in the immediate postoperative period: a systematic review and meta-analysis. Chest, 2020; 158(5):1934-1946.
8.
NayyarD, ManHSJ, GrantonJ, GuptaS. Defining and characterizing severe hypoxemia after liver transplantation in hepatopulmonary syndrome. Liver Transpl, 2014; 20(2):182-190.
9.
SunZ, SesslerDI, DaltonJE, DevereauxPJ, ShahinyanA, NaylorAJ, et al. Postoperative hypoxemia is common and persistent: a prospective blinded observational study. Anesth Analg, 2015; 121(3):709-715.
10.
Fernandez-BustamanteA, FrendlG, SprungJ, KorDJ, SubramaniamB, Martinez RuizR, et al. Postoperative pulmonary complications, early mortality, and hospital stay following noncardiothoracic surgery: a multicenter study by the Perioperative Research Network Investigators. JAMA Surg, 2017; 152(2):157-166.
11.
SuzukiS. Oxygen administration for postoperative surgical patients: a narrative review. J Intensive Care, 2020; 8:79.
12.
AhmadS, NagleA, McCarthyRJ, FitzgeraldPC, SullivanJT, PrystowskyJ. Postoperative hypoxemia in morbidly obese patients with and without obstructive sleep apnea undergoing laparoscopic bariatric surgery. Anesth Analg, 2008; 107(1):138-143.
13.
KawR, PasupuletiV, WalkerE, RamaswamyA, Foldvary-SchaferN. Postoperative complications in patients with obstructive sleep apnea. Chest, 2012; 141(2):436-441.
14.
SuenC, RyanCM, MubashirT, AyasNT, AbrahamyanL, WongJ, et al. Sleep study and oximetry parameters for predicting postoperative complications in patients with OSA. Chest, 2019; 155(4):855-867.
15.
McAlisterFA, BertschK, ManJ, BradleyJ, JackaM. Incidence of and risk factors for pulmonary complications after nonthoracic surgery. Am J Respir Crit Care Med, 2005; 171(5):514-517.
16.
HulzebosEHJ, Van MeeterenNLU, De BieRA, DagneliePC, HeldersPJM. Prediction of postoperative pulmonary complications on the basis of preoperative risk factors in patients who had undergone coronary artery bypass graft surgery. Phys Ther, 2003; 83(1):8-16.
17.
JiQ, MeiY, WangX, FengJ, CaiJ, SunY, et al. Study on the risk factors of postoperative hypoxemia in patients undergoing coronary artery bypass grafting. Circ J, 2008; 72(12):1975-1980.
18.
ShiS, GaoY, WangL, LiuJ, YuanZ, YuM. Elevated free fatty acid level is a risk factor for early postoperative hypoxemia after on-pump coronary artery bypass grafting: association with endothelial activation. J Cardiothorac Surg, 2015; 10(1):122.
19.
GuanZ, LvY, LiuJ, LiuL, YuanH, ShenX. Smoking cessation can reduce the incidence of postoperative hypoxemia after on-pump coronary artery bypass grafting surgery. J Cardiothorac Vasc Anesth, 2016; 30(6):1545-1549.
20.
WangY, XueS, ZhuH. Risk factors for postoperative hypoxemia in patients undergoing Stanford A aortic dissection surgery. J Cardiothorac Surg, 2013; 8:118.
21.
ShengW, YangH-Q, ChiY-F, NiuZ-Z, LinMS, LongS. Independent risk factors for hypoxemia after surgery for acute aortic dissection. Saudi Med J, 2015; 36(8):940-946.
22.
BurtonBN, PropheteL, CarterD, BetancourtJ, SchmidtUH, GabrielRA. Demographic and clinical variables associated with 30-day re-intubation following surgical aortic valve replacement. Respir Care, 2021; 66(2):248-252.
23.
