Evaluation of preoperative pulmonary risk
- Gerald W Smetana, MD
Gerald W Smetana, MD
- Professor of Medicine
- Harvard Medical School
- Section Editors
- Talmadge E King, Jr, MD
Talmadge E King, Jr, MD
- Editor-in-Chief — Pulmonary and Critical Care Medicine
- Section Editor — Interstitial Lung Disease
- Dean, School of Medicine
- Vice Chancellor, Medical Affairs
- University of California San Francisco
- Andrew D Auerbach, MD, MPH
Andrew D Auerbach, MD, MPH
- Section Editor - Hospital Medicine
- Professor of Medicine
- University of California, San Francisco
- Natalie F Holt, MD, MPH
Natalie F Holt, MD, MPH
- Section Editor — Preoperative and Postoperative Evaluation and Management
- Assistant Professor of Anesthesiology
- Yale School of Medicine
Postoperative pulmonary complications contribute significantly to overall perioperative morbidity and mortality. The National Surgical Quality Improvement Program (NSQIP) found that postoperative pulmonary complications occurred in 6 percent of 165,196 patients who underwent major abdominal surgery . In a separate study, postoperative pulmonary complications were the most costly of major postoperative medical complications (including cardiac, thromboembolic, and infectious) and resulted in the longest length of stay . As the impact of pulmonary complications following surgery has become increasingly apparent, estimation of their risk should be a standard element of all preoperative medical evaluations.
The definition of postoperative pulmonary complications, pertinent anesthetic physiology, identification of patient and procedure-related risk factors, and the role of preoperative pulmonary function testing and pulmonary risk indices will be reviewed here. Strategies for reducing postoperative pulmonary complications and the evaluation of candidates for lung resection surgery are discussed separately. (See "Strategies to reduce postoperative pulmonary complications in adults" and "Preoperative evaluation for lung resection".)
DEFINITION OF POSTOPERATIVE PULMONARY COMPLICATIONS
The reported frequency of postoperative pulmonary complications in the literature varies from 2 to 70 percent. This wide range is due in part to patient selection and procedure-related risk factors, although differing definitions for postoperative complications account for much of the variability and make comparison of reported incidences across different studies difficult.
The preferred definition is a postoperative pulmonary abnormality that produces identifiable disease or dysfunction that is clinically significant and adversely affects the clinical course . This would include several major categories of clinically significant complications, including [4,5]:
- Yang CK, Teng A, Lee DY, Rose K. Pulmonary complications after major abdominal surgery: National Surgical Quality Improvement Program analysis. J Surg Res 2015; 198:441.
- Dimick JB, Chen SL, Taheri PA, et al. Hospital costs associated with surgical complications: a report from the private-sector National Surgical Quality Improvement Program. J Am Coll Surg 2004; 199:531.
- O'Donohue WJ Jr. Postoperative pulmonary complications. When are preventive and therapeutic measures necessary? Postgrad Med 1992; 91:167.
- Smetana GW, Lawrence VA, Cornell JE, American College of Physicians. Preoperative pulmonary risk stratification for noncardiothoracic surgery: systematic review for the American College of Physicians. Ann Intern Med 2006; 144:581.
- Canet J, Mazo V. Postoperative pulmonary complications. Minerva Anestesiol 2010; 76:138.
- Meyers JR, Lembeck L, O'Kane H, Baue AE. Changes in functional residual capacity of the lung after operation. Arch Surg 1975; 110:576.
- Craig DB. Postoperative recovery of pulmonary function. Anesth Analg 1981; 60:46.
- Ford GT, Whitelaw WA, Rosenal TW, et al. Diaphragm function after upper abdominal surgery in humans. Am Rev Respir Dis 1983; 127:431.
- Marshall BE, Wyche MQ Jr. Hypoxemia during and after anesthesia. Anesthesiology 1972; 37:178.
- Sugimachi K, Ueo H, Natsuda Y, et al. Cough dynamics in oesophageal cancer: prevention of postoperative pulmonary complications. Br J Surg 1982; 69:734.
- Tisi GM. Preoperative evaluation of pulmonary function. Validity, indications, and benefits. Am Rev Respir Dis 1979; 119:293.
- Djokovic JL, Hedley-Whyte J. Prediction of outcome of surgery and anesthesia in patients over 80. JAMA 1979; 242:2301.
- Møller AM, Maaløe R, Pedersen T. Postoperative intensive care admittance: the role of tobacco smoking. Acta Anaesthesiol Scand 2001; 45:345.
- Kroenke K, Lawrence VA, Theroux JF, Tuley MR. Operative risk in patients with severe obstructive pulmonary disease. Arch Intern Med 1992; 152:967.
