Prevention Of Postoperative Pulmonary Complications Research Articles

Prehabilitation: a narrative review focused on exercise therapy for the prevention of postoperative pulmonary complications following lung resection.

Extensive preventive strategies in the perioperative period are popular worldwide. Novel "prehabilitation" approaches are being defined for every individual surgical discipline. With intention to reduce perioperative morbidity, "prehabilitation" was developed to increase "physical wellness" considering exercise capacity, nutritional status, and psychological support. Thus, prehabilitation could be well-suited for patients undergoing lung cancer surgery. Theoretically, improving physical condition may increase the chances of having a better post-operative course, especially among frail patients. In this review, we describe the concept of prehabilitation with possible benefits, its role in the Enhanced Recovery After Surgery protocols, and its potential for the future.

Individualized positive end-expiratory pressure guided by respiratory mechanics during anesthesia for the prevention of postoperative pulmonary complications: a systematic review and meta-analysis.

The optimization of positive end-expiratory pressure (PEEP) according to respiratory mechanics [driving pressure or respiratory system compliance (Crs)] is a simple and straightforward strategy. However, its validity to prevent postoperative pulmonary complications (PPCs) remains unclear. Here, we performed a meta-analysis to assess such efficacy. We searched PubMed, Embase, and the Cochrane Library to identify randomized controlled trials (RCTs) that compared personalized PEEP based on respiratory mechanics and constant PEEP to prevent PPCs in adults. The primary outcome was PPCs. Fourteen studies with 1105 patients were included. Compared with those who received constant PEEP, patients who received optimized PEEP exhibited a significant reduction in the incidence of PPCs (RR = 0.54, 95% CI 0.42 to 0.69). The results of commonly happened PPCs (pulmonary infections, hypoxemia, and atelectasis but not pleural effusion) also supported individualized PEEP group. Moreover, the application of PEEP based on respiratory mechanics improved intraoperative respiratory mechanics (driving pressure and Crs) and oxygenation. The PEEP titration method based on respiratory mechanics seems to work positively for lung protection in surgical patients undergoing general anesthesia.

Implication of age-related changes on anesthesia management.

Elderly patients have a high risk of perioperative morbidity and mortality. Pluri-morbidities, polypharmacy, and functional dependence may have a great impact on intraoperative management and request specific cautions. In addition to surgical stress, several perioperative noxious stimuli such as fasting, blood loss, postoperative pain, nausea and vomiting, drug adverse reactions, and immobility may trigger a derangement leading to perioperative complications. Older patients have a high risk of major hemodynamic derangement due to aging of the cardiovascular system and associated comorbidities. The hemodynamic monitoring as well as fluid therapy should be the most accurate as possible. Aging is accompanied by decreased renal function, which is related to a reduction in renal blood flow, renal mass, and the number and size of functioning nephrons. Drugs eliminated predominantly by the renal route need dosage adjustments based on residual renal function. Liver mass, hepatic blood flow, and intrinsic metabolic activity are decreased in the elderly, and all drugs metabolized by the liver have a variable half-life, thus requiring dose reduction. Decreased neural plasticity contributes to a high risk for postoperative delirium. Monitoring of anesthesia depth should be mandatory to avoid overdosage of hypnotic drugs. Prevention of postoperative pulmonary complications requires both protective ventilation strategies and adequate recovery of neuromuscular function at the end of surgery. Avoidance of hypothermia cannot be missed. The aim of this review is to describe comprehensive strategies for intraoperative management plans tailored to meet the unique needs of elderly surgical patients, thus improving outcomes in this vulnerable population.

Prophylactic Penehyclidine Inhalation for Prevention of Postoperative Pulmonary Complications in High-risk Patients: A Double-blind Randomized Trial: Erratum.

In the article beginning on page 551 in the April 2022 issue, overlapping bars appear in figure 3. The corrected figure appears below.The figure 3 legend is also being updated to avoid redundancy. Instead of “Forest plot in predefined subgroups. Forest plot assessing the effect of penehyclidine inhalation versus placebo inhalation in predefined subgroups. ...,” the legend is being updated to “Forest plot assessing the effect of penehyclidine inhalation versus placebo inhalation in predefined subgroups. ...”The publisher regrets the errors in the figure. The online version and PDF of the article have been corrected.

