Table Of ContentClinical
Free
Continuing Education
Foundations
for Respiratory
Therapists (CRCE)
and Nurses (CNE)
See Page 12
A Patient-focused Education Program
for Respiratory Care Professionals
Advisory Board Postoperative Pulmonary Complications
Richard Branson, MS, RRT, FAARC David A Grooms MSHS, RRT
Professor of Surgery
University of Cincinnati College of Medicine Postoperative pulmonary complications (PPCs) are a common outcome of cardiothoracic
Cincinnati, OH
Kathleen Deakins, MS, RRT, NPS surgery. When allowed to progress, PPCs can result in serious sequelae, such as respiratory
Supervisor, Pediatric Respiratory Care
Rainbow Babies & Children’s failure, pulmonary embolism, acute lung injury, or acute respiratory distress syndrome.
Hospital of University Hospitals
Cleveland, OH The prevention of PPCs requires a comprehensive approach that includes assessment of
William Galvin, MSEd, RRT, CPFT, AE-C, FAARC preoperative risk, smoking cessation, and attention to a number of factors before, during
Program Director, Respiratory Care Program
Gwynedd Mercy College, and after surgery. In this article, Dr. Grooms addresses several preventive measures such
Gwynedd Valley, PA.
Carl Haas, MS, RRT, FAARC as intraoperative and postoperative anesthetic/analgesic technique, the use of laparoscop-
Educational & Research Coordinator
University Hospitals and Health Centers ic surgery, selective nasogastric tube decompression, lung expansion modalities, oxygen
Ann Arbor, MI
therapy, deep breathing exercises, physical therapy, and the use of subglottic suction endo-
Richard Kallet, MSc, RRT, FAARC
Clinical Projects Manager tracheal tubes. Clinical trials in this area are needed to guide practice, but in the absence
University of California Cardiovascular Research Institute
San Francisco, CA of evidence, minimally studied or unproven therapies may still provide clinical benefit if
Neil MacIntyre, MD, FAARC used judiciously.
Medical Director of Respiratory Services
Duke University Medical Center
Durham, NC
Tim Myers, BS, RRT-NPS Panel Discussion: Postoperative Pulmonary Complications
Pediatric Respiratory Care
Rainbow Babies and Children’s Hospital
Cleveland, OH
Tim Op’t Holt, EdD, RRT, AE-C, FAARC Moderator: Faisal Masud, MD
Professor, Department of Respiratory Care
and Cardiopulmonary Sciences Panelists: Paul Marik, MD
University of Southern Alabama
Mobile, AL Ruben Restrepo, MD, RRT
Helen Sorenson, MA, RRT, FAARC Luis Angel, MD
Assistant Professor, Dept. of Respiratory Care
University of Texas Health Sciences Center David Wheeler, RRT
San Antonio, TX
The Clinical F oundations Understanding the nature of PPCs is paramount to their prevention and treatment. In this
Community
panel discussion, 5 experts in respiratory medicine discuss the many facets of PPCs and
measures clinicians can take to reduce their risk. The discussants address the definition of
PPCs, their impact on perioperative morbidity and mortality, PPC risk factors, surgical and
anesthesia issues, and strategies that can be implemented pre- and post-surgery to reduce
the risk of PPCs. Also discussed are issues related to cost, an ever-important consideration
in the era of pay-for-performance.
The Clinical Foundations Community
feature allows readers to comment,
ask questions, or respond to
questions from the author on
featured topics. Join our discussion
on the Clinical Foundations website
www.clinicalfoundations.org
This program is sponsored by Teleflex
2012-0669
Clinical Foundations
related to wound and urinary tract infec-
Postoperative Pulmonary tions.15 However, subsequent trials have
demonstrated reductions in wound heal-
ing complications in head and neck16 and
Complications
breast reduction surgery17 when smoking
was stopped 3 to 4 weeks prior to surgery.
Hypothetically, cessation less than 3 to 4
David A Grooms MSHS, RRT
weeks before surgery may benefit postop-
erative recovery.18
P
ostoperative pulmonary com- Intraoperative Anesthetic and
plications (PPC) can adversely Neuraxial blockade, via Analgesic Technique
influence a patient’s clinical Anesthetics disrupt central regula-
course following surgery and are tion of breathing and result in uncoordi-
equally as common as cardiac complica- spinal or epidural route, may nated neural messaging, hypoventilation,
tions for patients undergoing non-car- and positional-dependent regional atelec-
diothoracic surgery. These complications tasis shortly after induction.19 If these an-
improve recovery and prevent
include atelectasis, bronchospasm, and esthesia effects are unresolved, they can be
tracheobronchitis, which are considered compounded by limited respiratory ex-
self-limiting disorders known to induce cursion due to pain, and disruption of re-
complications by blocking a
perioperative hypoxemia. However, these spiratory muscles and neutrally mediated
complications may result in substan- diaphragmatic function.20 In a landmark
tial morbidity and mortality when they constellation of stress investigation assessing mortality rates in
progress to more severe forms or develop 599,548 surgical patients undergoing pro-
into respiratory failure, pulmonary em- cedures between 1948 and 1952, Beecher
bolism, postoperative pneumonia (PP), & Todd observed a 6-fold increase in the
empyema, pneumothorax, acute lung in- ness of common interventions and how risk of death in the perioperative period
jury (ALI), acute respiratory distress syn- they pertain to postoperative recovery. associated with the use of neuromuscu-
drome (ARDS), or the need for mechani- Examples include preoperative smoking lar blocking agents (NMBA).21 Over the
cal ventilation beyond 48 hours following cessation, anesthetic and analgesic tech- last 50 years, second and third generation
surgery.1,2 Special attention is often given nique, laparoscopic vs. open procedures, NMBA’s have been developed to mini-
to the prevention and development of at- nasogastric decompression, lung expan- mize hemodynamic compromise and
electasis because it is one of the primary sion therapy, and the use of subglottic- improve rapid onset and offset of effects,
mechanisms associated with ALI, a major suction endotracheal tubes. and recovery patterns. Despite improve-
cause of postoperative hypoxemia, lead- ments, residual neuromuscular blockade
ing to longer stay in the intensive care Preoperative Smoking Cessation remains a common and often undetected
unit (ICU) and increased length of stay It is well understood that smoke occurrence in the early postoperative pe-
(LOS) in the hospital.3 Although the clini- inhalation contributes to reduced muco- riod.22,23 The use of intermediate-active
cal evidence regarding PPC prevention is ciliary activity leading to decreased mucus NMBA (atracurium, vecuronium) in
often unclear and moderately strong at production and increased coughing due comparison to long-acting NMBA (pan-
best, essential measures must be taken to to bronchial irritation. Smoking increases curonium) has not proven to reduce PPCs,
reduce PPCs. These include carefully in- the frequency of complications in minor however, they have led to significantly re-
dividualized strategies for preventing at- surgical procedures,4,5 hernia surgery,6,7 duced incidence of residual neuromus-
electasis and aspiration of oral secretions, vascular surgery,8 gastrointestinal sur- cular blockade (5% vs 26%; P<.001).24
restoring functional residual capacity, and gery,9,10 gynecologic surgery,11 and ortho- Therefore, patients with residual blockade
increasing the patient’s ability to mobilize pedic surgery.12,13 Therefore, cessation of following pancuronium administration
and expectorate secretions. smoking prior to surgery is recommend- were 3 times more likely to develop PPCs
ed to reduce postoperative complications. than those without residual block (17% vs.
