1.
Sultan Qaboos University Hospital, Muscat

2.
JACKSON EQUESTRIAN MONUMENT
downtown Charlottesville,Virginia “Stonewall” Jackson
Confederate General
…dying of pneumonia 10 days after
an otherwise successful ether anesthetic
1863

3.
SIGNIFICANCE OF

4.
Pneumonia
Definite /
Suspected
Respiratory failure
Requiring mechanical
ventilatory support
Bronchospasm

5.
Unexplained fever
Excessive bronchial secretions
Abnormal breath sounds
“Productive” cough
Atelectasis
Hypoxemia

6.
22.7
9.610.7
5.7
0
5
10
15
20
25
Hospital stay Complis
PULM
CARDIAC

7.
Causes of

8.
Disruption of normal activity of
respiratory muscles
Altered neural drive for respiration
• Distribution
• Timing

9.
Begins with induction of anesthesia
Continues
into postop
period

10.
EXPIRATION

11.
INSPIRATION
AWAKE
COORDINATED

12.
INSPIRATION
ANESTHETISED
INCOORDINATED

13.
Reduces efficiency
Decreases FRC
Atelectasis in dependent lung
Impair pulmonary gas exchange

14.
Impair effectiveness
Voluntary limitation of
respiratory motion
Decreased phrenic
motor neuron output

15.
Bronchoconstriction
• Airway instrumentation; drugs- release of inflammatory
mediators
Impaired mucociliary transport
• Anesthetic gases; tracheal intubation
Functional impairment of pulm inflammatory cells
• Prolonged surgery, anesthesia
Surgical/anesth intervention related
• Aspiration pneuminitis;ALI –after CPB; Pneumothorax-
barotrauma/surgical trauma; Negative Pr Pulm Edema

16.
Risk factors for

17.
The most important risk factor for
postoperative pulmonary
complications?
A. High-risk surgical site B. General anesthesia
C. COPD D. Obesity

18.
Patient-related
Advanced age
ASA PS >2
Cong Heart failure
Functional dependency
COPD
Surgery-related
Aortic aneurysm repair
Thoracic surgery
Abdominal surgery
Upper abdominal surgery
Neurosurgery
Prolonged surgery
Head & Neck surgery
Emergency surgery
Vascular surgery
Use of GeneralAnesthesia

19.
Patient-related
Weight-loss
Impaired sensorium
Cigarette use
Alcohol use
Abnormal chest exam
Surgery-related
Perioperative transfusion

20.
Patient-related
Well-controlled asthma
Obesity
Surgery-related
Hip surgery
GU/Gynaec surgery

21.
Patient-related
Obstructive sleep apnoea #
Poor exercise capacity
Surgery-related
Esophageal surgery
# - subsequent evidence : OSA – possible risk factor

22.
Which of the following is a recently
identified novel risk factor for PPCs?
C. Pulmonary
Hypertension
B. Insulin-treated diabetesA. Epidural anesthesia
D. Immobility

23.
Strategies for risk reduction

24.
Postoperative lung expansion modalities
• Incentive spirometry
• Deep breathing exercises
• Int. Positive Pressure Breathing
• CPAP

25.
Selective postop NG tube use
NG tubes potentially increase risk of aspiration
Use in select patients:
• Symptomatic abdominal distention
• Inability to tolerate oral intake
• Nausea

26.
Laparoscopic (vs Open) operation
Evidence begins to follow intuition
Open surgery:
• Higher rate of sepsis
• CV events

27.
RoutineTPN or enteral nutrition
Right heart catheterization
While hypoalbuminemia and malnutrition
increase postoperative complications,
including pneumonia, routineTPN has no
benefit over eitherTEN or no
hyperalimentation.
Inadequate intake
Atrophy of intestinal villi
Bacterial translocation across
gut mucosa
Subsequent sepsis

28.
Intraop neuraxial blockade
Postop epidural analgesia
Insufficient or conflicting data
? Selection bias
? Insufficiently powered study
- Study on low-risk procedure

29.
Intraop neuraxial blockade
Postop epidural analgesia
IV PCA vs PCEA vs On-demand analgesia
?Timing issues (Heparin prophylaxis)

30.
Smoking cessation
Early reports - those who quit shortly
before surgery actually had higher
complication rates
Question remains unanswered

31.
Promising New Intervention

32.
 Preoperative lung expansion
 Inspiratory MuscleTraining

33.
Preop IMT can be done in chest physical
therapy OPD or a pulmonary rehabilitation
clinic

34.
Take Home Messages

35.
PPCs incidence
More common than cardiac
complications after non-
cardiac surgery

36.
Surgical site
Most important predictor of
risk of PPCs:
Aortic, thoracic and upper
abdominal surgeries are high-
risk procedures, even in
healthy patients

37.
OSA & Pulmonary HTN
Recently identified as risk
factors;
Limited available evidence
does not support preop
screening (in patients without
symptoms)

38.
Postop CPAP
Effective for reducing
pulmonary complications in
patients who are unable to
perform deep breathing or
incentive spirometry
exercises

39.
Smoking cessation
As an effective strategy to
reduce pulmonary risk
remains unanswered…

40.
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