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Postoperative pulmonary complications play an important role in strategies to reduce the perioperative pulmonary risk and focuses
the risk for patients undergoing noncardiothoracic surgery. Post- on atelectasis, pneumonia, and respiratory failure. The target audi-
operative pulmonary complications are as prevalent as cardiac com- ence for this guideline is general internists or other clinicians in-
plications and contribute similarly to morbidity, mortality, and volved in perioperative management of surgical patients. The target
length of stay. Pulmonary complications may even be more likely patient population is all adult persons undergoing noncardiothoracic
than cardiac complications to predict long-term mortality after sur- surgery.
gery. The purpose of this guideline is to provide guidance to clini-
cians on clinical and laboratory predictors of perioperative pulmo- Ann Intern Med. 2006;144:575-580. www.annals.org
nary risk before noncardiothoracic surgery. It also evaluates For author affiliations, see end of text.
*This paper, written by Amir Qaseem, MD, PhD, MHA; Vincenza Snow, MD; Nick Fitterman, MD; E. Rodney Hornbake, MD; Valerie A. Lawrence, MD; Gerald W. Smetana, MD;
Kevin Weiss, MD, MPH; and Douglas K. Owens, MD, MS, was developed for the Clinical Efficacy Assessment Subcommittee of the American College of Physicians (ACP): Douglas
K. Owens, MD, MS (Chair); Mark Aronson, MD; Patricia Barry, MD, MPH; Donald E. Casey Jr., MD, MPH, MBA; J. Thomas Cross Jr., MD, MPH; Nick Fitterman, MD; E.
Rodney Hornbake, MD; Katherine D. Sherif, MD; and Kevin B. Weiss, MD, MPH (Immediate Past Chair). Approved by the ACP Board of Regents on 21 January 2006.
Annals of Internal Medicine encourages readers to copy and distribute this paper, providing such distribution is not for profit. Commercial distribution is not permitted without the express
permission of the publisher.
nutrition or total enteral nutrition (for patients who are mal- predictor and was the second most commonly identified
nourished or have low serum albumin levels). risk factor. The odds ratio was 2.09 (95% CI, 1.70 to
2.58) for patients 60 to 69 years of age and 3.04 (CI, 2.11
to 4.39) for those 70 to 79 years of age compared with
INTRODUCTION younger patients (those ⬍60 years of age).
Postoperative pulmonary complications play a signifi-
cant role in the risk for surgery and anesthesia. The most Chronic Lung Disease
important and morbid postoperative pulmonary complica- Among studies reporting multivariable analyses,
tions are atelectasis, pneumonia, respiratory failure, and chronic obstructive pulmonary disease was the most com-
exacerbation of underlying chronic lung disease. While cli- monly identified risk factor for postoperative pulmonary
nicians are very conscious of the importance of, and risk complications (odds ratio, 1.79 [CI, 1.44 to 2.22]). No
factors for, cardiac complications, clinicians who care for eligible study determined the incremental risk for postop-
patients in the perioperative period may be surprised to erative pulmonary complications in patients with chronic
learn that postoperative pulmonary complications are restrictive lung disease or restrictive physiologic character-
equally prevalent and contribute similarly to morbidity, istics due to neuromuscular disease or chest wall deformity,
mortality, and length of stay (1–5). Pulmonary complica- such as kyphoscoliosis. While clinicians may consider such
tions may also be more likely than cardiac complications to patients with severe limitations to have an increased risk
predict long-term mortality after surgery, particularly for postoperative pulmonary complications, the literature
among older patients (6). did not support an estimate of the magnitude of this risk in
This guideline is based on a 2-part systematic review this group.