Prophylactic Penehyclidine Inhalation for Prevention of Postoperative Pulmonary Complications in High-risk Patients: A Double-blind Randomized Trial.

Postoperative pulmonary complications are common. Aging and respiratory disease provoke airway hyperresponsiveness, high-risk surgery induces diaphragmatic dysfunction, and general anesthesia contributes to atelectasis and peripheral airway injury. This study therefore tested the hypothesis that inhalation of penehyclidine, a long-acting muscarinic antagonist, reduces the incidence of pulmonary complications in high-risk patients over the initial 30 postoperative days. This single-center double-blind trial enrolled 864 patients age over 50 yr who were scheduled for major upper-abdominal or noncardiac thoracic surgery lasting 2 h or more and who had an Assess Respiratory Risk in Surgical Patients in Catalonia score of 45 or higher. The patients were randomly assigned to placebo or prophylactic penehyclidine inhalation from the night before surgery through postoperative day 2 at 12-h intervals. The primary outcome was the incidence of a composite of pulmonary complications within 30 postoperative days, including respiratory infection, respiratory failure, pleural effusion, atelectasis, pneumothorax, bronchospasm, and aspiration pneumonitis. A total of 826 patients (mean age, 64 yr; 63% male) were included in the intention-to-treat analysis. A composite of pulmonary complications was less common in patients assigned to penehyclidine (18.9% [79 of 417]) than those receiving the placebo (26.4% [108 of 409]; relative risk, 0.72; 95% CI, 0.56 to 0.93; P = 0.010; number needed to treat, 13). Bronchospasm was less common in penehyclidine than placebo patients: 1.4% (6 of 417) versus 4.4% (18 of 409; relative risk, 0.327; 95% CI, 0.131 to 0.82; P = 0.011). None of the other individual pulmonary complications differed significantly. Peak airway pressures greater than 40 cm H2O were also less common in patients given penehyclidine: 1.9% (8 of 432) versus 4.9% (21 of 432; relative risk, 0.381; 95% CI, 0.171 to 0.85; P = 0.014). The incidence of other adverse events, including dry mouth and delirium, that were potentially related to penehyclidine inhalation did not differ between the groups. In high-risk patients having major upper-abdominal or noncardiac thoracic surgery, prophylactic penehyclidine inhalation reduced the incidence of pulmonary complications without provoking complications.

Perioperative management of patients with respiratory failure: methodological recommendations of the All-Russian public organization “Federation of Anesthesiologists and Reanimatologists”

Perioperative respiratory complications are one of the main problems in anesthesiology and intensive care, in some areas of surgery they occupy the first place in the structure of all complications of the perioperative period. Initial respiratory failure, as well as the presence of disorders of respiratory functions increase the risk of its development, often leading to an unfavorable outcome of the disease. The recommendations on perioperative management of patients with respiratory failure include modern standards of preoperative assessment of risk factors for respiratory insufficiency, prevention and treatment of perioperative respiratory disorders in Russian Federation. The recommendations describe the principles of diagnosis of respiratory failure, the choice of anesthesia in concomitant lung diseases, the basics of protective ventilation and prevention of postoperative pulmonary complications.
 

Respiratory Prehabilitation for the Prevention of Postoperative Pulmonary Complications after Major Surgery

Respiratory Prehabilitation for the Prevention of Postoperative Pulmonary Complications after Major Surgery

