Risk Of Postoperative Pulmonary Complications Research Articles

Association between thoracic epidural anesthesia and driving pressure in adult patients undergoing elective major upper abdominal surgery: a randomized controlled trial

BackgroundThoracic epidural anesthesia (TEA) is associated with a knowledge gap regarding its mechanisms in lung protection and reduction of postoperative pulmonary complications (PPCs). Driving pressure (ΔP), an alternative indicator of alveolar strain, is closely linked to reduced PPCs with lower ΔP values. We aim to investigate whether TEA contributes to lung protection by lowering ΔP during mechanical ventilation.MethodsIn this prospective, randomized, patient and evaluator-blinded parallel study, adult patients scheduled for elective major upper abdominal surgery were assigned to either the TEA group with combined thoracic epidural anesthesia and general anesthesia (TEA-GA) (n = 30) or the control group with only general anesthesia (GA) (n = 30).MeasurementsThe primary outcome was the minimum ΔP determined based on positive end-expiratory pressure (PEEP) after intubation. Secondary outcomes included the incidence of PPCs within seven days, the minimum ΔP at various time points, blood gas analysis, intensive care unit (ICU) admission rates, length of hospital stay, and 30-day mortality rate.ResultsThe TEA group had a significantly lower minimum ΔP titrated based on PEEP compared to the control group (11.23 ± 2.19 cmH2O vs. 12.67 ± 2.70 cmH2O; P = 0.028). Multivariate linear regression analysis showed that intraoperative TEA application (compared with its absence; unstandardized beta coefficient (B) = -1.289; P = 0.008) significantly correlated with ΔP. The incidence of PPCs did not differ significantly between the two groups (8 of 30 [26.7%] vs. 12 of 30 [40%]; P = 0.273), but the incidence of atelectasis in the TEA group was significantly lower than in the control group (5 of 30 [16.7%] vs. 12 of 30 [40.7%]; P = 0.012). Multivariate logistic regression analysis indicated that ΔP was the only variable significantly associated with PPCs (Adjusted Odds Ratio [OR] = 2.190; 95% Confidence Interval [CI]: 1.300 to 3.689; P = 0.003).ConclusionCompared to GA, TEA-GA can reduce intraoperative ΔP in patients undergoing major upper abdominal surgery, especially those undergoing laparoscopic surgery. However, compared to GA combined with ΔP-guided ventilation, TEA-GA combined with ΔP-guided ventilation does not reduce the risk of PPCs. There was no significant difference in the total use of various vasoactive drugs between the two groups.Trial registrationThis study was registered in the Chinese Clinical Trial Registry (registration number ChiCTR2300068778 date of registration February 28, 2023).

Effect of high-flow nasal therapy on patient-centred outcomes in patients at high risk of postoperative pulmonary complications after cardiac surgery: update to the statistical analysis plan for NOTACS, a multicentre adaptive randomised controlled trial

BackgroundThe NOTACS trial will assess the efficacy, safety and cost-effectiveness of high-flow nasal therapy (HFNT) compared to standard oxygen therapy (SOT) on the outcomes of patients after cardiac surgery.Methods/designNOTACS is an adaptive, international, multicentre, parallel group, randomised controlled trial, with a pre-planned interim sample size re-estimation (SSR). A minimum of 850 patients will be randomised 1:1 to receive either HFNT or SOT. The primary outcome is days alive and at home in the first 90 days after the planned surgery (DAH90), with a number of secondary analyses and cost-effectiveness analyses also planned. The interim SSR will take place after a minimum of 300 patients have been followed up for 90 days and will allow for the sample size to increase up to a maximum of 1280 patients.ResultsThis manuscript provides detailed descriptions of the design of the NOTACS trial and the analyses to be undertaken at the interim and final analyses. The main purpose of the interim analysis is to assess safety and to perform a sample size re-estimation. The main purpose of the final analysis is to examine the safety, efficacy and cost-effectiveness of HFNT compared to SOT on the outcomes of patients after cardiac surgery.DiscussionThis manuscript outlines the key features of the NOTACS statistical analysis plan and was submitted to the journal before the final analysis in order to preserve scientific integrity under an adaptive design framework. A previous version of this SAP was published prior to the interim analysis (Dawson, 2022). The NOTACS SAP closely follows published guidelines for the content of SAPs in clinical trials (Gamble, 2017).Trial registrationISRCTN14092678. (13 May 2020).

