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Non-invasive ventilation in postoperative patients: a systematic review

D. Chiumello| G. Chevallard| C. Gregoretti
Review
Volume 37, Issue 6 / June , 2011

Pages 918 - 929

Abstract

Background

Postoperative pulmonary complications, generally defined as any pulmonary abnormality occurring in the postoperative period, are still a significant issue in clinical practice increasing hospital length of stay, morbidity and mortality. Non-invasive ventilation (NIV), primarily applied in cardiogenic pulmonary edema, decompensated COPD and hypoxemic pulmonary failure, is nowadays also used in perioperative settings.

Objective

Investigate the application and results of preventive and therapeutic NIV in postsurgical patients.

Design

A systematic review.

Data sources

Medical literature databases were searched for articles about “clinical trials,” “randomized controlled trials” and “meta-analyses.” The keywords “cardiac surgery,” “thoracic surgery,” “lung surgery,” “abdominal surgery,” “solid organ transplantation,” “thoraco-abdominal surgery” and “bariatric surgery” were combined with any of these: “non-invasive positive pressure ventilation,” “continuous positive airway pressure,” “bilevel ventilation,” “postoperative complications,” “postoperative care,” “respiratory care,” “acute respiratory failure,” “acute lung injury” and “acute respiratory distress syndrome.”

Results

Twenty-nine articles (N = 2,279 patients) met the inclusion criteria. Nine studies evaluated NIV in post-abdominal surgery, three in thoracic surgery, eight in cardiac surgery, three in thoraco-abdominal surgery, four in bariatric surgery and two in post solid organ transplantation used both for prophylactic and therapeutic purposes. NIV improved arterial blood gases in 15 of the 22 prophylactic and in 4 of the 7 therapeutic studies, respectively. NIV reduced the intubation rate in 11 of the 29 studies and improved outcome in only 1.

Conclusions

Despite these limited data and the necessity of new randomized trials, NIV could be considered as a prophylactic and therapeutic tool to improve gas exchange in postoperative patients.