- Thomas DR, Ritchie CS. Preoperative assessment of older adults. J Am Geriatr Soc 1995; 43:811.
- Gupta H, Ramanan B, Gupta PK, et al. Impact of COPD on postoperative outcomes: results from a national database. Chest 2013; 143:1599.
- Milledge JS, Nunn JF. Criteria of fitness for anaesthesia in patients with chronic obstructive lung disease. Br Med J 1975; 3:670.
- Wightman JA. A prospective survey of the incidence of postoperative pulmonary complications. Br J Surg 1968; 55:85.
- Grønkjær M, Eliasen M, Skov-Ettrup LS, et al. Preoperative smoking status and postoperative complications: a systematic review and meta-analysis. Ann Surg 2014; 259:52.
- Warner MA, Divertie MB, Tinker JH. Preoperative cessation of smoking and pulmonary complications in coronary artery bypass patients. Anesthesiology 1984; 60:380.
- Pasulka PS, Bistrian BR, Benotti PN, Blackburn GL. The risks of surgery in obese patients. Ann Intern Med 1986; 104:540.
- Clavellina-Gaytán D, Velázquez-Fernández D, Del-Villar E, et al. Evaluation of spirometric testing as a routine preoperative assessment in patients undergoing bariatric surgery. Obes Surg 2015; 25:530.
- Sood A, Abdollah F, Sammon JD, et al. The Effect of Body Mass Index on Perioperative Outcomes After Major Surgery: Results from the National Surgical Quality Improvement Program (ACS-NSQIP) 2005-2011. World J Surg 2015; 39:2376.
- Price LC, Montani D, Jaïs X, et al. Noncardiothoracic nonobstetric surgery in mild-to-moderate pulmonary hypertension. Eur Respir J 2010; 35:1294.
- Meyer S, McLaughlin VV, Seyfarth HJ, et al. Outcomes of noncardiac, nonobstetric surgery in patients with PAH: an international prospective survey. Eur Respir J 2013; 41:1302.
- Lai HC, Lai HC, Wang KY, et al. Severe pulmonary hypertension complicates postoperative outcome of non-cardiac surgery. Br J Anaesth 2007; 99:184.
- Memtsoudis SG, Ma Y, Chiu YL, et al. Perioperative mortality in patients with pulmonary hypertension undergoing major joint replacement. Anesth Analg 2010; 111:1110.
- Ramakrishna G, Sprung J, Ravi BS, et al. Impact of pulmonary hypertension on the outcomes of noncardiac surgery: predictors of perioperative morbidity and mortality. J Am Coll Cardiol 2005; 45:1691.
- Lawrence VA, Dhanda R, Hilsenbeck SG, Page CP. Risk of pulmonary complications after elective abdominal surgery. Chest 1996; 110:744.
- Tait AR, Malviya S. Anesthesia for the child with an upper respiratory tract infection: still a dilemma? Anesth Analg 2005; 100:59.
- Arozullah AM, Daley J, Henderson WG, Khuri SF. Multifactorial risk index for predicting postoperative respiratory failure in men after major noncardiac surgery. The National Veterans Administration Surgical Quality Improvement Program. Ann Surg 2000; 232:242.
- Qaseem A, Snow V, Fitterman N, et al. Risk assessment for and strategies to reduce perioperative pulmonary complications for patients undergoing noncardiothoracic surgery: a guideline from the American College of Physicians. Ann Intern Med 2006; 144:575.
- Brooks-Brunn JA. Predictors of postoperative pulmonary complications following abdominal surgery. Chest 1997; 111:564.
- Smetana GW, Macpherson DS. The case against routine preoperative laboratory testing. Med Clin North Am 2003; 87:7.
- Arozullah AM, Khuri SF, Henderson WG, et al. Development and validation of a multifactorial risk index for predicting postoperative pneumonia after major noncardiac surgery. Ann Intern Med 2001; 135:847.
- McAlister FA, Khan NA, Straus SE, et al. Accuracy of the preoperative assessment in predicting pulmonary risk after nonthoracic surgery. Am J Respir Crit Care Med 2003; 167:741.
- Cohen MM, Duncan PG, Tate RB. Does anesthesia contribute to operative mortality? JAMA 1988; 260:2859.
- Johnson RL, Kopp SL, Burkle CM, et al. Neuraxial vs general anaesthesia for total hip and total knee arthroplasty: a systematic review of comparative-effectiveness research. Br J Anaesth 2016; 116:163.
- Hausman MS Jr, Jewell ES, Engoren M. Regional versus general anesthesia in surgical patients with chronic obstructive pulmonary disease: does avoiding general anesthesia reduce the risk of postoperative complications? Anesth Analg 2015; 120:1405.