INFLUENCE OF RESPIRATORY SUPPORT STRATEGY DURING CARDIOPULMONARY BYPASS ON LUNGS OXYGENATING FUNCTION

Introduction There are high incidence of pulmonary complications and acute respiratory failure (3,2—28,6%)¹ after cardiac surgery with cardiopulmonary bypass. The study aimed to evaluate the effectiveness of various tactics of respiratory support during cardiopulmonary bypass (CPB) for the prevention of postoperative pulmonary complications. Methods This is a prospective, randomized, controlled clinical study in parallel groups. The study was approved by a local ethics committee. Informed consent was obligatory for all participants. Sixty patients were divided into two groups. In group 1 we provided a continuous positive airway pressure (CPAP) of +5 cm H2O during CPB. In group 2 patients underwent mechanical ventilation with reduced volume (volume control (VC) mode, tidal volume 3 ml / kg of ideal body weight) and respiratory rate of 6 breathes per minute with positive end-expiratory pressure + 5 cm H2O. The primary end-point of the study was the value of the partial pressure of oxygen in arterial blood to oxygen fraction in inhaled gas mixture ratio (paO2/FiO2) at different stages of perioperative management: T1 (after the beginning of mechanical ventilation, T2 (before the CPB), T3 (after CPB), T4 (at the end of the surgery), T5 (upon admission to the ICU), T6 and T7 (6 and 12 hours after surgery, respectively). Secondary end-points were the common lung complications rate (pneumonia, pleural effusion, atelectasis, pneumothorax), the frequency of recruitment maneuvers during the mechanical ventilation, the need for non-invasive ventilation after extubation, the frequency of re-intubation of the trachea. Statistical analysis was carried out in SPSS for Mac v19 (IBM, Inc, USA). Data were presented as mean (±standard deviation) or number (percent). A comparison of the quantitative characteristics was performed using the Mann Whitney U-test. Fisher's exact test was used for the incidence of complications between groups. A p value of less than 0.05 was considered statistically significant. Results The results are presented in Tables 1 and 2. The paO2/FiO2 in the VC group was higher than in the CPAP group at stages T3 and T5. The frequency of recruiting maneuvers in the VC group was lower than in the CPAP group. There was a lower incidence of atelectasis in the VC group than in the CPAP group (Table 2). The low-volume lung ventilation during the CPB is beneficial for oxygenating function of the lungs in comparison with CPAP respiratory support. Discussion The low-volume lung ventilation during the CPB is beneficial for oxygenating function of the lungs in comparison with CPAP respiratory support.

Individualized positive end-expiratory pressure (PEEP) during one-lung ventilation for prevention of postoperative pulmonary complications in patients undergoing thoracic surgery: A meta-analysis.

Background:Positive end-expiratory pressure (PEEP) is an important part of the lung protection strategies for one-lung ventilation (OLV). However, a fixed PEEP value is not suitable for all patients. Our objective was to determine the prevention of individualized PEEP on postoperative complications in patients undergoing one-lung ventilation.Method:We searched the PubMed, Embase, and Cochrane and performed a meta-analysis to compare the effect of individual PEEP vs fixed PEEP during single lung ventilation on postoperative pulmonary complications. Our primary outcome was the occurrence of postoperative pulmonary complications during follow-up. Secondary outcomes included the partial pressure of arterial oxygen and oxygenation index during one-lung ventilation.Result:Eight studies examining 849 patients were included in this review. The rate of postoperative pulmonary complications was reduced in the individualized PEEP group with a risk ratio of 0.52 (95% CI:0.37–0.73; P = .0001). The partial pressure of arterial oxygen during the OLV in the individualized PEEP group was higher with a mean difference 34.20 mm Hg (95% CI: 8.92–59.48; P = .0004). Similarly, the individualized PEEP group had a higher oxygenation index, MD: 49.07mmHg, (95% CI: 27.21–70.92; P < .0001).Conclusions:Individualized PEEP setting during one-lung ventilation in patients undergoing thoracic surgery was associated with fewer postoperative pulmonary complications and better perioperative oxygenation.

Weak evidence, supplemented with common sense for reduction in postoperative pulmonary complications

A clinical decision report appraising: Kaminski PN, Forgiarini LA, Jr., Andrade CF. Early respiratory therapy reduces postoperative atelectasis in children undergoing lung resection. Respir Care. 2013;58(5):805-809. https://doi.org/10.4187/respcare.01870 for prevention of postoperative pulmonary complications following thoracic surgery for a patient who is not able to participate in incentive spirometry.

Anesthetic management of patients with chronic obstructive pulmonary disease

Chronic obstructive pulmonary disease (COPD) is the third most common cause of death worldwide. It has a prevalence of 14% among Koreans aged above 40 years and a prevalence of 31% among those aged above 65 years. However, only 6% of the COPD patients receive treatment. Most of the patients do not seek medical attention, as they think that dyspnea, cough, and productive sputum, which are the common symptoms of COPD, are normal aging phenomena. Smoking is a major risk factor for COPD, but environmental hazards and genetic susceptibility are also involved. With aging, lung injuries due to these risk factors accumulate, leading to increased prevalence of COPD. The major concerns regarding perioperative management of COPD patients include preoperative evaluation of cardiopulmonary risks, optimization of lung function, and evaluation of COPD-related physiological functions that are easily aggravated during anesthesia. These include respiratory muscle dysfunction, dynamic hyperinflation and auto-positive end-expiratory pressure, hypoxia-hypercarbia, and pulmonary hypertension-associated heart failure. Therefore, anesthesia for COPD patients should focus on preoperative evaluation, risk reduction measures, and prevention of postoperative pulmonary complications.

