Strategies to reduce postoperative pulmonary complications
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This document discusses strategies to reduce postoperative pulmonary complications for a 67 year old female smoker undergoing upper abdominal surgery who has COPD. It recommends that she use incentive spirometry and selective use of a nasogastric tube postoperatively. Intensifying bronchodilators and steroids is not recommended. Multiple studies have found that smoking cessation reduces postoperative pulmonary complications compared to current smokers. Incentive spirometry is likely better than no lung expansion but not clearly superior to other techniques. Routine use of nasogastric tubes may increase complications.
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Strategies to reduce postoperative pulmonary complications
- 1. Strategies to Reduce Postoperative Pulmonary Complications Terry Shaneyfelt, MD, MPH Assoc. Professor, UAB Department of Medicine
- 2. • Which of the following strategies should not be undertaken to reduce her risk of postoperative pulmonary complications? a) Incentive spirometry b) Intensify bronchodilators +/- steroids c) Prophylactic NG tube postoperatively d) Smoking cessation e) None of the above 67 yo F current smoker with COPD is undergoing upper abdominal surgery. PE reveals mild diffuse expir wheezing.
- 3. “…found to be at higher risk should receive the following postoperative procedures….1) deep breathing exercises or incentive spirometry and 2) selective use of a nasogastric tube…” “The following procedures should not be used…1) right heart catheterization and 2) total parenteral nutrition or total enteral nutrition.” 2006 ACP Guideline
- 4. Employ multiple strategies • Smoking cessation • Optimize lung disease • Delay surgery if infected • Antibiotics if infected • Lung expansion modalities • Alternative surgical procedure • Regional anesthesia • Avoid long acting neuromuscular blockers • Lung expansion • Epidural pain management • Selective NG tubes
- 5. Smoking Cessation Reduces Total & PPC Pulmonary complications: 15% past smokers vs 20% for current smokers • RR 0.73 (0.61 – 0.87)
- 6. Recent Tobacco Cessation Might Be Harmful
- 7. do Nascimento Junior P, Módolo NSP, Andrade S, Guimarães MMF, Braz LG, El Dib R. Incentive spirometry for prevention of postoperative pulmonary complications in upper abdominal surgery. Cochrane Database of Systematic Reviews 2014, Issue 2. Art. No.: CD006058. DOI: 10.1002/14651858.CD006058.pub3.
- 8. Freitas ERFS, Soares BGO, Cardoso JR, Atallah ÁN. Incentive spirometry for preventing pulmonary complications after coronary artery bypass graft. Cochrane Database of Systematic Reviews 2012, Issue 9. Art. No.: CD004466. DOI: 10.1002/14651858.CD004466.pub3.
- 9. Routine NGTs Increase PPCs Verma R, Nelson RL. Prophylactic nasogastric decompression after abdominal surgery. Cochrane Database of Systematic Reviews 2007, Issue 3. Art. No.: CD004929. DOI: 10.1002/14651858.CD004929.pub3.
- 11. • Optimize underlying lung disease • Incentive spirometry probably is better than nothing but it isnt superior (or worse) than other lung expansion modalities and its cheap • Smoking cessation is beneficial and should be initiated as early as possible • More studies are needed Summary
Editor's Notes
- These PowerPoints will review preoperative, intraoperative, and postoperative strategies that could reduce postoperative pulmonary complications.
- Knowledge check. Answer this question
- The 2006 ACP guideline only makes the above recommendations to reduce postop pulmonary complications.
- Patients at intermediate or high risk should receive multiple strategies beginning in the preoperative period and extending into the postoperative period to reduce PPCs. The 2006 ACP guidelines focus on lung expansion maneuvers and selective NG tube use but do review the data on these other modalities but for some reason chose not to make formal recommendations on their use.
- Mills and colleagues performed a systematic review of RCTs and observational studies evaluating the effect of smoking cessation on postoperative complications. 6 studies met their inclusion criteria and showed that smoking cessation resulted in a 41% relative reduction on all postoperative complications. Smoking cessation reduced pulmonary complications by 27% in past smokers relative to current smokers (absolute difference of 5%, NNT 20). They found that each week of cessation increased the magnitude of effect by 19%.
- Observational studies have suggested that recent quitting may be associated with increased PPC. This meta-analysis by Myers and colleagues examined the effect of recent quitting (within 8 weeks of surgery) to continued smoking. Overall, total complications were not affected by recent smoking cessation (RR 0.78, 95% CI 0.57 – 1.07). The above figure shows the effect of recent tobacco cessation on pulmonary complications. Patients who recently quit had a nonsignificant increase on pulmonary complications of 18% but it could have been up to 46%. A major limitation of this analysis is that someone who quit 2 days prior to surgery would be lumped with someone who quit 8 weeks ago. It is postulated that sympathetic activity associated with recent tobacco withdrawal could lead to increased risk of cardiovascular and pulmonary complications. Further study is needed to answer this important question.
- This is a Cochrane systematic review published in Feb 2014 examining the effects of incentive spirometry (IS) on pulmonary complications in patients undergoing upper abdominal surgery. They included 4 RCTs that compared IS to no therapy, deep breathing exercises, and chest physiotherapy. The trials are small and of unknown methodological quality due to poor reporting. Overall, no statistically significant benefit was proven for IS compared to no therapy (top figure) but the point estimate suggests a 41% reduction in pulmonary complications with the majority of the CI on the side of benefit. There was no difference between IS and deep breathing exercises (lower figure) nor chest physiotherapy (not shown).
- This is a Cochrane systematic review published in Sept 2012 examining the effects of incentive spirometry (IS) on pulmonary complications in patients undergoing CABG. They included 7 RCTs (not all shown here) that compared IS to chest physiotherapy, positive pressure breathing techniques, CPAP, BiPAP, IPPB, active cycle breathing, and patient education. The trials are small and of limited methodological quality and poorly reporting. Overall, no statistically significant benefit of incentive spirometry in preventing pneumonia compared to CPAP and BiPAP (middle and bottom figures, respectively). There is a suggestion of benefit vs preop counseling (top figure) which I consider a placebo arm.
- In this meta-analysis Verma and colleagues wanted to determine the efficacy of routine nasogastric decompression after abdominal surgery in preventing pulmonary complications (amongst other outcomes). As you can see in the above figure routine NG tube placement actually increased pulmonary complications by 45% (RR 1.45 with 95% CI 1.10-1.92). Thus it is only recommended that NG tubes be placed in very select circumstances: postop nausea and abdominal distention. The NG tube likely facilitates microaspiration of gastric contents leading to pulmonary complications.
- This metaanalysis was published some time ago but shows that selective NG tube placement resulted in lower rates of pneumonia and atelectasis than routing placement of NG tubes after elective laparotomy. It is unclear what the findings would be for laparoscopic surgery.
- Underlying lung disease should be optimized prior to surgery. This may require additional medications or short course of steroids. Incentive spirometry seems to work but the data are limited. All lung expansion maneuvers similarly effective. Smoking cessation works but needs to be started early as possible. Data on interventions to limit postop pulmonary complications are limited and more studies are needed. Many of the studies are small with limited numbers of outcomes. They were also done many years ago and may not apply to todays more advanced technology.