FilaireM, BeduM, NaameeA, AubretonS, ValletL, NormandB, EscandeG. Prediction of hypoxemia and mechanical ventilation after lung resection for cancer. Ann Thorac Surg, 1999; 67(5):1460-1465.
24.
StéphanF, BoucheseicheS, HollandeJ, FlahaultA, CheffiA, BazellyB, BonnetF. Pulmonary complications following lung resection: a comprehensive analysis of incidence and possible risk factors. Chest, 2000; 118(5):1263-1270.
25.
MøllerAM, PedersenT, SvendsenPE, EngquistA. Perioperative risk factors in elective pneumonectomy: the impact of excess fluid balance. Eur J Anaesthesiol, 2002; 19(1):57-62.
26.
AgostiniP, CieslikH, RathinamS, BishayE, KalkatMS, RajeshPB, et al. Postoperative pulmonary complications following thoracic surgery: are there any modifiable risk factors?. Thorax, 2010; 65(9):815-818.
27.
ImY, ParkHY, ShinS, ShinSH, LeeH, AhnJH, et al. Prevalence of and risk factors for pulmonary complications after curative resection in otherwise healthy elderly patients with early stage lung cancer. Respir Res, 2019; 20(1):136.
28.
OhiM, ToiyamaY, OmuraY, IchikawaT, YasudaH, OkugawaY, et al. Risk factors and measures of pulmonary complications after thoracoscopic esophagectomy for esophageal cancer. Surg Today, 2019; 49(2):176-186.
SerejoLGG, da Silva-JúniorFP, BastosJPC, de BruinGS, MotaRMS, de BruinPFC. Risk factors for pulmonary complications after emergency abdominal surgery. Respir Med, 2007; 101(4):808-813.
31.
NobiliC, MarzanoE, OussoultzoglouE, RossoE, AddeoP, BachellierP, et al. Multivariate analysis of risk factors for pulmonary complications after hepatic resection. Ann Surg, 2012; 255(3):540-550.
32.
CanetJ, GallartL, GomarC, PaluzieG, VallesJ, CastilloJ, et al. ARISCAT Group. Prediction of postoperative pulmonary complications in a population-based surgical cohort. Anesthesiology, 2010; 113(6):1338-1350.
33.
AllegranziB, ZayedB, BischoffP, KubilayNZ, de JongeS, de VriesF, et al. WHO Guidelines Development Group. New WHO recommendations on intraoperative and postoperative measures for surgical site infection prevention: an evidence-based global perspective. Lancet Infect Dis, 2016; 16(12):e288-e303.
34.
LiJ, JingG, ScottJB. Year in review 2019: high-flow nasal cannula oxygen therapy for adult subjects. Respir Care, 2020; 65(4):545-557.
35.
GrovesN, TobinA. High flow nasal oxygen generates positive airway pressure in adult volunteers. Aust Crit Care, 2007; 20(4):126-131.
36.
MaggioreSM, BattilanaM, SeranoL, PetriniF. Ventilatory support after extubation in critically ill patients. Lancet Respir Med, 2018; 6(12):948-962.
37.
ParkeR, McGuinnessS, DixonR, JullA. Open-label, phase II study of routine high-flow nasal oxygen therapy in cardiac surgical patients. Br J Anaesth, 2013; 111(6):925-931.
38.
CorleyA, BullT, SpoonerAJ, BarnettAG, FraserJF. Direct extubation onto high-flow nasal cannulae post-cardiac surgery versus standard treatment in patients with a BMI ≥ 30: a randomised controlled trial. Intensive Care Med, 2015; 41(5):887-894.
39.
ZochiosV, CollierT, BlaudszunG, ButchartA, EarwakerM, JonesN, KleinAA. The effect of high-flow nasal oxygen on hospital length of stay in cardiac surgical patients at high risk for respiratory complications: a randomised controlled trial. Anaesthesia, 2018; 73(12):1478-1488.
40.
