Incidence Of Postoperative Pulmonary Complications In Patients Research Articles

Postoperative pulmonary complications in patients with chronic obstructive pulmonary disease undergoing primary laparoscopic bariatric surgery: an MBSAQIP analysis

BackgroundRecent research has shown beneficial effects of bariatric surgery (BaS) on the risk of developing acute exacerbations of chronic obstructive pulmonary disease (COPD). However, this patient population may be at increased risk of complications, especially postoperative pulmonary complications (PPC). ObjectivesTo analyze the incidence of PPC in patients with COPD undergoing BaS. SettingAcademic Hospital, United States. MethodsWe performed a retrospective analysis of the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database for patients aged ≥18 years undergoing laparoscopic sleeve gastrectomy and Roux-en-Y gastric bypass during 2015–2019. The primary outcome of the study was any PPC, defined as a composite variable including postoperative pneumonia, mechanical ventilation >48 hours and unplanned endotracheal intubation. A univariate analysis was performed to compare patients with and without COPD, and a multivariate logistic regression was performed to adjust for confounders. A subgroup analysis was performed to compare endpoints in patients with COPD with or without home oxygen requirements. ResultsA total of 752,722 patients were included in our analysis (laparoscopic sleeve gastrectomy = 73.2%, Roux-en-Y gastric bypass = 26.8%). PPC occurred in 2390 patients, 0.3% without COPD versus 1.3% with COPD (P < .001). Multivariable analysis confirmed that COPD independently increases the risk of PPC (OR = 1.7, CI = 1.4–2.1). Subgroup analysis showed that patients who are oxygen dependent had a much higher risk for PPC (2.4% versus 1.1%, P < .001). ConclusionPPC are higher among patients with obesity and concomitant COPD. Oxygen dependency confers an even higher complication rate. The risk and benefits of BaS in this population must be carefully addressed.

The impact of goal-directed fluid therapy on postoperative pulmonary complications in patients undergoing thoracic surgery: a systematic review and meta-analysis.

Pulmonary complications after thoracic surgery are common and associated with significant morbidity and high cost of care. Goal-directed fluid therapy (GDFT) could reduce the incidence of postoperative pulmonary complications (PPCs) and facilitate recovery in patients undergoing major abdominal surgery. However, whether GDFT could reduce the incidence of PPCs in patients undergoing thoracic surgery was unclear. The present meta-analysis was designed to assess the impact of Goal-directed Fluid Therapy on PPCs in patients undergoing thoracic surgery. Randomized controlled trials (RCTs) comparing GDFT with other conventional fluid management strategies in adult patients undergoing thoracic surgery were identified. Databases searched included PubMed, Web of Science, Embase, and Cochrane Library databases. Review Manager 5.4 (The Cochrane Collaboration, Oxford, UK) software was used for statistical analysis. Heterogeneity was analyzed using I2 statistics, and a standardized mean difference with 95% CI and P value was used to calculate the treatment effect for outcome variables. The primary study outcomes were the incidence of PPCs. Secondary outcomes were the total volume infused, the length of hospitalization, the incidence of cardiac complications, and the incidence of renal dysfunction. Subgroup analysis was planned to verify the definite role of GDFT. A total of 6 RCTs consisting of 680 patients were included in this meta-analysis, which revealed that GDFT did not reduce the incidence of PPCs in patients undergoing thoracic surgery (RR, 0.57; 95% CI 0.29-1.14). However, GDFT decreased the total intra-operative fluid input (MD, - 244.40ml; 95% CI - 397.06 to - 91.74). There was no statistical difference in the duration of hospitalization (MD; - 1.31, 95% CI - 3.00 to 0.38), incidence of renal dysfunction (RR, 0.62; 95% CI 0.29-1.35), and incidence of cardiac complications (RR, 0.62; 95% CI 0.27-1.40). The results of this meta-analysis indicate that GDFT did not reduce the postoperative incidence of pulmonary complications in individuals undergoing thoracic surgery. However, considering the small number of contributing studies, these results should be interpreted with caution.