Overview of Preoperative Risks However, there is insufficient evidence re- 5%; P<.02).
Success of postoperative recovery is garding the minimum duration of smok- Neuraxial blockade, via spinal or
dependent not only on pulmonary physi- ing cessation and its association with epidural route, may improve recovery
ology restoration after surgery, but also PPCs.14 Interventions to reduce smoke and prevent complications by blocking a
on preoperative education and intraoper- inhalation 6 to 8 weeks prior to elective constellation of stress responses to sur-
ative clinical care management. Therefore, hip and knee arthroplasty surgery proved gery (e.g. increase in neurodocrines and
it is necessary to discuss the appropriate- successful in minimizing complications cytokines, and reduction in pain thresh-
2 www.clinicalfoundations.org
Clinical Foundations
old) which contribute to a reduction in operative pain, surgical risk, and spiro-
respiratory muscle dysfunction and pain- The intent of postoperative metric data, it is unclear whether clinically
related hypoventilation. Epidural ad- important PPC’s are minimized with the
ministration is possible through a single use of laparoscopic surgical procedures.
injection or infusion and is commonly analgesia is to further reduce Many studies did not report PPCs and
used for intraoperative and postoperative others lack the ability to detect differences
analgesia. However, compared to epidural in PPC rate because of small sample size
surgical stress responses which
anesthesia, spinal anesthesia has a rapid and insufficient statistical power.
onset around 5 to10 minutes vs. 15 to 20
minutes, is easier to administer, and pro- Routine Nasogastric Tube
can lead to PPCs and organ
duces a denser sensory and motor block. Decompression vs Selective
Due to practical constraints of indwelling Nasogastric Tube Decompression
intrathecal catheters, spinal anesthesia is dysfunction. Following Surgery
administered solely as a single injection. Nasogastric tube decompression
Although intraoperative neuraxial block- (NTD) is the act of reducing gastric pres-
ade (with or without concomitant gen- sure through the use of a large bore tube
eral anesthesia) may prevent PPCs, data cularly, or subcutaneously and found no suction system inserted into the stom-
from two recent, good quality, systematic difference in opioid consumption, pain ach, which aims to minimize abdominal
reviews provide conflicting results with scores, hospital length of stay, and adverse distention, delays in early bowel return,
regards to reduction in postoperative effects.30 However, fewer PPCs occurred nausea or vomiting, and aspiration. The
pneumonia rates.25,26 Several meta-analy- in the PCA group (2 studies). Therefore, appropriateness of selective NTD over
ses which include small unblinded stud- postoperative epidural and PCA intrave- routine NTD has come to a favorable and
ies suggest that epidural anesthesia may nous analgesia both seem superior com- convincing consensus. Several studies and
reduce pulmonary risk, but recent large pared to on-demand delivery of opioids meta-analysis have failed to show a statis-
randomized controlled trials do not con- in preventing PPCs. tically significant benefit with regards to
firm benefit.19 improved pneumonia, aspiration, and re-
Laparoscopic vs Open Surgical turn to gastrointestinal function rates with
Postoperative Analgesic Technique Procedures routine NTD when compared to selective
The intent of postoperative anal- Few studies have reported PPC NTD. A recent prospective randomized
gesia is to further reduce surgical stress rates associated with laparoscopic vs controlled trial (RCT) examined the ne-
responses which can lead to PPCs and open surgical procedures. In those that cessity of routine NTD in radical gastrec-
organ dysfunction. Therefore, careful at- have reported them, PPCs were associ- tomy for gastric cancer patients.35 There
tention is required to interpret scientific ated with cholecystectomy and colorectal was no difference in overall PPCs between
findings related to postoperative recovery. surgery. Although a recent meta-analysis a tube group (TG), an intra-operative tube
The literature has been confounded by examining laparoscopic vs open resec- group (ITG), and a no-tube group (NTG).
many misunderstandings in different nar- tion of colorectal cancer demonstrates However, the TG group had an increased
rative reviews and meta-analyses. Studies faster postoperative recovery defined by hospital LOS compared to the NTG group
combining a variety of epidural analgesic spirometry (3 studies), and 21% shorter (11.3 vs. 10.2 days; P =.031) and a higher
techniques can be perceived as irrational hospital LOS (9 studies), the difference in incidence of nausea compared to the ITG
because opioid-based regimens have little risk and complications between the two and NTG groups (64% vs. 36% vs 29.6%).
or no effect on stress response and organ surgical methods were not statistically dif- Another recent meta-analysis of routine
dysfunction compared to local anesthe- ferent.31 A subsequent trial of laparoscop- NTD reported no statistically significant
sia regimens.27 Furthermore, interpreting ic vs open colorectal resection showed a differences between NTD and no NTD
these studies is difficult because of the in- non-significant trend favoring lower rates with respect to nausea, wound infection,
clusion of a variety of surgical procedures of pneumonia (1.8% vs. 3.5%) following or intestinal obstruction rates following
that demonstrate less pronounced surgi- laparoscopic surgery.32 Similarly, using elective colon and rectum surgery.36 How-
cal stress response in abdominal and tho- ICD-9-CM codes to identify PPCs follow- ever, 2 meta-analyses examining the use of
racic procedures compared to lower body ing laparosopic and open procedures, two routine NGT compared to selective NGT
procedures.28 However, a previous meta- studies reported a reduction in atelectasis following abdominal surgery reported
analysis revealed a reduction in atelectasis following laparoscopic surgery compared lower pneumonia, atelectasis, and overall
(11 studies) but not pneumonia (5 studies) with open cholecystectomy (2% vs. 4%; PPC rates with the use of selective NTD.
when using epidural opioids vs systemic P <.001), and less frequent PPCs follow- Subsequently, a recent Cochrane Data-
opioids.29 In contrast, a subsequent meta- ing laparoscopic vs open sigmoid resec- base Systematic Review of prophylactic
analysis identified 32 trials of PCA vs the tion (2.5% vs. 6%; P<.001).33,34 Although NTD following abdominal surgeries re-
same drug given intravenously, intramus- supported by improvements in LOS, post- flects these findings by reporting a earlier
www.clinicalfoundations.org 3
Clinical Foundations
return to bowel function (P<.00001), a a significant statistical difference in PPC
trend toward increase risk of wound in- Incentive spirometry remains when compared to IPPB in 30 patients,41
fection (P=.22), and a statistically signifi- a subsequent meta-analysis reported that
cant decrease in PPC (P=.01).37 Therefore, IS, IPPB, and deep breathing exercises
the evidence suggests that selective NTD attractive because it is less labor appeared to be more effective than no
for specific indications improves return to physical therapy intervention for prevent-
bowel functions and may reduce the risk ing PPCs following upper abdominal sur-
intensive, more economical,
of PPC compared to routine NTD. gery.42 While this study provided valuable
insight and contribution to the literature,
Lung Expansion Modalities and it failed to provide evidence to support a
and patient-driven.
