High Risk For Pulmonary Complications Research Articles

Effects of intraoperative PEEP on postoperative pulmonary complications in high-risk patients undergoing laparoscopic abdominal surgery: study protocol for a randomised controlled trial

IntroductionPostoperative pulmonary complications (PPCs), strongly associated with higher mortality risk, can develop in up to 58% of patients undergoing abdominal surgery. More and more evidence shows that the use of...

Octogenarian and Nonagenarians Are at a Higher Risk for Experiencing Adverse 30-Day Outcomes Following ORIF for Ankle Fractures

Category:Ankle, TraumaIntroduction/Purpose:Despite an increasing number of elderly individuals undergoing surgical fixation for ankle fractures, few studies have investigated peri-operative outcomes and safety of surgery in an octogenarian and nonagenarian population (age >=80 years). Past literature has shown octogenarians to be a potentially vulnerable population that have drastically different adverse outcomes and higher resource utilization as compared to individuals below the age of 80 years.Methods:The 2012-2017 American College of Surgeons – National Surgical Quality Improvement Program (ACS-NSQIP) was queried using Current Procedural Terminology codes for patients undergoing open reduction internal fixation (ORIF) for isolated uni-malleolar (CPT-27766, CPT-27769, CPT-27792), bi-malleolar (CPT-27814) and tri-malleolar (CPT-27822, CPT-27823) ankle fractures. The study cohort was divided into three distinct groups for comparisons (Age <65 years, Age 65-79 years and Age=>80 years/octogenarians + nonagenarians). Multi-variate regression analyses were used to compare the independent effect of varying age groups on 30-day post-operative outcomes while controlling for differences in baseline clinical characteristics (age, gender, sex, race, fracture type/severity, open vs. closed fracture, admission status, BMI, co-morbidities, functional health status, ASA group and operative time). For comparison purposes, Age<65 years was taken as reference group in multi-variate regression models.Results:A total of 19,585 patients were included – out of which 1,033 (5.3%) were octogenarians/nonagenarians (=>80 years). Following multivariate analysis, individuals aged =>80 years were at a significantly higher risk of 30-day wound complications (OR 1.84; p=0.019), pulmonary complications (OR 3.88; p<0.001), renal complications (OR 1.96; p=0.015), septic complications (OR 3.72; p=0.002), urinary tract infections (OR 2.24; p<0.001), bleeding requiring transfusion (OR 1.90; p=0.025), mortality (OR 7.44; p<0.001), readmissions (OR 1.65; p=0.004) and non-home discharge (OR 13.91; p<0.001). Individuals between the age of 65-79 years only had a higher risk of pulmonary complications (OR 2.30; p=0.004), urinary tract infections (OR 2.24; p<0.001), readmissions (OR 1.41; p=0.005) and non-home discharges (OR 3.55; p<0.001), with the effect sizes being small as compared to age >=80 years group.Conclusion:Based on the findings, it appears that octagenarians and nonagenarians (age =>80) are a fundamentally distinct and vulnerable age group that is at a higher risk of complications, readmissions, mortality and non-home discharges as compared to other geriatric (65-79 years) and non-geriatric (<65 years) patients. Providers should understand the importance of pre-operative counselling and risk-stratification in this vulnerable patient population.

Clinical predictors for oropharyngeal dysphagia and laryngeal dysfunction after lung and heart transplantation

