Official reprint from UpToDate®
www.uptodate.com ©2017 UpToDate, Inc. and/or its affiliates. All Rights Reserved.

Strategies to reduce postoperative pulmonary complications in adults

Gerald W Smetana, MD
Section Editors
Talmadge E King, Jr, MD
Mark D Aronson, MD
Roberta Hines, MD
Deputy Editor
Helen Hollingsworth, MD


Postoperative pulmonary complications are common and a major cause of perioperative morbidity and mortality [1,2]. The major categories of clinically significant complications include [3]:


Infection, including bronchitis and pneumonia

Prolonged mechanical ventilation and respiratory failure

Exacerbation of underlying chronic lung disease

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:

Subscribers log in here

Literature review current through: Nov 2017. | This topic last updated: Jun 30, 2017.
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 ©2017 UpToDate, Inc.
  1. 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.
  2. Smith PR, Baig MA, Brito V, et al. Postoperative pulmonary complications after laparotomy. Respiration 2010; 80:269.
  3. McAlister FA, Bertsch K, Man J, et al. Incidence of and risk factors for pulmonary complications after nonthoracic surgery. Am J Respir Crit Care Med 2005; 171:514.
  4. Brueckmann B, Villa-Uribe JL, Bateman BT, et al. Development and validation of a score for prediction of postoperative respiratory complications. Anesthesiology 2013; 118:1276.
  5. Agostini P, Cieslik H, Rathinam S, et al. Postoperative pulmonary complications following thoracic surgery: are there any modifiable risk factors? Thorax 2010; 65:815.
  6. Li C, Yang WH, Zhou J, et al. Risk factors for predicting postoperative complications after open infrarenal abdominal aortic aneurysm repair: results from a single vascular center in China. J Clin Anesth 2013; 25:371.
  7. Warner DO. Preoperative smoking cessation: the role of the primary care provider. Mayo Clin Proc 2005; 80:252.
  8. Schmid M, Sood A, Campbell L, et al. Impact of smoking on perioperative outcomes after major surgery. Am J Surg 2015; 210:221.
  9. Mastracci TM, Carli F, Finley RJ, et al. Effect of preoperative smoking cessation interventions on postoperative complications. J Am Coll Surg 2011; 212:1094.
  10. Thomsen T, Villebro N, Møller AM. Interventions for preoperative smoking cessation. Cochrane Database Syst Rev 2010; :CD002294.
  11. Myers K, Hajek P, Hinds C, McRobbie H. Stopping smoking shortly before surgery and postoperative complications: a systematic review and meta-analysis. Arch Intern Med 2011; 171:983.
  12. Mills E, Eyawo O, Lockhart I, et al. Smoking cessation reduces postoperative complications: a systematic review and meta-analysis. Am J Med 2011; 124:144.
  13. Wheatley IC, Hardy KJ, Barter CE. An evaluation of preoperative methods of preventing postoperative pulmonary complications. Anaesth Intensive Care 1977; 5:56.
  14. Warner MA, Divertie MB, Tinker JH. Preoperative cessation of smoking and pulmonary complications in coronary artery bypass patients. Anesthesiology 1984; 60:380.
  15. 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.
  16. Gourgiotis S, Aloizos S, Aravosita P, et al. The effects of tobacco smoking on the incidence and risk of intraoperative and postoperative complications in adults. Surgeon 2011; 9:225.
  17. Warner DO. Perioperative abstinence from cigarettes: physiologic and clinical consequences. Anesthesiology 2006; 104:356.
  18. 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.
  19. Wong J, Lam DP, Abrishami A, et al. Short-term preoperative smoking cessation and postoperative complications: a systematic review and meta-analysis. Can J Anaesth 2012; 59:268.
  20. Jung KH, Kim SM, Choi MG, et al. Preoperative smoking cessation can reduce postoperative complications in gastric cancer surgery. Gastric Cancer 2015; 18:683.
  21. National Asthma Education and Prevention Program: Expert panel report III: Guidelines for the diagnosis and management of asthma. Bethesda, MD: National Heart, Lung, and Blood Institute, 2007. (NIH publication no. 08-4051) www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm (Accessed on December 04, 2014).
  22. Woods BD, Sladen RN. Perioperative considerations for the patient with asthma and bronchospasm. Br J Anaesth 2009; 103 Suppl 1:i57.
  23. Kabalin CS, Yarnold PR, Grammer LC. Low complication rate of corticosteroid-treated asthmatics undergoing surgical procedures. Arch Intern Med 1995; 155:1379.