Oxygen Therapy significance difference between each of
The cascade of PPCs usually begins the modalities and was limited in scope
with the onset of atelectasis and decreased with regard to surgery and the number
lung volumes resulting from surgery- inspired oxygen (FIO) level of 1.0 dem- of studies involving IS. Previous surveys
2
related diaphragmatic dysfunction, im- onstrated a significant increase in oxygen reported 95% use of IS in US hospitals
mobilization, and impaired mucociliary tension following a deep breath hold for 3 following cardiothoracic and abdominal
clearance. Therefore, it is essential to use seconds, in comparison to a deep breath surgery,43 44% in UK hospitals following
the correct timing and methods for restor- without breath hold, and multiple deep coronary bypass graft surgery,44 and an
ing normal lung capacity and mobilizing breaths. Furthermore, the oxygen ten- increased usage rate of IS despite publi-
secretions in the postoperative phase of sion was significantly increased when the cations which cast doubt on the need for
recovery. Common techniques that are breath was extended to a 5-second hold. IS.45 However, a subsequent, systematic
currently employed to achieve such res- Subsequently, the first reports of such review failed to provide evidence to sup-
toration include deep breathing exercises, maneuvers used for the treatment of post- port the use of IS for decreasing the in-
such as incentive spirometry (IS), hyper- surgical patients originated in Great Brit- cidence of PPC’s following cardiac or up-
inflation therapy (intermittent positive- ain, and revealed a significantly lower in- per abdominal surgery.46 Furthermore, a
pressure breathing [IPPB], continuous cidence of postoperative atelectasis (27% recent systematic review confirms that no
positive airway pressure [CPAP], and in- vs. 42%) detected by chest radiograph in one lung expansion technique is superior
sufflation/exsufflation), and chest physi- patients treated with physical therapy in- over another, however, any type of lung
cal therapy (CPT), also known as chest cluding deep breathing exercises, with a expansion intervention is more clinically
physiotherapy (often combined with further reduction to 12% in patients who beneficial than no prophylaxis.19 Addi-
aerosolized mucolytic administration, received preoperative instruction in the tionally, combined therapies do not pro-
coughing exercises, postural drainage, exercises, when compared to no therapy.39 vide additional risk reduction in patients
and percussion and vibration). Despite Therefore, engineering of instrumenta- following non-cardiothoracic surgery.19
the clinical indication, lung capacity res- tion to guide this therapeutic interven- Therefore, IS remains attractive because
toration is dependent on 3 factors: patient tion lead to development of the IS device it is less labor intensive, more economi-
cooperation, modality of therapy, and in 1972. The incentive spirometer (Figure cal, and patient-driven. For patients who
proper caregiver application. Although 1) is designed to provide visual feedback cannot perform IS or deep breathing exer-
it is understood that patient cooperation to the patient, followed by documenta- cises, alternative hyperinflation therapies
is often necessary, lung expansion is pos- tion of the number of successful breath- such as CPAP, IPPB, and insufflation/ex-
sible in passively ventilated patients (i.e. ing maneuvers.40 Although the first report sufflation may be beneficial.
mechanically ventilated). Therefore, both of IS as a treatment option failed to show
the chosen therapy and caregiver appli- Chest Physical Therapy
cation are essential in obtaining optimal Chest physical therapy (CPT), also
benefit of lung expansion. These therapies called chest physiotherapy, is an inter-
are often used in combination and despite vention which incorporates external ma-
having little individual impact on clinical nipulation of the thorax by a caregiver to
studies, they are still commonly used. mobilize retained secretions. Tradition-
ally, this has been performed by special-
Deep Breathing Exercises (Incentive ized caregivers who performed manual
Spirometry and Hyperinflation percussion (clapping of the chest wall)
Therapies) and vibration (shaking of the chest wall)
The simple use of deep breath- during exhalation, targeting specific lobes
ing techniques was described in the late and lung regions. It is often coupled with
1960’s.38 In this report, a series of young, postural drainage which involves patient
unmedicated adults inspiring a fractional positioning of the effected lung regions to
Figure 1. Voldyne® Incentive Spirometer, Teleflex
4 www.clinicalfoundations.org
Clinical Foundations
facilitate gravitational drainage of secre- $11,873.00.55 Therefore, engineering and
tions. Today, percussion and vibration can creation of specialized ETT’s have proven
be performed by a variety of mechanical beneficial with regards to minimizing ear-
techniques. Despite the theoretical ad- ly onset VAP (within 48-72 hours) which
vantages of CPT, and its common place may reduce PPC’s.
in health care medicine, a large body of Subglottic-suction ETT’s incorpo-
literature fails to demonstrate a clinical rate an additional dorsal lumen suction
benefit associated with its routine use in channel directly above the cuff which
postoperative and nonsurgical patients. A is connected to an external evacuation
landmark systematic review reveals the system. Secretions are extracted either
concerns of many authors and their reluc- intermittently or continuously.56 A large
tance to endorse CPT as a standard of care. number of studies have sought to detect
These are highlighted below:47 clinical benefit of this tube type com-
“Although physiotherapy is seen as an pared to standard treatment. Although a
integral part of most multidisciplinary recent review of 6 RCT’s demonstrate a
intensive care units, there is only limited reduction in the incidence and delay in
evidence concerning the effectiveness of early onset VAP in a heterogenous patient
physiotherapy in this setting.48 population, half of the trials showed no
The literature concerning CPT and its statistically significant difference in VAP
Illustration depicting secretion removal using an ETT
effect on the pulmonary function of cystic with subglottic suction capability. (Courtesy Teleflex) between subglottic-suction ETT and
fibrosis patients is extensive and inconsis- erative risk evaluation of lung resection standard therapy (via chi-square test, in-
tent in its findings.49 candidates.53 Therefore, the routine use of tention-to-treat analysis).57 However, a
In mechanically ventilated children, CPT is not recommended to reduce PPC. previous meta-analysis of 5 studies con-
chest physiotherapy cannot be regarded Alternative therapy such as ambulation, firms benefit with an approximate 50%
as a standard treatment modality.50 and earlier extubation may improve clini- decrease in VAP in 896 patients expected
…we conclude that mechanical per- cal outcomes in high-risk surgeries.54 to require mechanical ventilation for 72
cussion of the chest as applied by physical hours.58 Therefore, the results of these tri-
/respiratory therapists is ineffective and Subglottic-suction ETT als proved powerful enough to support
perhaps even detrimental in the treatment During mechanical ventilation, the endorsement for VAP prevention by the
of patients with acute exacerbations of placement of an endotracheal tube (ETT) Center for Disease Control (CDC),59 the
chronic obstructive pulmonary disease.51 causes the airway to lose its natural abil- American Association of Respiratory Care
There continues to be widespread de- ity to prevent aspiration of oral, nasal, (AARC),60 the American Association of
bate as to which airway clearance regimen and gastric secretions. These secretions Critical-Care Nurses (AACN),61 and the
should be used and when.52 eventually penetrate the lungs via the ETT American Thoracic Society (ATS).62
Although the above statements ad- and accumulate below the epiglottis and
dress the global use of CPT in the health- above the ETT cuff (subglottic airway). Summary
care setting, the only RCT to date that ex- This accumulation is often later aspirated Despite the conflicting nature of
amined the association between CPT and through the inadvertent channels created clinical trials dedicated to reduction
PPC also failed to demonstrate a clinical within the ETT cuff resultant of cuff in- of PPCs, most interventions discussed
benefit of CPT following pulmonary re- flation and placement against the trachea above are still common in today’s health-
section via open thoracotomy.53 In con- wall. Penetration of these secretions into care. The basis for selection of patient
trast, using a propensity score matching the lungs can result in development of therapy often expands beyond clinical
method, a recent, prospectively reviewed ventilator-associated pneumonia (VAP), trials, which use statistical significance
database of 784 lung cancer patients which is associated with increased mortal- to validate treatment benefit. Therefore,
treated by lobectomy justified the imple- ity, morbidity, and ventilator LOS, with an selection should be driven by economi-
mentation of a perioperative intensive approximate increase in healthcare cost of cal and practical concerns, as well as the
CPT program which reduced overall pul- individual needs of patients. In a recent
monary morbidity. Despite the success of editorial, Dr. Athur Slutsky addresses the
the project to minimize the probability of phenomenon of the human attraction
pulmonary complication, this study did to physiology and the complex nature in
not include diffusion lung capacity for which the foundation of clinical decision-
carbon monoxide (DLCO) and predicted making is constructed. Although health-
postoperative diffusion lung capacity for care decisions should be clinically and ev-
carbon monoxide (ppoDLCO), measures idence-based, many clinical trials have yet
ISIS® HVT™Convertible Endotracheal Tube to remove
that are currently paramount in preop- subglottic secretions. (Courtesy Teleflex) to provide the necessary information we
www.clinicalfoundations.org 5
Clinical Foundations
require as caregivers. This is echoed in his 19 Lawrence VA, Cornell JE, Smetana GW. Strategies to postoperative atelectasis following abdominal and tho-
reduce postoperative pulmonary complications af- racic surgery. Chest. 1985;87(1):76.