Establishment and validation of a predictive model for postoperative pulmonary complications in elderly patients undergoing non-cardiac surgery

Objective: To develop and validate a predictive model for postoperative pulmonary complications (PPCs) in elderly patients undergoing non-cardiac surgery. Methods: This retrospective study included 51 354 elderly patients over 65 years old who underwent non-cardiac surgery at the First Medical Center of Chinese PLA General Hospital from January 2009 to December 2018. The patients were randomly divided into a modeling group [n=41 084; 21 550 males, 19 534 females; age: 70 (67, 74) years] and an internal validation group [n=10 270; 5 458 males, 4 812 females; age: 70 (67, 74) years] at a ratio of 4∶1. Additionally, an external validation group of 14 378 patients [7 893 males, 6 845 females; age: 70 (67, 75) years] who underwent non-cardiac surgery at Henan Provincial People's Hospital between November 2014 and May 2022 was retrospectively included. Multivariate logistic regression were performed to identify factors associated with PPCs. A nomogram prediction model was constructed based on these factors and validated internally and externally. The model's performance and clinical applicability were assessed using receiver operating characteristic (ROC) curves, calibration curves, and decision curves. Results: Among the 51 354 elderly patients underwent general anesthesia for non-cardiac surgery, the incidence of PPCs was 17.5% (9 008/51 354). Multivariate logistic regression analysis reveals that anesthesia duration 130-<183 min (OR=1.858, 95%CI: 1.529-2.266), anesthesia duration 183-<250 min (OR=2.537, 95%CI: 2.079-3.108), anesthesia duration≥250 min(OR=3.533, 95%CI: 2.868-4.368), crystalloid infusion volume 1 400-<2 000 ml (OR=1.481, 95%CI: 1.204-1.829), crystalloid infusion volume 2 000-<9 000 ml (OR=1.776, 95%CI: 1.426-2.220), upper abdominal surgery (OR=1.658, 95%CI: 1.498-1.835), malignancy (OR=1.796, 95%CI: 1.606-2.012), fentanyl dosage 0.40-<0.55 mg (OR=1.404, 95%CI: 1.203-1.640), fentanyl dosage≥0.55 mg (OR=1.601, 95%CI: 1.386-1.854), prophylactic use of antibiotics (OR=7.897, 95%CI: 5.124-12.983), age (OR=1.039, 95%CI: 1.030-1.049), smoking (OR=1.124, 95%CI: 1.014-1.246), preoperative chest X-ray abnormalities (OR=2.139, 95%CI: 1.820-2.509) and intraoperative hypotension (OR=3.184, 95%CI: 2.120-4.795) were risk factors for PPCs, while elective surgery (OR=0.301, 95%CI: 0.220-0.417) was a protective factor. The nomogram model incorporating these factors had an area under the curve (AUC) of 0.757 (95%CI: 0.748-0.766, P=0.309) in the modeling group, 0.779 (95%CI: 0.760-0.796, P=0.171) in the internal validation group, and 0.778 (95%CI: 0.763-0.792, P<0.001) in the external validation group. Calibration curves and decision curves demonstrated good consistency and benefit of the model. Conclusion: The nomogram model which based on anesthesia duration, crystalloid infusion volume, upper abdominal surgery, malignancy, fentanyl dosage, prophylactic use of antibiotics, age, smoking, preoperative chest X-ray abnormalities, intraoperative hypotension and elective surgery provides strong predictive value and clinical utility for assessing the risk of PPCs in elderly patients undergoing non-cardiac surgery.

Effects of Respiratory Muscle Training Pre- and Post-Cardiac Surgery in Adults: A Scoping Review.

Coronary artery bypass grafts (CABGs) and cardiac valve replacement surgeries (CVRSs) are common lifesaving cardiac surgeries. They are linked to an increased risk of postoperative pulmonary complications (PPCs). This review scopes the effects of inspiratory muscle training (IMT) on adult patients, considering mainly exercise capacity, lung function, and the occurrence of PPCs. This scoping review was built using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR). Four databases were searched in May 2024. Three reviewers independently screened the articles. The data were extracted and summarised in text and tables. Five studies were included in the final analysis, where IMT was compared to sham or placebo IMT, and some studies added an exercise program to both groups. PeakVO2, the six-minute walking test (6MWT), maximal inspiratory pressure (MIP), quality of life (QoL), PPCs, and spirometry outcomes showed significant improvements between the intervention group (IG) and control group (CG) and intragroup over time. IMT can be a non-conventional training method to prevent respiratory muscle weakness. It can be applied in pre- or post-surgical contexts, potentially affecting exercise capacity and quality of life in adult patients undergoing cardiac surgery.