Incentive Spirometry for Prevention of Postoperative Pulmonary Complications After Thoracic Surgery.

Incentive spirometry is frequently used after thoracic surgery as an adjunct to physiotherapy. Despite its widespread use, it has remained challenging to demonstrate a clinical benefit in terms of either incidence of postoperative pulmonary complications or hospital stay. In this literature review, we have observed that, although there is no study supporting clinical benefit in the thoracic surgical patient population generally, there is now emerging evidence of benefit in higher-risk patient populations such as those with COPD. There is an indication that incentive spirometry can lead to a reduction in the incidence of postoperative pulmonary complications in these patients. The problem with studies published to date is that there are many limitations, not least of which is the challenge of achieving patient adherence with performing incentive spirometry as prescribed. Despite the lack of evidence, there remains an appetite for persevering with incentive spirometry in the postoperative thoracic surgical patient because it is a relatively inexpensive intervention that motivates many patients to perform regular breathing exercises long after the therapist has moved on to the next patient.

PREOPERATIVE EXERCISE TRAINING TO PREVENT POSTOPERATIVE PULMONARY COMPLICATIONS IN ADULTS UNDERGOING MAJOR SURGERY: A SYSTEMATIC REVIEW AND META-ANALYSIS WITH TRIAL SEQUENTIAL ANALYSIS

TYPE: Abstract Publication TOPIC: Pulmonary Rehabilitation PURPOSE: Poor physical fitness and respiratory muscle weakness are risk factors of postoperative pulmonary complications (PPCs) and preoperative exercise training programs may reduce the risk of PPCs. METHODS: We searched MEDLINE, Web of Science, Embase, Pedro, and the Cochrane Central Register, until September 2019, for RCTs comparing exercise training with usual care before cardiac, lung, oesophageal or abdominal surgery. The main outcome was occurrence of PPCs; secondary outcomes were preoperative functional changes. The study was registered with PROSPERO (N° CRD42018096956). RESULTS: From 28 RCTs, 2’044 patients were pooled for meta-analysis. Compared with controls, preoperative exercise training was associated with a lower incidence of PPCs (22 RCTs, 1’838 patients, odds ratio [OR] 0.43; 95% CI 0.31-0.59); TSA provided evidence of the effectiveness of exercise training to reduce PPCs by > 30%. Prevention of PPCs was effective in patients undergoing cardiac surgery (OR 0.44, 95% CI 0.29-0.67) and lung surgery (OR, 0.33, 95% CI 0.21-0.51) and when patients were pretreated with endurance training (OR 0.39, 95%CI 0.24-0.65) or combined endurance and respiratory training modalities (OR 0.27, 95%CI 0.16-0.45). Exercise training was associated with increased peak oxygen uptake (mean weight difference [WMD] +2.1 ml/kg/min, 99%CI 0.2-4.0) and higher maximal inspiratory pressure (WMD +12.9 cmH20, 99%CI 7.2-18.7). CONCLUSIONS: Short-term exercise training improves patient physical fitness and reduces the risk to develop PPCs. CLINICAL IMPLICATIONS: Preoperative exercise training is a simple and low cost intervention to reduce the risk of PPCs. This information is important for healthcare providers involved in the clinical pathway of patients undergoing major surgery. DISCLOSURE: No significant relationships. KEYWORD: respiratory muscle, aerobic capacity

Dexmedetomidine for prevention of postoperative pulmonary complications in patients after oral and maxillofacial surgery with fibular free flap reconstruction:a prospective, double-blind, randomized, placebo-controlled trial