statement, “Does it make sense not to use ter noncardiothoracic surgery: systematic review for
44 Jenkins SC, Soutar SA. A survey into the use of incentive
the American College of Physicians. Ann Intern Med
a novel (or not so novel) therapeutic strat- 2006;144(8):596-608. spirometry following coronary artery by-pass graft sur-
gery. Physiotherapy. 1986;72(10):492–493.
egy that has a strong physiological ratio- 20 Bluman LG, Mosca L, Newman N, Simon DG. Preopera- 45 Wattie J. Incentive spirometry following coronary artery
tive smoking habits and postoperative pulmonary com-
bypass surgery. Physiotherapy. 1998;84(10):508–514.
nale, demonstrates a strong positive trend plications. Chest 1998;113(4):883-889.
46 The Effect of Incentive Spirometry on Postoperative
in an important clinical outcome, has an 21 Beecher HK, Todd DP. A study of the deaths associated Pulmonary Complications: A Systematic Review. Chest
with anesthesia and surgery: based on a study of 599, 548
2001;120(3):971-978
acceptable adverse effect profile, and is anesthesias in ten institutions 1948-1952, inclusive. Ann
Surg 1954;140(1):2-35. 47 Hess DR. The evidence for secretion clearance techniques.
inexpensive? 63” Therefore, consideration 22 Debaene B, Plaud B, Dilly M-P, Donati F. Residual paraly- Respir Care 2001;46(11):1276-1293.
sis in the PACU after a single intubating dose of nondepo- 48 Stiller K. Physiotherapy in Intensive Care: towards an
of minimally studied or unproven thera- larizing muscle relaxant with an intermediate duration of evidence-based practice. Chest 2000;118(6):1801-1813.
pies, which make physiologic and clinical action. Anesthesiology 2003;98(5):1042-1048. 49 Williams MT. Chest physiotherapy and cystic fibrosis.
23 Cammu G, De Witte J, De Veylder J, et al. Postoperative re- Why is the most effective form of treatment still unclear?
sense, may provide clinical benefit in the sidual paralysis in outpatients vs inpatients. Anesth Analg Chest 1994;106(6):1872-1882.
absence of an associated clinical trial or 2006;102(2):426-429. 50 Krause MF, Hoehn T. Chest physiotherapy in me-
24 Berg H, Roed J, Viby-Mogensen J, et al. Residual neu- chanically ventilated children: a review. Crit Care Med
science. romuscular block is a risk factor for postoperative pul- 2000;28(5):1648-1651.
monary complications. A prospective, randomised, and 51 McCrory DC, Brown C, Gelfand SE, Bach PB. Manage-
blinded study of postoperative pulmonary complications ment of acute exacerbations of COPD: a summary and
References after atracurium, vecuronium and pancuronium. Acta appraisal of published evidence. Chest 2001;119(4):1190-
1 Shander A, Fleisher LA, Barie PS, et al. Clinical and eco- Anaesthesiol Scand 1997;41(9):1095-1103. 1209.
nomic burden of postoperative pulmonary complica- 25 Urwin SC, Parker MJ, Griffiths R. General vs regional 52 Pryor JA. Physiotherapy for airway clearance in adults.
tions: Patient safety summit on definition, risk-reducing anaesthesia for hip fracture surgery: a meta-analysis of Eur Respir J 1999;14(6):1418-1424.
interventions, and preventive strategies. Crit Care Med randomized trials. Br J Anaesth 2000;84(4):450-455.
2011;39(9):1-10. 53 Reeve JC, Nicol K, Stiller K, et al. Does physiotherapy
26 Rodgers A, Walker N, Schug S, et al. Reduction of postop- reduce the incidence of postoperative pulmonary com-
2 Arozullah AM, Daley J, Henderson WG, Khuri SF. Multi- erative mortality and morbidity with epidural or spinal plications following pulmonary resection via open thora-
factorial risk index for predicting postoperative respira- anaesthesia: results from overview of randomised trials. cotomy? A preliminary randomised single-blind clinical
tory failure in men after major noncardiac surgery. The BMJ 2000;321(7275):1-12. trial. Eur J Cardiothorac Surg 2010;37(5):1158-1166.
National Veterans Administration Surgical Quality Im-
provement Program. Ann Surg 2000;232(2):242-253. 27 Kehlet H, Holte K. Effect of postoperative analgesia on 54 Ambrosino N, Gabbrielli L. Physiotherapy in the peri-
surgical outcome. Br J Anaesth 2001;87(1):62-72. operative period. Best Pract Res Clin Anaesthesiol
3 Talab HF, Zabani IA, Abdelrahman HS, et al. Intraopera- 28 Kehlet H. Modification of responses to surgery by neural 2010;24(2):283-289.
tive ventilatory strategies for prevention of pulmonary
atelectasis in obese patients undergoing laparoscopic bar- blockade: clinical implications. In: Cousins MJ, Briden- 55 Warren D, Shukla S, Olsen, M, Kollef M, et al. Outcome
iatric surgery. Anesth Analg 2009;109(5):1511-1516. baugh, eds. Neural Blockade in Clinical Anesthesia and and attributable cost of ventilator –associated pneumonia
Management of Pain, 3rd Edn. Philadelphia: Lippencott- among intensive care unit in a suburban medical center.
