Significant Postoperative Pulmonary Complications Research Articles

Small airway dysfunction associated with poor short-term outcomes in patients undergoing thoracoscopic surgery for lung cancer

BackgroundAlthough small airway dysfunction is a common respiratory dysfunction, its prognosis after lung cancer surgery is often neglected. This study investigated the relationship between small airway dysfunction and outcomes in patients who underwent thoracoscopic surgery for lung cancer. MethodsA retrospective cohort study of patients who underwent thoracoscopic surgery was conducted between December 2019 and March 2021 at Ningbo First Hospital. We used univariate and multivariate analyses to assess the possible associations between postoperative outcomes and clinical variables, including small airway dysfunction. To balance the potential confounding factors, propensity score matching was performed to establish 1:1 small airway dysfunction and small airway normal function group matching. ResultsIn this study, 1,012 patients undergoing thoracoscopic surgery for lung cancer were enrolled. Small airway dysfunction was present in 18.7% of patients (189/1,012). The incidence of postoperative pulmonary complications in the small airway dysfunction group was higher than that of the small airway normal function group (16.4% vs 6.2%, P < .001). The most significant postoperative pulmonary complications were pneumonia (7.4% vs 2.4%, P < .001) in the small airway dysfunction and normal function groups, respectively. In addition, a significantly prolonged median hospital length of stay was observed in the small airway dysfunction group compared to the small airway normal function group (median [interquartile range], 9 [7–12] vs 8 [7–9], P < .001). After 1:1 propensity score matching, 298 patients (149 pairs) were included in the comparison between small airway dysfunction and small airway normal function, and this association remained. Postoperative pulmonary complications (13.4% vs 6.0%, P = .032) were still higher, and length of stay (median [interquartile range] 9 [7–11] vs 8 [6–10] days, P = .001) was still longer in the small airway dysfunction group. Multivariate analysis indicated that small airway dysfunction was the independent risk factor associated with both postoperative pulmonary complications (odds ratio = 2.694, 95% confidence interval: 1.640–4.426, P < .001) and prolonged length of stay (beta = 1.045, standard error = 0.159, 95% confidence interval: 0.733–1.357, P < .001). ConclusionOur study showed that small airway dysfunction increased the incidence of postoperative pulmonary complications and prolonged length of stay in patients undergoing thoracoscopic surgery for lung cancer.

A Scoring Tool That Identifies the Need for Positive-Pressure Ventilation and Determines the Effectiveness of Allocated Respiratory Therapy.

Hospital-acquired pneumonia (HAP) and the need for positive-pressure ventilation (PPV) are significant postoperative pulmonary complications (PPCs) that increase patients' lengths of stay, mortality, and costs. Current tools used to predict PPCs use nonmodifiable preoperative factors; thus, they cannot assess provided respiratory therapy effectiveness. The Respiratory Assessment and Allocation of Therapy (RAAT) tool was created to identify HAP and the need for PPV and assist in assigning respiratory therapies. This study aimed to assess the RAAT tool's reliability and validity and determine if allocated respiratory procedures based on scores prevented HAP and the need for PPV. Electronic medical record data for nonintubated surgical ICU subjects scored with the RAAT tool were pulled from July 1, 2015-January 31, 2016, using a consecutive sampling technique. Sensitivity, specificity, and jackknife analysis were generated based on total RAAT scores. A unit-weighted analysis and mean differences of consecutive RAAT scores were analyzed with RAAT total scores ≥ 10 and the need for PPV. The first or second RAAT score of ≤ 5 (unlikely to receive PPV) and ≥ 10 (likely to receive PPV) provided a sensitivity of 0.833 and 0.783 and specificity of 0.761 and 0.804, respectively. Jackknifed sensitivity and specificity for identified cutoffs above were 0.800-0.917 and 0.775-0.739 for the first RAAT score and 0.667-0.889 and 0.815-0.79 for the second RAAT score. The initial RAAT scores of ≥ 10 predicted the need for PPV (P < .001) and was associated with higher in-hospital mortality (P < .001). Mean differences between consecutive RAAT scores revealed decreasing scores did not need PPV. The RAAT scoring tool demonstrated an association with the need for PPV using modifiable factors and appears to provide a quantitative method of determining if allocated respiratory therapy is effective.