Keywords

References

  1. Weiser TG, Regenbogen SE, Thompson KD, Haynes AB, Lipsitz SR, Berry WR, Gawande AA (2008) An estimation of the global volume of surgery: a modelling strategy based on available data. Lancet 372:139–144
    • View reference on PubMed
    • View reference on publisher's website
  2. O’Donohue WJ Jr (1992) Postoperative pulmonary complications. When are preventive and therapeutic measures necessary? Postgrad Med 91:167–175
    • View reference on PubMed
  3. Gardner B, Palasti S (1990) A comparison of hospital costs and morbidity between octogenarians and other patients undergoing general surgical operations. Surg Gynecol Obstet 171:299–304
    • View reference on PubMed
  4. Arozullah AM, Daley J, Henderson WG, Khuri SF (2000) Multifactorial risk index for predicting postoperative respiratory failure in men after major noncardiac surgery. The National Veterans Administration Surgical Quality Improvement Program. Ann Surg 232:242–253
    • View reference on PubMed
    • View reference on publisher's website
  5. Harpole DH Jr, DeCamp MM Jr, Daley J, Hur K, Oprian CA, Henderson WG, Khuri SF (1999) Prognostic models of thirty-day mortality and morbidity after major pulmonary resection. J Thorac Cardiovasc Surg 117:969–979
    • View reference on PubMed
    • View reference on publisher's website
  6. Wong DH, Weber EC, Schell MJ, Wong AB, Anderson CT, Barker SJ (1995) Factors associated with postoperative pulmonary complications in patients with severe chronic obstructive pulmonary disease. Anesth Analg 80:276–284
    • View reference on PubMed
  7. Esteban A, Frutos-Vivar F, Ferguson ND, Arabi Y, Apezteguia C, Gonzalez M, Epstein SK, Hill NS, Nava S, Soares MA, D’Empaire G, Alia I, Anzueto A (2004) Noninvasive positive-pressure ventilation for respiratory failure after extubation. N Engl J Med 350:2452–2460
    • View reference on PubMed
    • View reference on publisher's website
  8. Antonelli M, Conti G, Rocco M, Bufi M, De Blasi RA, Vivino G, Gasparetto A, Meduri GU (1998) A comparison of noninvasive positive-pressure ventilation and conventional mechanical ventilation in patients with acute respiratory failure. N Engl J Med 339:429–435
    • View reference on PubMed
    • View reference on publisher's website
  9. Kroenke K, Lawrence VA, Theroux JF, Tuley MR, Hilsenbeck S (1993) Postoperative complications after thoracic and major abdominal surgery in patients with and without obstructive lung disease. Chest 104:1445–1451
    • View reference on PubMed
    • View reference on publisher's website
  10. Smetana GW (1999) Preoperative pulmonary evaluation. N Engl J Med 340:937–944
    • View reference on PubMed
    • View reference on publisher's website
  11. Chawla G, Drummond GB (2008) Fentanyl decreases end-expiratory lung volume in patients anaesthetized with sevoflurane. Br J Anaesth 100:411–414
    • View reference on PubMed
    • View reference on publisher's website
  12. Hedenstierna G, Edmark L (2005) The effects of anesthesia and muscle paralysis on the respiratory system. Intensive Care Med 31:1327–1335
  13. Magnusson L, Spahn DR (2003) New concepts of atelectasis during general anaesthesia. Br J Anaesth 91:61–72
    • View reference on PubMed
    • View reference on publisher's website
  14. Eichenberger A, Proietti S, Wicky S, Frascarolo P, Suter M, Spahn DR, Magnusson L (2002) Morbid obesity and postoperative pulmonary atelectasis: an underestimated problem. Anesth Analg 95:1788–1792
    • View reference on PubMed
    • View reference on publisher's website
  15. Ferreyra G, Squadrone V, Ranieri VM (2005) Acute respiratory failure after abdominal surgery. In: Year of intensive care and emergency medicine, 1st edn. Springer, Berlin, pp 10–18
  16. Warner DO (2000) Preventing postoperative pulmonary complications: the role of the anesthesiologist. Anesthesiology 92:1467–1472
    • View reference on PubMed
    • View reference on publisher's website
  17. Dureuil B, Cantineau JP, Desmonts JM (1987) Effects of upper or lower abdominal surgery on diaphragmatic function. Br J Anaesth 59:1230–1235
    • View reference on PubMed
    • View reference on publisher's website
  18. Simonneau G, Vivien A, Sartene R, Kunstlinger F, Samii K, Noviant Y, Duroux P (1983) Diaphragm dysfunction induced by upper abdominal surgery. role of postoperative pain. Am Rev Respir Dis 128:899–903
    • View reference on PubMed
