Singapore General Hospital

Policy & Procedure

Title: Document No: Page 1 of 4

Guidelines on Preoperative Assessment of Respiratory
Conditions
Issued By: Perioperative Services, Dept of Approved By:
Anaesthesiology (Dr Hairil Abdullah) A/P Ruban Poopalalingam Head, Department of
Initial Date Issued: 3/1/2013 Anaesthesia
Date Revised: 1/7/2017
Revision number: 2

INTRODUCTION

Pulmonary complications occurs significantly more often than cardiac complications and were
associated with significantly longer hospital stays and contributes significantly to overall
1
perioperative morbidity and mortality . Important pulmonary complications include pneumonia,
respiratory failure with prolonged mechanical ventilation, bronchospasm, atelectasis, and
exacerbation of underlying chronic lung disease. This guideline aims to assist SGH anaesthetic
practitioners in risk stratification and optimisation of patients with respiratory co-morbidities coming
for non-lung resection cases

ASSESSMENT

1. History taking should aim to seek for presence of patient’s respiratory risk factors -
a. Age > 65
b. Chronic Obstructive Pulmonary Disease (COPD)
c. Asthma (Patients with asthma who are well controlled and who have a peak flow
measurement of >80 percent of predicted or personal best can proceed to surgery
at average risk)
d. Smoking within the past 2 months, >20 pack-year history
e. Moderate to severe obstructive sleep apnea (OSA)
f. Pulmonary hypertension (symptomatic, NYHA ≥2)
g. Heart failure (The risk of pulmonary complications may be higher in patients with
heart failure than in those with COPD)
h. General health status (ASA score >2)
i. Active respiratory infection, consider deferring surgery in patients with active upper
and lower respiratory infections to allow for treatment and recovery.

2. Patient’s risk factors should be matched against the procedure related risk factors
a. Surgical site - the single most important factor in predicting the overall risk of
postoperative pulmonary complications; the incidence of complications is
inversely related to the distance of the surgical incision from the diaphragm
b. Duration of surgery >3-4 hrs
c. General anaesthesia vs regional anaesthesia

3. Physical examination
a. Physical examination should be directed toward evidence for obstructive lung
disease, especially noting decreased breath sounds, wheezes, rhonchi, or prolonged
expiratory phase
 Singapore General Hospital
Policy & Procedure

Title: Document No: Page 2 of 4

Guidelines on Preoperative Assessment of Respiratory
Conditions
Issued By: Perioperative Services, Dept of Approved By:
Anaesthesiology (Dr Hairil Abdullah) A/P Ruban Poopalalingam Head, Department of
Initial Date Issued: 3/1/2013 Anaesthesia
Date Revised: 1/7/2017
Revision number: 2

b. Oxygen saturation by pulse oximetry helps to stratify risk and is useful before
high-risk surgeries (SpO2 ≤95%)

4. Investigations
a. Chest X-ray - patients with known cardiopulmonary disease or >50 years old
b. Arterial Blood Gas - Current data do not support the use of preoperative arterial
blood gas analyses to stratify risk for postoperative pulmonary complications unless
baseline SpO2 is ≤93% on room air. Case exceptions include those with known
Type II respiratory failure and/or cor pulmonale

5. Internal Medicine Perioperative Team (IMPT) – pls check monthly roster referrals: NOTE
only for patients with no pre-existing RCCM follow up or severe respiratory conditions. For
these patients, see point 6 below
a. Referral to IMPT should be made in cases where there is a clinical suspicion of chest
infections, for example, Pneumonia or pulmonary tuberculosis.

6. Respiratory medicine (RCCM) referrals –

a. Referral to respiratory physicians should be made if there are conditions that can
be optimised or need for specialised testing. These will include pulmonary function
test (PFT) and/or cardiopulmonary exercise testing (CPET). Respiratory registrar
on-call could be consulted first for advice on clinic appt date or inpatient review.
b. Referral should be made if chest X-rays are abnormal
c. Refer patients with COPD or asthma if clinical evaluation cannot determine if the
patient is at their best baseline and that airflow obstruction is optimally reduced.
In this case, PFTs may identify patients who will benefit from more aggressive
preoperative management.
d. Consider referring patients with dyspnea or exercise intolerance that remains
unexplained after clinical evaluation (differential diagnosis may include
cardiac disease or deconditioning). The results of PFTs may change
preoperative management.
e. Referral for PFT could also be considered in patients with severe restrictive lung
disease to investigate for presence of concomitant reversible obstructive component.
f. PFTs should not be used as the primary factor to deny surgery nor ordered
routinely prior to abdominal surgery or other high risk surgeries.
 Singapore General Hospital
Policy & Procedure