prepared by Smetana and colleagues (7) and Lawrence and
colleagues (8). The American College of Physicians (ACP) Cigarette Use
developed these guidelines to 1) guide clinicians on clinical The available data are mixed but suggest a modest
and laboratory predictors of perioperative pulmonary risk increase in risk for postoperative pulmonary complications
before noncardiothoracic surgery and 2) evaluate the effi- among current smokers. The odds ratio for cigarette use
cacy of strategies to reduce the risk for postoperative pul- was 1.26 (CI, 1.01 to 1.56). It is important to assess his-
monary complications. Studies of immunosuppressive tory of current smoking status and support for smoking
states other than HIV infection (for example, organ trans- cessation intervention very early in the preparation for
plantation) and of risk factors for postoperative venous nonemergency surgery.
thromboembolism were excluded from the review. The tar-
Congestive Heart Failure
get audience is general internists or other clinicians in-
volved in perioperative management of surgical patients. Good-quality evidence identified congestive heart fail-
This guideline applies to adult patients undergoing non- ure as a significant risk factor for postoperative pulmonary
cardiopulmonary surgery. The perioperative period as de- complications (odds ratio, 2.93 [CI, 1.02 to 8.43]).
fined in the studies ranged from 2 to 3 months before Functional Dependence
surgery and up to 3 months after surgery. A more in-depth The evidence review showed that functional depen-
discussion of the methods and the inclusion and exclusion dence is an important predictor of postoperative pulmo-
criteria is available in the accompanying background pa- nary complications. Total dependence was the inability to
pers in this issue (7, 8). In this paper, patient- and proce- perform any activities of daily living, and partial depen-
dure-related risk factors are discussed separately. dence was the need for equipment or devices and assistance
from another person for some activities of daily living. The
PATIENT-RELATED RISK FACTORS odds ratio was 2.51 (CI, 1.99 to 3.15) for total dependence
Potential patient-related risk factors fell into the fol- and 1.65 (CI, 1.36 to 2.01) for partial dependence.
lowing general categories: age; chronic lung disease; ciga- ASA Classification
rette use; congestive heart failure; functional dependence;
Several integrated measures of comorbidity have been
American Society of Anesthesiologists (ASA) classification;
evaluated as potential predictors of postoperative pulmo-
obesity; asthma; obstructive sleep apnea; impaired senso-
nary complications. The ASA classification (Table) aims to
rium, abnormal findings on chest examination, alcohol use,
predict perioperative mortality rates but has since been
and weight loss; and exercise capacity, diabetes, and HIV
proven to predict both postoperative pulmonary and car-
infection.
diac complications (9). Higher ASA class was associated
Age with a substantial increase in risk when an ASA class of II
The evidence review found that advanced age is an or greater was compared with an ASA class of less than II
important predictor of postoperative pulmonary complica- (odds ratio, 4.87 [CI, 3.34 to 7.10]) and when an ASA
tions, even after adjustment for comorbid conditions. Ten class of III or greater was compared with an ASA class of
multivariable studies showed that age was a significant risk less than III (odds ratio, 2.25 [CI, 1.73 to 3.76]).
576 18 April 2006 Annals of Internal Medicine Volume 144 • Number 8 www.annals.org
do not suggest a prohibitive spirometric threshold below basis of the multivariate analysis, a serum albumin level less
which the risks of surgery are unacceptable. Therefore, spi- than 35 g/L is one of the most powerful patient-related risk
rometry should be reserved for patients who are thought to factors and predictors of risk.
have undiagnosed chronic obstructive pulmonary disease.