Oropharyngeal dysphagia and laryngeal dysfunction are two lesser known complications after lung and heart transplantation. The presence of these features places this immunocompromised population at high risk of pulmonary complications and subsequent medical deterioration. Early identification of swallowing and voice dysfunction would be beneficial to optimize management. To examine the association between patient risk factors and postoperative outcomes with referral to speech pathology (SP) following signs of swallowing and voice dysfunction. A retrospective review was conducted on demographic data, patient risk factors and postoperative course in 284 patients following lung and/or heart transplantation between 2010 and 2013. Variables were analysed for any association between pre- and postoperative factors and SP referral. A total of 24% were referred to SP with a mean age of 47 years. Binary logistic regression identified a statistically significant association between the number of intubations (odds ratio (OR) = 2.066, p = 0.028), intubation duration (OR = 1.004, p < 0.01), length of stay in the intensive care unit (ICU) (OR = 1.068, p < 0.01), and number of ICU admissions (OR = 1.384, p = 0.046) and SP referral. Intubation time and the total days in ICU were greater for patients referred to SP. Mortality also increased for these variables and for the numbers of reintubations and readmissions. Analysis of pre-operative risk factors revealed cerebrovascular disease to be a significant predictor of SP referral (OR = 6.747, p = 0.032). This study demonstrates significant clinical indicators for referral to SP for the management of oropharyngeal dysphagia and laryngeal dysfunction in patients after lung or heart transplantation. Further studies are needed to investigate the most efficacious intervention approaches to manage swallowing and voice dysfunction in these patients.

Perioperative redistribution of regional ventilation and pulmonary function: a prospective observational study in two cohorts of patients at risk for postoperative pulmonary complications

BackgroundPostoperative pulmonary complications (PPCs) increase morbidity and mortality of surgical patients, duration of hospital stay and costs. Postoperative atelectasis of dorsal lung regions as a common PPC has been described before, but its clinical relevance is insufficiently examined. Pulmonary electrical impedance tomography (EIT) enables the bedside visualization of regional ventilation in real-time within a transversal section of the lung. Dorsal atelectasis or effusions might cause a ventral redistribution of ventilation. We hypothesized the existence of ventral redistribution in spontaneously breathing patients during their recovery from abdominal and peripheral surgery and that vital capacity is reduced if regional ventilation shifts to ventral lung regions.MethodsThis prospective observational study included 69 adult patients undergoing elective surgery with an expected intermediate or high risk for PPCs. Patients undergoing abdominal and peripheral surgery were recruited to obtain groups of equal size. Patients received general anesthesia with and without additional regional anesthesia. On the preoperative, the first and the third postoperative day, EIT was performed at rest and during spirometry (forced breathing). The center of ventilation in dorso-ventral direction (COVy) was calculated.ResultsBoth groups received intraoperative low tidal volume ventilation. Postoperative ventral redistribution of ventilation (forced breathing COVy; preoperative: 16.5 (16.0–17.3); first day: 17.8 (16.9–18.2), p < 0.004; third day: 17.4 (16.2–18.2), p = 0.020) and decreased forced vital capacity in percentage of predicted values (FVC%predicted) (median: 93, 58, 64%, respectively) persisted after abdominal surgery. In addition, dorsal to ventral shift was associated with a decrease of the FVC%predicted on the third postoperative day (r = − 0.66; p < 0.001). A redistribution of pulmonary ventilation was not observed after peripheral surgery. FVC%predicted was only decreased on the first postoperative day (median FVC%predicted on the preoperative, first and third day: 85, 81 and 88%, respectively). In ten patients occurred pulmonary complications after abdominal surgery also in two patients after peripheral surgery.ConclusionsAfter abdominal surgery ventral redistribution of ventilation persisted up to the third postoperative day and was associated with decreased vital capacity. The peripheral surgery group showed only minor changes in vital capacity, suggesting a role of the location of surgery for postoperative redistribution of pulmonary ventilation.Trial registrationThis prospective observational single centre study was submitted to registration prior to patient enrollment at ClinicalTrials.gov (NCT02419196, Date of registration: December 1, 2014). Registration was finalized at April 17, 2015.

Forced vital capacity less than 1: A mark for high-risk patients.