  19. Ingwersen UM, Larsen KR, Bertelsen MT, Kiil-Nielsen K, Laub M, Sandermann J, Bach K, Hansen H (1993) Three different mask physiotherapy regimens for prevention of post-operative pulmonary complications after heart and pulmonary surgery. Intensive Care Med 19:294–298
  20. Kyzer S, Charuzi I (1998) Obstructive sleep apnea in the obese. World J Surg 22:998–1001
    • View reference on PubMed
    • View reference on publisher's website
  21. Stock MC, Downs JB, Gauer PK, Alster JM, Imrey PB (1985) Prevention of postoperative pulmonary complications with CPAP, incentive spirometry, and conservative therapy. Chest 87:151–157
    • View reference on PubMed
    • View reference on publisher's website
  22. Evans TW (2001) International Consensus Conferences in Intensive Care Medicine: non-invasive positive pressure ventilation in acute respiratory failure. Organised jointly by the American Thoracic Society, the European Respiratory Society, the European Society of Intensive Care Medicine, and the Societe de Reanimation de Langue Francaise, and approved by the ATS Board of Directors, December 2000. Intensive Care Med 27:166–178
  23. Nava S, Hill N (2009) Non-invasive ventilation in acute respiratory failure. Lancet 374:250–259
    • View reference on PubMed
    • View reference on publisher's website
  24. British Thoracic Society Standards of Care Committee (2002) Non-invasive ventilation in acute respiratory failure. Thorax 57:192–211
    • View reference on publisher's website
  25. Ferrer M (2008) Non-invasive ventilation in the weaning process. Minerva Anestesiol 74:311–314
    • View reference on PubMed
  26. Nava S, Navalesi P, Carlucci A (2009) Non-invasive ventilation. Minerva Anestesiol 75:31–36
    • View reference on PubMed
  27. Ferreyra G, Long Y, Ranieri VM (2009) Respiratory complications after major surgery. Curr Opin Crit Care 15:342–348
    • View reference on PubMed
    • View reference on publisher's website
  28. Jaber S, Chanques G, Jung B (2010) Postoperative noninvasive ventilation. Anesthesiology 112:453–461
    • View reference on PubMed
    • View reference on publisher's website
  29. Chanques G, Jaber S, Delay JM, Perrigault PF, Lefrant JY, Eledjam JJ (2003) Phoning study about postoperative practice and application of non-invasive ventilation. Ann Fr Anesth Reanim 22:879–885
    • View reference on PubMed
  30. Covelli HD, Weled BJ, Beekman JF (1982) Efficacy of continuous positive airway pressure administered by face mask. Chest 81:147–150
    • View reference on PubMed
    • View reference on publisher's website
  31. Duncan SR, Negrin RS, Mihm FG, Guilleminault C, Raffin TA (1987) Nasal continuous positive airway pressure in atelectasis. Chest 92:621–624
    • View reference on PubMed
    • View reference on publisher's website
  32. Kindgen-Milles D, Buhl R, Gabriel A, Bohner H, Muller E (2000) Nasal continuous positive airway pressure: a method to avoid endotracheal reintubation in postoperative high-risk patients with severe nonhypercapnic oxygenation failure. Chest 117:1106–1111
    • View reference on PubMed
    • View reference on publisher's website
  33. Anderes C, Anderes U, Gasser D, Dittmann M, Turner J, Brennwald J, Keller R, Ferstl A, Wolff G (1979) Postoperative spontaneous breathing with CPAP to normalize late postoperative oxygenation. Intensive Care Med 5:15–21
  34. Bohner H, Kindgen-Milles D, Grust A, Buhl R, Lillotte WC, Muller BT, Muller E, Furst G, Sandmann W (2002) Prophylactic nasal continuous positive airway pressure after major vascular surgery: results of a prospective randomized trial. Langenbecks Arch Surg 387:21–26
    • View reference on PubMed
    • View reference on publisher's website
  35. Carlsson C, Sonden B, Thylen U (1981) Can postoperative continuous positive airway pressure (CPAP) prevent pulmonary complications after abdominal surgery? Intensive Care Med 7:225–229
  36. de Morais Coimbra VR, de Almeida Lara R, Flores EG, Nozawa E, Costa JO, Zanetti MI (2007) Application of noninvasive ventilation in acute respiratory failure after cardiovascular surgery. Arq Bras Cardiol 89:270–276
  37. Denehy L, Carroll S, Ntoumenopoulos G, Jenkins S (2001) A randomized controlled trial comparing periodic mask CPAP with physiotherapy after abdominal surgery. Physiother Res Int 6:236–250
    • View reference on PubMed
    • View reference on publisher's website
