Chapter 73 Preoperative Pulmonary Evaluation
Postoperative Pulmonary Complications
The frequency of postoperative pulmonary complications (PPCs) varies with type of surgery, the patient’s health, and the definition of the complication. Pulmonary complications of surgery are at least as common as cardiac complications and may result in prolonged hospital stays, increased morbidity and mortality, and increased costs (Table 73-1).
Table 73-1 Postoperative Pulmonary Complications
Surgery in General | Lung Resection Surgery |
---|---|
* Acute exacerbation of chronic obstructive pulmonary disease.
Risk Factors
The many risk factors for PPCs can be classified as patient or surgery related and assigned a simple rating based on the amount and quality of evidence available for support as a risk factor (Table 73-2).
Table 73-2 Selected Risk Factors for Developing Postoperative Pulmonary Complications
Risk Factor | Level of Prediction |
---|---|
Systemic Disease | |
Asthma (well controlled) | Poor |
Congestive heart failure | Good |
Chronic obstructive pulmonary disease | Good |
Diabetes mellitus | Fair |
Human immunodeficiency virus infection | I |
Obstructive sleep apnea | Good |
Pulmonary hypertension | Fair |
Signs and Symptoms | |
Abnormal chest auscultation | Good |
Arrhythmia | I |
Functionally dependent | Good |
Impaired mental status | Good |
Poor exercise capacity | Fair |
Weight loss | Good |
Patient Features | |
Alcohol user | Good |
Cigarette smoker | Good |
Corticosteroid use | I |
Objective Testing | |
Albumin <35 g/L | Good |
Blood urea nitrogen >25 mg/dL | Good |
Chest radiography, abnormal finding | Good |
Spirometry | I |
Surgical Site | |
Aortic aneurysm | Good |
Abdominal | Good |
Neurosurgery | Good |
Vascular | Good |
Hip | Poor |
Gynecologic or urologic | Poor |
Esophageal | I |
Surgical Factors | |
Prolonged surgical duration | Good |
Emergent surgery | Good |
General anesthesia | Fair |
Perioperative transfusion | Good |
Good, ACP “A” or “B” rating or other data to support; Fair, ACP “C” rating or other data to support; Poor, ACP “D” rating, or is not a risk factor; I, indeterminate (insufficient data to support a rating.
Data from current American Academy of Chest Physicians (AACP) guidelines; Smetana GW et al: Cleve Clin J Med 73(Suppl 1):36–41, 2006; and other sources (see Suggested Readings).
Patient-Related Factors
A patient’s general health may be assessed by using the American Society of Anesthesiologists (ASA) classification system (Table 73-3). Studies have shown a direct correlation between a higher ASA class and increased pulmonary complications. Patients with an ASA Class III or higher have a twofold to threefold increase in PPCs compared with those with ASA Class II or lower. Difficulty or inability to perform activities of daily living has also been linked to increased complications.
Table 73-3 ASA Classification for Surgical Candidates
Class | Patient Status |
---|---|
I | Normal healthy patient |
II | Patient with mild systemic disease (e.g., mild asthma) |
III | Patient with severe systemic disease, but not incapacitated |
IV | Patient with life-threatening illness who is incapacitated |
V | Moribund patient |
VI | “Brain-dead” patient eligible for organ donation |
ASA, American Society of Anesthesiologists.
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