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Postoperative Pulmonary Complications Free Clinical Continuing Education for Respiratory Therapists (CRCE) and Nurses (CNE) Foundations See Page 12 A Patient-focused Education Program for Respiratory Care Professionals Advisory Board Postoperative Pulmonary Complications Richard Branson, MS, RRT, FAARC David A Grooms MSHS, RRT Professor of Surgery University of Cincinnati College of Medicine Cincinnati, OH Postoperative pulmonary complications (PPCs) are a common outcome of cardiothoracic Kathleen Deakins, MS, RRT, NPS surgery. When allowed to progress, PPCs can result in serious sequelae, such as respiratory Supervisor, Pediatric Respiratory Care Rainbow Babies & Children’s failure, pulmonary embolism, acute lung injury, or acute respiratory distress syndrome. Hospital of University Hospitals Cleveland, OH The prevention of PPCs requires a comprehensive approach that includes assessment of William Galvin, MSEd, RRT, CPFT, AE-C, FAARC Program Director, Respiratory Care Program preoperative risk, smoking cessation, and attention to a number of factors before, during Gwynedd Mercy College, Gwynedd Valley, PA. and after surgery. In this article, Dr. Grooms addresses several preventive measures such Carl Haas, MS, RRT, FAARC as intraoperative and postoperative anesthetic/analgesic technique, the use of laparoscop- Educational & Research Coordinator University Hospitals and Health Centers ic surgery, selective nasogastric tube decompression, lung expansion modalities, oxygen Ann Arbor, MI therapy, deep breathing exercises, physical therapy, and the use of subglottic suction endo- Richard Kallet, MSc, RRT, FAARC Clinical Projects Manager University of California Cardiovascular Research Institute tracheal tubes. Clinical trials in this area are needed to guide practice, but in the absence San Francisco, CA of evidence, minimally studied or unproven therapies may still provide clinical benefit if Neil MacIntyre, MD, FAARC Medical Director of Respiratory Services used judiciously. Duke University Medical Center Durham, NC Tim Myers, BS, RRT-NPS Pediatric Respiratory Care Panel Discussion: Postoperative Pulmonary Complications Rainbow Babies and Children’s Hospital Cleveland, OH Tim Op’t Holt, EdD, RRT, AE-C, FAARC Moderator: Faisal Masud, MD Professor, Department of Respiratory Care and Cardiopulmonary Sciences Panelists: Paul Marik, MD University of Southern Alabama Mobile, AL Ruben Restrepo, MD, RRT Helen Sorenson, MA, RRT, FAARC Luis Angel, MD Assistant Professor, Dept. of Respiratory Care University of Texas Health Sciences Center David Wheeler, RRT San Antonio, TX The Clinical Foundations Understanding the nature of PPCs is paramount to their prevention and treatment. In this Community panel discussion, 5 experts in respiratory medicine discuss the many facets of PPCs and measures clinicians can take to reduce their risk. The discussants address the definition of PPCs, their impact on perioperative morbidity and mortality, PPC risk factors, surgical and anesthesia issues, and strategies that can be implemented pre- and post-surgery to reduce the risk of PPCs. Also discussed are issues related to cost, an ever-important consideration in the era of pay-for-performance. The Clinical Foundations Community feature allows readers to comment, ask questions, or respond to questions from the author on featured topics. Join our discussion on the Clinical Foundations website www.clinicalfoundations.org This program is sponsored by Teleflex 2012-0669 Clinical Foundations related to wound and urinary tract infec- tions.15 However, subsequent trials have demonstrated reductions in wound heal- Postoperative Pulmonary ing complications in head and neck16 and breast reduction surgery17 when smoking Complications was stopped 3 to 4 weeks prior to surgery. Hypothetically, cessation less than 3 to 4 David A Grooms MSHS, RRT weeks before surgery may benefit postop- erative recovery.18 ostoperative pulmonary com- Intraoperative Anesthetic and plications (PPC) can adversely Analgesic Technique influence a patient’s clinical Neuraxial blockade, via Anesthetics disrupt central regula- course following surgery and are tion of breathing and result in uncoordi- Pequally as common as cardiac complica- nated neural messaging, hypoventilation, spinal or epidural route, may tions for patients undergoing non-car- and positional-dependent regional atelec- diothoracic surgery. These complications tasis shortly after induction.19 If these an- include atelectasis, bronchospasm, and improve recovery and prevent esthesia effects are unresolved, they can be tracheobronchitis, which are considered compounded by limited respiratory ex- self-limiting disorders known to induce cursion due to pain, and disruption of re- perioperative hypoxemia. However, these complications by blocking