- Rodgers A, Walker N, Schug S, et al. Reduction of postoperative mortality and morbidity with epidural or spinal anaesthesia: results from overview of randomised trials. BMJ 2000; 321:1493.
- Berg H, Roed J, Viby-Mogensen J, et al. Residual neuromuscular block is a risk factor for postoperative pulmonary complications. A prospective, randomised, and blinded study of postoperative pulmonary complications after atracurium, vecuronium and pancuronium. Acta Anaesthesiol Scand 1997; 41:1095.
- Murphy GS, Szokol JW, Marymont JH, et al. Residual neuromuscular blockade and critical respiratory events in the postanesthesia care unit. Anesth Analg 2008; 107:130.
- Chung F, Yegneswaran B, Liao P, et al. STOP questionnaire: a tool to screen patients for obstructive sleep apnea. Anesthesiology 2008; 108:812.
- Gass GD, Olsen GN. Preoperative pulmonary function testing to predict postoperative morbidity and mortality. Chest 1986; 89:127.
- Saleh HZ, Mohan K, Shaw M, et al. Impact of chronic obstructive pulmonary disease severity on surgical outcomes in patients undergoing non-emergent coronary artery bypass grafting. Eur J Cardiothorac Surg 2012; 42:108.
- Wong DH, Weber EC, Schell MJ, et al. Factors associated with postoperative pulmonary complications in patients with severe chronic obstructive pulmonary disease. Anesth Analg 1995; 80:276.
- Fuso L, Cisternino L, Di Napoli A, et al. Role of spirometric and arterial gas data in predicting pulmonary complications after abdominal surgery. Respir Med 2000; 94:1171.
- Warner DO, Warner MA, Offord KP, et al. Airway obstruction and perioperative complications in smokers undergoing abdominal surgery. Anesthesiology 1999; 90:372.
- Canet J, Gallart L, Gomar C, et al. Prediction of postoperative pulmonary complications in a population-based surgical cohort. Anesthesiology 2010; 113:1338.
- Mazo V, Sabaté S, Canet J, et al. Prospective external validation of a predictive score for postoperative pulmonary complications. Anesthesiology 2014; 121:219.
- Fan ST, Lau WY, Yip WC, et al. Prediction of postoperative pulmonary complications in oesophagogastric cancer surgery. Br J Surg 1987; 74:408.
- Chung F, Yuan H, Yin L, et al. Elimination of preoperative testing in ambulatory surgery. Anesth Analg 2009; 108:467.
- Rucker L, Frye EB, Staten MA. Usefulness of screening chest roentgenograms in preoperative patients. JAMA 1983; 250:3209.
- Archer C, Levy AR, McGregor M. Value of routine preoperative chest x-rays: a meta-analysis. Can J Anaesth 1993; 40:1022.
- Smith TB, Stonell C, Purkayastha S, Paraskevas P. Cardiopulmonary exercise testing as a risk assessment method in non cardio-pulmonary surgery: a systematic review. Anaesthesia 2009; 64:883.
- Awdeh H, Kassak K, Sfeir P, et al. The SF-36 and 6-Minute Walk Test are Significant Predictors of Complications After Major Surgery. World J Surg 2015; 39:1406.
- Gupta H, Gupta PK, Fang X, et al. Development and validation of a risk calculator predicting postoperative respiratory failure. Chest 2011; 140:1207.
- Gupta H, Gupta PK, Schuller D, et al. Development and validation of a risk calculator for predicting postoperative pneumonia. Mayo Clin Proc 2013; 88:1241.
- DEFINITION OF POSTOPERATIVE PULMONARY COMPLICATIONS
- PERIOPERATIVE PULMONARY PHYSIOLOGY
- PATIENT-RELATED RISK FACTORS
- Chronic obstructive pulmonary disease (COPD)
- Obstructive sleep apnea
- Pulmonary hypertension
- Heart failure
- General health status
- Upper respiratory infection
- Metabolic and nutritional factors
- PROCEDURE-RELATED RISK FACTORS
- Surgical site
- Duration of surgery
- General anesthesia versus neuraxial or regional anesthesia
- Type of neuromuscular blockade
- PREOPERATIVE RISK ASSESSMENT
- Pulmonary function testing
- - American College of Physicians guidelines
- Assessment of oxygenation and hypercapnia
- Chest radiographs
- Exercise testing
- ASSESSMENT OF POSTOPERATIVE PULMONARY RISK
- ARISCAT (Canet)
- Arozullah respiratory failure index
- Gupta calculator for postoperative respiratory failure
- Gupta calculator for postoperative pneumonia
- SUMMARY AND RECOMMENDATIONS