Higher Incidence Of Postoperative Pulmonary Complications Research Articles

Outcomes of Patients Undergoing Elective Cancer Surgery After SARS-CoV-2 Infection: An Observational Cohort Study.

We evaluated the impact of preoperative SARS-CoV-2 infections on postoperative outcomes among patients undergoing elective cancer surgery. This ambidirectional (retrospective and prospective) study was conducted among patients undergoing elective cancer surgery between December 2022 and March 2023. Patients with different time intervals between SARS-CoV-2 infection and surgery (0-6 weeks and ≥7 weeks) were compared with those without SARS-CoV-2 infection. The primary outcome was 30-day postoperative pulmonary complications (PPCs). Secondary outcomes included 30-day postoperative mortality, major adverse cardiovascular events (MACE), and other postoperative adverse outcomes. Of the 830 patients analyzed, 239 (28.8%) had SARS-CoV-2 infection 0-6 weeks before cancer surgery, and they had a higher incidence of PPCs (4.6% in no SARS-CoV-2 infection, 12.1% in 0-6 weeks, and 5.1% in ≥7 weeks, p = 0.001). The logistic regression model revealed that, compared with patients without SARS-CoV-2 infection, surgery performed 0-6 weeks after SARSCoV-2 infection was associated with a higher risk of PPCs (adjusted odds ratio [aOR] 2.83; 95% confidence interval [CI] 1.34-5.98), and surgery performed ≥7 weeks after SARSCoV-2 infection was associated with a similar risk of PPCs (aOR 1.19; 95% CI 0.54-2.64). However, preoperative SARS-CoV-2 infection was not associated with a risk of 30-day postoperative mortality, MACE, or other adverse postoperative outcomes. In patients with preoperative Omicron variant infection, nonemergency cancer surgery can be scheduled ≥7 weeks after the infection to decrease the risk of PPCs, but it can be advanced if the risk of delay exceeds the risk of proceeding with the surgery.

Postoperative pulmonary complication as an emerging complication in major head and neck cancer surgery: A retrospective study.

Postoperative pulmonary complications (PPCs) are one of the most significant complications following head and neck cancer surgery (HNCS). Patients requiring tracheostomy, free tissue transfer reconstruction, and postoperative ventilation in an intensive care unit (ICU) may have a high incidence of PPCs. This study aimed to identify the most likely situations for developing PPCs in HNCS. A retrospective analysis of 40 patients who had undergone HNCS has been conducted. We individually traced each patient for 7 days postoperatively and collected data on various parameters. The incidence of PPCs after HNCS is more with free flap reconstruction. Patient-related risk factors with PPCs were advanced age, smoking, body mass index (BMI) >25, and bilateral or unilateral neck dissection. Postoperative ICU stay was significantly related to an increased incidence of PPCs. In terms of specific surgical sites, both the maxilla and mandible also showed significant relationship with PPCs. Tracheostomy was also considered a related factor in developing PPCs. To reduce PPCs in HNCS, patients with one or more of these risk factors should be subjected to exaggerated postoperative pulmonary care.

Increased diaphragm echodensity correlates with postoperative pulmonary complications in patients after major abdominal surgery: a prospective observational study

BackgroundAssociated with increased morbidity and mortality, postoperative pulmonary complications (PPCs) often occur after major abdominal surgery. Diaphragmatic dysfunction is suggested to play an important role in the development of PPCs and diaphragm echodensity can be used as an indicator of diaphragm function. This study aimed to determine whether diaphragm echodensity could predict the occurrence of PPCs in patients after major abdominal surgery.MethodsDiaphragm ultrasound images of patients after major abdominal surgery were collected during spontaneous breathing trials. Echodensity was quantified based on the right-skewed distribution of grayscale values (50th percentile, ED50; 85th percentile, ED85; mean, EDmean). Intra- and inter-analyzer measurement reproducibility was determined. Outcomes including occurrence of PPCs, reintubation rate, duration of ventilation, and length of ICU stay were recorded.ResultsDiaphragm echodensity was measured serially in 117 patients. Patients who developed PPCs exhibited a higher ED50 (35.00 vs. 26.00, p < 0.001), higher ED85 (64.00 vs. 55.00, p < 0.001) and higher EDmean (39.32 vs. 33.98, p < 0.001). In ROC curve analysis, the area under the curve of ED50 for predicting PPCs was 0.611. The optimal ED50 cutoff value for predicting the occurrence of PPCs was 36. According to this optimal ED50 cutoff value, patients were further divided into a high-risk group (ED50 > 36, n = 35) and low-risk group (ED50 ≤ 36, n = 82). Compared with the low-risk group, the high-risk group had a higher incidence of PPCs (unadjusted p = 0.003; multivariate-adjusted p < 0.001).ConclusionDiaphragm echodensity can be feasibly and reproducibly measured in mechanically ventilated patients. The increase in diaphragm echodensity during spontaneous breathing trials was related to an increased risk of PPCs in patients after major abdominal surgery.