  24. Silvanus MT, Groeben H, Peters J. Corticosteroids and inhaled salbutamol in patients with reversible airway obstruction markedly decrease the incidence of bronchospasm after tracheal intubation. Anesthesiology 2004; 100:1052.
  25. Dahl R. Systemic side effects of inhaled corticosteroids in patients with asthma. Respir Med 2006; 100:1307.
  26. Celli BR. Perioperative respiratory care of the patient undergoing upper abdominal surgery. Clin Chest Med 1993; 14:253.
  27. Tait AR, Knight PR. The effects of general anesthesia on upper respiratory tract infections in children. Anesthesiology 1987; 67:930.
  28. Fennelly ME, Hall GM. Anaesthesia and upper respiratory tract infections--a non-existent hazard? Br J Anaesth 1990; 64:535.
  29. Carli F, Scheede-Bergdahl C. Prehabilitation to enhance perioperative care. Anesthesiol Clin 2015; 33:17.
  30. Hulzebos EH, Smit Y, Helders PP, van Meeteren NL. Preoperative physical therapy for elective cardiac surgery patients. Cochrane Database Syst Rev 2012; 11:CD010118.
  31. Hulzebos EH, Helders PJ, Favié NJ, et al. Preoperative intensive inspiratory muscle training to prevent postoperative pulmonary complications in high-risk patients undergoing CABG surgery: a randomized clinical trial. JAMA 2006; 296:1851.
  32. Valkenet K, van de Port IG, Dronkers JJ, et al. The effects of preoperative exercise therapy on postoperative outcome: a systematic review. Clin Rehabil 2011; 25:99.
  33. Katsura M, Kuriyama A, Takeshima T, et al. Preoperative inspiratory muscle training for postoperative pulmonary complications in adults undergoing cardiac and major abdominal surgery. Cochrane Database Syst Rev 2015; :CD010356.
  34. Pouwels S, Willigendael EM, van Sambeek MR, et al. Beneficial Effects of Pre-operative Exercise Therapy in Patients with an Abdominal Aortic Aneurysm: A Systematic Review. Eur J Vasc Endovasc Surg 2015; 49:66.
  35. Nici L. Preoperative and postoperative pulmonary rehabilitation in lung cancer patients. Thorac Surg Clin 2008; 18:39.
  36. Shannon VR. Role of pulmonary rehabilitation in the management of patients with lung cancer. Curr Opin Pulm Med 2010; 16:334.
  37. Divisi D, Di Francesco C, Di Leonardo G, Crisci R. Preoperative pulmonary rehabilitation in patients with lung cancer and chronic obstructive pulmonary disease. Eur J Cardiothorac Surg 2013; 43:293.
  38. Pouwels S, Fiddelaers J, Teijink JA, et al. Preoperative exercise therapy in lung surgery patients: A systematic review. Respir Med 2015; 109:1495.
  39. 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.
  40. Lawrence VA, Cornell JE, Smetana GW, American College of Physicians. Strategies to reduce postoperative pulmonary complications after noncardiothoracic surgery: systematic review for the American College of Physicians. Ann Intern Med 2006; 144:596.
  41. Guay J, Choi P, Suresh S, et al. Neuraxial blockade for the prevention of postoperative mortality and major morbidity: an overview of Cochrane systematic reviews. Cochrane Database Syst Rev 2014; :CD010108.
  42. Barbosa FT, Jucá MJ, Castro AA, Cavalcante JC. Neuraxial anaesthesia for lower-limb revascularization. Cochrane Database Syst Rev 2013; :CD007083.
  43. 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.
  44. Murphy GS, Brull SJ. Residual neuromuscular block: lessons unlearned. Part I: definitions, incidence, and adverse physiologic effects of residual neuromuscular block. Anesth Analg 2010; 111:120.
  45. Brull SJ, Murphy GS. Residual neuromuscular block: lessons unlearned. Part II: methods to reduce the risk of residual weakness. Anesth Analg 2010; 111:129.
  46. Grosse-Sundrup M, Henneman JP, Sandberg WS, et al. Intermediate acting non-depolarizing neuromuscular blocking agents and risk of postoperative respiratory complications: prospective propensity score matched cohort study. BMJ 2012; 345:e6329.
  47. Brooks-Brunn JA. Predictors of postoperative pulmonary complications following abdominal surgery. Chest 1997; 111:564.
  48. Fagevik Olsén M, Hahn I, Nordgren S, et al. Randomized controlled trial of prophylactic chest physiotherapy in major abdominal surgery. Br J Surg 1997; 84:1535.
  49. Hall JC, Tarala RA, Tapper J, Hall JL. Prevention of respiratory complications after abdominal surgery: a randomised clinical trial. BMJ 1996; 312:148.
  50. Sandham JD, Hull RD, Brant RF, et al. A randomized, controlled trial of the use of pulmonary-artery catheters in high-risk surgical patients. N Engl J Med 2003; 348:5.
  51. Thomas JA, McIntosh JM. Are incentive spirometry, intermittent positive pressure breathing, and deep breathing exercises effective in the prevention of postoperative pulmonary complications after upper abdominal surgery? A systematic overview and meta-analysis. Phys Ther 1994; 74:3.