  38. Fagevik Olsèn M, Wennberg E, Johnsson E, Josefson K, Lönroth H, Lundell L (2002) Randomized clinical study of the prevention of pulmonary complications after thoracoabdominal resection by two different breathing techniques. Br J Surg 89:1228–1234
    • View reference on PubMed
    • View reference on publisher's website
  39. Gaszynski T, Tokarz A, Piotrowski D, Machala W (2007) Boussignac CPAP in the postoperative period in morbidly obese patients. Obes Surg 17:452–456
    • View reference on PubMed
    • View reference on publisher's website
  40. Jousela I, Rasanen J, Verkkala K, Lamminen A, Makelainen A, Nikki P (1994) Continuous positive airway pressure by mask in patients after coronary surgery. Acta Anaesthesiol Scand 38:311–316
    • View reference on PubMed
    • View reference on publisher's website
  41. Kindgen-Milles D, Muller E, Buhl R, Bohner H, Ritter D, Sandmann W, Tarnow J (2005) Nasal-continuous positive airway pressure reduces pulmonary morbidity and length of hospital stay following thoracoabdominal aortic surgery. Chest 128:821–828
    • View reference on PubMed
    • View reference on publisher's website
  42. Lindner KH, Lotz P, Ahnefeld FW (1987) Continuous positive airway pressure effect on functional residual capacity, vital capacity and its subdivisions. Chest 92:66–70
    • View reference on PubMed
    • View reference on publisher's website
  43. Neligan PJ, Malhotra G, Fraser M, Williams N, Greenblatt EP, Cereda M, Ochroch EA (2009) 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 110:878–884
    • View reference on PubMed
    • View reference on publisher's website
  44. Pasquina P, Merlani P, Granier JM, Ricou B (2004) Continuous positive airway pressure versus noninvasive pressure support ventilation to treat atelectasis after cardiac surgery. Anesth Analg 99:1001–1008, table
    • View reference on PubMed
    • View reference on publisher's website
  45. Pinilla JC, Oleniuk FH, Tan L, Rebeyka I, Tanna N, Wilkinson A, Bharadwaj B (1990) Use of a nasal continuous positive airway pressure mask in the treatment of postoperative atelectasis in aortocoronary bypass surgery. Crit Care Med 18:836–840
    • View reference on PubMed
    • View reference on publisher's website
  46. Ricksten SE, Bengtsson A, Soderberg C, Thorden M, Kvist H (1986) Effects of periodic positive airway pressure by mask on postoperative pulmonary function. Chest 89:774–781
    • View reference on PubMed
    • View reference on publisher's website
  47. Squadrone V, Coha M, Cerutti E, Schellino MM, Biolino P, Occella P, Belloni G, Vilianis G, Fiore G, Cavallo F, Ranieri VM (2005) Continuous positive airway pressure for treatment of postoperative hypoxemia: a randomized controlled trial. JAMA 293:589–595
    • View reference on PubMed
    • View reference on publisher's website
  48. Thomas AN, Ryan JP, Doran BR, Pollard BJ (1992) Nasal CPAP after coronary artery surgery. Anaesthesia 47:316–319
    • View reference on PubMed
    • View reference on publisher's website
  49. Zarbock A, Mueller E, Netzer S, Gabriel A, Feindt P, Kindgen-Milles D (2009) Prophylactic nasal continuous positive airway pressure following cardiac surgery protects from postoperative pulmonary complications: a prospective, randomized, controlled trial in 500 patients. Chest 135:1252–1259
    • View reference on PubMed
    • View reference on publisher's website
  50. Aguilo R, Togores B, Pons S, Rubi M, Barbe F, Agusti AG (1997) Noninvasive ventilatory support after lung resectional surgery. Chest 112:117–121
    • View reference on PubMed
    • View reference on publisher's website
  51. Antonelli M, Conti G, Bufi M, Costa MG, Lappa A, Rocco M, Gasparetto A, Meduri GU (2000) Noninvasive ventilation for treatment of acute respiratory failure in patients undergoing solid organ transplantation: a randomized trial. JAMA 283:235–241
    • View reference on PubMed
    • View reference on publisher's website
  52. Auriant I, Jallot A, Herve P, Cerrina J, Le Roy LF, Fournier JL, Lescot B, Parquin F (2001) Noninvasive ventilation reduces mortality in acute respiratory failure following lung resection. Am J Respir Crit Care Med 164:1231–1235
    • View reference on PubMed
  53. Conti G, Cavaliere F, Costa R, Craba A, Catarci S, Festa V, Proietti R, Antonelli M (2007) Noninvasive positive-pressure ventilation with different interfaces in patients with respiratory failure after abdominal surgery: a matched-control study. Respir Care 52:1463–1471