Rib fractures (RFx) continue to be a source of morbidity and mortality. A RFx care pathway has been used based on forced vital capacity (FVC). The objective of this study was to test the hypothesis that deterioration of FVC to less than 1 after admission is a marker for high-risk patients and affects outcomes. A retrospective study of patients enrolled in an RFx care pathway at a Level 1 trauma center from 2009 to 2014. All patients had an admission FVC greater than 1. 2 groups were analyzed: patients with a lowest inpatient FVC less than 1 (Group A) compared to patients with lowest inpatient FVC of 1 or greater (Group B). Complications [pneumonia, upgrade to the intensive care unit, readmission, and intubation] and demographics were examined. Patients without documented admission FVCs were excluded. p < 0.05 was considered significant. A total of 1,106 patients were analyzed (Group A, 187; Group B, 919). Patients whose FVC dropped less than 1 (Group A) had a higher complication rate [15% (Group A) vs 3.2% (Group B); p < 0.001]. Rates of pneumonia, readmission, unplanned upgrade, and intubation were all significantly higher in Group A [pneumonia: 9% (Group A) vs 1.4% (Group B), p < 0.001; readmission: 4% (Group A) vs 1.7% (Group B), p = 0.04; upgrade; 3.7% (Group A) vs 0.2% (Group B), p < 0.001; intubation: 1.6% (Group A) vs 0.1% (Group B), p = 0.02]. Hospital length of stay was longer in Group A [10 days (Group A) vs 4 days (Group B), p < 0.001]. Forced vital capacity predicts complications in patients with RFx. Patients whose FVC falls less than 1 during admission are at high risk for pulmonary complications. Daily FVC testing for patients admitted with RFx can predict outcomes. Forced vital capacity less than 1 should be considered as a marker for complications. Once FVC drops less than 1, patients should be considered for increased interventions. Even if the patient has not yet clinically deteriorated, consideration for higher level of care is warranted. Prognostic study, level III.

Robotic lobectomy has the greatest benefit in patients with marginal pulmonary function

BackgroundPatients with limited pulmonary function have a high risk for pulmonary complications following lobectomy. Robotic approach is currently the least invasive approach. We hypothesized that robotic lobectomy may be of particular benefit in high-risk patients.MethodsWe reviewed our institutional Society of Thoracic Surgeons (STS) data on lobectomy patients from 2012 to 2017. Postoperative outcomes were compared between robotic and open lobectomy groups. High-risk patients were identified by pulmonary function test. Risk of pulmonary complication was assessed by binary logistic regression analysis.ResultsA total of 599 patients underwent lobectomy by robotic (n = 287), or by open (n = 312) approach, including 189 high-risk patients. Robotic lobectomy patients had a lower rate of prolonged air leak (6% vs. 10%, p = 0.047), less atelectasis requiring bronchoscopy (6% vs. 16%, p = 0.02), pneumonia (3% vs. 8%, p = 0.01), and shorter length of stay (4 vs. 6 days, p = 0.001). Overall pulmonary complication rate was significantly lower after robotic lobectomy in high-risk patients (28% vs. 45%, p = 0.02), less in intermediate or low risk patients. No significant difference was seen relative to major complication rate (12% vs. 17%, p = 0.09). After multivariate analysis, when adjusting for age, gender, smoking history, FEV1, DLCO, cardiopulmonary comorbidities, and prior chest surgery, the robotic approach remained independently associated with decreased pulmonary complications (odds ratio 0.54, 95% confidence interval [0.34–0.85], p = 0.008).ConclusionsRobotic lobectomy has the potential to decrease the risk of postoperative pulmonary complication as compared with traditional open thoracotomy. In particular, patients with limited pulmonary function derive the most benefit from a robotic approach.

PCV33 - The Hospital Burden Of Amputation In Patients With Peripheral Artery Disease

