The Science Journal of the American Association for Respiratory Care

2007 OPEN FORUM Abstracts

IMPROVED OUTCOMES IN COPD PATIENTS UNDERGOING CARDIAC SURGERY: IMMEDIATE EXTUBATION REDUCES ICU AND HOSPITAL LENGTH OF STAY

E. Crimmins1, J. D. Gonzalez2, S. Cozine2


Background

The traditional management of cardiac surgical patients includes postoperative mechanical ventilation. Fast-track anesthetic techniques achieve tracheal extubation within eight hours of surgery and have been associated with reduced ICU duration and cost. Routine immediate extubation in the operating room, however, is not widely practiced. We have previously reported a series of 943 CABG patients demonstrating reduced hospital length of stay (LOS), morbidity and mortality in those who were extubated immediately after surgery. Patients with COPD are considered high risk for prolonged tracheal intubation and mechanical ventilation following cardiac surgery. We hypothesized that immediate extubation would benefit COPD patients undergoing cardiac surgery by reducing the complications of mechanical ventilation without increasing other adverse events.

Methods
A retrospective review of our institutional Society of Thoracic Surgeons (STS) database was conducted for all patients undergoing cardiac surgery from June 2003 through January 2007. Patients with a diagnosis of COPD were included in the study and classified as having mild, moderate, or severe COPD according to STS criteria. A total of 172 patients were identified having all types of cardiac surgery except transplantation. All surgeries were performed at a cardiac specialty hospital by a team of four surgeons and three anesthesiologists. Extubation in the OR was performed at the discretion of the anesthesiologist and surgeon.

Results
120 patients (69.7%) were extubated immediately in the OR. Intensive care (p<0.001) and hospital (p<0.053) length of stay was significantly shorter for those patients (Table 1). There was no difference in the incidence of reintubation, reoperation, or death. 105 patients (61%) had mild COPD while 67 (39%) had moderate or severe COPD. The latter group showed significant reduction in both ICU (p<0.004) and hospital (p<0.017) LOS if extubation was immediate.

Conclusions

The complications of mechanical ventilation are well known. We demonstrate that following cardiac surgery, routine immediate tracheal extubation of COPD patients is safe and reduces ICU and hospital length of stay, particularly in patients with more severe disease.

Immediate Extubation of COPD Patients Following Cardiac Surgery
All COPD Patients n=172
Outcome Intubated n=52 Extubated n=120 Fisher's Exact Test p-value
Reintubation 0/52 (0%) 5/120 (4.2%) 0.324
Reoperation 2/52 (3.8%) 2/120 (1.7%) 0.585
Mortality 1/52 (1.9%) 2/120 (1.7%) 1.000
 Mean +/- SD
Median (25%, 75%)
Mean +/- SD
Median (25%, 75%)
Mann-Whitney U Test p-value
ICU LOS (hours) 25.7 (34.8)
17.1 (6.0, 24.4)
15.0 (27.1)
3.0 (2, 19.78)
0.001
Hosp LOS (days) 4.54 (1.93)
4.0 (3.0, 5.0)
4.05 (1.86)
4.0 (3.0, 5.0)
0.053
Moderate and Severe COPD n=67
OutcomeIntubated n=21 Extubated n=46 Fisher's Exact Test p-value
Reintubation 0/21 (0%)
1/46 (2.2%)1.000
Reoperation1/21 (4.8%) 0/46 (0%) 0.313
Mortality1/21 (4.8%) 2/46 (4.3%) 1.000
  Mean +/- SD
Median (25%, 75%)
Mean +/- SD
Median (25%, 75%)
Mann-Whitney U Test p-value
ICU LOS (hours) 24.8 (38.8)
16.9 (6.5, 23.6)
11.4 (16.6)
2.0 (2.0, 18.1)
0.004
Hosp LOS (days) 4.67 (1.56)
4.0 (3.5, 6.0)
4.0 (2.15)
3.5 (3.0, 4.0)
0.017



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