Total intravenous anesthesia decreases hospital stay but not incidence of postoperative pulmonary complications after lung resection surgery: a propensity score matching study

BackgroundThere is no consensus regarding the superiority of volatile or total intravenous anesthesia (TIVA) in reducing the incidence of postoperative pulmonary complications (PPCs) after lung resection surgery (LRS). Thus, the aim of this study was to investigate the different anesthetic regimens and the incidence of PPCs in patients who underwent LRS. We hypothesized that TIVA is associated with a lower incidence of PPCs than volatile anesthesia.MethodsThis was a retrospective cohort study of patients who underwent LRS at Taipei Veterans General Hospital between January 2016 and December 2020. The patients’ charts were reviewed and data on patient characteristics, perioperative features, and postoperative outcomes were extracted and analyzed. The patients were categorized into TIVA or volatile anesthesia groups and their clinical data were compared. Propensity score matching was performed to reduce potential selection bias. The primary outcome was the incidence of PPCs, whereas the secondary outcomes were the incidences of other postoperative events, such as length of hospital stay (LOS) and postoperative nausea and vomiting (PONV).ResultsA total of 392 patients each were included in the TIVA and volatile anesthesia groups. There was no statistically significant difference in the incidence of PPCs between the volatile anesthesia and TIVA groups. The TIVA group had a shorter LOS (p < 0.001) and a lower incidence of PONV than the volatile anesthesia group (4.6% in the TIVA group vs. 8.2% in the volatile anesthesia group; p = 0.041). However, there were no significant differences in reintubation, 30-day readmission, and re-operation rates between the two groups.ConclusionsThere was no significant difference between the incidence of PPCs in patients who underwent LRS under TIVA and that in patients who underwent LRS under volatile anesthesia. However, TIVA had shorter LOS and lower incidence of PONV which may be a better choice for maintenance of anesthesia in patients undergoing LRS.

PCV-VG combined individualized PEEP determination in one-lung ventilated patients with PEEP step change direction: A randomized controlled trial.

The efficacy of pressure-controlled volume-guaranteed ventilation (PCV-VG) combined with a gradient-directional change in positive end-expiratory pressure (PEEP) during one-lung ventilation (OLV) in patients who underwent thoracoscopic surgery was investigated. Ninety patients were randomly divided into the PC (PCV-VG + 5 cm H2 O fixed PEEP), PI (PCV-VG + incremental PEEP titration), and PD (PCV-VG + decremental PEEP titration) groups. Hemodynamic (heart rate [HR] and mean arterial pressure [MAP]), respiratory mechanics (Ppeak , Pmean, and Cdyn), and arterial blood gas (pH, PaCO2 , PaO2 , and PaO2 /FiO2 ) indices were evaluated at T1 (10 min of two-lung ventilation [TLV]), T2 (10 min of OLV), and T3 (10 min of recovery, TLV). Enzyme-linked immunosorbent assay was performed to detect neutrophil elastase (NE), clara cell secretory protein (CC16), and interleukin-8 (IL-8) levels at T1 and T3. At T2 and T3 , Ppeak was lower in the PI and PD groups than in the PC group, while Pmean and Cdyn were higher than in the PC group. Ppeak in the PD group was lower than that in the PI group; however, Pmean was higher at T2 and T3 (P < 0.05). At T2 , PaO2 and PaO2 /FiO2 were higher, but PaO2 /FiO2 and VD /VT were lower in the PD and PI groups than in the PC group (P < 0.05). NE, CC16, IL-6, and IL-8 levels were elevated in all three groups at T3 , but the PI and PD groups had lower levels than the PC group (P < 0.05). The incidences of postoperative pulmonary complications (PPCs) and surgical intensive care unit hospitalizations in the PD and PI groups were much lower. Gradient-directed altered PEEP titration could improve respiratory mechanics, arterial blood gases, and inflammatory responses and reduce the incidence of PPCs in patients undergoing thoracoscopic surgery.