This study uses data from hospitals across the United States to estimate the economic burden when treating patients with advanced Peripheral Arterial Disease (PAD) with either revascularization or amputation. Data was derived from the MedAssets health system database of more than 400 hospitals across 42 states for the years 2010-2014. To be eligible for inclusion, inpatient hospitalizations required a primary diagnosis of PAD, a record of an intervention (revascularization or major/minor amputation exclusively) and expected payment information. Multivariable models were fitted for adverse events, length of stay (LOS), and expected payment per day; comparing the different interventions with adjustments for baseline patient characteristics, comorbid conditions and hospital characteristics. Of the over 17 million inpatient hospitalizations in the database, 62,883 (0.4%) have a primary diagnosis of PAD, with 48,072 (76.4%) having a record of the following intervention: revascularization alone 35,220 (73.3%), major amputation alone 6,852 (14.3%), minor amputation alone 2,103 (4.4%), and 3,897 (8.1%) having more than one procedure (excluded from multivariable analysis). Multivariable models of adverse events show patients with major amputation are at higher risk of pulmonary complications (OR 1.50 [1.25, 1.80]; P≤0.0001) and sepsis/infections (OR 2.65 [2.06, 3.41]; P≤0.0001) when compared to patients with revascularization. Multivariable models also show patients with major (10.0 vs 6.7 days; P≤0.0001) and minor amputation (8.2 vs 6.7 days; P≤0.0001) have longer stays. This finding contributes to less expected payment per day for patients with major amputation ($2,878 vs $4,592; P≤0.0001) and minor amputation ($2,797 vs $4,592; P≤0.0001) as well. PAD affects a significant number of inpatient admissions with a substantial hospital burden due to the complications and long lengths of stays typically associated with leg amputation. Hospital limb salvage programs that include revascularization procedures/algorithms may reduce this burden while providing cost savings to the hospital.

What are the optimum components in a care bundle aimed at reducing post-operative pulmonary complications in high-risk patients?

BackgroundPost-operative pulmonary complications (POPC) are common, predictable and associated with increased morbidity and mortality, independent of pre-operative risk. Interventions to reduce the incidence of POPC have been studied individually, but the use of a care bundle has not been widely investigated. The purpose of our work was to use Delphi consensus methodology and an independently chosen expert panel to formulate a care bundle for patients identified as being at high of POPC, as preparation towards an evaluation of its effectiveness at reducing POPC.MethodsWe performed a survey of members of the ESICM POIC section to inform a Delphi consensus and to share their opinions on a care bundle to reduce POPC, the POPC-CB. We formed a team of 36 experts to participate in and complete an email-based Delphi consensus over three rounds, leading to the formulation of the POPC-CB.ResultsThe survey had 362 respondents and informed the design of the Delphi consensus. The Delphi consensus resulted in a proposed POPC-CB that incorporates components before surgery-supervised exercise programmes and inspiratory muscle training, during surgery, low tidal volume ventilation with individualised PEEP (positive end-expiratory pressure), use of routine monitoring to avoid hyperoxia and efforts made to limit neuromuscular blockade, and post-operatively, deep breathing exercises and elevation of the head of the bed.ConclusionA care bundle has been suggested for evaluation in surgical patients at high risk of POPC. Evaluation of feasibility of both implementation and effectiveness is now indicated.

Perioperative lung protection strategies for patients with high risk of postoperative pulmonary complications

Background Postoperative pulmonary complications (PPCs) is a major risk in the whole perioperative period. It is closely related to the patient's own factors, anesthesia and operation process. Using the perioperative lung protective strategies can effectively improve the postoperative pulmonary oxygenation and better prognosis in patients. Objective To distinguish patients with high risk of PPCs before operation and review recent advances in perioperative lung protection strategies. Content Currently, clinical small tidal volume ventilation, positive end expiratory pressure (PEEP), recruitment maneuver(RM) strategy are widely applied in the protection of lung function. The effect of acu-point stimulation and permissive hypercapnia(PHC) on lung protection has been continued to study. The exploration for different patients using the appropriate clinical lung protective strategies has been a continuously research question. Trend Lung protection strategy should be used more in patients with high risk of pulmonary complications during perioperative period. Key words: Postoperative pulmonary complications; Perioperative; Lung protection; Small tidal volume; Positive end expiratory pressure; Recruitment maneuver strategy; Acupoint stimulation; Permissive hypercapnia

Prophylactic penehyclidine inhalation for prevention of postoperative pulmonary complications in high-risk patients: study protocol of a randomized controlled trial