Comprehensive strategies for preoperative pulmonary risk evaluation and management.

Postoperative pulmonary complications (PPCs) significantly increase morbidity and mortality in surgical patients, particularly those with pulmonary conditions. The incidence of PPCs varies widely, influenced by surgery type, patient age, smoking status, and comorbidities like chronic obstructive pulmonary disease (COPD) and congestive heart failure. Preoperative pulmonary function tests and chest radiographs, while critical for lung resection surgery, should be selectively used based on individual risk factors. Effective risk stratification models, including ASA classification, Arozullah Respiratory Failure Index, Gupta Calculators, and ARISCAT model, aid in predicting PPCs. Key strategies to reduce PPCs involve preoperative optimization of pulmonary conditions, smoking cessation, and respiratory rehabilitation. In COPD and asthma patients, maintaining optimal disease control through inhaled therapies, systemic corticosteroids, and preoperative respiratory exercises is crucial. Anemia and hypoalbuminemia are notable predictors of PPCs, warranting careful management. The type and duration of anesthesia significantly impact PPC risk, with regional anesthesia preferred over general anesthesia when feasible. Comprehensive preoperative evaluation and tailored interventions are essential to improve surgical outcomes and reduce PPC incidence. Further study involving domestic patients is needed to refine national guidelines for managing patients at risk of PPCs.

Driving pressure during general anesthesia for minimally invasive abdominal surgery (GENERATOR)—study protocol of a randomized clinical trial

BackgroundIntraoperative driving pressure (ΔP) has an independent association with the development of postoperative pulmonary complications (PPCs) in patients receiving ventilation during general anesthesia for major surgery. Ventilation with high intraoperative positive end–expiratory pressure (PEEP) with recruitment maneuvers (RMs) that result in a low ΔP has the potential to prevent PPCs. This trial tests the hypothesis that compared to standard low PEEP without RMs, an individualized high PEEP strategy, titrated to the lowest ΔP, with RMs prevents PPCs in patients receiving intraoperative protective ventilation during anesthesia for minimally invasive abdominal surgery.Methods“DrivinG prEssure duriNg gEneRal AnesThesia fOr minimally invasive abdominal suRgery (GENERATOR)” is an international, multicenter, two–group, patient and outcome–assessor blinded randomized clinical trial. In total, 1806 adult patients scheduled for minimally invasive abdominal surgery and with an increased risk of PPCs based on (i) the ARISCAT risk score for PPCs (≥ 26 points) and/or (ii) a combination of age > 40 years and scheduled surgery lasting > 2 h and planned to receive an intra–arterial catheter for blood pressure monitoring during the surgery will be included. Patients are assigned to either an intraoperative ventilation strategy with individualized high PEEP, titrated to the lowest ΔP, with RMs or one with a standard low PEEP of 5 cm H2O without RMs. The primary outcome is a collapsed composite endpoint of PPCs until postoperative day 5.DiscussionGENERATOR will be the first adequately powered randomized clinical trial to compare the effects of individualized high PEEP with RMs versus standard low PEEP without RMs on the occurrence of PPCs after minimally invasive abdominal surgery. The results of the GENERATOR trial will support anesthesiologists in their decisions regarding PEEP settings during minimally invasive abdominal surgery.Trial registrationGENERATOR is registered at ClinicalTrials.gov (study identifier: NCT06101511) on 26 October 2023.

Higher fraction of inspired oxygen during anesthesia increase the risk of postoperative pulmonary complications in patients undergoing non-cardiothoracic surgery: a retrospective cohort study.