Postoperative Pulmonary Complications in Patients With Transcatheter Tricuspid Valve Implantation-Implications for Physiotherapists.

ObjectivesTo investigate the incidence of postoperative pulmonary complications (PPCs) and short-term recovery after transcatheter tricuspid valve implantation (TTVI).MethodsA total of 17 patients diagnosed with severe tricuspid regurgitation who received a LuX-valve TTVI were included in this study. Spirometry lung function, maximal inspiratory pressure (MIP), and 6-min walk test distance (6MWD) were recorded. Prior to surgery, patients were stratified into high or low pulmonary risk groups based on published predefined criteria. A physiotherapist provided all patients with education on thoracic expansion exercises, effective cough and an inspiratory muscle training protocol at 50% of MIP for 3 days preoperatively. All patients received standard post-operative physiotherapy intervention including positioning, thoracic expansion exercises, secretion removal techniques and mobilization. Patients were assessed for PPCs as defined by the Melbourne-Group Score-version 2. Clinical characteristics and hospital stay, cost, functional capacity, and Kansas City Cardiomyopathy Questionnaire (KCCQ) heart failure score were recorded at admission, 1-week, and 30-days post-op.ResultsThe mean (SD) age of the 17 patients was 68.4 (8.0) years and 15 (88%) were female. Pre-surgical assessment identified 8 patients (47%) at high risk of PPCs. A total of 9 patients (53%) developed PPCs between the 1st and 3rd day post-surgery, and 7 of these 9 patients were amongst the 8 predicted as “high risk” prior to surgery. One patient died before the 30 day follow up. Pre-operative pulmonary risk assessment score, diabetes mellitus, a low baseline MIP and 6MWD were associated with a high incidence of PPCs. Compared to those without PPCs, patients with PPCs had longer ICU and hospital stay, and higher hospitalization cost. At 30 days post-surgery, patients without PPCs maintained higher MIP and 6MWD compared to those with PPCs, but there were no significant between-group differences in other lung function parameters nor KCCQ.ConclusionThis is the first study to report the incidence of PPCs post TTVI. Despite a 3-day prehabilitation protocol and standard post-operative physiotherapy, PPCs were common among patients after TTVI and significantly impacted on hospital and short-term recovery and outcomes. In the majority of patients, PPCs could be accurately predicted before surgery. A comprehensive prehabilitation program should be considered for patients prior to TTVI.Clinical Trial Registration[www.ClinicalTrials.gov], identifier [ChiCTR2000039671].

Diaphragm Thickening Fraction as a Prognostic Imaging Marker for Postoperative Pulmonary Complications in Robot-Assisted Laparoscopic Prostatectomy Requiring the Trendelenburg Position and Pneumoperitoneum.

Background Robot-assisted laparoscopic prostatectomy (RALP) frequently entails postoperative pulmonary complications (PPCs) due to the Trendelenburg position and pneumoperitoneum. Diaphragm thickening fraction (TF) as an imaging marker can offer the advantage of predicting respiratory outcomes. Therefore, we evaluated the effect of diaphragm TF on the occurrence of PPCs in RALP. Methods We measured the preoperative thickness of the diaphragm at peak inspiration (Tpi) and end expiration (Tee) using ultrasonography. Diaphragm TF was calculated as TF = (Tpi–Tee)/Tee. A receiver operating characteristic (ROC) curve analysis of TF was performed. After dividing patients into two groups according to the optimal TF cut-off value, we compared the occurrence of PPCs between the groups. The predictivity of diaphragm TF for the occurrence of PPCs was evaluated. Results Of 145 patients, 40 patients (27.6%) developed PPCs. Patients with PPCs had a significantly lower TF than those without PPCs (0.31 ± 0.09 vs. 0.39 ± 0.11, P < 0.001). In the ROC curve analysis, the optimal TF cut-off value was 0.28. The patients were divided into TF ≥ 0.28 group (n = 114) and TF < 0.28 group (n = 31). The incidence of PPCs was significantly higher in the TF < 0.28 group than in the TF ≥ 0.28 group (51.6% vs. 21.1%, P = 0.001). Diaphragm TF < 0.28 was associated with a higher incidence of PPCs than diaphragm TF ≥ 0.28 (odds ratio = 4.534, 95% confidence interval [1.763–11.658], P = 0.002). Conclusion Preoperative diaphragm TF < 0.28 was associated with an increased incidence of PPCs, suggesting that diaphragm TF as a prognostic imaging marker provides useful information on PPCs in RALP requiring the Trendelenburg position and pneumoperitoneum. Trial Registry Number. This trial is registered with KCT0005028.