Value of the oxygenation index during 1-lung ventilation for predicting respiratory complications after thoracic surgery

PurposeThoracic surgery requiring 1-lung ventilation (OLV) is associated with significant postoperative pulmonary complications (PPCs) due to patient- and surgery-specific risk factors. The aim of this study is to determine whether the oxygenation index (OI) (fraction of inspired oxygen × mean airway pressure/partial pressure of oxygen) during OLV predicts the development of PPC. Materials and methodsThe Society of Thoracic Surgeons General Thoracic Surgery Database at the University of Virginia was used to identify all thoracic cases in 2012 to 2014. All subjects requiring OLV and in whom a blood gas was available for analysis were included. Univariate and multivariate analyses were performed to determine whether the OI predicted the development of PPC. ResultsA total of 296 subjects had OLV with a calculable OI during the study period. Composite PPC were identified in 97 (33%) of subjects. In the PPC group, mortality at 30 days was 7.2%, whereas no deaths were identified in the non-PPC group. In both univariate and multivariate analyses, OI was not predictive of PPC analysis (odds ratio [OR], 1.0; 95% confidence interval [CI], 0.9-1.1; P = .8). The only predictors of mortality were forced expiratory volume (OR, 0.98; 95% CI, 0.96-0.99; P = .03) and diffusion capacity of carbon monoxide (OR, 0.98; 95% CI, 0.96-0.99; P = .03). ConclusionThe calculated OI during OLV is not predictive of PPC in our sample. Additional studies in a larger cohort of patients are needed to identify intraoperative ventilation parameters during OLV that can predict the risk of PPC.

Randomised clinical trial of physiotherapy after open abdominal surgery in high risk patients

Postoperative physiotherapy has been shown to reduce the incidence of postoperative pulmonary complications after open abdominal surgery. This study aimed to determine if the addition of deep breathing exercises and secretion clearing techniques to a standardised physiotherapist-directed program of early mobilisation improved clinical outcomes in patients undergoing open abdominal surgery. Fifty-six patients undergoing open abdominal surgery, at high risk of developing postoperative pulmonary complications, were randomised before operation to an early mobilisation-only group or an early mobilisation-plus-deep breathing and coughing group. Mobility duration, frequency and intensity of breathing interventions were quantified for both groups. All outcomes were assessed by a blinded outcomes researcher using a standardised outcomes measurement tool developed specifically for this population. Outcomes included incidence of clinically significant postoperative pulmonary complications, fever, length of stay, and restoration of mobility. There were no significant differences between groups in mean age, anaesthetic time, perioperative morbidity, or postoperative mobility. Outcome data were available for 89% of enrolled subjects. Overall incidence of postoperative pulmonary complications was 16%. The incidence of postoperative pulmonary complications in the non-deep breathing and coughing group was 14%, and the incidence of postoperative pulmonary complications in the deep breathing and coughing group was 17%, (absolute risk reduction -3%, 95% C1 -22 to 19%). There was no significant difference between groups in the incidence of fever, physiotherapist time, or the number of treatments. This study suggests that, in this clinical setting, the addition of deep breathing and coughing exercises to a physiotherapist-directed program of early mobilisation does not significantly reduce the incidence of clinically significant postoperative pulmonary complications in high risk open abdominal surgery subjects.