The ideal intra-operative inspired oxygen concentration remains controversial. We aimed to investigate the association between the intraoperative fraction of inspired oxygen (FiO2) and the incidence of postoperative pulmonary complications (PPCs) in patients undergoing non-cardiothoracic surgery. This was a retrospective cohort study of elderly patients who underwent non-cardiothoracic surgery between April 2020 and January 2022. According to intraoperative FiO2, patients were divided into low (≤60%) and high (>60%) FiO2 groups. The primary outcome was the incidence of a composite of pulmonary complications (PPCs) within the first seven postoperative days. Propensity score matching (PSM) and inverse probability treatment weighting (IPTW) were conducted to adjust for baseline characteristic differences between the two groups. Multivariate logistic regression analysis was used to calculate the odds ratios (OR) for FiO2 and PPCs. Among the 3,515 included patients with a median age of 70years (interquartile range: 68-74), 492 (14%) experienced PPCs within the first 7 postoperative days. Elevated FiO2 was associated with an increased risk of PPCs in all the logistic regression models. The OR of the FiO2 > 60% group was 1.252 (95%CI, 1.015-1.551, P = 0.038) in the univariate analysis. In the multivariate logistic regression models, the ORs of the FiO2 > 60% group were 1.259 (Model 2), 1.314 (Model 3), and 1.32 (model 4). A balanced covariate distribution between the two groups was created using PSM or IPTW. The correlation between elevated FiO2 and an increased risk of PPCs remained statistically significant with PSM analysis (OR, 1.393; 95% CI, 1.077-1.804; P = 0.012) and IPTW analysis (OR, 1.266; 95% CI, 1.086-1.476; P = 0.003). High intraoperative FiO2 (>60%) was associated with the postoperative occurrence of pulmonary complications, independent of predefined risk factors, in elderly non-cardiothoracic surgery patients. High intraoperative FiO2 should be applied cautiously in surgical patients vulnerable to PPCs.

High PEEP with recruitment maneuvers versus Low PEEP During General Anesthesia for Surgery - a Bayesian individual patient data meta-analysis of three randomized clinical trials.

The influence of high positive end-expiratory pressure (PEEP) with recruitment maneuvers on the occurrence of postoperative pulmonary complications after surgery is still not definitively established. Bayesian analysis can help to gain further insights from the available data and provide a probabilistic framework that is easier to interpret. Our objective was to estimate the posterior probability that the use of high PEEP with recruitment maneuvers is associated with reduced postoperative pulmonary complications in patients with intermediate-to-high risk under neutral, pessimistic, and optimistic expectations regarding the treatment effect. Multilevel Bayesian logistic regression analysis on individual patient data from three randomized clinical trials carried out on surgical patients at Intermediate-to-High Risk for postoperative pulmonary complications. The main outcome was the occurrence of postoperative pulmonary complications in the early postoperative period. We studied the effect of high PEEP with recruitment maneuvers versus Low PEEP Ventilation. Priors were chosen to reflect neutral, pessimistic, and optimistic expectations of the treatment effect. Using a neutral, pessimistic, or optimistic prior, the posterior mean odds ratio (OR) for High PEEP with recruitment maneuvers compared to Low PEEP was 0.85 (95% Credible Interval [CrI] 0.71 to 1.02), 0.87 (0.72 to 1.04), and 0.86 (0.71 to 1.02), respectively. Regardless of prior beliefs, the posterior probability of experiencing a beneficial effect exceeded 90%. Subgroup analysis indicated a more pronounced effect in patients who underwent laparoscopy (OR: 0.67 [0.50 to 0.87]) and those at high risk for PPCs (OR: 0.80 [0.53 to 1.13]). Sensitivity analysis, considering severe postoperative pulmonary complications only or applying a different heterogeneity prior, yielded consistent results. High PEEP with recruitment maneuvers demonstrated a moderate reduction in the probability of PPC occurrence, with a high posterior probability of benefit observed consistently across various prior beliefs, particularly among patients who underwent laparoscopy.

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.

Effect of Neoadjuvant Immunotherapy Combined with Chemotherapy on Pulmonary Function and Postoperative Pulmonary Complications in Esophageal Cancer: A Retrospective Study.

