PERIOPERATIVE CARE
Postoperative pulmonary
complications and their
prevention
Christina TY Cheung
Eva YF Chan
Abstract
Postoperative pulmonary complications are common. Despite ad-
vances in perioperative care for patients undergoing major surgery,
they are associated with increased morbidity, mortality and healthcare
costs. Strategies to reduce postoperative pulmonary complications
include identification of patients at risk for respiratory complications,
followed by risk stratification and perioperative optimization. This article
evaluates current literature on the definition of postoperative pulmonary
complications, their underlying biological mechanisms, contributing
risk factors and preventative measures. Of note, the wide variability in
the definition of postoperative pulmonary complications highlights the
importance of identifying outcome measures and standardized end
points as they affect the validity of clinical trials. Validated risk predic-
tion models are useful tools for clinicians to stratify patients at risk,
however there is still a lack of consensus over which model is the
best one to use. Evidence for preventative measures including smoking
cessation, correction of anaemia, perioperative respiratory physio-
therapy and intraoperative management including lung-protective
ventilation and goal-directed haemodynamic therapy are discussed.
Most importantly, perioperative care bundles demonstrate the impor-
tance of multidisciplinary involvement during different time points
when a patient undergoes surgery, and a combination of interventions
are found to be more beneficial than individual interventions alone.
Keywords Perioperative care; postoperative complications; preop-
erative assessment; respiratory complications; risk scoring
Royal College of Anaesthetists CPD Skills Framework: Airway and
resuscitation
Introduction
Postoperative pulmonary complications (PPCs) constitute the
most common medium- to long-term complications after major
surgery. The incidence is 1e23% after major surgery,1,15 and
several studies have shown that pulmonary complications are
more common than cardiac complications. PPCs have a sig-
nificant impact on both short- and long-term mortality, and
overall post-surgical outcome. Patients who underwent non-
cardiothoracic surgery under general anaesthesia were found
Christina TY Cheung MBBS is a Trainee in Anaesthesiology at Queen
Mary Hospital, Hong Kong. Conflict of interests: none declared.
Eva YF Chan MBChB FHKCA FHKAM(Anaesthesiology) is an Associate
Consultant in Anaesthesiology, Queen Mary Hospital, Hong Kong.
Conflict of interests: none declared.
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Learning objectives
After reading this article, you should be able to:
C Describe the risk factors associated with postoperative pulmo-
nary complications (PPCs)
C Quantify risks and predict the occurrence of PPCs using vali-
dated risk scores
C Identify patients presenting for surgery with high risk for PPCs
and implement relevant preoperative and intraoperative
interventions
to have higher rates of mortality, intensive care unit (ICU)
admissions and prolonged lengths of stay if they have at least
one pulmonary complication4 with a reported 30-day mortality
of 14e30% in those with PPCs versus 0.2e3% in those without
PPCs,5 and a reported 90-day mortality of 24.4% versus 1.2%,6
with major long-term differences lasting up to 5 years. A large
observational study in 2005 demonstrated major long-term
differences in mortality rates in patients with and without
PPCs: 45.9% vs 8.7% at 1 year and 71.4% vs 41.1% at 5
years.5
The underlying causes leading to the development of PPCs are
multifactorial, and they often involve a complex interplay of
patient, surgical and anaesthetic factors.1,2,15 This highlights the
importance of risk stratification and early implementation of risk
reduction strategies in high risk individuals. Not only do PPCs
have a significant impact on patients’ recovery and mortality,
they also increase the burden on healthcare services by
increasing the demand on mechanical ventilation, admission to
critical care and length of hospital stay.
This paper aims to review current literature on the wide
range of definitions of PPCs, and evaluates the underlying
mechanisms and contributing risk factors for subsequent risk
stratification, the use of prediction models, and emphasizes how
multidisciplinary involvement and preventive measures in the
perioperative periods may improve overall post-surgical
outcomes.
Definition of PPC
Definitions of PPCs vary between studies and are insufficient to
allow direct comparison for clinical effectiveness in various trials
of treatments. The differing definitions of PPCs account for the
variation in incidence and mortality rates reported in current
literature, alongside heterogeneous patient populations and sur-
gical specialties.
