PULMONARY COMPLICATIONS

POSTOPERATIVE

SANEESH P JSultan Qaboos University Hospital, Muscat

Respiratory complications after surgery

JACKSON EQUESTRIAN MONUMENT downtown Charlottesville, Virginia “Stonewall” Jackson

Confederate General

…dying of pneumonia 10 days after an otherwise successful ether anesthetic

1863

SIGNIFICANCE OF

PULMONARY COMPLICATIONS

POSTOPERATIVE

Lack of uniform definition

PneumoniaDefinite /Suspected Respiratory failure

Requiring mechanical ventilatory support

Bronchospasm

Lack of uniform definition

Unexplained fever

Excessive bronchial secretionsAbnormal breath sounds

“Productive” cough

Atelectasis

Hypoxemia

Cardiac / Pulmonary Complications?

Hospital stay

Complis05

10152025 22.7

9.610.75.7

PULMCARDIAC

Causes of

PULMONARY COMPLICATIONS

POSTOPERATIVE

Causes of PPCs

Disruption of normal activity of respiratory

muscles

Altered neural drive for respiration• Distribution• Timing

Causes of PPCs

Begins with induction of anesthesia

Continues into postop period

EXPIRATION

INSPIRATIONAWAKE

COORDINATED

INSPIRATIONANESTHETISED

INCOORDINATED

Incoordination of Resp Muscles

Reduces efficiency

Decreases FRC

Atelectasis in dependent lung

Impair pulmonary gas exchange

Effects of surgical trauma

Impair effectiveness

Voluntary limitation of respiratory motionDecreased phrenic

motor neuron output

Other factors

Bronchoconstriction • Airway instrumentation; drugs- release of

inflammatory mediatorsImpaired mucociliary transport• Anesthetic gases; tracheal intubationFunctional impairment of pulm inflammatory cells• Prolonged surgery, anesthesia

Surgical/anesth intervention related• Aspiration pneuminitis; ALI –after CPB;

Pneumothorax- barotrauma/surgical trauma; Negative Pr Pulm Edema

Risk factors for

PULMONARY COMPLICATIONS

POSTOPERATIVE

The most important risk factor for postoperative pulmonary complications?

A. High-risk surgical site

B. General anesthesia

C. COPD D. Obesity

GOOD evidencePatient-relatedAdvanced age

ASA PS >2

Cong Heart failureFunctional dependencyCOPD

Surgery-relatedAortic aneurysm repairThoracic surgery

Abdominal surgeryUpper abdominal surgeryNeurosurgery

Prolonged surgeryHead & Neck surgeryEmergency surgery

Vascular surgeryUse of General Anesthesia

FAIR evidence

Patient-relatedWeight-loss

Impaired sensorium

Cigarette use

Alcohol useAbnormal chest exam

Surgery-relatedPerioperative transfusion

Good evidence AGAINST being a risk factor

Patient-relatedWell-controlled asthmaObesity

Surgery-relatedHip surgery

GU/Gynaec surgery

Insufficient data

Patient-relatedObstructive sleep apnoea #Poor exercise capacity

Surgery-relatedEsophageal surgery

# - subsequent evidence : OSA – possible risk factor

Which of the following is a recently identified novel risk factor for PPCs?

C. Pulmonary Hypertension

B. Insulin-treated diabetes

A. Epidural anesthesia

D. Immobility

Strategies for risk reduction

PULMONARY COMPLICATIONS

POSTOPERATIVE

Strategies for Risk reduction

Postoperative lung expansion modalities• Incentive spirometry• Deep breathing exercises• Int. Positive Pressure

Breathing • CPAP

Strategies for Risk reduction

Selective postop NG tube useNG tubes potentially increase risk of aspirationUse in select patients:• Symptomatic abdominal distention• Inability to tolerate oral intake • Nausea

Strategies for Risk reduction

Laparoscopic (vs Open) operation

Evidence begins to follow intuitionOpen surgery:• Higher rate of sepsis• CV events

Strategies for Risk reduction

Routine TPN or enteral nutritionRight heart catheterization

While hypoalbuminemia and malnutrition increase postoperative complications, including pneumonia, routine TPN has no benefit over either TEN or no hyperalimentation.

Inadequate intake

Atrophy of intestinal villi

Bacterial translocation across

gut mucosa Subsequent sepsis

Strategies for Risk reduction

Intraop neuraxial blockadePostop epidural analgesia

Insufficient or conflicting data? Selection bias? Insufficiently powered study- Study on low-risk procedure

Strategies for Risk reduction

Intraop neuraxial blockadePostop epidural analgesia

IV PCA vs PCEA vs On-demand analgesia? Timing issues (Heparin prophylaxis)

Strategies for Risk reduction

Smoking cessation

The jury is still out!!!Early reports - those who quit shortly before surgery actually had higher complication rates Question remains unanswered

Promising New Intervention

PULMONARY COMPLICATIONS

POSTOPERATIVE

Preop Intensive Lung Expansion

Preoperative lung expansion Inspiratory Muscle Training

Preop Intensive Lung Expansion

Preop IMT can be done in chest physical therapy OPD or a pulmonary rehabilitation clinic

Take Home Messages

PULMONARY COMPLICATIONS

POSTOPERATIVE

Summary

PPCs incidence

More common than cardiac complications after non-cardiac surgery

Summary

Surgical site

Most important predictor of risk of PPCs:Aortic, thoracic and upper abdominal surgeries are high-risk procedures, even in healthy patients

Summary

OSA & Pulmonary HTN

Recently identified as risk factors;Limited available evidence does not support preop screening (in patients without symptoms)

Summary

Postop CPAP

Effective for reducing pulmonary complications in patients who are unable to perform deep breathing or incentive spirometry exercises

Summary

Smoking cessation

As an effective strategy to reduce pulmonary risk remains unanswered…

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