Neoadjuvant immunotherapy, targeting the PD-1 or PD-L1, combined with chemotherapy (NICT), can improve the radical resection and survival rates for locally advanced EC. However, it may impair pulmonary function, and the effect of NICT on pulmonary function and postoperative pulmonary complications in EC patients remains unknown. This study aimed to investigate whether NICT can affect pulmonary functions and postoperative pulmonary complications in EC patients. The study retrospectively recruited 220 EC patients who received NICT at the Department of Esophageal Cancer in Tianjin Medical University Cancer Institute & Hospital from January 2021 to June 2022. Changes in pulmonary function before and after NICT were compared. Logistic regression analysis was performed to analyze the correlations of pulmonary functions and clinical characteristics with postoperative pulmonary complications, respectively. The FEV1% pred, FVC, FVC% pred, and FEV1/FVC% significantly increased after NICT, with a P-value of 0.018, 0.005, 0.001, and 0.036, respectively. In contrast, there was a significant decline in the DLCO (8.92 ± 2.34 L before NICT vs. 7.79 ± 2.30 L after NICT; P < 0.05) and DLCO% pred (102.97 ± 26.22% before NICT vs. 90.18 ± 25.04% after NICT; P < 0.05). High DLCO and DLCO% pred at baseline levels were risk factors for DLCO reduction in EC patients after NICT. Advanced age, smoking history, FEV1% pred after NICT, and FVC% pred baseline and after therapy were risk factors for postoperative pulmonary complications, with a P-value of 0.043, 0.038, 0.048, 0.034, and 0.004, respectively. Although the DLCO level decreased after NICT, it did not increase the incidence of postoperative pulmonary complications. NICT may improve pulmonary ventilation function but also lead to a decrease in DLCO and DLCO% pred in EC patients. Nevertheless, the decreased DLCO after NICT did not increase the risk of postoperative pulmonary complications.

The role of prehabilitation in reducing the incidence of postoperative pulmonary complications in patients undergoing elective cardiac surgery: Results from the Pre Surgery Check Team study.

Despite its importance, prehabilitation, has only been implemented in very few cardiac surgery centers. The Pre Surgery Check Team study was designed to evaluate the impact of comprehensive interdisciplinary assessment and implementation of the prehabilitation program on the incidence of postoperative pulmonary complications after elective cardiac surgery. 725 adult patients (338 in the study group, 387 in the control group) were included in this single-center, prospective, observational study. Multimodal prehabilitation consisted of four elements: interdisciplinary medical assessment by cardiologist, anesthesiologist and cardiac surgeon, pulmonary assessment for patients at high risk of postoperative pulmonary complications, psychological assessment, and physiotherapeutic assessment and training. The primary endpoint was the occurrence of the postoperative pulmonary complications, and the secondary outcomes were: surgical site infection, rethoracotomy, ICU length of stay and hospital length of stay. Prehabilitation reduced the number of postoperative complications by 23%. Postoperative pneumonia was almost 3 times less common (5.33% vs 14.21%), and the surgical site infection - 1.4 times less common in the PreScheck group (8.28 vs 11.37%). In the logistic regression model, prehabilitation reduced the odds of postoperative pneumonia (by 0.346) and the odds of respiratory failure (by 0.479). Prehabilitation had no direct effect on ICU length of stay. Prehabilitation according to the Pre Surgery Check Team standard reduces the incidence of postoperative pulmonary complications and the total number of postoperative complications in patients undergoing elective cardiac surgery. The main benefit of attending the PreScheck Team visit is the opportunity to perform supportive preoperative interventions.

Utility of chronic obstructive pulmonary disease assessment test in perioperative assessment of patients with mild to moderate chronic obstructive pulmonary disease.

Chronic obstructive pulmonary disease (COPD) is a well-known risk factor for postoperative pulmonary complications (PPCs), necessitating careful preoperative evaluation in patients undergoing lung resection surgery. The risk of PPCs in patients with COPD may vary with severity of symptoms, and the COPD Assessment Test (CAT) score is commonly used to assess patient quality of life and predict acute exacerbations. However, few studies have explored the correlation between CAT score and PPC incidence in COPD. This study aimed to assess the predictive value of CAT scores for PPCs and compare them with other established PPC predictors in mild to moderate COPD. We retrospectively reviewed 83 patients with COPD who underwent preoperative evaluation before lung cancer surgery, including cardiopulmonary exercise tests (CPETs), between January 2020 and June 2022. We compared the predictive value of the following factors for the incidence of PPCs: spirometry, CPETs, 6-min walk tests, symptom-based scores (including CAT scores), the COPD composite severity index, surgery type, comorbidity index, and PPC prediction models. Among the 83 patients, 16 (19.2%) developed PPCs, with persistent air leakage being the most common complication. CAT scores significantly differed between PPC and non-PPC groups (mean value 9.4 vs. 6.7, P=0.002). In multivariable logistic regression analysis, a CAT score of ≥7 was an independent risk factor for the incidence of PPCs (odds ratio =9.88; 95% confidence interval: 1.95-50.04; P=0.005), whereas other factors demonstrated no significant predictive value. CAT scores are valuable for evaluating patients with mild to moderate COPD before lung resection surgery, reliably predicting PPCs.