4 Myles PS, Iacono GA, Hunt JO, et al. Risk of respiratory Raven, 1998:129-171. Critical Care Medicine 2003;31(5):1312-1317.
complications and wound infection in patients undergo-
ing ambulatory surgery: smokers vs nonsmokers. Anes- 29 Ballantyne JC, Carr DB, deFerranti S, et al. The compara- 56 Lacherade J-C, De Jonghe B, Guezennec P, et al. Intermit-
thesiology 2002;97(4):842-847. tive effects of postoperative analgesic therapies on pulmo- tent subglottic secretion drainage and ventilator-associat-
nary outcome: cumulative meta-analyses of randomized, ed pneumonia: a multicenter trial. Am J Respir Crit Care
5 Al-Khayat H, Al-Khayat H, Sadeq A, et al. Risk factors for controlled trials. Anesth Analg. 1998;86(3):598-612. Med 2010;182(7):910-917.
wound complication in pilonidal sinus procedures. J Am
Coll Surg 2007;205(3):439-444. 30 Walder B, Schafer M, Henzi I, Tramer MR. Efficacy 57 Gentile MA, Siobal MS. Are specialized endotracheal
and safety of patient-controlled opioid analgesia for tubes and heat-and-moisture exchangers cost-effective in
6 Finan KR, Vick CC, Kiefe CI, et al. Predictors of wound in- acute postoperative pain. Acta Anaesthesiol Scand preventing ventilator associated pneumonia? Respir Care
fection in ventral hernia repair. Am J Surg. 2005;190:676– 2001;45(7):795–804. 2010;55(2):184-197.
681.
31 Abraham NS, Young JM, Solomon MJ. Meta-analysis 58 Dezfulian C, Shojania K, Collard HR, et al. Subglottic
7 Lindström D, Sadr Azodi O, Bellocco R, et al. The effect of short-term outcomes after laparoscopic resection for secretion drainage for preventing ventilator-associated
of tobacco consumption and body mass index on com- colorectal cancer. Br J Surg 2004;91(9):1111-1124. pneumonia: a meta-analysis. Am J Med 2005;118(1):11-
plications and hospital stay after inguinal hernia surgery. 32 Vignali A, Braga M, Zuliani W, et al. Laparoscopic 18.
Hernia 2007;11(2):117-123.
colorectal surgery modifies risk factors for postoperative 59 Tablan OC, Anderson LJ, Besser R, et al. Guidelines for
8 Martin LF, Atnip RG, Holmes PA, et al. Prediction of morbidity. Dis Colon Rectum 2004;47(10):1686-1693. preventing health-care-associated pneumonia, 2003:
postoperative complications after elective aortic sur- 33 Guller U, Jain N, Hervey S, Purves H, Pietrobon R. recommendations of CDC and the Healthcare Infection
gery using stepwise logistic regression analysis. Am Surg Laparoscopic vs open colectomy: outcomes compari- Control Practices Advisory Committee. MMWR Re-
1994;60:163–168. son based on large nationwide databases. Arch Surg comm Rep 2004;53(RR-3):1-36.
9 Sorensen LT, Hemmingsen U, Kallehave F, et al. Risk fac- 2003;138(11):1179-1186. 60 Guidelines for preventing health-care-associated pneu-
tors for tissue and wound complications in gastrointesti- 34 Zacks SL, Sandler RS, Rutledge R, Brown RS Jr. A pop- monia, 2003 recommendations of the CDC and the
nal surgery. Ann Surg 2005; 241:654–658. ulation-based cohort study comparing laparoscopic cho- Healthcare Infection Control Practices Advisory Com-
10 Sadr Azodi O, Lindström D, Adami J, et al. Impact of body lecystectomy and open cholecystectomy. Am J Gastroen- mittee. Respir Care. 2004;49(8):926-939.
mass index and tobacco smoking on outcome after open terol 2002;97(2):334-340. 61 American Association of Critical-Care Nurses. AACN
appendicectomy. Br J Surg 2008;95(6):751-757. 35 Li C, Mei JW, Yan M, et al. Nasogastric decompression for practice alert: ventilator-associated pneumonia. Available
11 Pappachen S, Smith PR, Shah S, et al. Postoperative pul- radical gastrectomy for gastric cancer: a prospective ran- at: http://classic.aacn.org/AACN/practiceAlert.nsf/Files/
monary complications after gynecologic surgery. Int J domized controlled study. Dig Surg 2011;28(3):167-172. VAP/$file/Ventilator%20Associated%20Pneumonia%20
Gynaecol Obstet 2006;93(1):74-76. 11-2007.pdf. [Web]. Accessed July 26, 2011.
36 Rao W, Zhang X, Zhang J, et al. The role of nasogas-
12 Sadr Azodi O, Bellocco R, Eriksson K, Adami J. The im- tric tube in decompression after elective colon and 62 American Thoracic Society and the Infectious Diseases
pact of tobacco use and body mass index on the length of rectum surgery: a meta-analysis. Int J Colorectal Dis Society of America. Guidelines for the management of
stay in hospital and the risk of post-operative complica- 2011;26(4):423-429. adults with hospital-acquired, ventilator-associated, and
tions among patients undergoing total hip replacement. J healthcare-associated pneumonia. Am J Respir Crit Care
37 Nelson R, Edwards S, Tse B. Prophylactic nasogastric de-
Bone Joint Surg Br 2006;88(10):1316-1320. Med 2005;171(4):388-416.
compression after abdominal surgery. Cochrane Database
13 Castillo RC, Bosse MJ, MacKenzie EJ, Patterson BM. Im- Syst Rev 2007;(3):CD004929. 63 Slutsky AS. Improving Outcomes in Critically Ill Patients.
pact of smoking on fracture healing and risk of complica- JAMA 2009;302(18):2030 -2032.
38 Ward RJ, Danziger F, Bonica JJ, Allen GD, Bowes J. An
tions in limb-threatening open tibia fractures. J Orthop
evaluation of postoperative respiratory maneuvers. Surg
Trauma 2005;19(3):151-157.
Gynecol & Obstet 1966;123(1):51-54.
14 Thomsen T, Villebro N, Møller AM. Interventions for pre-
39 Bartlett RH, Brennan ML, Gazzaniga AB, Hanson EL. David Grooms, MHS, RRT is Respiratory Clinical
operative smoking cessation. Cochrane Database Syst Rev
Studies on the pathogenesis and prevention of postop-
2010;(7):CD002294. Program Manager at Sentra Norfolk, Leigh and
erative pulmonary complications. Surg Gynecol Obstet
15 Møller AM, Villebro N, Pedersen T, et al. Effect of pre- 1973;137(6):925-933. Bayside Hospitals in Norfolk, Virginia. He over-
operative smoking intervention on postoperative
complications: a randomised clinical trial. The Lancet 40 Bartlett RH, Gazzaniga AB, Geraghty TR. Respiratory sees respiratory care clinical activities for 3 hos-
maneuvers to prevent postoperative pulmonary compli-
2002;359(9301):114–117. cations. JAMA 1973;224(7):1017-1021. pitals as well as being responsible for the coor-
16 Kuri M, Nakagawa M, Tanaka H, Hasuo S, Kishi Y. De-
41 Van de Water JM, Watring WG, Linton LA, Murphy M, dination of staff orientation, research projects,
termination of the duration of preoperative smoking
Byron RL. Prevention of postoperative pulmonary com-
cessation to improve wound healing after head and neck operational duties of multi-specialty ICU. Addi-
plications. Surg Gynecol Obstet 1972;135(2):229.
surgery. Anesthesiology 2005;102(5):892-896.
42 Thomas JA, McIntosh JM. Are incentive spirometry, inter- tionally, Mr. Grooms has published and present-
17 Chan LKW, Withey S, Butler PEM. Smoking and wound
healing problems in reduction mammaplasty: is the in- mittent positive pressure breathing, and deep breathing ed at the state and national level on various re-
exercises effective in the prevention of postoperative pul-
troduction of urine nicotine testing justified? Ann Plast monary complications after upper abdominal surgery? A spiratory care topics and has been an speaker at
Surg 2006;56(2):111-115.
systematic overview and meta-analysis. Physical Therapy several local, state and national conferences.