The latest recommendations consider PPCs as a composite
adverse outcome measure. In 2015, a European joint taskforce
(EPCO) of the European Society of Anaesthesiology (ESA) and
the European Society of Intensive Care medicine (ESICM)
published updated standards for the definitions of PPCs. It in-
cludes respiratory infection, aspiration pneumonitis, pleural
effusion, atelectasis, pneumothorax, bronchospasm and respi-
ratory failure. Consequently, acute respiratory distress syn-
drome (ARDS) and pulmonary embolism were considered as
independent adverse outcomes.2 Subsequently in 2018, a
688 Ó 2022 Published by Elsevier Ltd.
 PERIOPERATIVE CARE
consensus definition of PPC was further published.1 The
Standardised Endpoints for Perioperative Medicine (StEP)
group, comprising a core group of international experts, pub-
lished four recommended outcome measures to be included as
PPCs: (i) atelectasis (ii) pneumonia (iii) acute respiratory
distress syndrome and (iv) pulmonary aspiration. An assess-
ment of severity was also incorporated into the definition.
Although not every definition may be universally applicable,
depending on the size of the trial, the authors believe the new
definition may be less prone to methodological bias.
Perioperative pulmonary physiology and mechanisms
leading to PPCs
Perioperative changes
Upon induction of anaesthesia, a series of changes arise in a
patient’s respiratory physiology. Anaesthetic agents cause cen-
tral respiratory drive depression, resulting in a dose-dependent
reduction in minute ventilation and tidal volume. Control of
ventilation will also be affected as there is a resultant decreased
ventilatory response to hypercapnia and hypoxia. Moreover, it
was found that during preoxygenation, the use of high frac-
tional inspired oxygen (FiO2) of 1.0 results in 5% atelectasis,
whereas the use of FiO2 of 0.6 only results in <0.2% atelectasis.
During general anaesthesia, functional residual capacity (FRC)
is reduced by 20% due to the loss of diaphragmatic and respi-
ratory muscle tone, irrespective of whether a neuromuscular
blocking agent is administered. FRC is further reduced by 20%
upon supine positioning due to cephalad movement of the
diaphragm, and vital capacity is reduced by 50e60%. Chest
wall compliance is reduced by the use of opioids and muscle
relaxants. Airway resistance is increased due to stimulated
sputum production and decreased ciliary clearance. Intermittent
positive pressure ventilation and reduced cardiac output will
also increase alveolar dead space, leading to ventilation-
perfusion mismatch. In summary, reduced ventilatory drive,
impaired cough reflex, altered muscle function and reduced FRC
as a result of general anaesthesia ultimately contribute to the
formation of atelectasis, which increases the risk of developing
PPCs in later stages of recovery.
Postoperatively, residual anaesthetic and opioid sedative effects,
hypercapnia and oropharyngeal dysfunction resulting from inade-
quate reversal of neuromuscular blockade may lead to immediate
pulmonary complications and hypoxia in the postoperative anaes-
thetic care unit. Moreover, postoperative pain causes a decrease in
tidal volume and an increase in respiratory rate, with more pro-
nounced effects from upper abdominal and thoracic incisions.
Long-term postoperative changes
After general anaesthesia, the reduction in FRC can take 5
e7 days to return to normal. Forced expiratory volume, forced
vital capacity and peak expiratory flow rate are effort-dependent,
and these are affected by postoperative pain. In addition,
impaired ventilatory responses to hypoxia and hypercapnia can
persist for up to 6 weeks after surgery.
Preoperative risk stratification
Preoperative risk predictive models allow clinicians to identify
patients with high risks of developing PPCs prior to surgery.
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Several risk prediction models and tools have been developed to
stratify patient risk for PPCs preoperatively. The following
highlights several multi-centre prospective cohorts.
Risk prediction models
ARISCAT
The Assess Respiratory Risk in Surgical Patient in Catalonia
Tool (ARISCAT) was published in 2010 using the Spanish registry
to predict postoperative pulmonary complications. It is a multi-
centre prospective trial and its target population includes multi-
specialty elective and emergency surgeries. It uses the EPCO
definition for composite postoperative respiratory outcomes. Nine
independent risk factors were identified using the logistic
regression model, and they are assigned a weighted point score:
age, male sex, low preoperative oxygen saturation (SpO2 <96%),
respiratory infection in the last month, preoperative anaemia
(haemoglobin (Hb) <10 g/dl), positive cough test, surgical inci-
sion of upper abdominal/intrathoracic, duration of surgery (>2
hours), and emergency procedure.6 This allows stratification of
patients into low-, intermediate- and high-risk groups for PPCs.