Postoperative pulmonary complications after major abdominal surgery in elderly patients and its association with patient-controlled analgesia

ObjectivesThis study aims to identify the risk factors for postoperative pulmonary complications (PPCs) in elderly patients undergoing major abdominal surgery and to investigate the relationship between patient-controlled analgesia (PCA) and PPCs.DesignA retrospective study.MethodClinical data and demographic information of elderly patients (aged ≥ 60 years) who underwent upper abdominal surgery at the First Affiliated Hospital of Sun Yat-sen University from 2017 to 2019 were retrospectively collected. Patients with PPCs were identified using the Melbourne Group Scale Version 2 scoring system. A directed acyclic graph was used to identify the potential confounders, and multivariable logistic regression analyses were conducted to identify independent risk factors for PPCs. Propensity score matching was utilized to compare PPC rates between patients with and without PCA, as well as between intravenous PCA (PCIA) and epidural PCA (PCEA) groups.ResultsA total of 1,467 patients were included, with a PPC rate of 8.7%. Multivariable analysis revealed that PCA was an independent protective factor for PPCs in elderly patients undergoing major abdominal surgery (odds ratio = 0.208, 95% confidence interval = 0.121 to 0.358; P < 0.001). After matching, patients receiving PCA demonstrated a significantly lower overall incidence of PPCs (8.6% vs. 26.3%, P < 0.001), unplanned transfer to the intensive care unit (1.1% vs. 8.4%, P = 0.001), and in-hospital mortality (0.7% vs. 5.3%, P = 0.021) compared to those not receiving PCA. No significant difference in outcomes was observed between patients receiving PCIA or PCEA after matching.ConclusionPatient-controlled analgesia, whether administered intravenously or epidurally, is associated with a reduced risk of PPCs in elderly patients undergoing major upper abdominal surgery.

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.

How to Prevent Ventilator-Induced Lung Injury in Intraoperative Mechanical Ventilation? A Randomized Prospective Study.

Intraoperative mechanical ventilation practices can lead to ventilator-induced lung injury (VILI) and postoperative pulmonary complications in healthy lungs. Mechanical power (MP) has been developed as a new concept in reducing the risk of postoperative pulmonary complications as it considers all respiratory mechanics that cause VILI. The most commonly used intraoperative modes are volume control ventilation (VCV) and pressure control ventilation (PCV). In this study, VCV and PCV modes were compared in terms of respiratory mechanics in patients operated in the supine and prone positions. The patients were divided into 4 groups (80 patients), volume control supine and prone, pressure control supine and prone with 20 patients each. MP, respiratory rate, positive end-expiratory pressure, tidal volume, peak pressure, plato pressure, driving pressure, inspiratory time, height, age, gender, body mass index, and predictive body weight data of the patients included in the groups have been obtained from "electronic data pool" with Structured Query Language queries. The supine and prone MP values of the VCV group were statistically significantly lower than the PCV group (P values were 0.010 and 0.001, respectively). Supine and prone MP values of the VCV group were calculated significantly lower than the PCV group. Intraoperative PCV may be considered disadvantageous regarding the risk of VILI in the supine and prone positions.

The effect of a hybrid structured pulmonary rehabilitation education program for patients with lung cancer with a high risk of postoperative pulmonary complications: A quasi-experimental study

PurposeThe absence of standardized protocols and education are the main obstacles to perioperative pulmonary rehabilitation (PR), especially for patients with high-risk factors of postoperative pulmonary complications (PPCs). We aimed to explore the effect of a hybrid structured pulmonary rehabilitation education program (SPREP) on patients with lung cancer at high risk of PPCs. MethodsA quasi-experimental trial with a pre-post test design was conducted. The control group (n = 53) adopted routine perioperative pulmonary rehabilitation, while the intervention group (n = 53) received SPREP. Respiratory function, 6-min walk distance, Borg dyspnea scale, quality of life, anxiety–depression scores at admission, discharge, 2 weeks and 3 months post-discharge, and incidence of PPCs were compared between the two groups. ResultsThere were no significant differences on the 6-min walk distance and Borg Dyspnoea Scale at discharge between the two groups (P > 0.05), whereas the intervention group showed improved performance at the remaining time points (P < 0.05). In addition, the intervention group had improved exercise capacity, pulmonary function and quality of life, reduced levels of anxiety and depression at discharge, 2 weeks post-discharge and 3 months post-discharge (P < 0.05). In addition, incidence of PPCs was significantly reduced in the intervention group, especially postoperative pneumonia. ConclusionsThe SPREP could show significant benefits in enhancing exercise capacity, lung function, and quality of life, while diminishing the occurrence of PPCs and mitigating the levels of anxiety and depression, future large RCT need to further explore the efficacy. Trial registrationThis study was registered with the China Clinical Trial Registration Center (ChiCTR) under the Clinical Trial Registration Number [ChiCTR2200066698].