Chest Radiographs STRATEGIES TO REDUCE POSTOPERATIVE PULMONARY
Clinicians frequently obtain chest radiographs as part COMPLICATIONS
of a routine preoperative evaluation. Most studies of the
Opportunities to reduce risk for postoperative pulmo-
value of preoperative chest radiographs, however, have not
nary complications occur throughout the perioperative pe-
studied postoperative pulmonary complications as the pri-
riod. Lawrence and colleagues’ background review (8) dis-
mary outcome measure but rather have evaluated the fre-
cusses the evidence for lung-specific strategies, anesthetic
quency with which an abnormal study changes periopera-
and analgesic techniques, surgical techniques, and periop-
tive management. In a recent review of this literature (13),
erative care. The review is limited to randomized, con-
it was found that 23.1% of preoperative chest radiographs
trolled trials; systematic reviews; or meta-analyses. Studies
were abnormal but only 3% had findings clinically impor-
that used administrative data (for example, International
tant enough to influence management. An earlier review
Classification of Diseases, Ninth Revision, codes) to iden-
(14) found that 10% of preoperative chest radiographs
tify postoperative complications were excluded. A more de-
were abnormal but only 1.3% showed unexpected abnor-
tailed description of the methods is available in the paper
malities and only 0.1% influenced management.
by Lawrence and colleagues (8).
Thus, the evidence suggests that clinicians may predict
most abnormal preoperative chest radiographs by history Lung-Specific Strategies
and physical examination and that this test only rarely pro- Preoperative Smoking Cessation
vides unexpected information that influences preoperative Studies evaluating the impact of smoking cessation on
management. There is some evidence that this test is help- rates of postoperative pulmonary complications have gen-
ful for patients with known cardiopulmonary disease and erally included patients undergoing pulmonary or cardiac
those older than 50 years of age who are undergoing upper surgery, which were excluded from the review. The authors
abdominal, thoracic, or abdominal aortic aneurysm sur- found only 1 randomized trial of a preoperative smoking
gery. cessation intervention that began approximately 6 to 8
weeks before hip or knee surgery and continued 10 days
Blood Urea Nitrogen
after surgery (25). Postoperative ventilatory support was
Fair evidence supports serum blood urea nitrogen lev- the only measured pulmonary outcome and occurred in 1
els of 7.5 mmol/L or greater (ⱖ21 mg/dL) as a risk factor. patient in each group. However, several factors limited this
However, the magnitude of the risk seems to be lower than study’s ability to show decreased risk for pulmonary com-
that for low levels of serum albumin. plications. The risk for postoperative pulmonary complica-
Oropharyngeal Culture tions is low with hip and knee replacement, and only 1
The evidence review found only a single small study potential postoperative pulmonary complication (ventila-
that evaluated the value of preoperative oropharyngeal cul- tory support) was evaluated. Future trials will need to strat-
ture to predict postoperative pulmonary complication risk ify risk by the duration of preoperative smoking cessation.
(15). More studies are needed in this area. Another study showed that postoperative pulmonary com-
plication rates did not decrease for smokers who stopped
Serum Albumin Measurement
smoking or reduced smoking within 2 months of cardio-
Four studies that reported univariate analyses stratified thoracic surgery (26).
postoperative pulmonary complication rates by serum al-
bumin level and used a threshold of 36 g/L to define low
levels (16 –19). Unadjusted rates of postoperative pulmo- Lung Expansion Modalities
nary complications for patients with low and normal serum Lung expansion techniques include incentive spirom-
albumin levels were 27.6% and 7.0%, respectively. In the etry; chest physical therapy, including deep breathing ex-
review of studies reporting multivariable analyses, a low ercises; cough; postural drainage; percussion and vibration;
serum albumin level was shown to be an important predic- suctioning and ambulation; intermittent positive-pressure
tor of postoperative pulmonary complications (low values breathing; and continuous positive-airway pressure.
were defined variably from 30 to 39 g/L) (20 –24). The The available evidence suggests that for patients un-
National VA Surgical Risk Study reported that a low se- dergoing abdominal surgery, any type of lung expansion
rum albumin level was also the most important predictor intervention is better than no prophylaxis at all. However,
of 30-day perioperative morbidity and mortality (17). In no one modality is clearly superior, and the literature varies
this report, the relationship between serum albumin levels substantially regarding how clinicians actually administer
and mortality was continuous when levels were below ap- the different methods. The available evidence does not sug-
proximately 35 g/L without a clear threshold value. On the gest that combined methods provide additional risk reduc-
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