Strategies to Reduce Postoperative Pulmonary Complications

Terry Shaneyfelt, MD, MPHAssoc. Professor, UAB Department of Medicine

• Which of the following strategies should not be undertaken to reduce her risk of postoperative pulmonary complications?a) Incentive spirometryb) Intensify bronchodilators +/- steroidsc) Prophylactic NG tube postoperativelyd) Smoking cessation e) None of the above

67 yo F current smoker with COPD is undergoing upper abdominal surgery. PE reveals mild diffuse expir wheezing.

“…found to be at higher risk should receive the following postoperative procedures….1) deep

breathing exercises or incentive spirometry and 2) selective use of a nasogastric tube…”

“The following procedures should not be used…1) right heart catheterization and 2) total parenteral nutrition

or total enteral nutrition.”

2006 ACP Guideline

Employ multiple strategies

PREOPERATIVE

• Smoking cessation• Optimize lung disease• Delay surgery if

infected• Antibiotics if infected• Lung expansion

modalities

INTRAOPERATIVE

• Alternative surgical procedure

• Regional anesthesia• Avoid long acting

neuromuscular blockers

POSTOPERATIVE

• Lung expansion• Epidural pain management• Selective NG tubes

Smoking Cessation Reduces Total & PPC

Pulmonary complications: 15% past smokers vs 20%

for current smokers • RR 0.73 (0.61 – 0.87)

Recent Tobacco Cessation Might Be Harmful

do Nascimento Junior P, Módolo NSP, Andrade S, Guimarães MMF, Braz LG, El Dib R. Incentive spirometry for prevention of postoperative pulmonary complications in upper abdominal surgery. Cochrane Database of Systematic Reviews 2014, Issue 2. Art. No.: CD006058. DOI: 10.1002/14651858.CD006058.pub3.

Freitas ERFS, Soares BGO, Cardoso JR, Atallah ÁN. Incentive spirometry for preventing pulmonary complications after coronary artery bypass graft. Cochrane Database of Systematic Reviews 2012, Issue 9. Art. No.: CD004466. DOI: 10.1002/14651858.CD004466.pub3.

Routine NGTs Increase PPCsVerma R, Nelson RL. Prophylactic nasogastric decompression after abdominal surgery. Cochrane Database of Systematic Reviews 2007, Issue 3. Art. No.: CD004929. DOI: 10.1002/14651858.CD004929.pub3.

• Optimize underlying lung disease

• Incentive spirometry probably is better than nothing but it isnt superior (or worse) than other lung expansion modalities and its cheap

• Smoking cessation is beneficial and should be initiated as early as possible

• More studies are needed

Summary