a spiratory muscles and neutrally mediated complications may result in substan- diaphragmatic function.20 In a landmark tial morbidity and mortality when they investigation assessing mortality rates in progress to more severe forms or develop constellation of stress 599,548 surgical patients undergoing pro- into respiratory failure, pulmonary em- cedures between 1948 and 1952, Beecher bolism, postoperative pneumonia (PP), & Todd observed a 6-fold increase in the empyema, pneumothorax, acute lung in- ness of common interventions and how risk of death in the perioperative period jury (ALI), acute respiratory distress syn- they pertain to postoperative recovery. associated with the use of neuromuscu- drome (ARDS), or the need for mechani- Examples include preoperative smoking lar blocking agents (NMBA).21 Over the cal ventilation beyond 48 hours following cessation, anesthetic and analgesic tech- last 50 years, second and third generation surgery.1,2 Special attention is often given nique, laparoscopic vs. open procedures, NMBA’s have been developed to mini- to the prevention and development of at- nasogastric decompression, lung expan- mize hemodynamic compromise and electasis because it is one of the primary sion therapy, and the use of subglottic- improve rapid onset and offset of effects, mechanisms associated with ALI, a major suction endotracheal tubes. and recovery patterns. Despite improve- cause of postoperative hypoxemia, lead- ments, residual neuromuscular blockade ing to longer stay in the intensive care Preoperative Smoking Cessation remains a common and often undetected unit (ICU) and increased length of stay It is well understood that smoke occurrence in the early postoperative pe- (LOS) in the hospital.3 Although the clini- inhalation contributes to reduced muco- riod.22,23 The use of intermediate-active cal evidence regarding PPC prevention is ciliary activity leading to decreased mucus NMBA (atracurium, vecuronium) in often unclear and moderately strong at production and increased coughing due comparison to long-acting NMBA (pan- best, essential measures must be taken to to bronchial irritation. Smoking increases curonium) has not proven to reduce PPCs, reduce PPCs. These include carefully in- the frequency of complications in minor however, they have led to significantly re- dividualized strategies for preventing at- surgical procedures,4,5 hernia surgery,6,7 duced incidence of residual neuromus- electasis and aspiration of oral secretions, vascular surgery,8 gastrointestinal sur- cular blockade (5% vs 26%; P<.001).24 restoring functional residual capacity, and gery,9,10 gynecologic surgery,11 and ortho- Therefore, patients with residual blockade increasing the patient’s ability to mobilize pedic surgery.12,13 Therefore, cessation of following pancuronium administration and expectorate secretions. smoking prior to surgery is recommend- were 3 times more likely to develop PPCs ed to reduce postoperative complications. than those without residual block (17% vs. Overview of Preoperative Risks However, there is insufficient evidence re- 5%; P<.02). Success of postoperative recovery is garding the minimum duration of smok- Neuraxial blockade, via spinal or dependent not only on pulmonary physi- ing cessation and its association with epidural route, may improve recovery ology restoration after surgery, but also PPCs.14 Interventions to reduce smoke and prevent complications by blocking a on preoperative education and intraoper- inhalation 6 to 8 weeks prior to elective constellation of stress responses to sur- ative clinical care management. Therefore, hip and knee arthroplasty surgery proved gery (e.g. increase in neurodocrines and it is necessary to discuss the appropriate- successful in minimizing complications cytokines, and reduction in pain thresh- 2 www.clinicalfoundations.org Clinical Foundations old) which contribute to a reduction in operative pain, surgical risk, and spiro- respiratory muscle dysfunction and pain- metric data, it is unclear whether clinically related hypoventilation. Epidural ad- The intent of postoperative important PPC’s are minimized with the ministration is possible through a single use of laparoscopic surgical procedures. injection or infusion and is commonly analgesia is to further reduce Many studies did not report PPCs and used for intraoperative and postoperative others lack the ability to detect differences analgesia. However, compared to epidural in PPC rate because of small sample size anesthesia, spinal anesthesia has a rapid surgical stress responses which and insufficient statistical power. onset around 5 to10 minutes vs. 15 to 20 minutes, is easier to administer, and pro- Routine Nasogastric Tube duces a denser sensory and motor block. can lead to PPCs and organ Decompression
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