SahinM, ElH, AkkoçI. Comparison of mask oxygen therapy and high-flow oxygen therapy after cardiopulmonary bypass in obese patients. Can Respir J, 2018; 2018:1039635.
41.
TatsuishiW, SatoT, KataokaG, SatoA, AsanoR, NakanoK. High-flow nasal cannula therapy with early extubation for subjects undergoing off-pump coronary artery bypass graft surgery. Respir Care, 2020; 65(2):183-190.
42.
AnsariBM, HoganMP, CollierTJ, BaddeleyRA, ScarciM, CoonarAS, et al. A randomized controlled trial of high-flow nasal oxygen (Optiflow) as part of an enhanced recovery program after lung resection surgery. Ann Thorac Surg, 2016; 101(2):459-464.
43.
BrainardJ, ScottBK, SullivanBL, Fernandez-BustamanteA, PiccoliJR, GebbinkMG, BartelsK. Heated humidified high-flow nasal cannula oxygen after thoracic surgery - a randomized prospective clinical pilot trial. J Crit Care, 2017; 40:225-228.
44.
YuY, QianX, LiuC, ZhuC. Effect of high-flow nasal cannula versus conventional oxygen therapy for patients with thoracoscopic lobectomy after extubation. Can Respir J, 2017; 2017:7894631.
45.
PennisiMA, BelloG, CongedoMT, MontiniL, NachiraD, FerrettiGM, et al. Early nasal high-flow versus Venturi mask oxygen therapy after lung resection: a randomized trial. Crit Care, 2019; 23(1):68.
46.
FutierE, Paugam-BurtzC, GodetT, Khoy-EarL, RozencwajgS, DelayJ-M, et al. OPERA study investigators. Effect of early postextubation high-flow nasal cannula vs conventional oxygen therapy on hypoxaemia in patients after major abdominal surgery: a French multicentre randomised controlled trial (OPERA). Intensive Care Med, 2016; 42(12):1888-1898.
47.
AguilóR, TogoresB, PonsS, RubíM, BarbéF, AgustíAGN. Noninvasive ventilatory support after lung resectional surgery. Chest, 1997; 112(1):117-121.
48.
JorisJL, SottiauxTM, ChicheJD, DesaiveCJ, LamyML. Effect of bi-level positive airway pressure (BiPAP) nasal ventilation on the postoperative pulmonary restrictive syndrome in obese patients undergoing gastroplasty. Chest, 1997; 111(3):665-670.
49.
EbeoCT, BenottiPN, ByrdRPJr, ElmaghrabyZ, LuiJ. The effect of bi-level positive airway pressure on postoperative pulmonary function following gastric surgery for obesity. Respir Med, 2002; 96(9):672-676.
50.
PerrinC, JullienV, VénissacN, BerthierF, PadovaniB, GuillotF, et al. Prophylactic use of noninvasive ventilation in patients undergoing lung resectional surgery. Respir Med, 2007; 101(7):1572-1578.
51.
CarlssonC, SondénB, ThylenU. Can postoperative continuous positive airway pressure (CPAP) prevent pulmonary complications after abdominal surgery?. Intensive Care Med, 1981; 7(5):225-229.
52.
LindnerKH, LotzP, AhnefeldFW. Continuous positive airway pressure effect on functional residual capacity, vital capacity and its subdivisions. Chest, 1987; 92(1):66-70.
53.
PinillaJC, OleniukFH, TanL, RebeykaI, TannaN, WilkinsonA, BharadwajB. Use of a nasal continuous positive airway pressure mask in the treatment of postoperative atelectasis in aortocoronary bypass surgery. Crit Care Med, 1990; 18(8):836-840.
JouselaI, RäsänenJ, VerkkalaK, LamminenA, MäkeläinenA, NikkiP. Continuous positive airway pressure by mask in patients after coronary surgery. Acta Anaesthesiol Scand, 1994; 38(4):311-316.
