Can non-invasive ventilation (NIV) be used in a patient with a history of pneumonectomy?

NIV in Post-Pneumonectomy Patients: Clinical Recommendation

Yes, NIV can be used in a patient with remote pneumonectomy (20 years ago), but only with careful patient selection, close monitoring in an ICU/HDU setting, and immediate availability of intubation as backup.

Key Clinical Considerations

Remote vs. Recent Surgery Distinction

• The primary contraindication relates to recent upper gastrointestinal or thoracic surgery, not remote procedures 1
• A pneumonectomy performed 20 years ago does not fall under "recent postoperative" contraindications, which typically refer to the immediate perioperative period 2, 3
• The British Thoracic Society guidelines specifically mention recent surgery as a contraindication, but do not list remote thoracic surgery as an absolute barrier 1

Specific Evidence for Post-Pneumonectomy NIV

• NIV has been successfully used in post-pneumonectomy patients, specifically for severe hypoxemia and ARDS following pneumonectomy, with documented successful outcomes 4
• Case reports demonstrate that bi-level positive airway pressure ventilation can prompt successful outcomes in early ARDS following pneumonectomy 4
• NIV has been used in various postoperative thoracic surgery scenarios with reduced intubation rates and improved outcomes 1, 2

Mandatory Safety Requirements

Setting and Monitoring

• NIV must be administered in an ICU or HDU setting with continuous monitoring 1
• Continuous pulse oximetry for at least 24 hours after commencing NIV, maintaining saturations between 85-90% 1
• Arterial blood gas analysis after 1-2 hours of NIV and again at 4-6 hours if initial improvement is minimal 1

Clinical Assessment Parameters

• Monitor patient comfort, conscious level, chest wall motion, accessory muscle recruitment, coordination of respiratory effort with ventilator, respiratory rate, and heart rate 1
• Regular review to assess response to treatment and optimize ventilator settings 1

Critical Contraindications to Assess

Absolute Contraindications (Must Rule Out)

• Recent facial or upper airway surgery 1
• Facial abnormalities such as burns or trauma 1
• Fixed obstruction of upper airway 1
• Active vomiting 1

Relative Contraindications (Require Contingency Planning)

• Inability to protect the airway 1
• Copious respiratory secretions 1
• Life-threatening hypoxemia 1
• Severe co-morbidity 1
• Confusion/agitation 1
• NIV can be used despite these relative contraindications only if contingency plans for intubation are in place OR if NIV represents the ceiling of treatment based on goals of care 1, 5

Special Considerations for Post-Pneumonectomy Anatomy

Pneumothorax Risk in Remaining Lung

• Although the guidelines address pneumothorax risk primarily in chest wall trauma, the principle applies to any patient with altered thoracic anatomy 1
• If any pneumothorax is present in the remaining lung, an intercostal drain should be inserted before commencing NIV 1, 5
• The space-occupying lesion principle: drain before applying positive pressure 5

Altered Respiratory Mechanics

• Post-pneumonectomy patients have fundamentally altered respiratory mechanics with the entire ventilatory burden on one lung 4
• The remaining lung may be more susceptible to barotrauma from positive pressure 4
• Close attention to ventilator settings is essential to avoid excessive pressures 1

Decision Algorithm

1. Confirm the surgery is remote (>6 months), not recent 1, 2
2. Rule out absolute contraindications (facial trauma, upper airway obstruction, vomiting) 1
3. Assess for relative contraindications and establish intubation contingency plan 1, 5
4. Obtain chest radiograph to rule out pneumothorax in remaining lung 5
5. Ensure ICU/HDU setting with trained staff and monitoring equipment 1
6. Initiate NIV with close monitoring of clinical parameters and blood gases 1
7. Reassess at 1-2 hours and 4-6 hours - if no improvement in PaCO2 and pH despite optimal settings, discontinue NIV and proceed to invasive ventilation 1

Common Pitfalls to Avoid

• Do not use NIV as a temporizing measure when urgent intubation is clearly needed 5
• Do not attempt NIV on a general ward - this patient requires ICU/HDU level monitoring 1
• Do not continue NIV beyond 4-6 hours without improvement in blood gases 1
• Do not overlook the need for immediate intubation capability - this is non-negotiable in post-pneumonectomy patients 1, 5
• Ensure any surgical complications are treated before initiating NIV 2