The risk factors used to predict the overall incidence of post-
operative pulmonary complications are easy to measure, which
makes it convenient to use in daily clinical practice. Modifiable
factors, such as anaemia and respiratory infection in the last
month, allow anaesthetists and surgeons to optimize patient
condition before proceeding with surgery. Of note, the disad-
vantage of using the ARISCAT risk score is related to the inclusion
of minor complications and the varied definition of PPCs, which
may not impact or contribute equally to mortality.
GUPTA calculator for postoperative respiratory failure
The NSQIP risk tool was created and developed by the Amer-
ican College of Surgeons in the 1990s to assess outcomes reported
in Veterans’ Affairs hospitals. Gupta calculators for postoperative
respiratory failure and pneumonia are derived from the NSQIP
2007e2008 data set. Variables include functional status, American
Society of Anesthesiologists (ASA) class, sepsis, emergency sur-
gery and type of procedure. However, limitations include that the
risk score cannot be calculated manually, and various underlying
patient factors such as obstructive sleep apnea and venous
thromboembolism are not evaluated as comorbidities.8
Arozullah respiratory failure index
The Arozullah respiratory failure index predicts the incidence
of postoperative respiratory failure (with need for postoperative
mechanical ventilation for >48 hours). It is derived from the
VASQIP database in 1995e1999. Its preoperative predictors
include the type of surgery, emergency surgery, laboratory re-
sults (albumin <3.0 g/dl, blood urea nitrogen (BUN) >30 mg/
dl), functional status, history of chronic obstructive pulmonary
disease (COPD) and age. Similarly, major limitations precluding
widespread clinical use of the tool include its complicated risk
calculation and lack of general applicability, as the data from
which the risk scores were generated were all based on veterans
(almost no females), and various surgical subspecialities were
excluded, such as cardiac surgeries, endoscopic, dental proced-
ures and transplantations.9
During the development of these tools, it was found that the
definitions used to define postoperative pulmonary
689 Ó 2022 Published by Elsevier Ltd.
 PERIOPERATIVE CARE

complications vary widely in literature. Therefore, it is important
to note that these risk stratification tools may provide a risk score
for patients that is only relative to the respective study pop-
ulations, and do not necessarily represent individualized risk
predictions. Nonetheless, the current models allow us to identify
at-risk patients, and a few studies have measured the effect of
using prediction models and stratification tools on patient
outcome and resource utilization.
Risk factors for PPCs
A comprehensive preoperative risk assessment requires a thor-
ough evaluation of modifiable and non-modifiable risk factors.
Potential risk factors with strong evidence are highlighted in
Table 1 in bold.
Importantly, patient-related factors including well-controlled
asthma, obesity and procedure-related factors including hip,
genitourinary and gynaecological surgeries are not risk factors
for PPCs.