Comparison effects of two muscle relaxant strategies on postoperative pulmonary complications in transapical transcatheter aortic valve implantation: a propensity score-matched analysis

BackgroundPrior studies have reported conflicting results on the effect of sugammadex on postoperative pulmonary complications (PPCs) and research on this topic in transapical-transcatheter aortic valve implantation (TA-TAVI) was sparse. The current study aimed to investigate whether there were differences in the incidence of PPCs between two muscle relaxant strategies (rocuronium/sugammadex vs. cisatracurium/neostigmine) in patients undergoing TA-TAVI.MethodsThis retrospective observational study enrolled 245 adult patients underwent TA-TAVI between October 2018 and January 2021. The patients were grouped according to the type of muscle relaxant strategies (115 with rocuronium/sugammadex in the R/S group and 130 with cisatracurium/neostigmine in the C/N group, respectively). Pre- and intraoperative variables were managed by propensity score match (PSM) at a 1:2 ratio. PPCs (i.e., respiratory infection, pleural effusion, pneumothorax, atelectasis, respiratory failure, bronchospasm and aspiration pneumonitis) were evaluated from the radiological and laboratory findings.ResultsAfter PSM, 91 patients in the R/S group were selected and matched to 112 patients in the C/N group. Patients in the R/S group showed lower PPCs rate (45.1% vs. 61.6%, p = 0.019) compared to the C/N group. In addition, the R/S group showed significant shorter extubation time (7.2 ± 6.2 vs. 10.3 ± 8.2 min, p = 0.003) and length of hospital stay (6.9 ± 3.3 vs. 8.0 ± 4.0 days, p = 0.034).ConclusionThe rocuronium/sugammadex muscle relaxant strategy decreases the incidence of PPCs in patients undergoing TA-TAVI when compared to cisatracurium/neostigmine strategy.Trial registration ChiCTR, ChiCTR2100044269. Registered March 14, 2021-Prospectively registered, http://www.Chictr.org.cn.

Does Neoadjuvant Radiation Therapy Contribute to the Incidence of Pulmonary Complications Following Esophagectomy for Malignant Neoplasm?

Post-operative pulmonary complications (POPC) are common in patients undergoing esophagectomy and neoadjuvant radiotherapy may exacerbate POPC. This study assessed whether neoadjuvant radiation increases the incidence of POPC in patients undergoing esophagectomy for malignancy. The American College of Surgeons-National Surgical Quality Improvement Program database files from 2016 to 2018 were queried for patients undergoing esophagectomy for malignancy. Inverse probability treatment weighting (IPTW) was used to create balanced cohorts in which the control group received neoadjuvant chemotherapy (nCT) and the treatment cohort received neoadjuvant chemoradiotherapy (nCRT). A subset analysis was performed on patients with pre-existing pulmonary disease (PEPD). Primary outcomes were POPC and 30-day mortality. The all-patient analysis did not demonstrate a consistent association between neoadjuvant radiation and POPC. However, in patients with PEPD, POPC occurred more often in the nCRT cohort. Comparing nCRT to nCT and after IPTW adjustment for confounders, there was higher odds of pneumonia (aOR = 3.0, P = .002), unplanned intubation (aOR = 2.0, P = .03), and extended mechanical ventilation (aOR = 3.6, P = .002). In esophageal cancer patients with PEPD that undergo nCRT vs nCT prior to esophagectomy, the greater risk of POPCs must be weighed against the potential for improved oncologic outcomes.

Effect of Driving Pressure-Oriented Ventilation on Patients Undergoing One-Lung Ventilation During Thoracic Surgery: A Systematic Review and Meta-Analysis.