A prognostic model for use before elective surgery to estimate the risk of postoperative pulmonary complications (GSU-Pulmonary Score): a development and validation study in three international cohorts

Pulmonary complications are the most common cause of death after surgery. This study aimed to derive and externally validate a novel prognostic model that can be used before elective surgery to estimate the risk of postoperative pulmonary complications and to support resource allocation and prioritisation during pandemic recovery. Data from an international, prospective cohort study were used to develop a novel prognostic risk model for pulmonary complications after elective surgery in adult patients (aged ≥18 years) across all operation and disease types. The primary outcome measure was postoperative pulmonary complications at 30 days after surgery, which was a composite of pneumonia, acute respiratory distress syndrome, and unexpected mechanical ventilation. Model development with candidate predictor variables was done in the GlobalSurg-CovidSurg Week dataset (global; October, 2020). Two structured machine learning techniques were explored (XGBoost and the least absolute shrinkage and selection operator [LASSO]), and the model with the best performance (GSU-Pulmonary Score) underwent internal validation using bootstrap resampling. The discrimination and calibration of the score were externally validated in two further prospective cohorts: CovidSurg-Cancer (worldwide; February to August, 2020, during the COVID-19 pandemic) and RECON (UK and Australasia; January to October, 2019, before the COVID-19 pandemic). The model was deployed as an online web application. The GlobalSurg-CovidSurg Week and CovidSurg-Cancer studies were registered with ClinicalTrials.gov, NCT04509986 and NCT04384926. Prognostic models were developed from 13 candidate predictor variables in data from 86 231 patients (1158 hospitals in 114 countries). External validation included 30 492 patients from CovidSurg-Cancer (726 hospitals in 75 countries) and 6789 from RECON (150 hospitals in three countries). The overall rates of pulmonary complications were 2·0% in derivation data, and 3·9% (CovidSurg-Cancer) and 4·7% (RECON) in the validation datasets. Penalised regression using LASSO had similar discrimination to XGBoost (area under the receiver operating curve [AUROC] 0·786, 95% CI 0·774-0·798 vs 0·785, 0·772-0·797), was more explainable, and required fewer covariables. The final GSU-Pulmonary Score included ten predictor variables and showed good discrimination and calibration upon internal validation (AUROC 0·773, 95% CI 0·751-0·795; Brier score 0·020, calibration in the large [CITL] 0·034, slope 0·954). The model performance was acceptable on external validation in CovidSurg-Cancer (AUROC 0·746, 95% CI 0·733-0·760; Brier score 0·036, CITL 0·109, slope 1·056), but with some miscalibration in RECON data (AUROC 0·716, 95% CI 0·689-0·744; Brier score 0·045, CITL 1·040, slope 1·009). This novel prognostic risk score uses simple predictor variables available at the time of a decision for elective surgery that can accurately stratify patients' risk of postoperative pulmonary complications, including during SARS-CoV-2 outbreaks. It could inform surgical consent, resource allocation, and hospital-level prioritisation as elective surgery is upscaled to address global backlogs. National Institute for Health Research.