Preventative measures for PPCs
Identification of modifiable risk factors allows early imple-
mentation of various perioperative interventions to prevent the
development of PPCs. Current literature have extensively
investigated individual preventative measures, but not the use
of care bundles. In 2020, Odor et al. published a meta-analysis
looking at various interventions that aim to reduce the inci-
dence of PPCs in patients undergoing non-cardiac surgery. So
far, only low-quality evidence exists for perioperative in-
terventions such as prophylactic mucolytics, prophylactic non-
invasive ventilation, respiratory physiotherapy, epidural anal-
gesia and enhanced recovery pathways (ERAS). Moderate
quality evidence was found for goal-directed haemodynamic
therapy and lung protective ventilation, but further data are
required.10 Other studies also implicate risk reduction strategies
such as good oral hygiene, patient education and motivation,
antibiotics and optimization of underlying chronic lung dis-
eases, and surgical delay may be considered on an individual

Modifiable and non-modifiable perioperative risk factors for the development of postoperative pulmonary complications
(PPCs)
Non-modifiable risk factors Modifiable risk factors

Patient factors Age Cigarette smoking

Male sex Chronic obstructive pulmonary disease
ASA class
II Congestive heart failure
Partial or total functional dependency Obstructive sleep apnoea
Comorbidities: Body mass index (<18.5 or >40 kg/m2)
Acute respiratory infection, interstitial lung disease, Preoperative anaemia (<10 g/dl)
pulmonary hypertension, neuromuscular Preoperative sepsis
disease/weakness, long-term steroid use Renal failure
Chronic liver disease
Gastrooesophageal reflux disease
Altered sensorium
Surgical factors Type and site of surgery Minimal invasive surgery
C Highest risk: aortic and thoracic Timing of surgery
C Upper abdominal
C Neurosurgery
C Head and neck
C Vascular
Emergency surgery
Duration of surgery (
4 hours doubles risk of PPCs)
Reoperation/reintervention, multiple general anaesthesia during
same admission
Open laparotomy
Anaesthesia-related factors / Mechanical ventilation strategies
Inadequate ventilator settings
Mode of anaesthesia:
C General anaesthesia (versus regional anaesthesia)
Excessive fluid administrations
Perioperative blood transfusion (>4 units)
Hypothermia
Use of nasogastric tube
Use of long acting neuromuscular blocking drugs
(i.e. pancuronium),
residual neuromuscular blockade

Table 1

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 PERIOPERATIVE CARE

basis given the substantially increased risk for PPCs. A sum-
mary of perioperative strategies to reduce PPCs in patients at
risk is shown in Table 2.
The following section evaluates in depth various imple-
mentation strategies with relatively higher efficacy for the risk
reduction of PPCs.
Smoking cessation
Current smokers are more likely to develop PPCs compared to
ex-smokers, and the incidence of PPCs increases with the num-
ber of pack-years smoked (>20 pack-years). Ex-smokers also
have a higher respiratory risk compared to never-smokers.
However, 30-day mortality is found to be similar in both

A summary of perioperative strategies to reduce postoperative pulmonary complications in patients at risk

Preoperative strategies
Intraoperative strategies
Postoperative strategies
1. Identify individuals at risk (use of risk prediction tools and thorough evaluation of patient history and
condition)
2. Smoking cessation (at least 4e8 weeks before surgery)
3. Optimize underlying chronic lung diseases
a. Optimize control of chronic obstructive pulmonary disease (COPD)/asthma with inhaled bronchodilators and
inhaled corticosteroids (Global Initiative for Asthma guidelines)
b. Treat acute exacerbations of COPD/acute asthmatic attacks with short courses of systemic glucocorticoids,
and consider administering antibiotics to patients with lower respiratory infections
c. Counsel patients on preoperative oral hygiene (preoperative chlorhexidine mouthwash, dental care)
d. Patient education on medication compliance, incentive spirometry and lung expansion manoeuvres
4. Correct underlying anaemia
5. Premedication with inhaled short-acting bronchodilators prior to surgery
6. Chest physiotherapy (up to 2 weeks before surgery for at-risk individuals)
a. Tailored, monitored, with motivational interviews and feedback (ICOUGH)
i. Aerobic exercises
ii. Deep breathing exercises
iii. Inspiratory muscle training
iv. Incentive spirometry
7. Consider delay for elective surgeries on an individual basis
a. >4 weeks for patients with recent chest infections
b. >7 weeks for patients after recent coronavirus disease (COVID-19) infection28
Surgical
1. Minimal invasive surgical techniques (balance with operative time and surgical suitability)
2. Minimize duration of surgery (<3 hours)
Anaesthetic
1. Consider central neuraxial/regional blockade when possible
2. Lung-protective ventilatory strategies
3. Consider epidural analgesia, opioid-sparing strategies
4. Avoid long-acting neuromuscular blocking agents if possible and ensure full reversal at emergence, use of
quantitative monitoring for neuromuscular blockade
5. Avoid hypothermia
6. Goal-directed haemodynamic therapy
1. Commence chest physiotherapy when appropriate
a. Deep breathing exercises
b. Incentive spirometry
2. Consider non-invasive ventilatory support in patients with early respiratory complications as appropriate
a. High-flow nasal oxygen
b. Continuous positive airway pressure ventilation
c. Bilevel positive airway pressure ventilation
3. Adequate pain control
a. Regular review by acute pain team
b. Avoid high dose parenteral opioids
c. Consider epidural analgesia in selected cases
d. Avoid bronchospasm/exacerbation of respiratory disease with use of non-steroid anti-inflammatory drugs in
susceptible individuals e.g. asthma
4. Avoid unnecessary use of nasogastric tubes/Foley catheter
5. Early mobilization
6. Enhanced recovery pathways (ERAS, ERASþ)

Table 2

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 PERIOPERATIVE CARE
non-smokers and ex-smokers (quit 1 year before surgery),
regardless of whether they have a 10 or 50 pack-year history.