56.
BöhnerH, Kindgen-MillesD, GrustA, BuhlR, LillotteWC, MüllerBT, et al. Prophylactic nasal continuous positive airway pressure after major vascular surgery: results of a prospective randomized trial. Langenbecks Arch Surg, 2002; 387(1):21-26.
57.
GaszynskiT, TokarzA, PiotrowskiD, MachalaW. Boussignac CPAP in the postoperative period in morbidly obese patients. Obes Surg, 2007; 17(4):452-456.
58.
NeliganPJ, MalhotraG, FraserM, WilliamsN, GreenblattEP, CeredaM, OchrochEA. Continuous positive airway pressure via the Boussignac system immediately after extubation improves lung function in morbidly obese patients with obstructive sleep apnea undergoing laparoscopic bariatric surgery. Anesthesiology, 2009; 110(4):878-884.
59.
Kindgen-MillesD, MüllerE, BuhlR, BöhnerH, RitterD, SandmannW, TarnowJ. Nasal-continuous positive airway pressure reduces pulmonary morbidity and length of hospital stay following thoracoabdominal aortic surgery. Chest, 2005; 128(2):821-828.
60.
ZarbockA, MuellerE, NetzerS, GabrielA, FeindtP, Kindgen-MillesD. 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(5):1252-1259.
61.
StockMC, DownsJB, GauerPK, AlsterJM, ImreyPB. Prevention of postoperative pulmonary complications with CPAP, incentive spirometry, and conservative therapy. Chest, 1985; 87(2):151-157.
62.
RickstenSE, BengtssonA, SoderbergC, ThordenM, KvistH. Effects of periodic positive airway pressure by mask on postoperative pulmonary function. Chest, 1986; 89(6):774-781.
63.
DenehyL, CarrollS, NtoumenopoulosG, JenkinsS. A randomized controlled trial comparing periodic mask CPAP with physiotherapy after abdominal surgery. Physiother Res Int, 2001; 6(4):236-250.
64.
Fagevik OlsénM, WennbergE, JohnssonE, JosefsonK, LönrothH, LundellL. Randomized clinical study of the prevention of pulmonary complications after thoracoabdominal resection by two different breathing techniques. Br J Surg, 2002; 89(10):1228-1234.
65.
MatteP, JacquetL, Van DyckM, GoenenM. Effects of conventional physiotherapy, continuous positive airway pressure and non-invasive ventilatory support with bilevel positive airway pressure after coronary artery bypass grafting. Acta Anaesthesiol Scand, 2000; 44(1):75-81.
66.
PasquinaP, MerlaniP, GranierJM, RicouB. Continuous positive airway pressure versus noninvasive pressure support ventilation to treat atelectasis after cardiac surgery. Anesth Analg, 2004; 99(4):1001-1008, table of contents.
LeoneM, EinavS, ChiumelloD, ConstantinJ-M, De RobertisE, De AbreuMG, et al. Guideline contributors. Noninvasive respiratory support in the hypoxaemic peri-operative/periprocedural patient: a joint ESA/ESICM guideline. Intensive Care Med, 2020; 46(4):697-713.
69.
AntonelliM, ContiG, BufiM, CostaMG, LappaA, RoccoM, et al. Noninvasive ventilation for treatment of acute respiratory failure in patients undergoing solid organ transplantation: a randomized trial. JAMA, 2000; 283(2):235-241.
70.
AuriantI, JallotA, HervéP, CerrinaJ, Le Roy LadurieF, FournierJL, et al. Noninvasive ventilation reduces mortality in acute respiratory failure following lung resection. Am J Respir Crit Care Med, 2001; 164(7):1231-1235.
71.
MicheletP, D'JournoXB, SeinayeF, ForelJM, PapazianL, ThomasP. Non-invasive ventilation for treatment of postoperative respiratory failure after oesophagectomy. Br J Surg, 2009; 96(1):54-60.
