Postoperative Pulmonary Complications

							Perioperative Pulmonary
     Complications


    Dr. Behrooz Yaghchi,
    PGY 3 Anesthesiology
               Objectives:

   Preoperative Risk Stratification

   Arouzalah respiratory failure index

   Strategies to reduce perioperative
    pulmonary complications
Postoperative pulmonary
complications are as common as
cardiac complications for patients
undergoing non-cardiothoracic
surgery.
          Postoperative pulmonary
               complications


   5- 10% all surgical patients

   9- 40% after abdominal surgery



    Wong et al.Factors associated with postoper.
    pulmonary complications in patients with severe
    COPD. Anesthesia Analgesia 1995;80:276-284.
Postoperative pulmonary
complications are equally prevalent
and contribute similarly to morbidity,
mortality and length of stay as
cardiac complications
Pulmonary complications may even
be more likely than
cardiac complications to predict
long-term mortality after surgery,
particularly among older patients.

Qassem A et al. Guideline from the American
College of Physicians.
Ann Intern Med. 2006
The most important and morbid
postoperative pulmonary complications


1. Atelectasis

2. Pneumonia

3. Respiratory failure

4. Exacerbation of underlying chronic lung
disease
    Postoperative respiratory failure
                (PRF):
   the most serious postoperative
    complication

   inability to be extubated 48 hours or
    (some experts) up to 5 days
    postoperatively

   Unplanned intubation after surgery
    Postoperative respiratory failure
                (PRF):

   After AAA , the rate of PRF is 5%-21% ,
    depending on the type of aneurysm

   the in-hospital death rate is 40%-42%
    vs. 6% for those without PRF



Money SR et al.Risk of respiratory failure after repair of
thoracoabdominal aortic aneurysms.Am J Surg
1994;168:152-155.
     Preoperative Pulmonary Risk
  Stratification for Noncardiothoracic
  Surgery: Systematic Review for the
   American College of Physicians



Gerald W. Smetana et al. Ann Inten Med.
2006;144:575-580.
Patient-Related Risk Factors

   Age

    Studies showed:

    • age was a significant risk predictor
    • the second most commonly identified risk
      factor
    • 60-69 years of age- odds ratio 2.09
    • 70-79 years of age-odds ratio 3.04
    Patient-Related Risk Factors

   Chronic Lung Disease

    • COPD the most commonly identified risk
      factor
      odds ratio 1.79
    Patient-Related Risk Factors

   Cigarette Use:

    • increase in risk for postoperative pulmonary
      complications among current smokers
      odds ratio 1.26

    • No paradoxical increase in pulm. complications
      among smokers who have recently quit
      smoking (1w- 2 mo)


    Barrera R et al, Chest 2005
    Patient-Related Risk Factors
   CHF:

    • significant risk factor
      odds ratio 2.93
    Patient-Related Risk Factors
   Functional Dependence

    • Total dependence (inability to perform any
      activities of daily living)
      odds ratio 2.51

    • Partial dependence (need for equipment or
      devices and assistance from another person for
      some activities of daily living)
     odds ratio 1.65
    Patient-Related Risk Factors
   ASA Classification and
    postoperative pulmonary
    complication rates:

          Class I     1.2%
          Class II    5.4%
          Class III   11.4%
          Class IV    10.9%
    Patient-Related Risk Factors

   Obesity - no increased risk, even for
    patients with morbid obesity

   Asthma - not a risk factor for
    postoperative pulmonary complications

   OSA - complication rates may be higher,
    but this needs to be confirmed by more
    studies
 Procedure-Related Risk Factors

Surgical Site:

     Increased risk:
         AAA repair and vascular surgery
         Thoracic
         Abdominal
         Neurosurgery
         Head and neck surgery
Procedure-Related Risk Factors
   Duration of Surgery:

    • Prolonged surgery 3-4 hours -
      independent predictor of
      postoperative pulm. complications
      odds ratio 2.14
Procedure-Related Risk Factors
   Anesthetic Technique

    • increased risk after GA (4 studies)
      odds ratio 1.83
    Procedure-Related Risk Factors

   Emergency Surgery

    • significant predictor of postoper. pulm.
     complications (6 studies)
     odds ratio 2.21
Laboratory Testing To Estimate Risk

   Albumin level < 35 g/L - powerful marker of
    increased risk for postoper. pulmonary
    complications
    odds ratio 2.53

   Albumin should be measured in all patients, who
    are clinically suspected of having
    hypoalbuminemia and having 1 or more another
    risk factors

   The most important predictor of 30-day perioper.
    Morbidity and mortality (National VA Surgical
    Risk Study)
    Laboratory Testing To Estimate Risk



   serum BUN >21 mg /dl - risk factor
           Preoperative testing
   Rarely provided unexpected information that influences
    preop. Management
   Most abnormalities can be predicted by history and PE
     • Joo HS et al. Can J Anesth. 2005

   Chest X-ray
     • should not be used routinely
     • helpful for patients with cardiopulm. disease or > 50
       years of age undergoing upper abdominal, thoracic, or
       AAA repair

   Spirometry
     • should be reserved for undiagnosed COPD patients
Table 5
Table 6
                   Table 7




Arozullah AM et al,Multifactorial risk factor for
predicting postoper.respiratory failure in men after
major noncardiac surgery Ann Surg.2000;232:242-53.
    Strategies to reduce postoperative
         pulmonary complications

   Smoking cessation for 8 weeks

   Inhaled ipratropium or tiotropium in
    clinically significant COPD

   Inhaled beta-agonists in COPD or asthma
    who have wheezes or dyspnea
    Strategies to reduce postoperative
         pulmonary complications

   Preop. Corticosteroids in non-optimized
    COPD or asthma

   Delay elective surgery if resp. infection
    present

   Antibiotics for patients with infected
    sputum

   Patient education regarding lung
    expansion maneuvers
    Strategies to reduce postoperative
         pulmonary complications
   Choose alternative procedure < 3-4 hours
    duration if possible

   Minimize duration of anesthesia

   Surgery other than upper abdominal or
    thoracic when possible ?

   Regional anesthesia in high-risk patients
    Strategies to reduce postoperative
         pulmonary complications
   Avoid use of pancuronium in high-risk
    patient (residual blockage)

   Postoperative epidural pain management
    seems superior to other routes of
    delivering opioids

   Choosing laparascopic vs. open abdominal
    may be beneficial (futher studies need)

   Periop. pulmonary artery catheterization is
    not beneficial
               Reference :
   Lawrence,VA , Cornell, JE, Smetana, GW.
    Strategies to Reduce Postoperative
    Pulmonary Complications after
    noncardiothoracic surgery: systematic
    review for the American College of
    Physicians. Ann Intern Med
    2006;144:596.
     Strategies of No Benefit

Good evidence indicates:

 Routine TPN or enteral hyperalimentation
nutrition (except for patients with severe
malnutrition)

 Pulmonary artery catheter
doesn’t reduce risk of pulmonary complications
   Strategies of Proven Benefit

Good evidence suggests that lung expansion
therapy like:

 Incentive spirometry
 Deep breathing exercises
 CPAP

reduces postoperative pulmonary risk after
abdominal surgery.
    Strategies of Probable Benefit

Fair evidence suggests:

 selective nasogastric tube decompression after
abdominal surgery

 Use of short-acting neuromuscular blocking
agents

reduce risk for pulmonary complications
  Strategies of Possible Benefit

 Laparascopic vs. open abdominal operations
    Strategies of Unclear Benefit
 Smoking cessation within 2 months of surgery

 Intraoperative epidural anesthesia and
postoperative epidural analgesia
(more good-quality efficacy trials of sufficient
size are needed)