Smarter Decisions,
Better Care

UpToDate synthesizes the most recent medical information into evidence-based practical recommendations clinicians trust to make the right point of care decisions.

  • Rigorous editorial process: Evidence-based treatment recommendations
  • World-Renowned physician authors: over 5,100 physician authors around the globe
  • Innovative technology: integrates into the workflow; access from EMRs

For more information, click below.


Subscribers log in here


Evaluation of preoperative pulmonary risk

INTRODUCTION

Postoperative pulmonary complications contribute significantly to overall perioperative morbidity and mortality. In a study of patients undergoing elective abdominal surgery, as an example, pulmonary complications occurred significantly more often than cardiac complications and were associated with significantly longer hospital stays [1]. The National Surgical Quality Improvement Program (NSQIP) also found that 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 [2].

The field of preoperative pulmonary evaluation is increasingly driven by evidence-based medicine, rather than expert opinion. 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" 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.

One broad definition of postoperative pulmonary complications includes all patients with fever and either pulmonary signs, symptoms (eg, productive cough, rhonchi, or diminished breath sounds), or changes on chest x-ray (eg, atelectasis, consolidation, or incomplete expansion) [3,4]. However, many such liberally defined postoperative complications are of no clinical relevance.

                            

Subscribers log in here

To continue reading this article you must have access through your hospital or your group practice, log in to your personal subscription, or purchase a personal subscription. For more information, click below.
Literature review current through: May 2013. | This topic last updated: Jan 24, 2013.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2013 UpToDate, Inc.
References
Top
  1. Lawrence VA, Hilsenbeck SG, Mulrow CD, et al. Incidence and hospital stay for cardiac and pulmonary complications after abdominal surgery. J Gen Intern Med 1995; 10:671.
  2. 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.
  3. Wightman JA. A prospective survey of the incidence of postoperative pulmonary complications. Br J Surg 1968; 55:85.
  4. Mohr DN, Jett JR. Preoperative evaluation of pulmonary risk factors. J Gen Intern Med 1988; 3:277.
  5. O'Donohue WJ Jr. Postoperative pulmonary complications. When are preventive and therapeutic measures necessary? Postgrad Med 1992; 91:167.
  6. Hall JC, Tarala RA, Hall JL, Mander J. A multivariate analysis of the risk of pulmonary complications after laparotomy. Chest 1991; 99:923.
  7. Gracey DR, Divertie MB, Didier EP. Preoperative pulmonary preparation of patients with chronic obstructive pulmonary disease: a prospective study. Chest 1979; 76:123.
  8. 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.
  9. Meyers JR, Lembeck L, O'Kane H, Baue AE. Changes in functional residual capacity of the lung after operation. Arch Surg 1975; 110:576.
  10. Craig DB. Postoperative recovery of pulmonary function. Anesth Analg 1981; 60:46.
  11. Ford GT, Whitelaw WA, Rosenal TW, et al. Diaphragm function after upper abdominal surgery in humans. Am Rev Respir Dis 1983; 127:431.
  12. Marshall BE, Wyche MQ Jr. Hypoxemia during and after anesthesia. Anesthesiology 1972; 37:178.
  13. Sugimachi K, Ueo H, Natsuda Y, et al. Cough dynamics in oesophageal cancer: prevention of postoperative pulmonary complications. Br J Surg 1982; 69:734.
  14. Tisi GM. Preoperative evaluation of pulmonary function. Validity, indications, and benefits. Am Rev Respir Dis 1979; 119:293.