BackgroundPostoperative pulmonary complications (PPCs) are major causes of morbidity, mortality, and prolonged hospital stay in patients after surgery. Using effective strategies to prevent its occurrence is essential to improve outcome. However, despite various efforts, the incidence of PPCs remains elevated in high-risk patients. Anticholinergic inhalation is used to reduce high airway resistance and improve pulmonary function; it may be helpful to decrease the risk of PPCs. Penehyclidine is a long-acting anticholinergic agent which selectively blocks M1 and M3 receptors. We hypothesize that, in high-risk patients, prophylactic penehyclidine inhalation may decrease the incidence of PPCs.MethodsThis is a randomized, double-blind, placebo-controlled trial with two parallel arms. A total of 864 patients at high risk of PPCs will be enrolled and randomized to receive prophylactic inhalation of either penehyclidine or placebo (water for injection). Study drug inhalation will be administered from the night (7 pm) before surgery until the second day after surgery, in an interval of every 12 hours. The primary outcome is the incidence of PPCs within 30 days after surgery. Secondary outcomes include the time to onset of PPCs (from end of surgery to first diagnosis of PPCs), the number of PPCs (indicates the number of diagnosed individual PPCs), the incidence of postoperative extrapulmonary complications, the length of stay in hospital after surgery, and the 30-day all-cause mortality.DiscussionResults of the present study will provide evidence to guide clinical practice in using prophylactic inhalation of an anticholinergic to prevent PPCs in high-risk patients.Trial registrationThe study was registered prospectively in Chinese Clinical Trial Registry (www.chictr.org.cn, ChiCTR-IPC-15006603) on 14 May 2015 and retrospectively in ClinicalTrials.gov (NCT02644876) on 30 December 2015.

Evaluation of Pulmonary Complications in Robotic-Assisted Gynecologic Surgery

Study ObjectiveTo conduct a study to assess the incidence of pulmonary complications associated with robotic-assisted surgeries in women with various gynecologic conditions. DesignRetrospective study. SettingTertiary care center. PatientsThere were 296 patients included in this study. Patient characteristics and comorbidities were noted. Surgical characteristics and respiratory parameters were recorded for all patients. Intraoperative complications and postoperative complications were noted for up to 30 days after surgery. Patients were followed for a median of 231 days in an effort to detect any long-term complications. The primary outcome was postoperative pulmonary complications, and the secondary outcome measure was all complications. InterventionsNone. Measurements and Main ResultsThe study was composed of 296 patients. Only 5 patients (2%) experienced a pulmonary complication. Overall, 38 patients (13%) experienced complications, including both major and minor complications. Average airway pressure and maximum airway pressure were both associated with a significantly higher risk of pulmonary complications (p = .02 and p = .008, respectively). Age, body mass index, tidal volume, respiratory rate, estimated blood loss, and length of procedure were all found to not be statistically significant in patients who experienced a pulmonary complication versus patients who did not experience one. ConclusionRobotic gynecologic surgery is safe and tolerated well by most patients. This study supports that there is a low rate of pulmonary complications in those who undergo robotic-assisted surgery for gynecologic indications, as well as a low overall complication rate.

Comparative Study on the Immediate Effects of Deep Breathing Exercises with PEP Device Verses Incentive Spirometry with EPAP on Preventing Pulmonary Complications Following CABG

Background: The initial days following CABG is a crucial period as it imposes a high risk of pulmonary complications and morbidity. In an effort to increase lung volume following surgery, various deep breathing manoeuvres have been implemented as a main component in the care of the postoperative patient. The rationale for Deep Breathing Exercises with PEP and Incentive Spirometry is that they prevent postoperative complications (PPC), thereby improving cardiorespiratory function. Various studies to substantiate the effectiveness of Deep Breathing Exercises with PEP devices and Incentive Spirometry on preventing pulmonary complications following CABG surgery have been done. The need to study immediate effects of both techniques is yet to be studied.Methods: 30 subjects undergoing CABG and fulfilling the inclusion criteria were selected for the study. They were randomly assigned into two groups: Group A and Group B having 15 subjects each. Group A received Deep Breathing Exercises with a positive expiratory pressure (PEP) device and Group B received Incentive Spirometry with Expiratory Positive Airway Pressure (EPAP).Results: The value of F = 45.729 to find the difference in PEFR in Group B is significant (p=0.00). It has been found that PEFR increased significantly after application of incentive spirometer with EPAP to the patients after 4th day. On Day 4, t = 3.750, which is significant (p = 0.001) implying that deep breathing exercise with PEP device is more effective to increase PEFR as compared to incentive spirometer with EPAP.Conclusion: PEP device is more effective than Incentive Spirometry with EPAP in preventing postoperative complications following CABG surgery. It can be inferred that deep breathing exercise with PEP device is more effective than incentive spirometer with EPAP in improving SPO2 and PEFR in both the groups.