18 Thomsen T, Tonnesen H, Møller AM. Effect of preop- 1994;74(1):3.
erative smoking cessation interventions on postoperative
43 O’Donohue WJ. National survey of the usage of lung ex-
complications and smoking cessation. British Journal of
pansion modalities for the prevention and treatment of
Surgery. 2009;96(5):451–461.
6 www.clinicalfoundations.org
Clinical Foundations
Panel Discussion: and needs to be distinguished from ven-
tilator-associated pneumonia. In addi-
tion to those mentioned by Dr. Marik,
Postoperative Pulmonary
other clinically significant PPCs include
respiratory failure requiring mechanical
Complications ventilation and pneumothorax or pleural
effusion requiring percutaneous interven-
tion.2,3 Minor PPCs include most atelec-
tasis, bronchospasm, laryngospasm, and
the unanticipated need for supplemental
Moderator: Faisal Masud, MD oxygen beyond the immediate postopera-
In our scope of practice,
tive period.4
Panelists: Paul Marik, MD
Wheeler: Frequently the literature con-
Ruben Restrepo, MD, RRT
the most common PPC is cerning PPCs lumps together pneumo-
Luis Angel, MD
nia, respiratory failure, atelectasis, bron-
David Wheeler, RRT-NPS
chospasm, and exacerbation of chronic
atelectasis followed perhaps obstructive pulmonary disease (COPD).
However, I find it easier to think about
PPCs as discrete categories of clinically
An increasingly elderly patient popula-
tion, a high incidence of obesity, and by retained secretions, significant complications such as atelec-
tasis, infection (including bronchitis and
the need for repeated operations all
pneumonia), bronchospasm/reactive air-
contribute to the complex problems
hospitals face today. Yet the expecta- compromise in mucocilliary way and respiratory failure requiring non-
invasive ventilation. In our scope of prac-
tions of patients and payers are going
tice, the most common PPC is atelectasis
ever higher. Public reporting, pay-for-
followed perhaps by retained secretions,
performance and shrinking healthcare clearance and pulmonary
compromise in mucocilliary clearance
dollars significantly impacts hospitals
and pulmonary effusion. Another com-
and clinicians. Within this setting, post-
mon yet generally inconsequential PPC in
operative pulmonary complications effusion.
our practice is the appearance of a pneu-
represent a significant burden on our
mopericardium.
healthcare system. The short- and long-
term impact of pulmonary complica-
tions is not fully understood; best prac- Marik: Patients undergoing surgical What is the impact of PPCs on periopera-
procedures are at risk for a number of tive morbidity and mortality?
tices are not applied consistently, and
pulmonary complications which may Angel: PCCs are the most common post-
awareness of the problem is lacking. In
result in postoperative respiratory fail- surgical complications, especially in pa-
this panel discussion, our distinguished
ure. These complications may be short tients who have major surgical procedures,
experts present an overview of postop-
lived with the patient returning to their and more specifically, patients residing in
erative pulmonary complications and
previous level of functioning. However, ICUs or telemetry units. PPCs are differ-
the evidence-based strategies to prevent
not infrequently, the patient experiences ent than complications associated with
them.
a progressive clinical decline to become the underlying disease or surgical com-
permanently ventilator-dependent. The plications, and are more frequently re-
What are generally considered to be post- most important postoperative pulmonary ported than cardiovascular complications.
operative pulmonary complications complications are atelectasis and mucous Without medical intervention, PCCs can
(PPCs)? plugging, hospital-acquired pneumonia, lead to prolonged hospitalization, and sig-
Angel: The definition of PPCs has been pulmonary embolism, pleural effusions, nificant morbidity. Even though mortality
inconsistent across different studies. diaphragmatic and intercostal muscle has decreased significantly with improved
Some include complications not associ- weakness (atrophy), aspiration pneumo- surgical techniques, anesthesia and criti-
ated with symptoms, or poor outcomes nitis, and postoperative acute respiratory cal care management, PPCs are cited as
such as mild asymptomatic decrease of distress syndrome (ARDS) due to delayed the most frequent reason for increased
function on a pulmonary function test or transfusion related lung injury (TRALI). hospital length-of-stay (LOS).2,5
lower oxygen saturation on pulse oxim-
etry; others focus on complications with Restrepo: PCCs are defined as respirato- Restrepo: Almost 25% percent of post-
significant clinical consequences. It is ry complications that occur within 48-to- operative deaths that occur during the
important to classify these complications 72 hours following surgery. Only patients first week are associated with PCCs.1,6 Re-
consistently. The most important post- at risk typically develop major PCCs as gardless of event rate, patients experienc-
operative pulmonary complications are a result of decreased vital capacity, post- ing a PCC have a significantly increased
atelectasis, pneumonia, respiratory failure, surgical mucus hypersecretion, or reten- hospital LOS and significantly decreased
pleural effusion or pneumothorax requir- tion. Pneumonia is the third most com- short- and long-term survival when com-
ing external drainage, and exacerbation of mon postoperative infection after urinary pared with patients of similar age and
underlying chronic lung disease. tract infection and surgical site infection1 comorbid conditions who experience an
www.clinicalfoundations.org 7
Clinical Foundations
uncomplicated hospital course.7,8 Without patient-related risk factors can be identi-
medical intervention, PCCs could prolong Almost 25% percent of fied during a good presurgical assessment,
hospitalization by as much as 6-fold.2,5 A a good evaluation of preoperative pul-
recent analysis revealed that more than 1 monary risks is the main priority in de-
million US patients experienced a PCC in termining the potential for PCCs as their
postoperative deaths that
2008, and these cases were associated with presence may predict long-term mortality
46,200 deaths, 2.9 million added days on after surgery.5 According to the American
the hospital floor and 1.9 million added College of Physicians (ACP), the major
occur during the first week are
ICU days.2 patient-related risk factors are advanced
age, American Society of Anesthesiolo-
Wheeler: It is rather disheartening that gists (ASA) Physical Status >2, COPD,
associated with PCCs.
postoperative deaths are predominantly functional dependence, and congestive
due to PPCs. Indeed, if we examine the heart failure.10-13 Even in situations where
most devastating perioperative complica- preoperative and operative conditions are
tion, postoperative respiratory failure, we - Restrepo - optimal, postoperative factors such as the
find that it exhibits significant morbidity. quality, quantity, and duration of post-
Johnson and colleagues examined the out- operative pain, anticipated analgesic re-
comes of patients with respiratory failure tube placement might merely be a marker quirements and analgesic techniques, and
as a complication of surgery and found for upper abdominal surgery, it remained length of time at bed rest all need to be
that 26% of the patients with respiratory significantly associated with PPCs in mul- considered.
