Understanding and Mitigating Postoperative Pulmonary Complications

Defining Postoperative Pulmonary Complications

Postoperative pulmonary complications represent a significant concern within the realm of surgical medicine. These complications can have profound implications for patients’ overall well-being, contributing substantially to perioperative morbidity and mortality. In this article, we will delve into the definition of postoperative pulmonary complications, delve into pertinent anesthetic physiology, identify patient and procedure-related risk factors, discuss the role of preoperative pulmonary function testing and pulmonary risk indices, and explore strategies for reducing these complications.

The reported frequency of postoperative pulmonary complications in medical literature is notably broad, ranging from 2 to 70 percent. This wide range can be attributed to various factors, including patient selection and procedure-related risks. However, a significant portion of this variability can be traced back to differing definitions of postoperative complications across studies, making it challenging to compare reported incidences accurately.

The preferred definition of postoperative pulmonary complications is a pulmonary abnormality arising after surgery that leads to clinically significant disease or dysfunction adversely affecting the patient’s clinical course. This encompasses several major categories, including:

  1. Infections: These can manifest as bronchitis or pneumonia, posing a considerable threat to postoperative patients.
  2. Respiratory Failure: Defined as the need for mechanical ventilation for more than 48 hours after surgery or unplanned reintubation.
  3. Hypoxemia: Low oxygen levels in the blood, which can impede recovery.
  4. Exacerbation of Underlying Chronic Obstructive Pulmonary Disease (COPD) or Asthma: Surgical stress can worsen pre-existing respiratory conditions, requiring vigilant management.

Assessing and Reducing the Risk of Postoperative Pulmonary Complications

Given the frequency and potential severity of postoperative pulmonary complications, it is imperative to incorporate risk assessment into all preoperative medical evaluations. This assessment involves evaluating both patient-specific factors and procedure-related risks.

Patient-Related Risk Factors
  • Chronic Respiratory Conditions: Patients with pre-existing conditions like COPD or asthma require meticulous management to prevent exacerbation.
  • Smoking: Smoking is a significant risk factor for pulmonary complications. Encouraging smoking cessation before surgery can significantly reduce this risk.
  • Obesity: Obese patients often experience respiratory issues due to increased abdominal pressure on the diaphragm. Weight loss strategies preoperatively can help mitigate this risk.
  • Age: Older patients may have reduced pulmonary reserves, making them more susceptible to complications.
Procedure-Related Risk Factors
  • Type and Duration of Surgery: Extensive surgeries or those involving the chest or upper abdomen may carry a higher risk of pulmonary complications.
  • Anesthesia Technique: The choice of anesthesia can influence respiratory outcomes. Close monitoring and appropriate adjustments are crucial.
  • Postoperative Pain Management: Adequate pain control can prevent shallow breathing and promote early mobilization, reducing the risk of complications.

Preoperative Pulmonary Function Testing and Risk Indices

Pulmonary Function Tests (PFTs)

Pulmonary function tests (PFTs) are valuable tools in assessing baseline lung function and guiding decisions about the suitability of surgery and postoperative care. They are particularly important in the following scenarios:

  • Lung Resection Surgery: Patients scheduled for lung resection surgery must undergo preoperative PFTs to evaluate their pulmonary function thoroughly.
  • Patients with Known or Suspected Respiratory Disease: PFTs are useful for patients with known or suspected respiratory diseases like COPD or interstitial lung disease.
  • Dyspnea or Exercise Intolerance: If patients experience unexplained dyspnea or exercise intolerance after clinical evaluation, PFTs can aid in diagnosis and management.

A reasonable approach to ordering PFTs follows certain criteria:

  1. FEV1 < 70 percent predicted.
  2. FVC < 70 percent predicted.
  3. FEV1/FVC ratio < 0.65.

However, it’s important to note that PFTs should not be routinely ordered for all patients undergoing surgery, except for lung resection surgery.

Assessment of Oxygenation and Hypercapnia

Assessing oxygenation and hypercapnia is essential, especially for high-risk surgeries. Key methods include:

  • Pulse Oximetry (SpO2): Measuring SpO2 by oximetry is a simple and valuable tool for stratifying risk, particularly before high-risk surgeries.
  • Arterial Blood Gas (ABG) Analysis: Rarely needed in preoperative assessment, ABG analysis may be considered in patients with specific indications, such as resting SpO2 < 93 percent, abnormal serum bicarbonate levels, or severe abnormalities in PFTs.

Patients with hypercapnia are typically identified based on clinical risk factors, such as severe COPD or neuromuscular disease, rather than routine ABGs. Severe hypercapnia may necessitate reevaluation of the surgery’s indication and aggressive preoperative preparation.

Chest Radiographs

Routine preoperative chest radiographs are generally not recommended unless specific indications are present. Indications for chest radiographs include:

  • Evidence of undiagnosed or unstable cardiopulmonary disease, as evidenced by symptoms like exertional dyspnea, wheezing, angina, orthopnea, edema, hypoxemia, rales/rhonchi, or heart murmurs.

Chest radiographs do not significantly contribute to the assessment of perioperative pulmonary complications in patients without these risk factors.

Exercise Testing

Exercise testing, such as cardiopulmonary exercise testing (CPET)

and the six-minute walk test, can be valuable in specific situations:

  • CPET: CPET helps assess patients with abnormal PFTs, especially for lung resection surgery. It can also be considered for patients with unexplained dyspnea undergoing non-cardiopulmonary surgery.
  • Six-Minute Walk Test: This simpler test measures the distance a patient can walk in six minutes and can help predict the risk of postoperative complications, including pulmonary complications.

Estimating Postoperative Pulmonary Risk

Risk prediction tools are essential for estimating the risk of postoperative pulmonary complications and guiding patient care. Here are some widely used risk prediction tools:

ARISCAT (Assess Respiratory Risk in Surgical Patients in Catalonia) Risk Index
  • Predicts the overall incidence of postoperative pulmonary complications.
  • Provides a numerical estimate of risk based on readily available clinical information.
  • Includes minor complications that may not significantly impact outcomes.
Arozullah Respiratory Failure Index
  • Predicts the incidence of postoperative respiratory failure, defined as mechanical ventilation for ≥48 hours.
  • Considers factors like surgery type, laboratory results, functional status, history of COPD, and age.
  • Provides a risk score that stratifies patients into five classes.
Gupta Calculators for Postoperative Respiratory Failure and Pneumonia
  • Predict the risk of specific complications: respiratory failure (failure to wean from mechanical ventilation) and pneumonia.
  • Utilize multiple preoperative factors to calculate risk.
  • Available for free download or online access.

These risk prediction tools assist in stratifying patients by risk and can guide decisions regarding postoperative care, including the level of care required.


Postoperative pulmonary complications are a significant concern in surgical medicine, impacting patients’ morbidity and mortality rates. To address these issues effectively, healthcare providers must define complications accurately, assess patient-specific risks, and employ strategies for risk reduction. Preoperative evaluations, pulmonary function testing, and risk indices play vital roles in ensuring patient safety during the perioperative period. By taking a proactive approach to identify and mitigate risk factors, healthcare teams can enhance patient outcomes and reduce the burden of postoperative pulmonary complications.


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