BackgroundHypoxemia and fluctuations in respiratory mechanics parameters are common during one-lung ventilation (OLV) in thoracic surgery. Additionally, the incidence of postoperative pulmonary complications (PPCS) in thoracic surgery is higher than that in other surgeries. Previous studies have demonstrated that driving pressure-oriented ventilation can reduce both mortality in patients with acute respiratory distress syndrome (ARDS) and the incidence of PPCS in patients undergoing general anesthesia. Our aim was to determine whether driving pressure-oriented ventilation improves intraoperative physiology and outcomes in patients undergoing thoracic surgery.MethodsWe searched MEDLINE via PubMed, Embase, Cochrane, Web of Science, and ClinicalTrials.gov and performed a meta-analysis to compare the effects of driving pressure-oriented ventilation with other ventilation strategies on patients undergoing OLV. The primary outcome was the PaO2/FiO2 ratio (P/F ratio) during OLV. The secondary outcomes were the incidence of PPCS during follow-up, compliance of the respiratory system during OLV, and mean arterial pressure during OLV.ResultsThis review included seven studies, with a total of 640 patients. The PaO2/FiO2 ratio was higher during OLV in the driving pressure-oriented ventilation group (mean difference [MD]: 44.96; 95% confidence interval [CI], 24.22–65.70.32; I2: 58%; P < 0.0001). The incidence of PPCS was lower (OR: 0.58; 95% CI, 0.34–0.99; I2: 0%; P = 0.04) and the compliance of the respiratory system was higher (MD: 6.15; 95% CI, 3.97–8.32; I2: 57%; P < 0.00001) in the driving pressure-oriented group during OLV. We did not find a significant difference in the mean arterial pressure between the two groups.ConclusionDriving pressure-oriented ventilation during OLV in patients undergoing thoracic surgery was associated with better perioperative oxygenation, fewer PPCS, and improved compliance of the respiratory system.Systematic Review RegistrationPROSPERO, identifier: CRD42021297063.

Lung-Protective Effects of Lidocaine Infusion on Patients with Intermediate/ High Risk of Postoperative Pulmonary Complications: A Double-Blind Randomized Controlled Trial.

PurposeThe non-local anesthetic effects of lidocaine have been widely reported, but there are still few studies on lung protection. We aimed to test the hypothesis that intravenous infusion of lidocaine exerts lung-protective effects in patients at intermediate/high risk of postoperative pulmonary complications (PPCs) on major abdominal surgery.Patients and MethodsPatients ≥18 years, ASA II or III, with intermediate/high risk for PPCs, were included. Patients were randomly assigned into group lidocaine (received a bolus of lidocaine 1.5 mg kg−1 before the induction of anesthesia, then followed by a continuous infusion of 2.0 mg kg−1 h−1 intraoperatively until the end of surgery) or group control (received 0.9% saline in place of lidocaine at the same time points). The incidence of PPCs within 7 postoperative days was measured, defined as a collapsed composite outcome of atelectasis, respiratory infection, pleural effusion, pneumonia, respiratory failure or acute respiratory distress syndrome (ARDS) developed within 7 postoperative days, or hospital discharge, whichever came sooner.ResultsOf 200 subjects screened, 195 patients were finally analyzed. Overall, 35.9% (70/195) patients sustained PPCs, which occurred fewer in group lidocaine 25.8% (25/97), compared with group control 45.9% (45/98) (relative risk: 0.56, 95% CI: 0.38 to 0.84; absolute risk reduction: −20.1%; P = 0.003). Considering single PPCs episode, the most common PPC in both groups was atelectasis. The atelectasis incidence was 11.3% (11/97) in group lidocaine, much lower than that in group control 29.6% (29/98) (relative risk: 0.38, 95% CI: 0.20 to 0.72; absolute risk reduction: −18.3%, P = 0.002). However, the incidences of any other PPCs episodes were similar between the two groups.ConclusionIntraoperative intravenous infusion lidocaine could decrease the incidence of PPCs in patients at intermediate/high risk of postoperative pulmonary complications undergoing major abdominal surgery.

Effect of ventilation strategy during cardiopulmonary bypass on postoperative pulmonary complications after cardiac surgery: a randomized clinical trial