BackgroundPostoperative pulmonary complications (PPCs) are common and significant problems for oral and maxillofacial surgery patients. Dexmedetomidine (DEX), an α2-adrenoreceptor agonist, has been proven having lung protection effects. However, since now, there has not been final conclusion about whether DEX can reduce the incidence of PPCs. We hypothesize that, in oral and maxillofacial surgery with fibular free flap reconstruction patients, DEX may decrease the incidence of PPCs.MethodsThis was a prospective, double-blind, randomized, placebo-controlled, single-centered trial with two parallel arms. A total of 160 patients at intermediate-to-high risk of PPCs undergoing oral and maxillofacial surgery with fibular free flap reconstruction and tracheotomy were enrolled and randomized to receive continuous infusion of either DEX or placebo (normal saline). 0.4 μg/kg of DEX was given over 10mins as an initial dose followed by a maintaining dose of 0.4 μg/kg/h till the second day morning after surgery. At the same time, the normal saline was administered a similar quantity. The primary outcome was the incidence of PPCs according to Clavien-Dindo score within 7 days after surgery.ResultsThe two groups had similar characteristics at baseline. 18(22.5%) of 80 patients administered DEX, and 32(40.0%) of 80 patient administered placebo experienced PPCs within the first 7 days after surgery (relative risk [RR] 0.563,95% confidence interval [CI] 0.346–0.916; P = 0.017). In the first 7 days after surgery, the DEX group had a lower incidence of PPCs and a better postoperative survival probability (Log-rank test, P = 0.019), and was less prone to occur PPCs (Cox regression, P = 0.025, HR = 0.516). When the total dose of DEX was more than 328 μg, the patients were unlikely to have PPCs (ROC curve, AUC = 0.614, P = 0.009).ConclusionsFor patients undergoing oral and maxillofacial surgery with fibular free flap reconstruction and tracheotomy who were at intermediate or high risk of developing PPCs, continuous infusion of DEX could decrease the occurrence of PPCs during the first 7 days after surgery and shorten the length of hospital stay after surgery, but did not increase the prevalence of bradycardia or hypotension.Trial registrationChinese Clinical Trial Registry, www.chictr.org.cn, number: ChiCTR1800016153; Registered on May 15, 2018.

Positive End-Expiratory Pressure During Anesthesia for Prevention of Postoperative Pulmonary Complications: A Meta-analysis With Trial Sequential Analysis of Randomized Controlled Trials.

Whether intraoperative positive end-expiratory pressure (PEEP) can reduce the risk of postoperative pulmonary complications remains controversial. We performed a systematic review of currently available literature to investigate whether intraoperative PEEP decreases pulmonary complications in anesthetized patients undergoing surgery. We searched PubMed, Embase, and the Cochrane Library to identify randomized controlled trials (RCTs) that compared intraoperative PEEP versus zero PEEP (ZEEP) for postoperative pulmonary complications in adults. The prespecified primary outcome was postoperative pulmonary atelectasis. Fourteen RCTs enrolling 1238 patients met the inclusion criteria. Meta-analysis using a random-effects model showed a decrease in postoperative atelectasis (relative risk [RR], 0.51; 95% confidence interval [CI], 0.35-0.76; trial sequential analyses [TSA]-adjusted CI, 0.10-2.55) and postoperative pneumonia (RR, 0.48; 95% CI, 0.27-0.84; TSA-adjusted CI, 0.05-4.86) in patients receiving PEEP ventilation. However, TSA showed that the cumulative Z-curve of 2 outcomes crossed the conventional boundary but did not cross the trial sequential monitoring boundary, indicating a possible false-positive result. We observed no effect of PEEP versus ZEEP ventilation on postoperative mortality (RR, 1.78; 95% CI, 0.55-5.70). The evidence that intraoperative PEEP reduces postoperative pulmonary complications is suggestive but too unreliable to allow definitive conclusions to be drawn.

Residual Neuromuscular Blockade and Postoperative Pulmonary Complications: What Does the Recent Evidence Demonstrate?

Purpose of ReviewThe purpose of this review is to assess how residual neuromuscular block impacts postoperative pulmonary complications and whether we can modify the risk by improving certain aspects in daily clinical care.Recent findingsPostoperative respiratory impairment may be due to various causes, such as age, surgery type, comorbidity, smoking, preoperative anemia, and general anesthesia. However, increasing evidence suggests that residual neuromuscular block is an important risk factor for postoperative pulmonary complications and may affect the outcome. Conflicting data from some recent reports show that the use of quantitative neuromuscular monitoring alone does not preclude residual neuromuscular block and that improvements in the interpretation of neuromuscular monitoring may be required. Pulmonary complications seem to be reduced for train-of-four ratios > 0.95 before tracheal extubation compared with > 0.9.SummaryThis review stresses the need for appropriate management of neuromuscular block in the prevention of postoperative pulmonary complications but acknowledges that the causes are multifactorial.

