MECHANICAL VENTILATION

AFTER CARDIAC SURGERY

Dr. Hala MF Hamed, MD.
Department of Anesthesia Cairo University, Egypt

Impaired pulmonary function including atelectasis and intra-pulmonary shunt is a

common problem after cardiac surgery with cardiopulmonary bypass. CPB exposes blood
to large areas of synthetic materials that trigger the production and release of numerous
chemotactic and vasoactive substances. Activation of neutrophils, with subsequent
trapping in the pulmonary circulation, causes profound pulmonary endothelial, epithelial,
and interstitial damage. This damage may contribute to increases in pulmonary capillary
endothelial permeability, decreases in lung compliance, and impaired gas exchange.
However, CPB may not be the sole reason behind pulmonary dysfunction after cardiac
surgery. Other factors exist including general anesthesia, sternotomy, and breach of the
pleura. Whatever the etiology, some degree of lung injury is noted in most patients
undergoing cardiac surgery.
Based on the previous data, it is recommended that mechanical ventilation of patients
after cardiac surgery should take a lung-protective pathway. This strategy should aim at
limitation of peak airway pressure (and hence alveolar overdistension) thereby avoiding
mechanical alveolar damage and the overdistension-induced release of inflammatory
mediators. It should also target use of enough PEEP to maintain integrity of the lung
units, without causing hemodynamic compromise or pressure on newly placed grafts.
These goals are best achieved using pressure-targeted ventilatory modes, which also tend
to offer more patient-ventilator synchrony, and therefore less use of sedation, leading to a
smoother extubation process.
It is also important to identify patients who are at higher risk of difficulty in liberation
from mechanical ventilation postoperatively. Previous studies have shown that risk
factors of delayed extubation can include: increased age, female gender, postoperative
use of intraaortic balloon pump, inotropes, bleeding, and atrial arrhythmia. Whenever a
higher risk of weaning failure exists, it becomes more and more crucial to adhere to the
policy of lung protection.
References:
1. Calvin SNg, Wan S, Yim APC, Arifi AA. Pulmonary dysfunction after cardiac
surgery. Chest 2002; 121(4): 1269-77
2. Roosens C, Heerman J, De Somer F, et al. Effects of off-pump coronary surgery on
the mechanics of the respiratory system, lung, and chest wall: Comparison with
extracorporeal circulation. Crit Care Med 2002; 30(11): 2430-7
3. Warltier DC, Laffey JG, Boylan JF, Cheng DCH. The systemic inflammatory
response to cardiac surgery: implications for the anesthesiologist. Anesthesiology
2002; 97(1): 215-52
4. Wong DT, Cheng DC, Kustra R, et al. Risk factors of delayed extubation, prolonged
length of stay in the intensive care unit and mortality in patients undergoing coronary
artery bypass graft surgery with fast track cardiac anesthesia. Anesthesiology 1999;
91:936–944