Impact of Prognostic Nutritional Index on Postoperative Pulmonary Complications in Radical Cystectomy: A Propensity Score-Matched Analysis.

BackgroundRadical cystectomy is a standard treatment for muscle-invasive bladder cancer but frequently entails postoperative pulmonary complications (PPCs). Nutrition is closely associated with postoperative outcomes. Therefore, we evaluated the impact of preoperative prognostic nutritional index (PNI) on PPCs in radical cystectomy.MethodsPNI was calculated as 10 × (serum albumin) + 0.005 × (total lymphocyte count). The risk factors for PPCs were evaluated using multivariate logistic regression analysis. A receiver operating characteristic curve analysis of PNI was performed, and an optimal cut-off value was identified. Propensity score-matched analysis was used to determine the impact of PNI on PPCs. Postoperative outcomes were also evaluated.ResultsPPCs occurred in 112 (13.6%) of 822 patients. Multivariate logistic regression analysis identified PNI, age, and serum creatinine level as risk factors. The area under the receiver operating characteristic curve of PNI for predicting PPCs was 0.714 (optimal cut-off value: 45). After propensity score matching, the incidence of PPCs in the PNI ≤ 45 group was significantly higher compared with the PNI > 45 group (20.8% vs. 6.8%; p < 0.001), and PNI ≤ 45 was associated with a higher incidence of PPCs (odds ratio 3.308, 95% confidence interval 1.779–6.151; p < 0.001). The rates of intensive care unit admission and prolonged (> 2 days) stay thereof were higher in patients who developed PPCs.ConclusionsPreoperative PNI ≤ 45 was associated with a higher incidence of PPCs in radical cystectomy, suggesting that PNI provides useful information regarding pulmonary complications after radical cystectomy.

Intraoperative mechanical ventilation practice in thoracic surgery patients and its association with postoperative pulmonary complications: results of a multicenter prospective observational study

BackgroundIntraoperative mechanical ventilation may influence postoperative pulmonary complications (PPCs). Current practice during thoracic surgery is not well described.MethodsThis is a post-hoc analysis of the prospective multicenter cross-sectional LAS VEGAS study focusing on patients who underwent thoracic surgery. Consecutive adult patients receiving invasive ventilation during general anesthesia were included in a one-week period in 2013. Baseline characteristics, intraoperative and postoperative data were registered. PPCs were collected as composite endpoint until the 5th postoperative day. Patients were stratified into groups based on the use of one lung ventilation (OLV) or two lung ventilation (TLV), endoscopic vs. non-endoscopic approach and ARISCAT score risk for PPCs. Differences between subgroups were compared using χ2 or Fisher exact tests or Student’s t-test. Kaplan–Meier estimates of the cumulative probability of development of PPC and hospital discharge were performed. Cox-proportional hazard models without adjustment for covariates were used to assess the effect of the subgroups on outcome.ResultsFrom 10,520 patients enrolled in the LAS VEGAS study, 302 patients underwent thoracic procedures and were analyzed. There were no differences in patient characteristics between OLV vs. TLV, or endoscopic vs. open surgery. Patients received VT of 7.4 ± 1.6 mL/kg, a PEEP of 3.5 ± 2.4 cmH2O, and driving pressure of 14.4 ± 4.6 cmH2O. Compared with TLV, patients receiving OLV had lower VT and higher peak, plateau and driving pressures, higher PEEP and respiratory rate, and received more recruitment maneuvers. There was no difference in the incidence of PPCs in OLV vs. TLV or in endoscopic vs. open procedures. Patients at high risk had a higher incidence of PPCs compared with patients at low risk (48.1% vs. 28.9%; hazard ratio, 1.95; 95% CI 1.05–3.61; p = 0.033). There was no difference in the incidence of severe PPCs. The in-hospital length of stay (LOS) was longer in patients who developed PPCs. Patients undergoing OLV, endoscopic procedures and at low risk for PPC had shorter LOS.ConclusionPPCs occurred frequently and prolonged hospital LOS following thoracic surgery. Proportionally large tidal volumes and high driving pressure were commonly used in this sub-population. However, large RCTs are needed to confirm these findings.Trial registrationThis trial was prospectively registered at the Clinical Trial Register (www.clinicaltrials.gov; NCT01601223; registered May 17, 2012.)