PULMONARY FUNCTION TESTS IN PREOPERATIVE PULMONARY EVALUATION

Pulmonary function testing (PFT) is used extensively by pulmonary specialists to address two common clinical questions: (1) What is the risk of a postoperative pulmonary complication in an individual with lung disease? and (2) Will the patient be able to tolerate lung resection surgery? Today, there are numerous tests available to measure pulmonary function; making judicious use of these tests essential. In this article, the authors describe significant postoperative pulmonary complications, and discuss the surgical and patient factors contributing to the risk of these complications. They provide an evidence-based approach using pulmonary function data to determine an individual patient's risk for pulmonary complications associated with three types of surgical procedures-upper abdominal, cardiac, and lung resection-and discuss recommendations for risk education.

Pulmonary function after cardiac and thoracic surgery

Cardiac and thoracic surgery cause alterations in ventilatory function that can lead to significant postoperative pulmonary complications. These complications often occur among patients with pre-existing pulmonary dysfunction and cause significantly longer hospital stays. This review explores some of the recent literature concerning this issue, including the effects of lung reduction surgery.

Preoperative Pulmonary Evaluation

Postoperative pulmonary complications are an important part of the risk of surgery and prolong the hospital stay by an average of one to two weeks.1 Much of the literature on the assessment of perioperative risk has focused on identifying the now well-defined cardiac risk factors. However, clinically significant postoperative pulmonary complications are as common as postoperative cardiac complications. According to one review, pulmonary complications were at least as common as or more common than cardiac complications in 17 of 25 studies of postoperative complications.2 This article reviews patient- and procedure-related risk factors, clinical evaluation, pulmonary-function testing, and risk-reduction strategies. The . . .

Preoperative pulmonary evaluation.

Postoperative pulmonary complications are an important part of the risk of surgery and prolong the hospital stay by an average of one to two weeks.1 Much of the literature on the assessment of perioperative risk has focused on identifying the now well-defined cardiac risk factors. However, clinically significant postoperative pulmonary complications are as common as postoperative cardiac complications. According to one review, pulmonary complications were at least as common as or more common than cardiac complications in 17 of 25 studies of postoperative complications.2 This article reviews patient- and procedure-related risk factors, clinical evaluation, pulmonary-function testing, and risk-reduction strategies. The . . .

The incidence of pulmonary complications in patients not receiving prophylactic chest physiotherapy after cardiac surgery

Following the recommendations of Stiller et al (1994), patients undergoing routine cardiac surgery in our unit no longer receive pre- or post-operative prophylactic chest physiotherapy. The purpose of this prospective study was to document the incidence of clinically significant pulmonary complications subsequent to this change in management. Altogether, 127 patients who underwent cardiac surgery during an 8-week period completed the study. Nine (7.1%) patients developed clinically significant post-operative pulmonary complications. This was not significantly different from the incidence reported by Stiller et al (1994). These results provide further evidence that prophylactic chest physiotherapy is not required after routine cardiac surgery.

Unit rod segmental spinal instrumentation in the management of patients with progressive neuromuscular spinal deformity.

Thirty-four nonambulatory patients with progressive neuromuscular spinal deformity were surgically managed using a 1/4" U-shaped double rod construct with segmental instrumentation from T2 to the pelvis accompanied by posterior spinal fusion. Diagnoses included 17 patients with cerebral palsy, six with spinal bifida, and 11 with other diseases (spinal muscular atrophy, Friedreich's ataxia, polyneuropathy, nemaline myopathy, and polio). Twenty-three patients had single uncompensated thoracolumbar curves, and 11 had a double curve pattern. The mean preoperative major curve was 66 degrees (range, 22-132 degrees), the secondary curve 58 degrees (range, 23-84 degrees). No postoperative spinal support was used. Mean curve correction was 36 degrees or 54.6%. There were four major complications, including two implant failures requiring revision and two patients sustaining excessive intraoperative blood loss necessitating completion of the procedure in a second stage. There were two neurologic complications including one case of postoperative seizures and an L4 monoradicular neuropathy in a spina bifida patient. Four patients had temporary postoperative ileus, one gastroesophageal reflex, and four had urinary tract infections. There were no significant postoperative pulmonary complications. Excluding the patients with rod failure, mean loss of correction at mean follow-up of 21.3 months was 6.5%. The stability and curve correction obtained using this system supports its continued use in patients with progressive neuromuscular scoliosis.