  15. Djokovic JL, Hedley-Whyte J. Prediction of outcome of surgery and anesthesia in patients over 80. JAMA 1979; 242:2301.
  16. Møller AM, Maaløe R, Pedersen T. Postoperative intensive care admittance: the role of tobacco smoking. Acta Anaesthesiol Scand 2001; 45:345.
  17. Kroenke K, Lawrence VA, Theroux JF, Tuley MR. Operative risk in patients with severe obstructive pulmonary disease. Arch Intern Med 1992; 152:967.
  18. Thomas DR, Ritchie CS. Preoperative assessment of older adults. J Am Geriatr Soc 1995; 43:811.
  19. Smetana GW. Preoperative pulmonary evaluation. N Engl J Med 1999; 340:937.
  20. Kroenke K, Lawrence VA, Theroux JF, et al. Postoperative complications after thoracic and major abdominal surgery in patients with and without obstructive lung disease. Chest 1993; 104:1445.
  21. Lawrence VA, Dhanda R, Hilsenbeck SG, Page CP. Risk of pulmonary complications after elective abdominal surgery. Chest 1996; 110:744.
  22. Straus SE, McAlister FA, Sackett DL, Deeks JJ. The accuracy of patient history, wheezing, and laryngeal measurements in diagnosing obstructive airway disease. CARE-COAD1 Group. Clinical Assessment of the Reliability of the Examination-Chronic Obstructive Airways Disease. JAMA 2000; 283:1853.
  23. Milledge JS, Nunn JF. Criteria of fitness for anaesthesia in patients with chronic obstructive lung disease. Br Med J 1975; 3:670.
  24. Warner DO, Warner MA, Barnes RD, et al. Perioperative respiratory complications in patients with asthma. Anesthesiology 1996; 85:460.
  25. Warner MA, Divertie MB, Tinker JH. Preoperative cessation of smoking and pulmonary complications in coronary artery bypass patients. Anesthesiology 1984; 60:380.
  26. Bluman LG, Mosca L, Newman N, Simon DG. Preoperative smoking habits and postoperative pulmonary complications. Chest 1998; 113:883.
  27. Brooks-Brunn JA. Predictors of postoperative pulmonary complications following abdominal surgery. Chest 1997; 111:564.
  28. 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.
  29. Warner MA, Offord KP, Warner ME, et al. Role of preoperative cessation of smoking and other factors in postoperative pulmonary complications: a blinded prospective study of coronary artery bypass patients. Mayo Clin Proc 1989; 64:609.
  30. Nakagawa M, Tanaka H, Tsukuma H, Kishi Y. Relationship between the duration of the preoperative smoke-free period and the incidence of postoperative pulmonary complications after pulmonary surgery. Chest 2001; 120:705.
  31. Pasulka PS, Bistrian BR, Benotti PN, Blackburn GL. The risks of surgery in obese patients. Ann Intern Med 1986; 104:540.
  32. Dales RE, Dionne G, Leech JA, et al. Preoperative prediction of pulmonary complications following thoracic surgery. Chest 1993; 104:155.
  33. Gross JB, Bachenberg KL, Benumof JL, et al. Practice guidelines for the perioperative management of patients with obstructive sleep apnea: a report by the American Society of Anesthesiologists Task Force on Perioperative Management of patients with obstructive sleep apnea. Anesthesiology 2006; 104:1081.
  34. Gupta RM, Parvizi J, Hanssen AD, Gay PC. Postoperative complications in patients with obstructive sleep apnea syndrome undergoing hip or knee replacement: a case-control study. Mayo Clin Proc 2001; 76:897.
  35. Hwang D, Shakir N, Limann B, et al. Association of sleep-disordered breathing with postoperative complications. Chest 2008; 133:1128.
  36. Memtsoudis S, Liu SS, Ma Y, et al. Perioperative pulmonary outcomes in patients with sleep apnea after noncardiac surgery. Anesth Analg 2011; 112:113.
  37. Sareli AE, Cantor CR, Williams NN, et al. Obstructive sleep apnea in patients undergoing bariatric surgery--a tertiary center experience. Obes Surg 2011; 21:316.
  38. Price LC, Montani D, Jaïs X, et al. Noncardiothoracic nonobstetric surgery in mild-to-moderate pulmonary hypertension. Eur Respir J 2010; 35:1294.