  52. do Nascimento Junior P, Módolo NS, Andrade S, et al. Incentive spirometry for prevention of postoperative pulmonary complications in upper abdominal surgery. Cochrane Database Syst Rev 2014; :CD006058.
  53. Agostini P, Naidu B, Cieslik H, et al. Effectiveness of incentive spirometry in patients following thoracotomy and lung resection including those at high risk for developing pulmonary complications. Thorax 2013; 68:580.
  54. Westerdahl E. Optimal technique for deep breathing exercises after cardiac surgery. Minerva Anestesiol 2015; 81:678.
  55. Freitas ER, Soares BG, Cardoso JR, Atallah ÁN. Incentive spirometry for preventing pulmonary complications after coronary artery bypass graft. Cochrane Database Syst Rev 2012; :CD004466.
  56. Silva YR, Li SK, Rickard MJ. Does the addition of deep breathing exercises to physiotherapy-directed early mobilisation alter patient outcomes following high-risk open upper abdominal surgery? Cluster randomised controlled trial. Physiotherapy 2013; 99:187.
  57. Cassidy MR, Rosenkranz P, McCabe K, et al. I COUGH: reducing postoperative pulmonary complications with a multidisciplinary patient care program. JAMA Surg 2013; 148:740.
  58. Schwieger I, Gamulin Z, Forster A, et al. Absence of benefit of incentive spirometry in low-risk patients undergoing elective cholecystectomy. A controlled randomized study. Chest 1986; 89:652.
  59. Stock MC, Downs JB, Gauer PK, et al. Prevention of postoperative pulmonary complications with CPAP, incentive spirometry, and conservative therapy. Chest 1985; 87:151.
  60. Andersen BN, Madsen JV, Schurizek BA, Juhl B. Residual curarisation: a comparative study of atracurium and pancuronium. Acta Anaesthesiol Scand 1988; 32:79.
  61. Zarbock A, Mueller E, Netzer S, et al. Prophylactic nasal continuous positive airway pressure following cardiac surgery protects from postoperative pulmonary complications: a prospective, randomized, controlled trial in 500 patients. Chest 2009; 135:1252.
  62. Ireland CJ, Chapman TM, Mathew SF, et al. Continuous positive airway pressure (CPAP) during the postoperative period for prevention of postoperative morbidity and mortality following major abdominal surgery. Cochrane Database Syst Rev 2014; :CD008930.
  63. van der Leeden M, Huijsmans R, Geleijn E, et al. Early enforced mobilisation following surgery for gastrointestinal cancer: feasibility and outcomes. Physiotherapy 2016; 102:103.
  64. Haines KJ, Skinner EH, Berney S, Austin Health POST Study Investigators. Association of postoperative pulmonary complications with delayed mobilisation following major abdominal surgery: an observational cohort study. Physiotherapy 2013; 99:119.
  65. van Lier F, van der Geest PJ, Hoeks SE, et al. Epidural analgesia is associated with improved health outcomes of surgical patients with chronic obstructive pulmonary disease. Anesthesiology 2011; 115:315.
  66. Svircevic V, Passier MM, Nierich AP, et al. Epidural analgesia for cardiac surgery. Cochrane Database Syst Rev 2013; :CD006715.
  67. Pöpping DM, Elia N, Van Aken HK, et al. Impact of epidural analgesia on mortality and morbidity after surgery: systematic review and meta-analysis of randomized controlled trials. Ann Surg 2014; 259:1056.
  68. Nishimori M, Low JH, Zheng H, Ballantyne JC. Epidural pain relief versus systemic opioid-based pain relief for abdominal aortic surgery. Cochrane Database Syst Rev 2012; :CD005059.
  69. Liu SS, Wu CL. Effect of postoperative analgesia on major postoperative complications: a systematic update of the evidence. Anesth Analg 2007; 104:689.
  70. Engberg G, Wiklund L. Pulmonary complications after upper abdominal surgery: their prevention with intercostal blocks. Acta Anaesthesiol Scand 1988; 32:1.
  71. Hashimi H, Stewart AL, Ah-Fat G. Continuous intercostal nerve block for postoperative analgesia after surgical treatment of the upper part of the abdomen. Surg Gynecol Obstet 1991; 173:116.
  72. Ballantyne JC, Carr DB, deFerranti S, et al. The comparative effects of postoperative analgesic therapies on pulmonary outcome: cumulative meta-analyses of randomized, controlled trials. Anesth Analg 1998; 86:598.
  73. Cheatham ML, Chapman WC, Key SP, Sawyers JL. A meta-analysis of selective versus routine nasogastric decompression after elective laparotomy. Ann Surg 1995; 221:469.
  74. Nelson R, Edwards S, Tse B. Prophylactic nasogastric decompression after abdominal surgery. Cochrane Database Syst Rev 2005; :CD004929.