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POST-OPERATIVE PULMONARY COMPLICATIONS by K Postgrad Med J: first published as 10.1136/pgmj.31.351.25 on 1 January 1955. Downloaded from 25 v' POST-OPERATIVE PULMONARY COMPLICATIONS By K. N. V. PALMER, M.D.(Camb.), M.R.C.P.(Lond.) Senior Lecturer in Medicine, University of Aberdeen Pulmonary complications after operation still viscosity of the bronchial secretion reduce ciliary remain a common and often serious complication activity (Hill, I928; Negus, I933). Thus, the in the surgical patient despite extensive investiga- normal mechanism for the removal of secretion tion of their mechanism and treatment. from large and small bronchi is seriously deranged The common post-operative pulmonary abnor- following operations. mality is the development of segmental atelectasis; (2) Reduction in Bronchial Calibre. Congestion less commonly atelectasis involving the lobe of a of the bronchial mucosa and bronchial spasm lung or the whole lung occurs. Atelectatic areas reduce bronchial calibre. Bronchial spasm may in the lung readily become infected leading to a occur in the induction period if an endotracheal patchy bronchopneumonia and it is often only tube is introduced into an insufficiently anaes- when bronchopneumonic changes have super- thetized patient, and when anaesthetics such as that the patient complains of respiratory cyclopropane (Rovenstine, and vened 1942) barbituratesby copyright. symptoms. Atelectasis results from the reten- (Burnstein and Rovenstine, 1938) are used. It tion in the lungs of viscous bronchial secretions may be caused during the operation through which occlude bronchi with the subsequent rough handling of the viscera and traction on the absorption of air from the area of lung involved mesentery (De Takats et al., 1942), or after the (Coryllos, I929 and 1930). The prevention and Qperation if there is severe pain (Lucas, I950). treatment of this condition therefore depends Congestion of the bronchial mucosa may be pro- upon the recognition of the factors which cause duced by irritant anaesthetic vapours or by aspira- the retention of sputum in the lungs after opera- tion of irritant material into the lungs. The tion (Palmer and Sellick, 1953). inhalation of stomach contents may follow vomit- The main mechanisms which are responsible for ing which is obvious to the anaesthetist, but silent http://pmj.bmj.com/ the retention of sputum in patients after operation regurgitation may occur which may not be noticed are: (i) a deficient expulsive mechanism, (2) a until the mask is removed at the end of the reduction in bronchial calibre, and (3) qualitative or operation (Culver et al., 1951). quantitative changes in the bronchial secretion. When there is congestion or spasm of the All these factors are probably involved in the bronchi, very small amounts of secretion may majority of patients who develop pulmonary com- produce bronchial occlusion and atelectasis. plications after operations, but occasionally one (3) Changes in Bronchial Secretion. The amount may be predominant. Atelectasis has occurred of bronchial secretion is increased by infection and on September 28, 2021 by guest. Protected during operations (Cassells and Rapoport, I944), irritation of the bronchi and by stimulation of the and these cases are probably due to reflex broncho- secretory glands of the bronchi reflexly via the constriction. vagus (Florey et al., 1932; De Takats et al., (i) Deficient Expulsive Mechanism. Excess bron- I942). The viscosity of the bronchial secretion chial secretion is normally removed from the is increased in dehydration, chronic bronchitis larger bronchi by the cough reflex (Ballon, 1939; and when large doses of atropine (Thomas et al., Bullowa, I944), but secretion in the smaller I938), scopolamine (Hibima and Curreri, I942) or bronchi is normally moved by the activity of the pethedine (Blanschard, 1954) are given. This is ciliated bronchial epithelium (Jackson and Jackson, an important factor in the production of atelec- I933; Boyd et al., I943). After operations pain tasis, for when the viscosity of the bronchial from the wound, reduced diaphragmatic move- secretion is increased, ciliary movement is reduced ment (Howkins, I944), tight abdominal binders aad stagnation of secretion occurs in the smaller and opiates restrict coughing, while anaesthetics, bronchi. anoxia, carbon dioxide excess and changes in the There are, therefore, many factors involved in Postgrad Med J: first published as 10.1136/pgmj.31.351.25 on 1 January 1955. Downloaded from 26 POSTGRADUATE MEDICAL JOURNAL January I955 TABLE I INCIDENCE OF PULMONARY COMPLICATIONS FOLLOWING ABDOMINAL OPERATIONS No. of Incidence of Author cases complication Type of complication Type of operation Beekman and Sullivan, 1939 . 250 13.6% Bronchitis Inguinal hernia Lucas, 1944 ........ 