Non-invasive respiratory support for postoperative acute hypoxemic respiratory failure: a narrative review

Pulmonary complications after surgery continue to represent a significant postoperative challenge, accounting for considerable rates of morbidity and mortality. Among these, acute hypoxemic respiratory failure (AHRF) is particularly critical, with mortality rates of up to 27%. In recent years, non-invasive respiratory strategies have been increasingly adopted to lower the risk of reintubation and reduce complications related to invasive ventilation. This narrative review examines the application of non-invasive ventilation (NIV)—namely Continuous Positive Airway Pressure (CPAP), Bilevel Positive Airway Pressure (BiPAP), and High-Flow Nasal Cannula (HFNC)—in the perioperative management of AHRF. We synthesized current evidence and guideline recommendations, with attention to patient selection criteria, preventive versus therapeutic use, and key outcomes, such as gas exchange, atelectasis, reintubation rates, morbidity, and mortality. CPAP and BiPAP may be advantageous in specific subsets of patients, such as those with chronic obstructive pulmonary disease (COPD) or cardiogenic pulmonary edema, while HFNC is increasingly favored for its comfort and ability to deliver consistent oxygenation. However, findings remain heterogeneous across surgical settings, and robust head-to-head trials are still lacking. Further studies are essential to refine patient stratification, optimize initiation timing, and determine the impact on long-term outcomes.

Hypoxia; Postoperative pulmonary complication; Continuous positive airway pressure (CPAP); BiPAP; High-flow nasal cannula (HFNC)

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