Importantly, existing data showed that short-term smoking
cessation (>4 weeks abstinence) in the preoperative period re-
duces respiratory complications.11 Briefer periods of cessation
are also beneficial and may still reduce non-respiratory compli-
cations. Smoking cessation is therefore an effective and simple
intervention to reduce the risk of developing PPCs. Also, a
combination of pharmacotherapy (nicotine replacement therapy,
varenicline and bupropion) and behavioural support (brief
advice and counselling) maybe more efficacious than brief advice
alone.
Preoperative anaemia
Patients with preoperative anaemia (Hb level <100 g/litre)
undergoing any surgery have a threefold increase in the risk of
developing PPCs.6 Adverse outcomes related to allogeneic
blood transfusion also increases overall healthcare costs. A UK
national guideline published in 2015 by the British Com-
mittee for Standards in Haematology (BCSH)12 recommends the
following:
1. Iron therapy for anaemic patients with absolute or functional
iron deficiency:
e Oral iron for patients undergoing non-urgent surgery
e Intravenous iron for patients who are intolerant or
unresponsive to oral iron, or those with a short interval
between detection of anaemia and surgery
2. Vitamin B12 and folate therapy in patients with megaloblastic
anaemia
3. Erythropoiesis-stimulating agents for patients when alloge-
neic transfusion is to be avoided (i.e. patients who refuse
whole blood/blood components or those with complex
alloimmunization/rare blood groups)
e May be given together with iron supplementation for
maximum efficacy
4. No good evidence found to support preoperative transfusion
to improve surgical outcomes.
Respiratory physiotherapy
Current evidence supports the benefits of involving physiother-
apists preoperatively for at-risk individuals to educate and train
patients to perform sputum clearance, inspiratory muscle
training and deep breathing exercises. Preoperative physio-
therapy allows patients to practise and strengthen their respira-
tory muscles, subsequently reducing postoperative atelectasis
and pneumonia, hence reducing the length of hospital stay.13 Of
note, incentive spirometry alone without physiotherapist
involvement has not been found to be beneficial.
More recently, ICOUGH represents a multidisciplinary patient-
care programme that is designed to reduce the risk of post-
operative pneumonia and unplanned intubation in patients who
undergo general or vascular surgery.13 ICOUGH is an acronym
for Incentive spirometry, Coughing and deep breathing, Oral
care, Understanding (patient and family education), Getting out
of bed (at least three times daily), and Head of bed elevation.
Upon implementation of the mentioned programme, the inci-
dence of postoperative pneumonia was found to decrease from
2.6% to 1.6%, and that of unplanned intubations decreased from
2% to 1.2%.
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Lung-protective ventilation
Mechanical ventilation strategies play an important role in res-
piratory risk reduction. For instance, lung-protective ventilation,
which primarily includes principles of utilizing low tidal volumes
and avoiding high positive end-expiratory pressures (PEEP),
have been shown to be effective in reducing the incidence of
PPCs in multiple studies. Currently, there is still ongoing debate
about the ideal level of PEEP and the use of recruitment ma-
noeuvres. Low levels of PEEP can cause atelectasis, but high
levels of PEEP may affect haemodynamic stability and may lead
to lung injury from overdistension.
The ARDSnet/ARMA trial shows benefits of lung-protective
ventilation in patients with acute lung injury and ARDS in the
perioperative period and intensive care settings. The study ad-
vocates the use of low tidal volume ventilation (6e8 ml/kg of
ideal body weight) and limiting plateau pressures <30 cmH2O,
titrated PEEP according to lung compliance, as well as adjusting
respiratory rates to reduce respiratory acidaemia, and it has been
found that the above ventilation strategies resulted in a reduction
in mortality by 8.8% and increased ventilator-free days in the
study group.14
Regarding the use of PEEP, the PROVHILO study is a large
multicentre randomized controlled trial involving patients who
are at risk of PPCs and undergoing open abdominal surgery.15
Patients were allocated into the high-PEEP group (with recruit-
ment manoeuvres) and lower-PEEP group (without recruitment).