Association between night-time surgery and occurrence of intraoperative adverse events and postoperative pulmonary complications

BackgroundThe aim of this post hoc analysis of a large cohort study was to evaluate the association between night-time surgery and the occurrence of intraoperative adverse events (AEs) and postoperative pulmonary complications (PPCs). MethodsLAS VEGAS (Local Assessment of Ventilatory Management During General Anesthesia for Surgery) was a prospective international 1-week study that enrolled adult patients undergoing surgical procedures with general anaesthesia and mechanical ventilation in 146 hospitals across 29 countries. Surgeries were defined as occurring during ‘daytime’ when induction of anaesthesia was between 8:00 AM and 7:59 PM, and as ‘night-time’ when induction was between 8:00 PM and 7:59 AM. ResultsOf 9861 included patients, 555 (5.6%) underwent surgery during night-time. The proportion of patients who developed intraoperative AEs was higher during night-time surgery in unmatched (43.6% vs 34.1%; P<0.001) and propensity-matched analyses (43.7% vs 36.8%; P=0.029). PPCs also occurred more often in patients who underwent night-time surgery (14% vs 10%; P=0.004) in an unmatched cohort analysis, although not in a propensity-matched analysis (13.8% vs 11.8%; P=0.39). In a multivariable regression model, including patient characteristics and types of surgery and anaesthesia, night-time surgery was independently associated with a higher incidence of intraoperative AEs (odds ratio: 1.44; 95% confidence interval: 1.09–1.90; P=0.01), but not with a higher incidence of PPCs (odds ratio: 1.32; 95% confidence interval: 0.89–1.90; P=0.15). ConclusionsIntraoperative adverse events and postoperative pulmonary complications occurred more often in patients undergoing night-time surgery. Imbalances in patients' clinical characteristics, types of surgery, and intraoperative management at night-time partially explained the higher incidence of postoperative pulmonary complications, but not the higher incidence of adverse events. Clinical trial registrationNCT01601223.

Pulmonary Complications following Percutaneous Nephrolithotomy: A Prospective Study

Introduction: Pulmonary complications may occur in the post-operative period and are a significant cause of morbidity and mortality in patients undergoing anesthesia and surgery. Complication rates vary according to different procedures and different types of anesthesia and may be affected by the patient condition. The purpose of this study was to examine pulmonary complications following percutaneous nephrolithotomy (PCNL) and to search for associations between the pre- and intra- operative factors and the risk of post-operative pulmonary complications (PPC). Patients and Methods: This was a prospective observational study of 100 consecutive adult patients who underwent PCNL surgery. We collected data of the patient, surgery and anesthesia and analyzed it to find correlations with PPC. Results: Eight (8%) patients had PPC following PCNL, 7 patients had pneumothorax and 1 had atelectasis and pleural effusion. The latter patient died at post-operative day 24 due to respiratory failure. It was found that patients who had PCNL on the right kidney were at lower risk for PPC. In addition it was found that younger patients had a higher incidence of PPC. Conclusions: Based on this study the most common type of post-operative complication following PCNL is pulmonary, with pneumothorax being the main complication. PPC may result in patient mortality. The side of the operation and the patient's age might affect the risk of PPC.