Perioperative interventions for prevention of postoperative pulmonary complications: systematic review and meta-analysis

ObjectiveTo identify, appraise, and synthesise the best available evidence on the efficacy of perioperative interventions to reduce postoperative pulmonary complications (PPCs) in adult patients undergoing non-cardiac surgery.DesignSystematic review and meta-analysis...

Prevention of postoperative pulmonary complications in the hypoxaemic patient - gathering the evidence for noninvasive respiratory support.

Prevention of postoperative pulmonary complications in the hypoxaemic patient - gathering the evidence for noninvasive respiratory support.

Comparison of high-flow oxygen therapy with standard oxygen therapy for prevention of postoperative pulmonary complications after major head and neck surgery involving insertion of a tracheostomy: a feasibility study.

Major operations on the head and neck that involve microvascular reconstruction and a tracheostomy are prolonged procedures with considerable postoperative risk. Postoperative pulmonary complications are common because of mechanical ventilation, immobility, and inadequate humidification. High-flow heated oxygen therapy (HFOT) may overcome some of these issues, but we know of no published studies to support its use. The aim of this single-site randomised controlled trial therefore was to explore its feasibility and safety in these patients. Twenty patients were randomised to have HFOT (10 patients) or standard oxygen therapy (10 patients). HFOT was used from cessation of mechanical ventilation until decannulation of the tracheostomy. The primary outcome was feasibility. The secondary outcome measures explored the incidence of postoperative pulmonary complications, achievement of milestones of weaning from the tracheostomy, and hospital length of stay. A total of 21 patients were consecutively recruited and all provided informed consent. One who did not require a tracheostomy was later excluded. All patients initially had the intervention as planned, and one was electively changed to the control group because of discomfort caused by the high-flow oxygen. There were no adverse events or safety concerns in either group. Secondary outcomes showed a reduction in the incidence of pulmonary complications in the HFOT group. The use of HFOT is safe and feasible in patients who have microvascular reconstruction of the head and neck and a tracheostomy.

Routine practice in mechanical ventilation in cardiac surgery in Italy.

Management of mechanical ventilation is a key issue in the prevention of postoperative pulmonary complications (PPCs) and the improvement of surgical outcome. This is especially true in cardiac surgery where the use of the cardiopulmonary bypass (CPB) increases the risk of lung injury. In the last years a growing number of studies have shown that protective ventilation has led to excellent results. However, the literature in this regard is lacking in cardiac surgery and there are no univocal guidelines in this sense. The aim of this survey was to investigate the actual clinical practice about ventilation techniques used in the Italian cardiac surgery centers. A questionnaire of 32-item was sent to 69 Italian cardiac surgery centers, 56 of which return a completed form (81.2%). The questionnaire was assembled by three independent researchers and the final version was e-mailed to all members of the SIAARTI (Italian society of anesthesia resuscitation and intensive care medicine) Study Group on Cardiothoracic and Vascular Anesthesia. The answers were collected using a Google Forms sheet. In case of multiple questionnaires returned from the same center (i.e., different physicians from the same center responded) the head of department was asked to give a definite answer. Furthermore, for the 17 centers who reported multiple questionnaires, no large differences were found between the responses of different doctors belonging to the same center (12.3%±4.2% of discordant answers). Intraoperatively, patients were ventilated with a tidal volume (TV) of 6-8 mL/kg (91.1% of centers), a positive end-expiration pressure of 3-5 cmH2O (76.8% of centers) and a fraction of inspired oxygen (FiO2) of 50-80% (60.7% of centers). During the CPB, the "stop ventilation" technique was frequently adopted (73.2%). Before the discharge from the intensive care unit (ICU) non-invasive ventilation (NIV) was never applied in 32.1% of the centers, but it was used in 46.4% of patients with postoperative complications. This study shows a significant heterogeneity in ventilatory techniques among the Italian centers during CPB, whereas in the other surgical time the majority of the responding centers adopted a protective mechanical ventilation strategy.