Interestingly, the incidence of PPCs was similar in both groups,
and the use of high PEEP and recruitment manoeuvres did not
provide any protection against PPCs. Further RCTs to investigate
the potential for PEEP titration in perioperative pulmonary out-
comes include the ART trial conducted in 2017 for ARDS patients,
using an ‘open lung approach’ (OLA) in ventilation. OLA involved
a relatively high baseline PEEP, and intermittent stepwise PEEP
increases, followed by subsequent gradual PEEP down-titration to
achieve optimal driving pressures, in effect creating individual-
ized alveolar recruitment manoeuvres aiming to reduce atelec-
tasis and improve oxygenation. The ‘optimal PEEP’ was defined
as the PEEP level (þ2 cmH2O) that achieves the best lung
compliance. However, compared with conventional ventilation as
described in the ARDSnet trial, the OLA ventilation strategy
increased 28-day mortality and morbidity and 6-month mortality,
as well as increased incidences of barotrauma (pneumothorax,
pneumomediastinum, subcutaneous emphysema, pneumato-
cele), which was probably caused by breath-stacking. The above
findings do not support routine use of lung recruitment ma-
noeuvres or excessive PEEP titration in patients with ARDS. In
line with previous evidence, the study concluded by supporting
the use of low tidal volumes with limited plateau pressures and
titrated respiratory rates without PEEP individualization, together
with judicious use of neuromuscular blockade and sedative in-
fusions in patients needing prolonged mechanical ventilation.
Goal-directed haemodynamic therapy
Goal-directed haemodynamic therapy (GDHT) includes the
perioperative use of intravenous fluids and vasoactive agents
(inotropes or vasopressor) to achieve haemodynamic goals and
optimize end-organ perfusion. Subgroup meta-analysis of studies
investigating GDHT shows relative risk reduction in PPCs only by
use of fluid administration but not vasoactive agents.
692 Ó 2022 Published by Elsevier Ltd.
 PERIOPERATIVE CARE
Traditionally, trials investigating the use of restrictive versus
liberal fluid management have shown that restrictive fluid
management is associated with an increased risk of acute kidney
injury. In contrast, liberal fluid management is associated with
fluid overload, pulmonary congestion, poor wound healing and
paralytic ileus. Therefore, neither restrictive nor liberal fluid
management is protective against PPCs, and must be balanced
with other systemic effects that may arise from inappropriate
fluid management.
More recently, the FEDORA trial investigated the effect of
GDHT versus standard care on the incidence of postoperative
complications within 180 days of surgery in patients undergoing
major surgery.16 The intervention group (GDHT) has defined
haemodynamic targets, oesophageal doppler guided fluid
management, optimization of preload with crystalloid or
colloid, use of inotropes when there is an inadequate response
to fluid, and vasopressors when required. The control group
(standard care) received a continuous infusion of Ringer’s
lactate fluid, colloid or vasoactive agents at the clinician’s
discretion, with no use of cardiac output monitor and no pre-
defined intraoperative goals. The incidence of postoperative
complications in the GDHT group versus standard care group
were 0.48% versus 5.69% for ARDS (odds ratio 0.08), and
1.191% versus 8.53% for pneumonia (odds ratio 0.21). This
highlights the importance of goal-directed fluid therapy in place
of conventional fluid therapy in PPC risk reduction, with the
concept of optimal fluid management also extending to the
postoperative care period.
Neuromuscular blocking drugs
It is known that the use of neuromuscular blocking drugs
(NMBD) in general anaesthesia and inadequate reversal are
associated with increased risk of PPCs. However, there are
conflicting evidence regarding the choice of NMBD (interme-
diate versus long duration) and its dose-dependent relationship
with development of PPCs. The latest POPULAR trial was a
multicentre, prospective cohort study which recruited surgical
patients (excluding cardiac surgery) in European centres. Re-
sults showed the use of NMBD is associated with increased
risk of PPCs in patients who had general anaesthesia (7.6%,
OR 1.86). The use of sugammadex or neostigmine and extu-
bation with neuromuscular monitoring with train-of-four
(TOF) ratio >0.9 are not associated with better pulmonary
outcomes. However, a post-hoc analysis found that extubating
with TOF ratio >0.95 versus TOF ratio >0.9 reduced the
adjusted risk of PPCs by 3.5%.3 Therefore it is important to
balance the potential benefits and risks regarding the use of
NMBD, and properly use neuromuscular monitoring to guide
reversal.