PREVENTION OF POSTOPERATIVE PULMONARY COMPLICATIONS. USE OF ISOPROTERENOL AND INTERMITTENT POSITIVE PRESSURE BREATHING ON INSPIRATION.

The purpose of this study was to determine whether the use of intermittent positive pressure breathing during inspiration (IPPB[I]) combined with administration of nebulized isoproterenol (Isuprel) would reduce the incidence of postoperative pulmonary complications. There were 160 patients in the control group and 42 in the group receiving IPPB(I) with isoproterenol. The treated group contained more patients of more than 60 years of age and more with maximum breathing capacities of less than 60% of that predicted; otherwise, the two groups were similar. Significant postoperative pulmonary complications were experienced by 19.5% of the control group and 2.5% of the treated group. The incidence of postoperative pulmonary complications in the control group was 2.5 times as great for those patients who had maximum breathing capacities of less than 60% of that predicted than for those in the same group whose maximum breathing capacities were greater than 60% of that predicted.

THE DECREASING HAZARD OF SURGICAL PROCEDURES ON PATIENTS WITH ASTHMA

SUMMARY In a series of 153 patients with asthma who underwent major surgical procedures at the Mayo Clinic from January, 1950, through December, 1955, there were six (3.9 per cent) who had pulmonary complications after operation. This percentage is significantly less than the 13.2 per cent and 15 per cent respectively observed in two previously reported series from the clinic prior to the widespread use of antibiotics. The decrease is attributed mainly to the optimal control of asthma before and after operation, to the use of antibiotics when indicated, and to the newer steroid therapy. Thus, 96.1 per cent of these patients underwent major surgical procedures without the development of significant postoperative pulmonary complications. It is concluded that the properly prepared asthmatic patient is a good surgical risk. Pulmonary complications occurred in four of 178 asthmatic patients (2.2 per cent) who underwent minor operations. All the complications consisted of severe asthma and all were associated with bronchoscopy. There was one death in this category. The mortality rates for the two previously reported series and for the present series of 153 patients who underwent major operations were approximately the same (2.1, 1.4 and 1.3 per cent respectively). It is impossible, however, to compare these rates statistically because of the variety of diseases present other than bronchial asthma. The majority of complications occurred in those patients with intrinsic asthma of long duration. No untoward effects were attributed to the anesthetic agents used.

The Decreasing Hazard of Surgical Procedures on Patients with Asthma

In a series of 153 patients with asthma who underwent major surgical procedures at the Mayo Clinic from January, 1950, through December, 1955, there were six (3.9 per cent) who had pulmonary complications after operation. This percentage is significantly less than the 13.2 per cent and 15 per cent respectively observed in two previously reported series from the clinic prior to the widespread use of antibiotics. The decrease is attributed mainly to the optimal control of asthma before and after operation, to the use of antibiotics when indicated, and to the newer steroid therapy. Thus, 96.1 per cent of these patients underwent major surgical procedures without the development of significant postoperative pulmonary complications. It is concluded that the properly prepared asthmatic patient is a good surgical risk. Pulmonary complications occurred in four of 178 asthmatic patients (2.2 per cent) who underwent minor operations. All the complications consisted of severe asthma and all were associated with bronchoscopy. There was one death in this category. The mortality rates for the two previously reported series and for the present series of 153 patients who underwent major operations were approximately the same (2.1, 1.4 and 1.3 per cent respectively). It is impossible, however, to compare these rates statistically because of the variety of diseases present other than bronchial asthma. The majority of complications occurred in those patients with intrinsic asthma of long duration. No untoward effects were attributed to the anesthetic agents used.