72.
ZhuG-f, WangD-j, LiuS, JiaM, JiaS-j. Efficacy and safety of noninvasive positive pressure ventilation in the treatment of acute respiratory failure after cardiac surgery. Chin Med J (Engl), 2013; 126(23):4463-4469.
73.
JaberS, LescotT, FutierE, Paugam-BurtzC, SeguinP, FerrandiereM, et al. NIVAS Study Group. Effect of noninvasive ventilation on tracheal reintubation among patients with hypoxemic respiratory failure following abdominal surgery: a randomized clinical trial. JAMA, 2016; 315(13):1345-1353.
74.
YangY, LiuN, SunL, ZhouY, YangY, ShangW, LiX. Noninvasive positive-pressure ventilation in treatment of hypoxemia after extubation following type-A aortic dissection. J Cardiothorac Vasc Anesth, 2016; 30(6):1539-1544.
75.
SquadroneV, CohaM, CeruttiE, SchellinoMM, BiolinoP, OccellaP, et al. Piedmont Intensive Care Units Network (PICUN). Continuous positive airway pressure for treatment of postoperative hypoxemia: a randomized controlled trial. JAMA, 2005; 293(5):589-595.
76.
OlperL, BignamiE, Di PrimaAL, AlbiniS, NascimbeneS, CabriniL, et al. Continuous positive airway pressure versus oxygen therapy in the cardiac surgical ward: a randomized trial. J Cardiothorac Vasc Anesth, 2017; 31(1):115-121.
77.
PatelBK, WolfeKS, PohlmanAS, HallJB, KressJP. Effect of noninvasive ventilation delivered by helmet vs face mask on the rate of endotracheal intubation in patients with acute respiratory distress syndrome: a randomized clinical trial. JAMA, 2016; 315(22):2435-2441.
78.
RochwergB, BrochardL, ElliottMW, HessD, HillNS, NavaS, et al. Official ERS/ATS clinical practice guidelines: noninvasive ventilation for acute respiratory failure. Eur Respir J, 2017; 50(2):1602426.
79.
VaschettoR, LonghiniF, PersonaP, OriC, StefaniG, LiuS, et al. Early extubation followed by immediate noninvasive ventilation vs. standard extubation in hypoxemic patients: a randomized clinical trial. Intensive Care Med, 2019; 45(1):62-71.
80.
LiuK, HaoG-W, ZhengJ-L, LuoJ-C, SuY, HouJ-Y, et al. Effect of sequential noninvasive ventilation on early extubation after acute type A aortic dissection. Respir Care, 2020; 65(8):1160-1167.
81.
KangBJ, KohY, LimC-M, HuhJW, BaekS, HanM, et al. Failure of high-flow nasal cannula therapy may delay intubation and increase mortality. Intensive Care Med, 2015; 41(4):623-632.
82.
RocaO, MessikaJ, CaraltB, Garcia-de-AciluM, SztrymfB, RicardJD, et al. Predicting success of high-flow nasal cannula in pneumonia patients with hypoxemic respiratory failure: the utility of the ROX index. J Crit Care, 2016; 35:200-205.
83.
RocaO, CaraltB, MessikaJ, SamperM, SztrymfB, HernándezG, et al. An index combining respiratory rate and oxygenation to predict outcome of nasal high-flow therapy. Am J Respir Crit Care Med, 2019; 199(11):1368-1376.
84.
RicardJ-D, RocaO, LemialeV, CorleyA, BraunlichJ, JonesP, et al. Use of nasal high flow oxygen during acute respiratory failure. Intensive Care Med, 2020; 46(12):2238-2247.
85.
DuanJ, HanX, BaiL, ZhouL, HuangS. Assessment of heart rate, acidosis, consciousness, oxygenation, and respiratory rate to predict noninvasive ventilation failure in hypoxemic patients. Intensive Care Med, 2017; 43(2):192-199.