Regional anaesthesia
There is ongoing debate whether neuraxial blockade may be
advantageous over general anaesthesia in reduction of PPCs.
Studies have shown added benefit when neuraxial blockade is
performed in patients with increased respiratory risk factors,
such as COPD and obstructive sleep apnoea. Thoracic epidural
analgesia (TEA) is useful in reducing opioid requirement and
hypoventilation associated with postoperative pain, therefore
reduces risk of development of atelectasis and pneumonia.7
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Surgical planning and timing
In addition, surgical planning and timing of surgery also play
important roles in postoperative outcomes. Whilst minimally
invasive surgical techniques can reduce postoperative pain and
thus PPCs, the consequent longer surgical time should also be
taken into consideration. Timing of elective surgeries warrants a
multidisciplinary approach, and the general consensus is to delay
major surgeries for at least 4 weeks after lower respiratory chest
infections, with special considerations for the risks of delaying
time-sensitive surgeries. With regards to the recent pandemic
coronavirus disease (COVID-19) era, studies have shown that 30-
day mortality and PPC risks are higher in patients with COVID-19
who undergo surgery. For instance, the overall 30-day mortality
after COVID infection is estimated to be 4.1%, whilst that of non-
COVID patients is 1.5%. There is an increased risk of post-
operative complications when patients receive surgery 0
e4 weeks from the time of COVID diagnosis, whereas the base-
line risk is similar to non-COVID patients when they receive
surgery 7 weeks later.20 Therefore, anaesthetists should be aware
of the ongoing evolution of consensus guidelines related to the
optimal timing of surgery, and elective surgery should ideally be
postponed for at least 7 weeks after a recent COVID-19 infection.
However, evidence on perioperative outcomes after COVID-19
vaccination is still lacking.
Perioperative care bundle
In current literature, there are many studies that investigated the
effectiveness of individual preventative measures for PPC
reduction, but there are few that investigate the effectiveness of
care bundles. Recently, the concept of care bundles for post-
operative pulmonary complications was used in the ICOUGH
study, which showed promising results in the reduction of PPCs.
A care bundle is defined as a set of evidence-based practices
(ideally limited to five or less interventions in one bundle), with
a better overall outcome when applied collectively. A scoping
review published in 2019 highlighted some key findings that
may improve the compliance of care bundles, including the use
of fewer, simpler elements in a care bundle, interventions that
reflect best practice, and co-design of interventions by health-
care staff and patients using a multidisciplinary team
approach.17
ERASþ is a UK-based patient-centred quality improvement
project published in 2017 showing promising results for PPC
reduction in at-risk patients. ERASþ is a holistic care bundle
based on existing ERAS pathways, emphasising a multidisci-
plinary approach including the involvement of medical, nursing
and allied-health professionals (physiotherapy, dietetics and
pharmacy). Apart from a tailored respiratory bundle based on
ICOUGH recommendations, the programme highlights the
importance of active partnership with both patient and family,
including the provision of information and education resources
to both parties. The programme also stresses the importance of
prehabilitation, with special emphasis on improving cardiovas-
cular activity, muscle strengthening, lifestyle advice and nutri-
tional support, as patients with lower functional capacity or
physiological reserve have higher risks of mortality and
morbidity after major surgery.18 Conventional ERAS programmes
consist of the following components:
693 Ó 2022 Published by Elsevier Ltd.