    • View reference on PubMed
  54. Ebeo CT, Benotti PN, Byrd RP Jr, Elmaghraby Z, Lui J (2002) The effect of bi-level positive airway pressure on postoperative pulmonary function following gastric surgery for obesity. Respir Med 96:672–676
    • View reference on PubMed
    • View reference on publisher's website
  55. Joris JL, Sottiaux TM, Chiche JD, Desaive CJ, Lamy ML (1997) Effect of bi-level positive airway pressure (BiPAP) nasal ventilation on the postoperative pulmonary restrictive syndrome in obese patients undergoing gastroplasty. Chest 111:665–670
    • View reference on PubMed
    • View reference on publisher's website
  56. Michelet P, D’Journo XB, Seinaye F, Forel JM, Papazian L, Thomas P (2009) Non-invasive ventilation for treatment of postoperative respiratory failure after oesophagectomy. Br J Surg 96:54–60
    • View reference on PubMed
    • View reference on publisher's website
  57. Perrin C, Jullien V, Venissac N, Berthier F, Padovani B, Guillot F, Coussement A, Mouroux J (2007) Prophylactic use of noninvasive ventilation in patients undergoing lung resectional surgery. Respir Med 101:1572–1578
    • View reference on PubMed
    • View reference on publisher's website
  58. Rocco M, Conti G, Antonelli M, Bufi M, Costa MG, Alampi D, Ruberto F, Stazi GV, Pietropaoli P (2001) Non-invasive pressure support ventilation in patients with acute respiratory failure after bilateral lung transplantation. Intensive Care Med 27:1622–1626
  59. Matte P, Jacquet L, Van Dyck M, Goenen M (2000) 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 44:75–81
    • View reference on PubMed
    • View reference on publisher's website
  60. Jaber S, Delay JM, Chanques G, Sebbane M, Jacquet E, Souche B, Perrigault PF, Eledjam JJ (2005) Outcomes of patients with acute respiratory failure after abdominal surgery treated with noninvasive positive pressure ventilation. Chest 128:2688–2695
    • View reference on PubMed
    • View reference on publisher's website
  61. Ginsberg RJ, Hill LD, Eagan RT, Thomas P, Mountain CF, Deslauriers J, Fry WA, Butz RO, Goldberg M, Waters PF (1983) Modern thirty-day operative mortality for surgical resections in lung cancer. J Thorac Cardiovasc Surg 86:654–658
    • View reference on PubMed
  62. Patel RL, Townsend ER, Fountain SW (1992) Elective pneumonectomy: factors associated with morbidity and operative mortality. Ann Thorac Surg 54:84–88
    • View reference on PubMed
    • View reference on publisher's website
  63. Keagy BA, Lores ME, Starek PJ, Murray GF, Lucas CL, Wilcox BR (1985) Elective pulmonary lobectomy: factors associated with morbidity and operative mortality. Ann Thorac Surg 40:349–352
    • View reference on PubMed
    • View reference on publisher's website
  64. Harpole DH, Liptay MJ, DeCamp MM Jr, Mentzer SJ, Swanson SJ, Sugarbaker DJ (1996) Prospective analysis of pneumonectomy: risk factors for major morbidity and cardiac dysrhythmias. Ann Thorac Surg 61:977–982
    • View reference on PubMed
    • View reference on publisher's website
  65. Kutlu CA, Williams EA, Evans TW, Pastorino U, Goldstraw P (2000) Acute lung injury and acute respiratory distress syndrome after pulmonary resection. Ann Thorac Surg 69:376–380
    • View reference on PubMed
    • View reference on publisher's website
  66. Sen S, Sen S, Senturk E, Kuman NK (2010) Postresectional lung injury in thoracic surgery pre and intraoperative risk factors: a retrospective clinical study of a hundred forty-three cases. J Cardiothorac Surg 5:62
    • View reference on PubMed
    • View reference on publisher's website
  67. Lefebvre A, Lorut C, Alifano M, Dermine H, Roche N, Gauzit R, Regnard JF, Huchon G, Rabbat A (2009) Noninvasive ventilation for acute respiratory failure after lung resection: an observational study. Intensive Care Med 35:663–670
  68. Money SR, Rice K, Crockett D, Becker M, Abdoh A, Wisselink W, Kazmier F, Hollier L (1994) Risk of respiratory failure after repair of thoracoabdominal aortic aneurysms. Am J Surg 168:152–155
    • View reference on PubMed
    • View reference on publisher's website
  69. Svensson LG, Hess KR, Coselli JS, Safi HJ, Crawford ES (1991) A prospective study of respiratory failure after high-risk surgery on the thoracoabdominal aorta. J Vasc Surg 14:271–282
    • View reference on PubMed
    • View reference on publisher's website