failure died within 30 days.9 Addition- tivariate analyses. Several other variables
ally, 6% had a myocardial infarction and commonly cited in PPC risk assessment, Wheeler: The ACP guideline clearly de-
a devastating 35% developed pneumonia. such as hypercapnia or spirometry abnor- lineates between patient- and procedure-
Furthermore, 10% developed acute re- malities, were not identified as useful or related risk factors. In addition to the
nal failure while 3% developed deep vein independent predictors. patient-related risk factors Dr. Restrepo
thrombosis or pulmonary embolism. listed, the guideline adds smoking his-
Clearly, better-quality prospective studies tory, impaired sensorium, alcohol inges-
Please describe the risk factors for PPCs. are required to identify which elements tion, abnormal chest exam, obesity and
Angel: There is a paucity of well-done of the history, clinical examination, pre- obstructive sleep apnea. The ACP review
clinical studies looking at the risk factors operative laboratory testing, surgery, and identifies procedure-related risk factors
for PPCs, unlike cardiac complications, anesthesia are independently predictive such as aortic aneurysm repair, thoracic
which have been extensively studied and of PPCs. Ultimately, these studies should surgery, abdominal surgery, upper ab-
for which there are better predictors. In lead to the development and prospective dominal surgery, prolonged surgery, head
the McAllister prospective cohort study, validation of a multivariate risk assess- and neck surgery, emergency surgery, vas-
the multivariate regression analysis iden- ment model for PPCs, which would make cular surgery, perioperative transfusion
tified 4 variables that were independently preoperative assessments simpler, more and general anesthesia.
associated with increased risk of com- efficient, and accurate while avoiding un-
plications: advanced age (OR 5.9 for age necessary, harmful, or costly evaluations. Does type of surgery and anesthesia play
>65 years, P<.001), positive cough test a role?
(OR 3.8, P<.01), perioperative nasogastric Marik: The most important risk factor for Angel: The surgical site is the single most
tube (OR 7.7, P<.001), and duration of PPCs is underlying, preexistent lung dis- important factor in predicting the overall
anesthesia (OR 3.3 for operations lasting ease. Patients with significant obstructive risk of PPCs—the incidence of complica-
at least 2.5 hours, P< .008).2 and restrictive lung disease are at high risk tions is inversely related to the distance of
of PPCs. In such patients, preoperative the surgical incision from the diaphragm.
Many other studies provide conflicting lung function tests are absolutely manda- Thus, the complication rate is significantly
information on which of these variables tory to assess risk-benefit. In patients with higher for thoracic and upper abdominal
are independent predictive factors. The very poor preoperative lung function tests surgery than for lower abdominal and all
low statistical power resulting from small (i.e. minimal respiratory reserve), alterna- other procedures. PCC rates range from
sample sizes, and the heterogeneity be- tive treatment strategies may be more ap- 5% to 10% for lower abdominal surgery
tween studies further lower confidence propriate. to as high as 20% to 25% for upper ab-
in the validity and general applicability dominal, aortic, or esophageal surgeries.
of these identified variables to patients Furthermore, in patients with marked ab- The higher rates of complications in up-
undergoing nonthoracic surgery. Only normalities of lung function, preoperative per versus lower abdominal surgery relate
2 variables (duration of anesthesia and optimization, local or spinal anesthesia to the effect upon respiratory muscles and
postoperative nasogastric tube place- and an aggressive postoperative respira- diaphragmatic function. Surgical proce-
ment) were associated significantly with tory program may be indicated. Addition- dures lasting more than 3-to-4 hours are
PPCs in more than one study. The identi- al patient factors such as morbid obesity, associated with a higher risk of pulmo-
fication of nasogastric tube placement in malnutrition, history of smoking, diabe- nary complications. This observation sug-
the postoperative period as an indepen- tes, cardiac failure, liver failure and renal gests that, when available, a less ambitious,
dent predictor is surprising as it was not failure increase the risk of PPCs. briefer procedure should be considered in
listed as a risk factor in most of the litera- a very high-risk patient.
ture. Although postoperative nasogastric Restrepo: Since the great majority of
8 www.clinicalfoundations.org
Clinical Foundations
There are conflicting data with regard to techniques, and forced expiration tech-
the pulmonary risk of spinal or epidural The incidence of complications niques. Postoperative pulmonary compli-
anesthesia when compared with general cation rates are lower and median LOS
anesthesia. It appears likely that general is shorter for patients completing inspi-
anesthesia leads to a higher risk of clini- ratory muscle training. While it is time
is inversely related to the
cally important pulmonary complications intensive and potentially expensive, this
than does epidural or spinal anesthesia, strategy appears to have no risk and offers
although further studies are required to an additional approach to the preopera-
distance of the surgical
confirm this observation. Regional nerve tive preparation of high-risk patients.
block is associated with lower risk and
should be considered when possible for Lung expansion techniques include incen-
incision from
high-risk patients. tive spirometry; chest physical therapy, in-
cluding deep breathing exercises; cough-
Marik: The type and duration of surgery ing; postural drainage; percussion and
are major risk factors for PPCs. Patients the diaphragm. vibration; suctioning and ambulation;
with cardiothoracic and upper abdomi- intermittent positive-pressure breathing;
nal surgery are at an increased risk of and continuous positive-airway pressure.
PPCs. This may be related to pain which Deep breathing exercises and incentive
- Angel -
“splints” respiratory efforts and leads to spirometry appear to be equally effec-
decreased coughing as well as the pres- tive and capable of reducing the risk of
ence of chest tubes. Longer surgery times PPCs by about one-half. Deep breathing
with increased tissue trauma will result in thesia. Any patient with a prior history of exercises are a component of chest physi-
a greater degree of immune suppression, cardiopulmonary disease who requires cal therapy. Incentive spirometry involves
increasing the risk of infectious compli- endotracheal intubation and general an- deep breathing facilitated by a simple me-
cations. Furthermore, multiple intra and esthesia will be at much greater risk for chanical device.
postoperative blood transfusions increase PPCs. It is imperative that we assess and
the risk of the delayed TRALI syndrome. identify patients at greater risk for PPCs Adequate postoperative pain control may
Patients who undergo surgery under spi- so that we may intervene and employ pre- help to minimize PPCs by enabling earlier
nal anesthesia rather than general anes- ventive measures. ambulation and improving the patient’s
thesia, and who undergo laparoscopic ability to take deep breaths. This is partic-
surgery are at a lower risk of postopera- Describe strategies that can be implement- ularly important after thoracic and upper
tive pulmonary complications. ed pre-and immediately post-surgery to abdominal surgery. Studies of the effect
reduce the risk of PPCs. of postoperative pain management on
Restrepo: While general anesthesia, in Angel: Patients undergoing upper ab- pulmonary complications have focused
comparison to neuraxial blockade (spi- dominal or thoracic surgery or aortic an- on the use of epidural analgesia and inter-
nal or epidural anesthesia), may represent eurysm repair with additional risk factors costal nerve blocks as alternatives to more
a greater risk for PPCs, this remains an for PPCs are candidates for risk reduction traditional parenteral opioids. Epidural
area of controversy.14 If required, inter- strategies. Interventions should begin analgesia seems superior to other meth-
mediate-active neuromuscular blocking in the preoperative period and continue ods for delivering opioids in preventing
agents such as atracurium and vecuroni- through the postsurgical period. Clini- PPCs.
um should be preferred over long-acting cians should employ multiple strategies to
agents.15,16 reduce the risk of PPCs to the fullest pos- Marik: The most important strategy
sible extent. Patient education regarding to reduce the risk of PPCs is to identify
Whenever possible, alternatives to open lung expansion maneuvers should begin those patients who are at an increased risk
surgical procedures should be considered. prior to surgery. The preoperative evalu- of respiratory problems prior to surgery.