86.
KottaPA, AliJM. Incentive spirometry for prevention of postoperative pulmonary complications after thoracic surgery. Respir Care, 2021; 66(2):327-333.
EltoraiAEM, SzaboAL, AntociVJr, VentetuoloCE, EliasJA, DanielsAH, HessDR. Clinical effectiveness of incentive spirometry for the prevention of postoperative pulmonary complications. Respir Care, 2018; 63(3):347-352.
90.
OdorPM, BampoeS, GilhoolyD, Creagh-BrownB, MoonesingheSR. Perioperative interventions for prevention of postoperative pulmonary complications: systematic review and meta-analysis. BMJ, 2020; 368:m540.
91.
EltoraiAEM, BairdGL, EltoraiAS, HealeyTT, AgarwalS, VentetuoloCE, et al. Effect of an incentive spirometer patient reminder after coronary artery bypass grafting: a randomized clinical trial. JAMA Surg, 2019; 154(7):579-588.
92.
EltoraiAEM, BairdGL, EltoraiAS, PangbornJ, AntociVJr, CullenHA, et al. Incentive spirometry adherence: a national survey of provider perspectives. Respir Care, 2018; 63(5):532-537.
93.
ChenJ, EltoraiAEM. Incentive spirometry after lung resection: the importance of patients' adherence. Ann Thorac Surg, 2019; 107(3):985.
94.
GriffithsMJD, EvansTW. Inhaled nitric oxide therapy in adults. N Engl J Med, 2005; 353(25):2683-2695.
BenedettoM, RomanoR, BacaG, SarridouD, FischerA, SimonA, MarczinN. Inhaled nitric oxide in cardiac surgery: evidence or tradition?. Nitric Oxide, 2015; 49:67-79.
97.
MaG-G, HaoG-W, LaiH, YangX-M, LiuL, WangCS, et al. Initial clinical impact of inhaled nitric oxide therapy for refractory hypoxemia following type A acute aortic dissection surgery. J Thorac Dis, 2019; 11(2):495-504.
98.
LiJ, HarnoisLJ, MarkosB, RobertsKM, HomoudSA, LiuJ, et al. Epoprostenol delivered via high flow nasal cannula for ICU subjects with severe hypoxemia comorbid with pulmonary hypertension or right heart dysfunction. Pharmaceutics, 2019; 11(6):281.
99.
LiJ, GurnaniPK, RobertsKM, FinkJB, VinesD. The clinical impact of flow titration on epoprostenol delivery via high flow nasal cannula for ICU patients with pulmonary hypertension or right ventricular dysfunction: a retrospective cohort comparison study. J Clin Med, 2020; 9(2):464.
100.
SardoS, OsawaEA, FincoG, Gomes GalasFRB, de AlmeidaJP, CutuliSL, et al. Nitric oxide in cardiac surgery: a meta-analysis of randomized controlled trials. J Cardiothorac Vasc Anesth, 2018; 32(6):2512-2519.
101.
WeingartenTN, WarnerLL, SprungJ. Timing of postoperative respiratory emergencies: when do they really occur?. Curr Opin Anaesthesiol, 2017; 30(1):156-162.
102.
TuranA, EssberH, SaasouhW, HovsepyanK, MakarovaN, AyadS, et al. FACTOR Study Group. Effect of intravenous acetaminophen on postoperative hypoxemia after abdominal surgery: the FACTOR randomized clinical trial. JAMA, 2020; 324(4):350-358.
103.
ThilleAW, MullerG, GacouinA, CoudroyR, DecaveleM, SonnevilleR, et al. HIGH-WEAN Study Group and the REVA Research Network. Effect of postextubation high-flow nasal oxygen with noninvasive ventilation vs high-flow nasal oxygen alone on reintubation among patients at high risk of extubation failure: a randomized clinical trial. JAMA, 2019; 322(15):1465-1475.