 PERIOPERATIVE CARE
 Preoperative: smoking cessation, reducing alcohol intake,
management of anaemia, preoperative carbohydrate
loading, same day admission for elective surgery, cardio-
pulmonary exercise testing (CPET)
 Intraoperative: goal-directed haemodynamic therapy,
normothermia, minimally invasive surgery
 Postoperative: multimodal analgesia (local anaesthetic
infusion, epidural, tissue plane blocks), physiotherapy for
chest and mobilization, early oral feeding, early removal of
surgical drains
The ERASþ programme consists of the following elements in
addition to baseline ERAS programmes:
 Preoperative: individualized introduction, education and
training for major surgery (including Surgery School with
education tools and forums for discussion amongst pa-
tients and family members, ICOUGH-UK videos, incentive
spirometry, increase physical activity by 50%, muscle
strengthening, oral health advice, nutritional preparation)
 Intraoperative: same as above
 Postoperative: continued education and managing patient
expectations for recovery, ICOUGH prescriptions, breath-
ing and coughing exercises with incentive spirometry
every 4e8 hours, mobilization twice daily, oral hygiene,
preparation for recovery at home
With the ERASþ implementation, it was found that the inci-
dence of PPCs was reduced from 18.7% to 10.5%, and conse-
quently further reduced to 8.7% after 1 year of ERASþ
implementation. The median hospital length of stay was also
reduced. However, the project is a single-centre project with
various limitations including measurement bias and deliberate
use of Hawthorne effect to improve bundle compliance. Other
studies investigated geriatric patients and patients undergoing
major oncological surgeries receiving pulmonary care bundles,
and similar results were found, including reduced incidences of
postoperative pneumonia, unplanned intubation and respiratory
failure. However, other respiratory complications such as pul-
monary embolism or use of ventilator >48 hours were not
affected by the implementation of care bundles.19
Despite statistical limitations, differences in study popula-
tion and heterogeneity, the studies above generally support the
use of perioperative care bundles, which may reduce periop-
erative pulmonary complications and shorten length of stay.
They highlight the efficacy of combined therapies over indi-
vidualized single strategies, and encourage a holistic multidis-
ciplinary care approach. However, further research is needed to
determine the ideal components within an individual care
bundle, as there are still considerable variations between each
care bundle.
Conclusion
Postoperative pulmonary complications are common and are a
leading cause of morbidity and mortality. However, careful
assessment of patients and identification of at-risk individuals
allow early implementation of various preventative measures to
improve clinical outcomes. Although there are numerous
scoring systems that may improve preoperative risk stratifica-
tion of patients undergoing major surgery, methodological lim-
itations and limited generalizability often preclude their
ANAESTHESIA AND INTENSIVE CARE MEDICINE 23:11
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widespread use in clinical practice. Variations in outcome defi-
nitions of postoperative respiratory complications and study
populations are also significant factors affecting calculated risk
scores. The precision of these tools in specific populations are
unclear at present, but current models still serve as a useful aid
for healthcare staff to identify patients at risk of developing
PPCs.
Modifiable risk factors including most cardiorespiratory
comorbidities, preoperative anaemia, and behaviour (i.e. smok-
ing and alcohol use) should be optimized before surgical in-
terventions if time allows. A multidisciplinary approach with
patient education and motivational interviews, together with a
tailored programme to improve physiological reserve and func-
tional status increases the benefits of PPC reduction. Importantly,
perioperative physiotherapy programmes such as the ICOUGH
protocol, which encompasses a combination of inspiratory
muscle training and deep breathing exercises, as well as oral
hygiene, patient education and early mobilization, shows
promising results in PPC risk reduction after major surgery.
Similarly, a holistic approach based on ERAS programmes ad-
vocates the importance of perioperative care bundles, which
represent multiple interventions that can be individualised to
expedite patient recovery and improve overall surgical outcomes.
This can be combined with intraoperative interventions
including regional anaesthesia, lung protective ventilation and
goal-directed hemodynamic therapy to improve the overall
benefit of PPC risk reduction. However, these programmes
require manpower, workforce commitment, and institutional
support for sustained success in compliance, which may pose
potential barriers to successful implementation.
Moreover, current evidence is still controversial regarding the
use of OLAs for ventilation, optimal levels of PEEP and the use of
recruitment manoeuvres for different patient populations,
although evidence generally support the use of small tidal vol-
umes of 6e8 ml/kg of ideal body weight and limiting inspiratory
plateau pressures <30 cmH2O. Avoidance of high doses of long-
acting opioids or continuous opioid infusions, and quantitative
monitoring of neuromuscular blockade with adequate reversal
are also important measures to reduce the incidence of PPCs.A
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