BackgroundTo determine whether maintaining ventilation during cardiopulmonary bypass (CPB) with a different fraction of inspired oxygen (FiO2) had an impact on the occurrence of postoperative pulmonary complications (PPCs).MethodsA total of 413 adult patients undergoing elective cardiac surgery with CPB were randomly assigned into three groups: 138 in the NoV group (received no mechanical ventilation during CPB), 138 in the LOV group (received a tidal volume (VT) of 3–4 ml/kg of ideal body weight with the respiratory rate of 10–12 bpm, and the positive end-expiratory pressure of 5–8 cmH2O during CPB; the FiO2 was 30%), and 137 in the HOV group (received the same ventilation parameters settings as the LOV group while the FiO2 was 80%).ResultsThe primary outcomes were the incidence and severity of PPCs during hospitalization. The composite incidence of PPCs did not significantly differ between the NoV (63%), LOV (49%) and HOV (57%) groups (P = 0.069). And there was also no difference regarding the incidence of PPCs between the non-ventilation (NoV) and ventilation (the combination of LOV and HOV) groups. The LOV group was observed a lower proportion of moderate and severe pulmonary complications (grade ≥ 3) than the NoV group (23.1% vs. 44.2%, P = 0.001).ConclusionMaintaining ventilation during CPB did not reduce the incidence of PPCs in patients undergoing cardiac surgery.Trial registration: Chinese Clinical Trial Registry ChiCTR1800015261. Prospectively registered 19 March 2018. http://www.chictr.org.cn/showproj.aspx?proj=25982

Incidence and Risk Factors of Pulmonary Complications after Robot-Assisted Laparoscopic Prostatectomy: A Retrospective Observational Analysis of 2208 Patients at a Large Single Center.

Robot-assisted laparoscopic prostatectomy (RALP) is a minimally invasive technique for the treatment of prostate cancer. RALP requires the patient to be placed in the steep Trendelenburg position, along with pneumoperitoneum, which may increase the risk of postoperative pulmonary complications (PPCs). This large single-center retrospective study evaluated the incidence and risk factors of PPCs in 2208 patients who underwent RALP between 2014 and 2017. Patients were divided into those with (PPC group) and without (non-PPC group) PPCs. Postoperative outcomes were evaluated, and univariate and multivariate logistic regression analyses were performed to assess risk factors of PPCs. PPCs occurred in 682 patients (30.9%). Risk factors of PPCs included age (odds ratio [OR], 1.023; p = 0.001), body mass index (OR, 1.061; p = 0.001), hypoalbuminemia (OR, 1.653; p = 0.008), and positive end-expiratory pressure (PEEP) application (OR, 0.283; p < 0.001). The incidence of postoperative complications, rate of intensive care unit (ICU) admission, and duration of ICU stay were significantly greater in the PPC group than in the non-PPC group. In conclusion, the incidence of PPCs in patients who underwent RALP under pneumoperitoneum in the steep Trendelenburg position was 30.9%. Factors associated with PPCs included older age, higher body mass index, hypoalbuminemia, and lack of PEEP.

Restrictive Spirometric Pattern and Postoperative Pulmonary Complications Following Non-cardiothoracic Surgery

Despite a substantial population of patients with a restrictive spirometric pattern, few studies have evaluated postoperative pulmonary complications (PPCs) after non-cardiothoracic surgery in these patients. We conducted a retrospective cohort study of 681 adults with a normal or restrictive spirometric pattern who were referred for preoperative evaluation of PPC risk before non-cardiothoracic surgery between March 2014 and January 2015. Overall, 8.7% (59/681) of study participants developed a PPC following non-cardiothoracic surgery. The occurrence of PPCs in patients with a restrictive spirometric pattern was higher than that in those with normal spirometry (12.4% [35/282] vs. 6.0% [24/399], P = 0.003). The occurrence of PPCs increased across the categories of restrictive spirometric pattern severity (6.0% with a normal spirometric pattern vs. 6.5% with a mild restrictive spirometric pattern [60 ≤ forced vital capacity (FVC) < 80% predicted] vs. 21.2% with a moderate-to-severe restrictive spirometric pattern [FVC < 60% predicted], P for trend test < 0.001). The length of hospital stay (P for trend = 0.002) was longer, and all-cause mortality at 30 days (P for trend = 0.008) and 90 days (P for trend = 0.001) was higher across the restrictive spirometric pattern severity. In multivariable-adjusted analyses, a moderate-to-severe restrictive spirometric pattern was associated with a higher risk of PPCs compared with a normal spirometric pattern (adjusted odds ratio 2.64, 95% confidence interval 1.22–5.67). The incidence of PPCs in patients with a restrictive spirometric pattern was higher than that in those with a normal spirometric pattern, especially in patients with a moderate-to-severe restrictive spirometric pattern. Patients with a moderate-to-severe restrictive spirometric pattern should be regarded as high risk for developing PPCs following non-cardiothoracic surgery.