  70. Etz CD, Di Luozzo G, Bello R, Luehr M, Khan MZ, Bodian CA, Griepp RB, Plestis KA (2007) Pulmonary complications after descending thoracic and thoracoabdominal aortic aneurysm repair: predictors, prevention, and treatment. Ann Thorac Surg 83:S870–S876
    • View reference on PubMed
    • View reference on publisher's website
  71. Bishop DG, McKeown KC (1979) Postoperative hypoxaemia: oesophagectomy with gastric replacement. Br J Surg 66:810–812
    • View reference on PubMed
    • View reference on publisher's website
  72. Black J, Kalloor GJ, Collis JL (1977) The effect of the surgical approach on respiratory function after oesophageal resection. Br J Surg 64:624–627
    • View reference on PubMed
    • View reference on publisher's website
  73. Crozier TA, Sydow M, Siewert JR, Braun U (1992) Postoperative pulmonary complication rate and long-term changes in respiratory function following esophagectomy with esophagogastrostomy. Acta Anaesthesiol Scand 36:10–15
    • View reference on PubMed
    • View reference on publisher's website
  74. Stock MC, Downs JB, Cooper RB, Lebenson IM, Cleveland J, Weaver DE, Alster JM, Imrey PB (1984) Comparison of continuous positive airway pressure, incentive spirometry, and conservative therapy after cardiac operations. Crit Care Med 12:969–972
    • View reference on PubMed
    • View reference on publisher's website
  75. Morino M, Toppino M, Forestieri P, Angrisani L, Allaix ME, Scopinaro N (2007) Mortality after bariatric surgery: analysis of 13, 871 morbidly obese patients from a national registry. Ann Surg 246:1002–1007
    • View reference on PubMed
    • View reference on publisher's website
  76. Ogunnaike BO, Jones SB, Jones DB, Provost D, Whitten CW (2002) Anesthetic considerations for bariatric surgery. Anesth Analg 95:1793–1805
    • View reference on PubMed
    • View reference on publisher's website
  77. Pelosi P, Croci M, Ravagnan I, Vicardi P, Gattinoni L (1996) Total respiratory system, lung, and chest wall mechanics in sedated-paralyzed postoperative morbidly obese patients. Chest 109:144–151
    • View reference on PubMed
    • View reference on publisher's website
  78. Pelosi P, Croci M, Ravagnan I, Cerisara M, Vicardi P, Lissoni A, Gattinoni L (1997) Respiratory system mechanics in sedated, paralyzed, morbidly obese patients. J Appl Physiol 82:811–818
    • View reference on PubMed
  79. Pelosi P, Croci M, Ravagnan I, Tredici S, Pedoto A, Lissoni A, Gattinoni L (1998) The effects of body mass on lung volumes, respiratory mechanics, and gas exchange during general anesthesia. Anesth Analg 87:654–660
    • View reference on PubMed
  80. Chung SA, Yuan H, Chung F (2008) A systemic review of obstructive sleep apnea and its implications for anesthesiologists. Anesth Analg 107:1543–1563
    • View reference on PubMed
    • View reference on publisher's website
  81. Ahmad S, Nagle A, McCarthy RJ, Fitzgerald PC, Sullivan JT, Prystowsky J (2008) Postoperative hypoxemia in morbidly obese patients with and without obstructive sleep apnea undergoing laparoscopic bariatric surgery. Anesth Analg 107:138–143
    • View reference on PubMed
    • View reference on publisher's website
  82. Huerta S, DeShields S, Shpiner R, Li Z, Liu C, Sawicki M, Arteaga J, Livingston EH (2002) Safety and efficacy of postoperative continuous positive airway pressure to prevent pulmonary complications after Roux-en-Y gastric bypass. J Gastrointest Surg 6:354–358
    • View reference on PubMed
    • View reference on publisher's website
  83. Cooper JD, Patterson GA, Trulock EP (1994) Results of single and bilateral lung transplantation in 131 consecutive recipients. Washington University Lung Transplant Group. J Thorac Cardiovasc Surg 107:460–470
    • View reference on PubMed
  84. Shapiro BJ, Veeraraghavan S, Barbers RG (1999) Lung transplantation for cystic fibrosis: an update and practical considerations for referring candidates. Curr Opin Pulm Med 5:365–370
    • View reference on PubMed
    • View reference on publisher's website
  85. Ferreyra GP, Baussano I, Squadrone V, Richiardi L, Marchiaro G, Del Sorbo L, Mascia L, Merletti F, Ranieri VM (2008) Continuous positive airway pressure for treatment of respiratory complications after abdominal surgery: a systematic review and meta-analysis. Ann Surg 247:617–626
    • View reference on PubMed
    • View reference on publisher's website

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