Obesity and perioperative pulmonary complications in robotic gynecologic surgery

Robotic gynecological surgery is feasible in obese patients, but there remain concerns about the safety of this approach because the positioning required for pelvic surgery can exacerbate obesity-related changes in respiratory physiology. The objective of our study was to evaluate pulmonary and all-cause complication rates in obese women undergoing robotic gynecological surgery and to assess variables that may be associated with complications. A retrospective chart review was performed on obese patients (body mass index of ≥30 kg/m(2)) who underwent robotic gynecological surgery at 2 academic institutions between 2006 and 2012. The primary outcome was pulmonary complications and the secondary outcome was all-cause complications. Univariate and multivariate logistic regression analyses were used to determine the associations between patient baseline variables, operative variables, ventilator parameters, and complications. Of 1032 patients, 146 patients (14%) had any complication, whereas only 33 patients (3%) had a pulmonary complication. Median body mass index was 37 kg/m(2). Only age was significantly associated with a higher risk of pulmonary complications (P = .01). Older age, higher estimated blood loss, and longer case length were associated with a higher rate of all-cause complications (P = .0001, P < .0001, and P = .004, respectively). No other covariates were strongly associated with complications. The vast majority of obese patients can successfully tolerate robotic gynecological surgery and have overall low complications rates and even lower rates of pulmonary complications. The degree of obesity was not predictive of successful robotic surgery and subsequent complications.

Worse Prognosis for Stage IA Lung Cancer Patients with Smoking History and More Severe Chronic Obstructive Pulmonary Disease.

This retrospective study examined whether the severity of chronic obstructive lung disease (COPD) affects surgical outcomes. The subjects were 243 consecutive patients who underwent lobectomy for clinical stage IA lung cancer from 1999 to 2008 in our hospital. The Global Initiative for Chronic Obstructive Lung Disease (GOLD) grading system was used to classify the severity of COPD in smokers. Among the 149 smokers, 62 were diagnosed with COPD (25 as GOLD 1, 33 as GOLD 2, and 4 as GOLD 3). In univariate analysis, postoperative pulmonary complications were associated with male sex and more severe COPD. The frequencies were 17.1% in non-COPD, 24.0% in GOLD 1-COPD, and 46.0% in GOLD 2/3-COPD smokers (p = 0.0006). In univariate analysis, older age, smoking history, higher smoking pack-years and more severe COPD were associated with poor relapse-free survival. Relapse-free survival at five years was 80.7%, 66.9%, and 61.3% in non-COPD, GOLD 1-COPD, and GOLD 2/3-COPD smokers, respectively (p = 0.0005). Multivariate analyses showed that only GOLD 2/3-COPD was associated with postoperative pulmonary complications and relapse-free survival. Inhaled bronchodilators were prescribed preoperatively to 24.3% of the GOLD 2/3-COPD group. Smokers with GOLD 2/3-COPD are at high risk for pulmonary complications and have an unfavorable long-term prognosis.

Benefits of lung-protective ventilation: looking beyond the ICU.

AbstractNo abstract.