The Effects of an Open-Lung Approach During One-Lung Ventilation on Postoperative Pulmonary Complications and Driving Pressure: A Descriptive, Multicenter National Study

Thoracic surgical procedures are associated with an increased risk of postoperative pulmonary complications (PPCs), which seem to be related directly to intraoperative driving pressure. The authors conducted this study to describe the incidence of PPCs in patients in whom an individualized open-lung approach was applied during one-lung ventilation. This was a prospective, multicenter, national descriptive study. Thoracic surgery patients undergoing one-lung ventilation. Eligible participants were included consecutively from October 1, 2016, to September 30, 2017. A total of 690 patients were included. An individualized open-lung approach that consisted of an alveolar recruitment maneuver followed by a positive end-expiratory pressure adjusted to best respiratory system compliance was performed in all patients. Preoperative and intraoperative data were recorded; the primary outcome was a description of the incidence of PPCs in these patients during the first 7 postoperative days. The patients were mainly male, and half of them had a high risk of PPCs (ARISCAT score exceeding 44). Eleven percent of participants developed a PPC within the first postoperative week. The mean open lung positive end-expiratory pressure was 8 ± 3 cmH2O. When compared with pre-open lung approach values, the open-lung approach significantly decreased the driving pressure (14±4 cmH2O v 11±3 cmH2O; p<0.001) and increased dynamic compliance (30±10 mL/cmH2O v 43 ±15 mL/cmH2O; p <0.001). The low incidence of PPCs in patients who underwent an open-lung approach during one-lung ventilation compared with that reported for other thoracic surgery series and the decrease in the driving pressure in these patients justify an additional randomized controlled trial to compare the open-lung approach with the standard protective strategy of low tidal volume and low positive end-expiratory pressure.

The effect of an intraoperative, lung-protective ventilation strategy in neurosurgical patients undergoing craniotomy: study protocol for a randomized controlled trial

BackgroundVentilator-induced lung injury is a major cause of postoperative pulmonary complications (PPCs) in patients undergoing neurosurgery after general anesthesia. However, there is no study on the effect of a lung-protective ventilation strategy in patients undergoing neurosurgery.MethodsThis is a single-center, randomized, parallel-group controlled trial which will be carried out at Beijing Tiantan Hospital, Capital Medical University. Three hundred and thirty-four patients undergoing intracranial tumor surgery will be randomly allocated to the control group and the protective-ventilation strategy group. In the control group, tidal volume (VT) will be set at 10–12 ml/kg of predicted body weight but PEEP and recruitment maneuvers will not be used. In the protective group, VT will be set at 6–8 ml/kg of predicted body weight, PEEP at 6–8 cmH2O, and a recruitment maneuver will be used intermittently. The primary outcome is pulmonary complications within 7 days postoperatively. Secondary outcomes include intraoperative brain relaxation, the postoperative complications within 30 days and the cost analysis.DiscussionThis study aims to determine if the protective, pulmonary-ventilation strategy decreases the incidence of PPCs in patients undergoing neurosurgical anesthesia. If our results are positive, the study will indicate whether the protective, pulmonary-ventilation strategy is efficiently and safely used in neurosurgical patients undergoing the craniotomy.Trial registrationClinicalTrials.gov, ID: NCT02386683. Registered on 18 October 2014.

Postoperative pulmonary complications, pulmonary and systemic inflammatory responses after lung resection surgery with prolonged one-lung ventilation. Randomized controlled trial comparing intravenous and inhalational anaesthesia