Title: Document No: Page 3 of 4

Guidelines on Preoperative Assessment of Respiratory
Conditions
Issued By: Perioperative Services, Dept of Approved By:
Anaesthesiology (Dr Hairil Abdullah) A/P Ruban Poopalalingam Head, Department of
Initial Date Issued: 3/1/2013 Anaesthesia
Date Revised: 1/7/2017
Revision number: 2

7. OPTIMIZATION OF PATIENTS

1. Smoking cessation prior to surgery

 Consider referring to SGH smoking cessation clinic at Clinic A (ext: 4307)
 Smoking cessation should be advised regardless of the time frame prior to surgery
2. Lung expansion training
 Should be considered in high risk patients. 
 Incentive spirometry, and voluntary deep breaths are best taught prior to surgery. It
is more difficult to emphasize the importance of these strategies to a postoperative
 patient who may be in pain and sedated from analgesic medication. 
 Referral for incentive spirometry training (outpatient physiotherapist ext 4132/4130)

3. Antibiotics
 They should be administered only in patients with a clinically apparent respiratory
infection such as bronchitis, manifest by purulent sputum or a change in the
character of sputum (to inform primary team and refer to IMPT or RCCM – see
 above) 
 Consider delaying surgery if active respiratory infection is present 

4. COPD
 Baseline SpO2 and spirometry evaluation for those with impaired effort
 tolerance (NYHA ≥2) 
  Pre-operative chest X-ray must be done 
 2DE for suspected complications such as pulmonary hypertension 

 Evaluation by RCCM for further optimisation of medication in non-urgent
 surgery if FEV1 <50% or NYHA >2 
 To counsel on regional or local anesthesia when possible 

 Continue inhalers both pre and post op and consider usage of nebulisers and steroids
 if necessary 
 Pre and post operative incentive spirometry and chest physiotherapy 

5. Asthma
 Evaluate Asthma Control Test score (ACT) 

 If ACT score ≤19 and need optimisation of medications, postpone surgery if feasible
and refer RCCM 

 Continue inhalers both pre and post op and consider usage of nebulisers and steroids
if necessary 



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 Singapore General Hospital
Policy & Procedure

Title: Document No: Page 4 of 4

Guidelines on Preoperative Assessment of Respiratory
Conditions
Issued By: Perioperative Services, Dept of Approved By:
Anaesthesiology (Dr Hairil Abdullah) A/P Ruban Poopalalingam Head, Department of
Initial Date Issued: 3/1/2013 Anaesthesia
Date Revised: 1/7/2017
Revision number: 2





RISK COUNSELLING

1. Risk discussion should be undertaken with patients with respiratory risk factors (as
listed above) coming in for surgery under anaesthesia
2. Important pulmonary complications include pneumonia, respiratory failure with prolonged
mechanical ventilation, bronchospasm, atelectasis, and exacerbation of underlying
chronic lung disease.
3. Postoperative pulmonary complications prolong the hospital stay by an average of 1-2
weeks, and are likewise associated with increased morbidity and mortality.
4. While risks in terms of percentage are difficult to define due to lack of data, the more risk
factors present, the higher is the risk.
An estimate of postoperative respiratory failure (PRF) risk (failure to wean from
mechanical ventilation within 48 hrs of surgery or unplanned intubation/ventilation
postoperatively) can be calculated from the PRF calculator available in the dept
website. This validated risk healthcare setting and is intended to supplement the
anaesthetist’s own judgment and should not be taken as absolute.calculator is based on
a model derived from a large sample of patients in the American

REFERENCES

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postoperative respiratory failure in men after major noncardiac surgery. The National
Veterans Administration Surgical Quality Improvement Program. Ann Surg 2000; 232:242–
253.
4. Gupta H, Gupta PK, Fang X, Miller WJ, Cemaj S, Forse RA, Morrow LE. Development and
validation of a risk calculator predicting postoperative respiratory failure. Chest 2011 Nov;
140(5):1207-15.
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pulmonary complications after nonthoracic surgery. Am J Respir Crit Care Med. Mar 1
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6. Overend TJ, Anderson CM, Lucy SD, et al. The effect of incentive spirometry on
postoperative pulmonary complications: a systematic review. Chest. Sep 2001;120(3):971-8
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population-based surgical cohort. Anesthesiology 2010; 113:1338.
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