  39. 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.
  40. Lai HC, Lai HC, Wang KY, et al. Severe pulmonary hypertension complicates postoperative outcome of non-cardiac surgery. Br J Anaesth 2007; 99:184.
  41. Memtsoudis SG, Ma Y, Chiu YL, et al. Perioperative mortality in patients with pulmonary hypertension undergoing major joint replacement. Anesth Analg 2010; 111:1110.
  42. 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.
  43. 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.
  44. Smetana GW, Macpherson DS. The case against routine preoperative laboratory testing. Med Clin North Am 2003; 87:7.
  45. 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.
  46. Celli BR, Rodriguez KS, Snider GL. A controlled trial of intermittent positive pressure breathing, incentive spirometry, and deep breathing exercises in preventing pulmonary complications after abdominal surgery. Am Rev Respir Dis 1984; 130:12.
  47. Pedersen T, Eliasen K, Henriksen E. A prospective study of risk factors and cardiopulmonary complications associated with anaesthesia and surgery: risk indicators of cardiopulmonary morbidity. Acta Anaesthesiol Scand 1990; 34:144.
  48. Cohen MM, Duncan PG, Tate RB. Does anesthesia contribute to operative mortality? JAMA 1988; 260:2859.
  49. Tarhan S, Moffitt EA, Sessler AD, et al. Risk of anesthesia and surgery in patients with chronic bronchitis and chronic obstructive pulmonary disease. Surgery 1973; 74:720.
  50. Yeager MP, Glass DD, Neff RK, Brinck-Johnsen T. Epidural anesthesia and analgesia in high-risk surgical patients. Anesthesiology 1987; 66:729.
  51. 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.
  52. 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.
  53. 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.
  54. Chung F, Yegneswaran B, Liao P, et al. STOP questionnaire: a tool to screen patients for obstructive sleep apnea. Anesthesiology 2008; 108:812.
  55. Canet J, Gallart L, Gomar C, et al. Prediction of postoperative pulmonary complications in a population-based surgical cohort. Anesthesiology 2010; 113:1338.
  56. Lawrence VA, Page CP, Harris GD. Preoperative spirometry before abdominal operations. A critical appraisal of its predictive value. Arch Intern Med 1989; 149:280.
  57. De Nino LA, Lawrence VA, Averyt EC, et al. Preoperative spirometry and laparotomy: blowing away dollars. Chest 1997; 111:1536.
  58. Gass GD, Olsen GN. Preoperative pulmonary function testing to predict postoperative morbidity and mortality. Chest 1986; 89:127.
  59. 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.
  60. 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.
  61. Warner DO, Warner MA, Offord KP, et al. Airway obstruction and perioperative complications in smokers undergoing abdominal surgery. Anesthesiology 1999; 90:372.
  62. Fan ST, Lau WY, Yip WC, et al. Prediction of postoperative pulmonary complications in oesophagogastric cancer surgery. Br J Surg 1987; 74:408.
  63. Rucker L, Frye EB, Staten MA. Usefulness of screening chest roentgenograms in preoperative patients. JAMA 1983; 250:3209.
  64. Archer C, Levy AR, McGregor M. Value of routine preoperative chest x-rays: a meta-analysis. Can J Anaesth 1993; 40:1022.
  65. 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.
  66. Goldman L, Caldera DL, Nussbaum SR, et al. Multifactorial index of cardiac risk in noncardiac surgical procedures. N Engl J Med 1977; 297:845.
  67. Johnson RG, Arozullah AM, Neumayer L, et al. Multivariable predictors of postoperative respiratory failure after general and vascular surgery: results from the patient safety in surgery study. J Am Coll Surg 2007; 204:1188.
  68. Gupta H, Gupta PK, Fang X, et al. Development and validation of a risk calculator predicting postoperative respiratory failure. Chest 2011; 140:1207.