Strategies to reduce postoperative pulmonary complications in patients at increased risk

Preoperative strategies

Smoking cessation: preferably more than eight weeks prior to surgery (however, briefer periods of cessation are not harmful and may still provide nonrespiratory benefits)

For patients with COPD or asthma, optimize control with inhaled bronchodilators and possibly inhaled glucocorticoids

For patients with a flare of COPD or asthma, administer systemic glucocorticoids (eg, prednisone 40 mg/day for five days) and delay elective surgery until COPD/asthma is under good control and has returned to baseline

Reserve preoperative antibiotics for patients with symptoms and signs of lower respiratory infection*

Delay elective surgery for at least 30 days for patients with lower respiratory tract infection and at least six weeks for patients with COVID-19

Counsel patients on preoperative oral care (eg, dental hygienist visit, preoperative chlorhexidine mouthwash)

Provide preoperative education regarding lung expansion maneuvers

For patients at increased risk of pulmonary complications, initiate chest physical therapy (eg, aerobic exercises, breathing exercises, inspiratory muscle training) up to two weeks before surgery

Intraoperative strategies

Choose shorter procedure (less than three hours) when possible

Choose less invasive procedure when possible (eg, laparoscopic), as long as operative time not prolonged

Consider neuraxial anesthesia rather than general anesthesia

Utilize regional anesthesia (nerve block) when this is an option

For patients with COPD or asthma, administer inhaled short-acting beta-adrenergic (eg, albuterol) 2 to 4 puffs within 30 minutes before intubation

When invasive mechanical ventilation is used, use lung-protective ventilation methods (ie, lower tidal volume [6-8 mL/kg], higher positive end-expiratory pressure [6 to 8 cm H₂O], alveolar recruitment maneuvers)

Avoid long-acting neuromuscular blocking agents for induction or during procedure

Assure full reversal of neuromuscular blocking agents with appropriate use of reversal agents and quantitative monitoring, if available

Postoperative strategies

Initiate deep breathing exercises or incentive spirometry in high-risk patients; noninvasive ventilatory support (CPAP, high-flow nasal oxygen, or noninvasive ventilation) may also be beneficial in patients with early respiratory compromise

Provide epidural analgesia in place of parenteral opioids, as appropriate

For patients with asthma and AERD, avoid using NSAIDS for pain control (eg, ketorolac, ibuprofen)

Avoid use of nasogastric tubes after abdominal surgery (unless needed for symptom control)

Use enhanced recovery pathways and goal-directed hemodynamic therapy in high-risk patients if appropriate resources and protocols available

COPD: chronic obstructive pulmonary disease; AERD: aspirin exacerbated respiratory disease; NSAIDS: nonsteroidal anti-inflammatory drugs; CPAP: continuous positive airway pressure; ICU: intensive care unit.

* Does not refer to perioperative antibiotic prophylaxis for wound infection.

Graphic 102665 Version 3.0

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Strategies to reduce postoperative pulmonary complications in patients at increased risk