Evaluation of Preoperative Breathing Techniques on Functional Mobility in On-Pump Versus Off-Pump Coronary Artery Bypass Graft Patients: A Comprehensive Review

This review investigates and contrasts the effects of various preoperative chest rehabilitation techniques in patients undergoing coronary artery bypass graft (CABG) surgery, both on-pump and off-pump. Utilizing databases such as Pedro, Cochrane, and PubMed, a comprehensive literature review was conducted, focusing on studies published between 2017 and 2023. We identified 14 relevant articles that met specific inclusion and exclusion criteria, examining the effects of preoperative physiotherapy in adult patients undergoing CABG surgery. Preoperative physiotherapy encompasses a variety of approaches, including counseling, cardiovascular exercise, instruction on breathing techniques, and inspiratory muscle training (IMT). Numerous studies have highlighted the benefits of integrating these methods, such as reducing the risk of postoperative pulmonary complications, shortening hospital stays, achieving earlier extubation, and decreasing anxiety. Despite these findings, further research is needed to evaluate the effectiveness of combination therapies, particularly those involving IMT, in preoperative physical therapy. The goal is to develop a comprehensive understanding of the mechanisms through which these treatments reduce pulmonary complications post-surgery.

Breathing reserve as a predictor of postoperative pulmonary complications in patients with lung cancer

The objective was to assess the possibility of using breathing reserve (BR) to evaluate the individual risk of postoperative pulmonary complications (PPC) in patients who underwent open surgery for lung cancer.Materials and methods. The study involved 185 patients who underwent open surgery for lung cancer in the clinic of the Pavlov University in 2018–2020. All patients underwent cardiopulmonary exercise testing (CPET) in the preoperative period to determine the BR. All patients were retrospectively divided into 2 groups depending on the presence of PPC during 7 days after the surgery. To assess the information content of BR for predicting PPC and their outcome, the data were statistically processed: the Mann–Whitney U-test, Fisher’s exact test, Youden index and linear regression method were used.Results. PPC developed in 7 patients (3.8%), in 3 of them (42.9% of the group with PC and 1.6% of the total group) they were accompanied by acute respiratory failure (ARF), requiring reintubation and mechanical ventilation; these patients died. At the anaerobic threshold (AT), there were significant differences in BR (p = 0.003). A direct correlation was found between BR at the AT not only at the peak load but also during the unloaded cycling (UC) (closeness of connection on the Chaddock scale BR (AT) – BR (peak) ρ = 0.724, BR (AT) – BR (UC) ρ = 0.734, p &lt; 0.001). The chances to develop PC changed as follows: in the group of patients with BR (UC) &lt; 72.025% were 21.4 times higher (95% CI: 2.499 – 182.958); with BR (AT) &lt; 44.136% were 27.2 times higher (95% CI: 4.850 – 152.167); with BR (peak) &lt; 36.677% were 7.6 times higher (95% CI: 1.426 – 40.640).Conclusions. Dynamic measurement of the BR is informative at all stages of CPET. The risk of PPC and their unfavorable outcome increases when the BR is below 72.025% at the unloaded cycling, below 44.136% at the anaerobic threshold and below 36.377% at the peak load. BR can be used as a marker of the development of PPC in patients undergoing lung cancer surgery.

Does coronavirus disease 2019 history alone increase the risk of postoperative pulmonary complications after surgery? Prospective observational study using serology assessment.

Concern exists about the increasing risk of postoperative pulmonary complications in patients with a history of coronavirus disease 2019 (COVID-19). We conducted a prospective observational study that compared the incidence of postoperative pulmonary complications in patients with and without a history of COVID-19. From August 2022 to November 2022, 244 adult patients undergoing major non-cardiac surgery were enrolled and allocated either to history or no history of COVID-19 groups. For patients without a history of confirming COVID-19 diagnosis, we tested immunoglobulin G to nucleocapsid antigen of SARS-CoV-2 for serology assessment to identify undetected infection. We compared the incidence of postoperative pulmonary complications, defined as a composite of atelectasis, pleural effusion, pulmonary edema, pneumonia, aspiration pneumonitis, and the need for additional oxygen therapy according to a COVID-19 history. After excluding 44 patients without a COVID-19 history who were detected as seropositive, 200 patients were finally enrolled in this study, 100 in each group. All subjects with a COVID-19 history experienced no or mild symptoms during infection. The risk of postoperative pulmonary complications was not significantly different between the groups according to the history of COVID-19 (24.0% vs. 26.0%; odds ratio, 0.99; 95% confidence interval, 0.71-1.37; P-value, 0.92). The incidence of postoperative pulmonary complications was also similar (27.3%) in excluded patients owing to being seropositive. Our study showed patients with a history of no or mild symptomatic COVID-19 did not show an increased risk of PPCs compared to those without a COVID-19 history. Additional precautions may not be needed to prevent PPCs in those patients.