150 20o.I% ,,. Howkins, 1948 .. .. .. 200 I6.6% ,,. Palmer, 1952 ...... .. 160 6.25 % Segmental atelectasis . Stringer, x1947 .. .. .. 55 30% Atelectasis Partial gastrectomy Mimpriss and Etheridge, 1944 .. 0oo 25% | ... Palmer, I1952 . .. IOO 34% , the production of post-operative atelectasis. All this incidence after laparotomy and hernia repair act eventually by causing the retention of sputum, was so definite that for the purpose of analysis which in turn leads to atelectasis and broncho- other operations could be disregarded. Atelec- pneumonia. tasis is uncommon after gynaecological operations, but pulmonary embolism is relatively common. The Incidence The surgeon may unwittingly predispose a The definition of chest complications in the patient to dwelop these complications by causing literature varies considerably from author to reflex bronchoconstriction and the secretion of author. Most writers consider a productive sticky mucus through traction on the mesentery and cough after operation to be evidence of a chest abdominal xiscera, if the surgery is not as gentle by copyright. complication, but unless routine radiographs of as possible. the chest are taken it is difficult to be sure that segmental atelectasis is not present. In a per- Age and Sex sonal series of 260 cases where clinical and radio- These complications are, in general, much logical examinations of the chest were made commoner in men than women, and there is also before, and at daily intervals after the operation, a definite increase with advancing years (Palmer, the incidence of atelectasis diagnosed radio- I952). logically was 26/I60 (I6.25 per cent.) in a group of patients undergoing operation for repair of Time of Year http://pmj.bmj.com/ inguinal hernia, and 34/100oo (34 per cent.) in a Griffith (i934) considered chest complications group who were undergoing partial gastrectomy to be commoner in the first three months of the for chronic peptic ulcer. The lesion was com- year, when the incidence of respiratory tract monly basal and unilateral, but it was bilateral in infection is highest. Other workers, however, i6.6 per cent. of cases. There were three cases have been unable to find any definite increase in of lobar atelectasis (3 per cent.), all of which the winter months (Brunn and Brill, 1930; King, occurred in cases after partial gastrectomy. These I933; Brock, I936; Stringer, Palmer, I952). I947; on September 28, 2021 by guest. Protected figures are similar to the findings of others It has been suggested that in dry weather the (Table i). bronchial secretion may be reduced in amount and become more viscid, thus causing a greater lia- Factors Affecting the Incidence bility to chest complications (Brock, I936). The Operation Chest complications are especially common after Smoking and Bronchitis abdominal procedures particularly those in the Smokers taking ten cigarettes or half an ounce upper abdomen such as gastrectomy, cholecystec- of tobacco a day are six times more liable to tomy and operations for the repair of inguinal develop chest complications after operations than hernia. King (I933) showed that of 3,037 opera- non-smokers (Morton, i914). During the late tions upon the abdomen, including operations for war it was found that Service patients were more the repair of inguinal hernia, 13 per cent. were prone to develop these complications than civilians followed by chest complications, whereas of 4,o28 (Bird et al., I913). This may be due to heavy operations on other parts of the body only i per smoking which is common in the Service, and to cent. was thus complicated. King remarked that the high incidence of upper respiratory tract Postgrad Med J: first published as 10.1136/pgmj.31.351.25 on 1 January 1955. Downloaded from January I 955 PALMER: Post-Operative Pulmonary Complications 27 TABLE 2 INCIDENCE OF BRONCHITIS IN PATIENTS WHO DEVELOPED POST-OPERATIVE PULMONARY COMPLICATIONS Group with chest Group without chest complications complications 60 200 No. % No. % History of bronchitis .. .. .. 39 65 7 35.5 Clinical evidence of bronchitis .. 20 33.3 8 9.0 Radiological evidence of bronchitis .. I8 30.0 13 6.5 infections which occur under barrack conditions. was made in 30 per cent. of the cases who de- Smoking is of importance because it is an im- veloped chest complications, but in only 6.5 per portant factor in the development of bronchitis cent. of those who were not so complicated. (Palmer, 1954), but unless bronchitis is present, Ideally a chest radiograph should always be even a heavy smoker is not necessarily a high risk taken in patients about to undergo a major case (Palmer, I952). Table 2 shows the incidence of surgical procedure in order to exclude the bronchitis pre-operatively in a consecutive group of presence of unsuspected
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