Evaluation of Spirometric Testing as a Routine Preoperative Assessment in Patients Undergoing Bariatric Surgery

The value of spirometry as a routine preoperative test for bariatric surgery is debatable. The aim of this study was to assess the relationship between spirometry results and the frequency of postoperative pulmonary complications in 602 obese patients. Clinical files of patients undergoing bariatric surgery between 2004 and 2013 were reviewed. Demography, risk factors, respiratory symptoms, and spirometry results (forced expiratory volume in the first second (FEV1), forced vital capacity (FVC), FEV1/FVC) were recorded, and their relationship with postoperative pulmonary complications was evaluated. There were 256 males and 346 females with a mean age of 40.2 ± 11.6 years and a mean BMI of 42.1 ± 6.4 kg/m2. History of smoking was found in 408 patients (68 %). Preoperative respiratory symptoms were present in 328 (54.5 %). Most frequent symptoms were snoring (288), dyspnea (119), bronchospasm [6], and chronic productive cough [6]. In 153 patients, history of respiratory disease was documented. The obstructive sleep apnea syndrome (OSAS) was present in 124, 20 requiring continuous positive airway pressure (CPAP). Asthma was present in 27 and chronic obstructive pulmonary disease (COPD) in 2. Variables associated to a higher risk of pulmonary complications were OSAS (OR 2.3), an abnormal spirometry (OR 2.6), male gender (OR 1.9), and preoperative respiratory symptoms (OR 1.9). Using multivariate logistic regression, an abnormal spirometry was a significant predictor of postoperative pulmonary complications in patients with respiratory symptoms and/or OSAS. However, it lost prognostic significance when both conditions were subtracted. In obese patients undergoing bariatric surgery, abnormal preoperative spirometry predicts postoperative respiratory complications only in patients with OSAS.

Correlation between intra-abdominal pressure and pulmonary volumes after superior and inferior abdominal surgery

OBJECTIVE:Patients undergoing abdominal surgery are at risk for pulmonary complications. The principal cause of postoperative pulmonary complications is a significant reduction in pulmonary volumes (FEV1 and FVC) to approximately 65-70% of the predicted value. Another frequent occurrence after abdominal surgery is increased intra-abdominal pressure. The aim of this study was to correlate changes in pulmonary volumes with the values of intra-abdominal pressure after abdominal surgery, according to the surgical incision in the abdomen (superior or inferior).METHODS:We prospectively evaluated 60 patients who underwent elective open abdominal surgery with a surgical time greater than 240 minutes. Patients were evaluated before surgery and on the 3rd postoperative day. Spirometry was assessed by maximal respiratory maneuvers and flow-volume curves. Intra-abdominal pressure was measured in the postoperative period using the bladder technique.RESULTS:The mean age of the patients was 56±13 years, and 41.6% 25 were female; 50 patients (83.3%) had malignant disease. The patients were divided into two groups according to the surgical incision (superior or inferior). The lung volumes in the preoperative period showed no abnormalities. After surgery, there was a significant reduction in both FEV1 (1.6±0.6 L) and FVC (2.0±0.7 L) with maintenance of FEV1/FVC of 0.8±0.2 in both groups. The maximum intra-abdominal pressure values were similar (p = 0.59) for the two groups. There was no association between pulmonary volumes and intra-abdominal pressure measured in any of the groups analyzed.CONCLUSIONS:Our results show that superior and inferior abdominal surgery determines hypoventilation, unrelated to increased intra-abdominal pressure. Patients at high risk of pulmonary complications should receive respiratory care even if undergoing inferior abdominal surgery.

Pilot study for home monitoring of cough capacity in amyotrophic lateral sclerosis: A case series

BackgroundCough capacity derangement is associated with a high risk of pulmonary complications in amyotrophic lateral sclerosis patients when cough assistance is not routinely performed at home. The primary aim of this study was to evaluate the feasibility of a long-term home based daily self-monitoring cough capacity. MethodsEighteen subjects were enrolled in a 9-month study at home. Changes in peak cough expiratory flow, oxygen saturation, respiratory discomfort and incidence of respiratory deterioration events were evaluated. In subjects presenting respiratory deterioration events, decline in the abovementioned respiratory variables was evaluated (#NCT00613899). ResultsDuring an average follow-up of 125±102 days, a total of 1175 measures were performed on 12 subjects. Mean compliance to proposed evaluations was 37±32% which worsened over time. Peak cough expiratory flow decreased by 15.08±32.43L/min monthly. Five subjects reported 6 episodes of respiratory deterioration events, after a mean period of 136±108 days. They had poor respiratory function and more years of disease. There was no difference in peak cough expiratory flow and its decline whether subjects presented respiratory deterioration events or not. In 4 subjects the respiratory discomfort score significantly worsened after respiratory deterioration events from 3.0±1.41 to 4.25±1.71. ConclusionDaily self-monitoring of peak cough expiratory flow, oxygen saturation and respiratory discomfort seems difficult to obtain because of poor adherence to measures; this protocol does not seem to add anything to current practice of advising on clinical derangements. Confirmatory larger studies are necessary.

