Preoperative Assessment of Pulmonary Risk

doi:10.1378/chest.115.suppl_2.58S

Chest

Volume 115, Issue 5, Supplement, May 1999, Pages 58S-63S

https://doi.org/10.1378/chest.115.suppl_2.58S Get rights and content

Study objectives

A summary of current modalities for and the utility of preoperative assessment of pulmonary risk.

Design

Review of recent literature published in the English language.

Setting

Not applicable.

Patients or participants

Patients who undergo elective cardiothoracic or abdominal operations.

Interventions

Not applicable.

Measurements and results

Postoperative pulmonary complications occur after 25 to 50% of major surgical procedures. The accuracy of the preoperative assessment of the risk of such complications is only fair. The routine assessment for all preoperative patients includes age, general physiologic status, and the nature of the planned operation. Specific tests such as measurement of spirometric values and diffusing capacity are indicated routinely only for patients who are candidates for major lung resection or esophagectomy.

Conclusions

Pulmonary complications are an important form of postoperative morbidity after major cardiothoracic and abdominal operations. The appropriate preoperative assessment of the risk of such complications is well defined for lung resection and esophagectomy operations, but it requires refinement for general surgical and cardiovascular operations.

Section snippets

Pathophysiology of Postoperative Respiratory Complications

A prescient commentary in 1910 by W. Pasteur⁹ pointed the direction to our current understanding of the etiology of postoperative pulmonary complications. He noted that “when the true history of postoperative lung complications comes to be written, active collapse of the lung, from deficiency of inspiratory power, will be found to occupy an important position among determining causes.”⁹ Most postoperative pulmonary complications develop as a result of changes in lung volumes that occur in

Thoracotomy and Lung Resection

The incidence of postoperative pulmonary complications after thoracotomy and lung resection is about 30% and is related not only to the removal of lung tissue but is also caused by alterations in chest wall mechanics due to the thoracotomy itself.¹⁷¹⁸¹⁹²⁰²¹ All spirometric measurements fall precipitously immediately postoperatively and do not return toward normal until 6 to 8 weeks postoperatively.¹⁶

Knowledge about the utility of preoperative assessment of the lung resection candidate was first

Cardiac Surgery

The incidence of pulmonary complications after cardiac surgical procedures is high and includes pneumonitis, bronchospasm, or lobar collapse in 40%, prolonged mechanical ventilation in 5 to 10%, and generalized respiratory dysfunction in most patients who undergo cardiopulmonary bypass.³⁷³⁸³⁹ The etiology of pulmonary complications in patients who undergo cardiac surgery has some factors that are similar to those that have been identified for pulmonary complications that develop after lung

Esophagectomy

Postoperative pulmonary complications occur in 25 to 50% of patients after esophagectomy.⁴³⁴⁴⁴⁵ These complications arise from a number of factors, including the type of incision used, the extent of mediastinal dissection, the development of a recurrent laryngeal nerve injury that may impair coughing efficiency postoperatively, and the presence of an intrathoracic reconstructive organ or pleural effusion that may directly impair ventilation in the early postoperative period.

The risk of

Abdominal Surgery

The incidence of pulmonary complications after abdominal surgery is about 30%, a frequency that is high enough to have stimulated considerable research into the etiology of this problem.⁴⁹⁵⁰⁵¹⁵²⁵³ In addition to dysfunction of abdominal wall musculature, the supine position, the development of ascites, and other factors that reduce FRC postoperatively after laparotomy, abdominal surgery has the unique propensity to impair diaphragmatic function, an effect that further contributes to the

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Citation Excerpt :
Absolute cutoff levels as contraindications for surgery [23] or predictors of the perioperative risk of COPD patients are missing. Nevertheless, patients with an FEV1 of >60% are typically considered to be at low risk of PPC, even if they had planned to undergo lung resection [24]. Evidence suggests that avoiding general anesthesia and intubation per se results in lower incidences of postoperative morbidity, pneumonia, prolonged ventilator dependence, and unplanned postoperative intubation [25].
A variety of patient characteristics and comorbidities have been identified, which increase the risk of postoperative pulmonary complications (PPCs), including smoking, age, chronic obstructive pulmonary disease, pulmonary hypertension, obstructive sleep apnea, cardiac and neurologic diseases as well as critical illness. In contrast to the variety of conditions, evidence for specific intraoperative ventilation strategies to reduce PPC is very limited for most comorbidities. Here, we provide an overview of and discuss possible implications for the intraoperative ventilatory management of patients with comorbidities.

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Chest

Preoperative Assessment of Pulmonary Risk

Study objectives

Design

Setting

Patients or participants

Interventions

Measurements and results

Conclusions

Section snippets

Pathophysiology of Postoperative Respiratory Complications

Thoracotomy and Lung Resection

Cardiac Surgery

Esophagectomy

Abdominal Surgery

Lancet

Am J Surg

Br J Anaesth

Chest

J Thorac Cardiovasc Surg

Chest

Chest

Chest

J Thorac Cardiovasc Surg

Chest

Ann Thorac Surg

Ann Thorac Surg

J Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

Clin Chest Med

Chest

Ann Thorac Surg

J Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

Ann Thorac Surg

Ann Thorac Surg

Chest

Ann Thorac Surg

Am J Surg

Chest

Respir Med

Am J Med

Respir Med

Lung complaints after operations with anaesthesia

BMJ