General Considerations
- Postoperative pulmonary complications are as common as postoperative cardiac complications and are associated with increased morbidity, mortality, and prolonged hospitalization
- Common Complications: Infections, respiratory failure, atelectasis, aspiration, pleural effusions, bronchospasm, pneumothorax, and worsening of chronic lung disease
- Pathophysiology: Often due to reduced lung volumes (VC and FRC) after surgery due to increased respiratory rate, splinting due to inadequate pain management, volume overload
Pulmonary Risk Assessment
- History and Physical: Goal is to uncover unexplained or suboptimally managed pulmonary processes
- Ask: Exercise tolerance, chronic cough, and dyspnea
- Evaluate: Tachypnea, accessory muscles, prolonged expiratory phase, abnormal auscultation
PATIENT RISK FACTORS |
SURGICAL RISK FACTORS |
Age > 60 Obesity & general health status Smoking COPD, asthma Heart failure & pulmonary hypertension ASA class ≥ II Nutritional deficiency, albumin < 3.5 g/dL |
Thoracic surgery and abdominal surgery Emergency surgery Prolonged surgery >3-4 hours General anesthesia |
Pulmonary Testing
Additional testing is not routinely indicated. Below are tests to consider for certain patients.
TEST |
CONSIDER IF |
PFTs |
Planned lung resection |
Known or suspected lung disease for risk stratification |
|
CXR |
Known cardiopulmonary disease |
Age >50 undergoing high risk surgery |
|
ABG |
NOT INDICATED |
Risk Factor Modification
Preoperative:
- Smoking cessation ideally at least 8 weeks prior to surgery
- Optimize any underlying chronic pulmonary disease
- Delay surgery during acute exacerbation of COPD, asthma, or respiratory infection
Postoperative:
- Lung expansion maneuvers and patient education
- Incentive spirometry, CPAP, Ez-PAP, deep breathing
- Early ambulation
- Elevate head of bed 30 degrees
Canet J et al. Pulmonary Complications in a Population-based Surgical Cohort. Anesthesiology 2010; 113: 1338-1350.
Qaseem A et al. Risk assessment for and strategy to reduce perioperative pulmonary complications for patients undergoing noncardiothoracic surgery: a guideline from the American College of Physicians. Ann Intern Med 2006;144(8):575-80.
Bapoje et al. Preoperative Evaluation of the Patient with Pulmonary Disease. Chest 2007; 132(5):1637-45
Cassidy MR et al. I COUGH Reducing Postoperative Pulmonary Complications with a Multidisciplinary Patient Care Program. JAMA Surg. 2013: 148(8): 740-745.