Pulmonary complications after major head and neck surgery: A retrospective cohort study

Postoperative pulmonary complications (PPCs) following head and neck surgery are common. Patients undergoing tracheostomy, free tissue transfer reconstruction, and postoperative ventilation in an intensive care unit (ICU) have a high incidence of PPCs. We sought to define the incidence of PPCs in this cohort and to determine what factors PPCs correlate with. Retrospective cohort study. Following institutional research ethics board approval, a retrospective review of patients undergoing major head and neck surgery at a Canadian tertiary care center was conducted. The development of PPCs was the outcome of interest. Quality assurance parameters including ICU and hospital lengths of stay, and mortality were also recorded. There were 105 patients enrolled, of which 47 (44.8%) sustained one or more PPCs. The most frequent PPC was respiratory failure, accounting for 39 of 94 PPCs observed. Hypertension was the only comorbidity that correlated with development of a PPC (P = .031). Those who sustained PPCs were older than those who did not (median age, 65.6 vs. 58.7 years; P = .005). Development of PPCs correlated with longer ICU and hospital stays. There was increased mortality among patients with PPCs compared to those without (12.8% vs. 1.7%, P = .04). Patients undergoing major head and neck surgery are at high risk of PPCs. Advanced age and hypertension significantly correlated with PPCs. PPCs correlate with prolonged ICU and hospital stays, and increased mortality. Further research is needed to define risk factors, useful investigations, and effective optimization strategies to mitigate PPCs.

Implications of extubation failure and prolonged mechanical ventilation in the postoperative period following elective intracranial surgery

Patients undergoing neurosurgery are predisposed to a variety of complications related to mechanical ventilation (MV). There is an increased incidence of extubation failure, pneumonia, and prolonged MV among such patients. The aim of the present study was to assess the influence of extubation failure and prolonged MV on the following variables: postoperative pulmonary complications (PPC), mortality, reoperation, tracheostomy, and duration of postoperative hospitalization following elective intra-cranial surgery. The study involved a prospective observational cohort of 317 patients submitted to elective intracranial surgery for tumors, aneurysms and arteriovenous malformation. Preoperative assessment was performed and patients were followed up for the determination of extubation failure and prolonged MV (>48 h) until discharge from the hospital or death. The occurrence of PPC, incidence of death, the need for reoperation and tracheostomy, and the length of hospitalization were assessed during the postoperative period. Twenty-six patients (8.2%) experienced extubation failure and 30 (9.5%) needed prolonged MV after surgery. Multivariate analysis showed that extubation failure was significant for the occurrence of death (OR = 8.05 [1.88; 34.36]), PPC (OR = 11.18 [2.27; 55.02]) and tracheostomy (OR = 7.8 [1.12; 55.07]). Prolonged MV was significant only for the occurrence of PPC (OR = 4.87 [1.3; 18.18]). Elective intracranial surgery patients who experienced extubation failure or required prolonged MV had a higher incidence of PPC, reoperation and tracheostomy and required a longer period of time in the ICU. Level of consciousness and extubation failure were associated with death and PPC. Patients who required prolonged MV had a higher incidence of extubation failure.

Don't Forget the Heart When Looking at the Risk of Postoperative Pulmonary Complications

We read with great interest the recent study by Canet et al. 1In this investigation, based on 2,464 surgical patients, the incidence of postoperative pulmonary complications (PPCs) was 5%, with a related mortality rate at Day 30 of 19.5% (95% CI, 12.5–26.5%).Predicting risk factors for PPCs is a cornerstone of better patient management. However, reliable knowledge of PPC incidence in a broad, heterogeneous surgical population remains difficult because of nonrepresentative samples and statistical flaws. Furthermore, definitions of PPC are often not explicit and differ among studies. The recent study of Canet et al. 1has similarities with that of McAlister et al. 2Both investigations were built with a strong statistical methodology and included a large representative surgical population. Yet, the 5% incidence of PPC reported by Canet et al. 1is almost double the 2.7% reported by McAlister et al. 2This higher rate of complications observed by Canet et al. 1could be explained, in part, by the inclusion of emergency cases (14.2%), whereas McAlister et al. 2included only scheduled cases. The risk of PPC increases significantly in emergency cases.3In addition, Canet et al. 1included some thoracic surgical cases. Another major difference is related to the use of different PPC definitions. The diagnostic criteria used by McAlister et al. 2were stricter, including supplementary therapeutic action, such as mechanical ventilation for respiratory failure, percutaneous intervention for treatment of pleural effusion, and bronchoscopic intervention for atelectasis.2Nevertheless, the most striking result reported by Canet et al. 1is not the high incidence of PPC per se but the high percentage of mortality (19.5%) associated with these cases. It seems difficult to conceive that PPC alone can explain this finding. A previous study by Lawrence et al. 4showed that, in a cohort of patients undergoing major abdominal surgery, 33% who developed PPC also had cardiovascular complications. This result suggests that a significant proportion of patients studied by Canet et al. 1also had cardiovascular complications that were not evaluated and that these complications may have been the cause of death in these patients.In conclusion, further studies are necessary to examine prospectively comparative incidence, outcomes, and predictors of both types of complications.*Hôpital Foch, Suresnes, France. m.fischler@hopital-foch.org

Predicting pulmonary complications after pneumonectomy for lung cancer.