Acute respiratory distress syndrome in patients with malignancies.

Little attention has been given to ARDS in cancer patients, despite their high risk for pulmonary complications. We sought to describe outcomes in cancer patients with ARDS meeting the Berlin definition. Data from a cohort of patients admitted to 14 ICUs between 1990 and 2011 were used for a multivariable analysis of risk factors for hospital mortality. Of 1,004 included patients (86 % with hematological malignancies and 14 % with solid tumors), 444 (44.2 %) had neutropenia. Admission SOFA score was 12 (10-13). Etiological categories were primary infection-related ARDS (n = 662, 65.9 %; 385 bacterial infections, 213 invasive aspergillosis, 64 Pneumocystis pneumonia); extrapulmonary septic shock-related ARDS (n = 225, 22.4 %; 33 % candidemia); noninfectious ARDS (n = 76, 7.6 %); and undetermined cause (n = 41, 4.1 %). Of 387 (38.6 %) patients given noninvasive ventilation (NIV), 276 (71 %) subsequently required endotracheal ventilation. Hospital mortality was 64 % overall. According to the Berlin definition, 252 (25.1 %) patients had mild, 426 (42.4 %) moderate and 326 (32.5 %) severe ARDS; mortality was 59, 63 and 68.5 %, respectively (p = 0.06). Mortality dropped from 89 % in 1990-1995 to 52 % in 2006-2011 (p < 0.0001). Solid tumors, primary ARDS, and later admission period were associated with lower mortality. Risk factors for higher mortality were allogeneic bone-marrow transplantation, modified SOFA, NIV failure, severe ARDS, and invasive fungal infection. In cancer patients, 90 % of ARDS cases are infection-related, including one-third due to invasive fungal infections. Mortality has decreased over time. NIV failure is associated with increased mortality. The high mortality associated with invasive fungal infections warrants specific studies of early treatment strategies.

Pilot study for home monitoring of cough capacity in amyotrophic lateral sclerosis: A case series

BackgroundCough capacity derangement is associated with a high risk of pulmonary complications in amyotrophic lateral sclerosis patients when cough assistance is not routinely performed at home. The primary aim of this study was to evaluate the feasibility of a long‐term home based daily self‐monitoring cough capacity. MethodsEighteen subjects were enrolled in a 9‐month study at home. Changes in peak cough expiratory flow, oxygen saturation, respiratory discomfort and incidence of respiratory deterioration events were evaluated. In subjects presenting respiratory deterioration events, decline in the abovementioned respiratory variables was evaluated (#NCT00613899). ResultsDuring an average follow‐up of 125±102 days, a total of 1175 measures were performed on 12 subjects. Mean compliance to proposed evaluations was 37±32% which worsened over time. Peak cough expiratory flow decreased by 15.08±32.43L/min monthly. Five subjects reported 6 episodes of respiratory deterioration events, after a mean period of 136±108 days. They had poor respiratory function and more years of disease. There was no difference in peak cough expiratory flow and its decline whether subjects presented respiratory deterioration events or not. In 4 subjects the respiratory discomfort score significantly worsened after respiratory deterioration events from 3.0±1.41 to 4.25±1.71. ConclusionDaily self‐monitoring of peak cough expiratory flow, oxygen saturation and respiratory discomfort seems difficult to obtain because of poor adherence to measures; this protocol does not seem to add anything to current practice of advising on clinical derangements. Confirmatory larger studies are necessary.