BackgroundRecent studies report the immunomodulatory lung-protective role of halogenated anaesthetics during lung resection surgery (LRS) but have not investigated differences in clinical postoperative pulmonary complications (PPCs). The main goal of the present study was to compare the effect of sevoflurane and propofol on the incidence of PPCs in patients undergoing LRS. The second aim was to compare pulmonary and systemic inflammatory responses to LRS. MethodsOf 180 patients undergoing LRS recruited, data from 174 patients were analysed. Patients were randomized to two groups (propofol or sevoflurane) and were managed otherwise using the same anaesthetic protocol. Bronchoalveolar lavage (BAL) was performed in both lungs before and after one-lung ventilation for analysis of cytokines. Arterial blood was drawn for measurement of the cytokines analysed in the BAL fluid at five time points. Intraoperative haemodynamic and respiratory parameters, PPCs (defined following the ARISCAT study), and mortality during the first month and yr were recorded. ResultsMore PPCs were detected in the propofol group (28.4% vs 14%, OR 2.44 [95% CI, 1.14–5.26]). First-yr mortality was significantly higher in the propofol group (12.5% vs 2.3%, OR 5.37 [95% CI, 1.23–23.54]). Expression of lung and systemic pro-inflammatory cytokines was greater in the propofol group than in the sevoflurane group. Pulmonary and systemic IL-10 release was less in the propofol group. ConclusionsOur results suggest that administration of sevoflurane during LRS reduces the frequency of the PPCs recorded in our study and attenuates the pulmonary and systemic inflammatory response. Clinical trial registrationNCT 02168751; EudraCT 2011-002294-29.

Comparison of Two Preoperative Inspiratory Muscle Training Programs to Prevent Pulmonary Complications in Patients Undergoing Esophagectomy: A Randomized Controlled Pilot Study

Postoperative pulmonary complications (PPCs) are the most commonly reported complications after esophagectomy. The aim of this study was to examine the effect and feasibility of preoperative inspiratory muscle training-high intensity (IMT-HI), and IMT-endurance (IMT-E) on the incidence of PPCs in patients following esophagectomy for esophageal cancer (EC). A single-blind, randomized, clinical pilot study was conducted between 2009 and 2012. Forty-five participants were assigned to either IMT-HI or IMT-E. Effectiveness was assessed by analyzing PPCs, length of hospital stay (LOS), duration of mechanical ventilation, stay on the intensive care unit, and number of reintubations. Maximal inspiratory pressure and lung function changes were recorded pre- and post-training. Feasibility was assessed by IMT-related adverse events, training compliance, and patients' satisfaction. Thirty-nine patients could be analyzed, 20 patients in the IMT-HI arm and 19 patients in the IMT-E arm. The incidence of PPCs differed significantly between groups and was almost three times lower for the IMT-HI group (4 vs. 11 patients; p = 0.015). Other differences in favor of the IMT-HI group were LOS (13.5 vs. 18 days; p = 0.010) and number of reintubations (0 vs. 4 patients; p = 0.030). Both interventions proved to be equally feasible. Preoperative IMT-HI showed to be a promising, effective, and feasible intervention to reduce PPCs in EC patients undergoing esophagectomy. Further research with a larger sample size is recommended.

Mechanical aids to lung expansion in non-intubated surgical patients.

The reported incidence of postoperative pulmonary complications (PPC) varies markedly with the extent and type of surgery; for many types of major surgery, such as intracranial operations, data are unavailable. After upper abdominal surgery, the incidence ranges from 6 to 70%, depending on the diagnostic criteria used for detection and the physical status of the patients. Thus, the potential for serious PPC after major surgery is so great that some form of preventive respiratory care is mandatory. The most efficient methods remain to be determined. Mechanical aids to lung expansion have received widespread use. Unfortunately, few randomized, controlled trials have been reported, and results are difficult to compare because of important differences in protocol, specific details of therapy, and statistical methods used. We conclude the following: (1) There is little or no evidence documenting the efficacy of intermittent positive-pressure breathing (as customarily used) or blow bottles in decreasing the incidence of PPC. (2) Incentive spirometry may be of value in patients receiving routine "stir-up" regimen (turning, coughing, walking) by surgical housestaff and nurses, but does not appear to decrease further the incidence of PPC in patients treated with systematic preoperative regimens of chest physical therapy. (3) Data on the use of positive end-expiratory pressure and continuous positive airway pressure by face mask are to sparse to permit drawing definite conclusions concerning their efficacy. (4) Incentive spirometry and continuous positive airway pressure by mask are both based on sound physiologic rational and warrant further studies to determine their role in postoperative respiratory care.