Patients undergoing pneumonectomy for lung cancer are thought to be at high risk for the development of postoperative pulmonary complications (PC) and these complications are associated with high mortality rates. The purpose of this study was to identify independent factors associated with increased risk for the development of postoperative PC after pneumonectomy for lung cancer, and to assess the usefulness of predicted pulmonary function to identify high risk patients and other adverse outcomes. We reviewed retrospectively 242 patients undergoing pneumonectomy for lung cancer during a 12-year period. Perioperative data (clinical, pulmonary function test, and surgical) were recorded to identify risk factors of PC by univariate and multivariate analyses. Overall mortality and morbidity rates were 5.4 and 59%, respectively. Thirty-four patients (14%) developed PC (acute respiratory failure, ARF = 8.7%, reintubation = 5.4%, pneumonia = 3.3%, atelectasis = 2.9%, postpneumonectomy pulmonary edema = 2.5%, mechanical ventilation more than 24 h = 1.2%, pneumothorax = 0.8%). Patients with surgical (P < 0.001), cardiac (P < 0.001) and other complications (P < 0.01) had higher incidence of PC than those without postoperative complications. Intensive care unit stay (53 +/- 39 h vs. 35 +/- 19 h; P < 0.001) and hospital stay (18 +/- 11 days vs. 12 +/- 7 days; P < 0.001) was significantly longer in patients with PC. The mortality rate associated with PC was 35.5% (P < 0.001). By univariate analysis, it was found that older patients (P = 0.007), chronic obstructive pulmonary disease (COPD) (P = 0.023), heart disease (P = 0.019), no previous record of chest physiotherapy (P = 0.008), poor predicted postoperative forced expiratory volume in 1s (ppo-FEV1) (P = 0.001), and prolonged anesthetic time (P < 0.001) were related with higher risk of PC. In the multiple logistic regression model, the anesthetic time (minutes; odds ratio, OR = 1.012), ppo-FEV1 (ml/s; OR = 0.998), heart disease (OR = 2.703), no previous record of previous chest physiotherapy (OR = 2.639), and COPD (OR = 2.277) were independent risk factors of PC. PC after pneumonectomy are associated with high mortality rates. Careful attention must be paid to patients with COPD and heart disease. Our results confirm the relevance of previous chest physiotherapy and the importance of the length of the surgical procedure to minimize the incidence of PC. The predicted pulmonary function (ppo-FEV1) may be useful to identify high risk patients for PC development and adverse outcomes.

Postoperative pulmonary complications and lung function in high‐risk patients: a comparison of three physiotherapy regimens after upper abdominal surgery in general anesthesia

The effect of three postoperative regimens of respiratory therapy on pulmonary complications and lung function was compared in high-risk patients. Fifty-one patients were randomized to: 1) conventional chest physiotherapy alone (PHYS), 2) chest physiotherapy and positive expiratory pressure (PEP), or 3) chest physiotherapy with both positive expiratory pressure and inspiratory resistance (RMT). Treatments were given twice daily by a physiotherapist and self-administered. The incidence of postoperative pulmonary complications (PPC) was respectively, 71%, 76% and 65% in the PHYS-, PEP- and RMT-groups. The incidence of PPC requiring treatment with antibiotic, bronchodilator or supplementary oxygen according to the existing clinical practice was 47%, 47% and 29%. The incidence of atelectasis was 65%, 64% and 60% and of pneumonia 29%, 35% and 6%. There was no difference between the groups, except for a tendency to a lower frequency of pneumonia in the RMT-group. Postoperatively forced vital capacity (FVC) decreased to mean 54%, forced expired volume in 1 s to 48% and functional residual capacity to 76% of preoperative values. Arterial oxygen tension (PaO2) declined to mean 8.1 kPa and arterial saturation (SaO2) to 89%. There was no difference between the groups except for FVC, PaO2 and SaO2 (P = 0.008, P = 0.008 and P = 0.002), which showed the least decrease in the RMT-group. None of the regimens could be considered as satisfactory concerning the prevention of PPC, but RMT seemed to be the most efficient. Insufficient self-administration of treatment was probably one of the causes of the overall high incidence of PPC in this study.