Laparoscopic rather than open bariatric ation provides an opportunity to discuss These patients are likely to benefit from
surgery has been found to be an effective the benefits of smoking cessation. Current preoperative optimization, the use of
strategy to reduce PCC, since it is associ- cigarette smokers have an increased risk anesthetic techniques that limit the like-
ated with less postoperative pain.5,6,17 for PPCs, although the incremental risk is lihood of pulmonary complications and
small in the absence of chronic lung dis- scrupulous attention in the postoperative
Wheeler: Definitely, upper abdominal ease. Patients undergoing elective surgery period. Pain management, restricted use
surgery manifests the greatest degree of should be advised to stop smoking at least of sedative agents, aggressive postopera-
PPC. Aortic aneurysm repair, thoracic 8 weeks before surgery; a brief period of tive physiotherapy and early mobilization
surgery of any kind, cardiac surgery and abstinence does not improve periopera- are key interventions likely to reduce the
lower abdominal surgery all have poten- tive pulmonary outcomes and may in- risks of respiratory complications. All pa-
tial for PPCs. When surgery takes more crease the risk of PPCs. tients undergoing surgery should be strat-
than 2 hours, the risk for PPCs increases. ified according to their risk of developing
The patient receiving general anesthesia A program of preoperative inspiratory thromboembolic complications, and an
with its attendant artificial airway and re- muscle training may reduce the risk of appropriate level of prophylaxis should
quired mechanical ventilation is at much PPCs. The program is intensive and in- then be instituted.
greater risk for PPCs than a patient receiv- volves breathing exercises, incentive spi-
ing a neuromuscular block or local anes- rometry, education in active breathing Restrepo: Adequate treatment of co-
www.clinicalfoundations.org 9
Clinical Foundations
morbidities plays an essential role in pre- added days on the hospital floor, 1.9 mil-
venting PPCs. Cigarette cessation,3,4,18,19 The most important strategy lion added ICU days and $11.9 billion in
treatment of underlying lung infections, a additional costs.24
peak flow of >80% predicted and absence
of wheezing should be the goals prior to Marik: A comprehensive program to re-
to reduce the risk of PPCs is to
any surgical procedure. The role of lung duce postoperative respiratory complica-
expansion maneuvers such as incentive tions has enormous value for both the
spirometry alone in preventing PPCs is patient and the institution. Postopera-
identify those patients who
questionable.20 However, a combination tive respiratory complications lead to in-
of deep breathing, incentive spirometry, creased morbidity and mortality which
adequate postsurgical pain control, early increase patient distress and suffering.
are at an increased risk of
ambulation, and in some patients con- From the hospital’s perspective, these
tinuous positive airway pressure (CPAP) complications lead to an increase in the
may prevent PPCs.21,22,23 LOS and use of hospital resources, both of
respiratory problems prior to which have significant financial implica-
Wheeler: The presurgical assessment of tions.
every patient is critically important. The
most important of these preoperative surgery. Restrepo: A postoperative complication
interventions is of course, smoking ces- results in additional and often unexpected
sation. Patients scheduled for elective sur- medical costs. These are primarily associ-
gery should quit smoking at least 8 weeks device effectively. ated with increased length of hospital-
prior to their scheduled surgery. It must ization requiring intensive therapeutic
be noted that a brief period of smok- Perhaps the most important postoperative intervention, pharmacological interven-
ing cessation may not have any effect of procedure to prevent PPCs is an aggressive tion, diagnostics, and increased use of
postoperative complications. Any patient extubation protocol. The literature ex- health disciplines.5 Pulmonary complica-
presenting with a prior history of cardio- amines this issue from the perspective of tions may double or triple the associated
pulmonary impairment must have this systems dynamics and delineates between costs of other postsurgical complications
impairment managed effectively prior to mediator variables (i.e. patient-centric and increase by 12-fold the median hos-
surgery. Perhaps the most difficult pa- variables) and moderator variables (relat- pital cost when compared to the cost of
tients are those with COPD. This is an ed to the treatment and support of the pa- not having respiratory complications.25
extremely important patient-related risk tient). Mechanical ventilation falls in the In 2004, postoperative complications ac-
factor for PPCs and these patients should category of moderator variable and has counted for nearly $2 billion dollars.26
be aggressively treated. tremendous potential to either attenuate
or exacerbate the postoperative course. Wheeler: Hospitals must respond to the
The patient with asthma is another very Indeed, the significance of an aggressive immense and ever-changing pressures
troubling preoperative management chal- assessment-based, evidence-driven wean- and demands of payers. PPCs increase
lenge. Asthma that is not well-controlled ing protocol cannot be understated. The mechanical ventilation length-of-stay in-
poses a noteworthy risk for the develop- liberation from mechanical ventilation of tensive care unit LOS and overall hospi-
ment of PPCs, however, asthma that is the postoperative patient will eliminate tal stay. In the mindset of the data-driven,
well-controlled may attenuate this risk. It their risk of ventilator-associated pneu- outcome driven, cost conscious, nonclini-
is imperative that any asthmatic patient monia and significantly decrease the po- cal performance examiner, any postop-
undergo a thorough preoperative assess- tential for PPCs of any kind. erative complication may be viewed as
ment and management strategey in order iatrogenic in nature and therefore a non-
to reduce the risk for PPCs. With increased emphasis on pay for per- reimbursable service. Increasingly, health-
formance is prevention of PPC a relevant care systems will be told to absorb the sig-
In patients presenting with elevated risk issue for hospitals? If so, what are the ram- nificant cost and burden of PPCs that are
factors, a preoperative inspiratory muscle ifications? deemed to be preventable. If past experi-
training program may lessen the possibil- Angel: The National Surgical Quality Im- ence is a predictor of future behavior, one
ity of PPCs. Another essential strategy for provement Program (NSQIP) compared must assume that the payers will deem
high-risk patients is a thorough patient hospitalization costs and LOS among every postoperative complication as pre-
education program that includes a discus- patients with various postoperative com- ventable and therefore will feel no com-
sion of the type of surgery, anesthesia and plications.24 Among infectious, cardio- pulsion to reimburse for the increased
recovery procedures they will be asked vascular, venous thromboembolic, and cost to the healthcare system. It has been
to undergo. The education of the patient pulmonary complications, the latter were estimated that all postoperative complica-
must include an orientation to any lung by far the most costly. Pulmonary com- tions cost approximately $2 billion a year.
expansion or mucous clearing devices plications and venous thromboembolic I trust we can all appreciate the enormity
they may be asked to use in the postopera- complications required the longest mean of these forces and their implications both
tive period. Lung expansion therapy such hospital stay. Projecting to national lev- for our patients and the future of our sys-
as deep breathing, incentive spirometry, els, the study determined that more than tems as well.
PEP and CPAP are all extremely effec- 1 million patients experienced a PPC in References
1. Arozullah AM, Khuri SF, Henderson WG, et al. Partici-
tive in the prevention and attenuation of the US in 2008, and these cases were as- pants in the National Veterans Affairs Surgical Quality
PPCs. The key is to match the patient and sociated with 46,200 deaths, 2.9 million Improvement Program. Development and validationof
a multifactorial risk index for predicting postoperative
pneumonia after major noncardiac surgery. Ann Intern
10 www.clinicalfoundations.org
Description:Assistant Professor, Dept. of Respiratory Care. University of Texas .. when compared to IPPB in 30 patients,41 . Critical-Care Nurses (AACN),61 and the.
