Valerie A. Lawrence, MD; John E. Cornell, PhD; Gerald W. Smetana, MD
Disclosure: Members of the American Society of Anesthesiologists also reviewed the manuscript. Their review implies neither agreement with nor endorsement of this document.
Acknowledgments: The authors gratefully acknowledge the tremendous contribution of medical librarian Martha R. Harris, MA, for her time and expertise in searching the medical literature and managing the resulting project database. They also thank the Department of Anesthesiology, especially Christopher Jankowski, MD, of the Mayo Clinic, Rochester, Minnesota, for assistance in interpreting the anesthesiology literature.
Grant Support: By the Veterans Evidence-based Research, Dissemination, and Implementation Center (VERDICT) (Veterans Affairs Health Services Research and Development, HFP 98-002).
Potential Financial Conflicts of Interest: Stock ownership or options (other than mutual funds): G.W. Smetana (SafeMed Harvard Imaging); Other: G.W. Smetana (Novartis Pharma Schweiz).
Requests for Single Reprints: Valerie A. Lawrence, MD, Medicine/General Medicine, University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive, Mail Code 7879, San Antonio, TX 78229-3900; e-mail, firstname.lastname@example.org.
Current Author Addresses: Drs. Lawrence and Cornell: Medicine/General Medicine, University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive, Mail Code 7879, San Antonio, TX 78229-3900.
Dr. Smetana: Division of General Medicine and Primary Care, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA 02215.
Postoperative pulmonary complications are as frequent and clinically important as cardiac complications in terms of morbidity, mortality, and length of stay. However, there has been much less research and no previous systematic reviews of the evidence of interventions to prevent pulmonary complications.
To systematically review the literature on interventions to prevent postoperative pulmonary complications after noncardiothoracic surgery.
MEDLINE English-language literature search, 1 January 1980 through 30 June 2005, plus bibliographies of retrieved publications.
Randomized, controlled trials (RCTs); systematic reviews; or meta-analyses that met predefined inclusion criteria.
Using standardized forms, the authors abstracted data on study methods, quality, intervention and control groups, patient characteristics, surgery, postoperative pulmonary complications, and adverse events.
The authors qualitatively synthesized, without meta-analysis, evidence from eligible studies. Good evidence (2 systematic reviews, 5 additional RCTs) indicates that lung expansion interventions (for example, incentive spirometry, deep breathing exercises, and continuous positive airway pressure) reduce pulmonary risk. Fair evidence suggests that selective, rather than routine, use of nasogastric tubes after abdominal surgery (2 meta-analyses) and short-acting rather than long-acting intraoperative neuromuscular blocking agents (1 RCT) reduce risk. The evidence is conflicting or insufficient for preoperative smoking cessation (1 RCT), epidural anesthesia (2 meta-analyses), epidural analgesia (6 RCTs, 1 meta-analysis), and laparoscopic (vs. open) operations (1 systematic review, 1 meta-analysis, 2 additional RCTs), although laparoscopic operations reduce pain and pulmonary compromise as measured by spirometry. While malnutrition is associated with increased pulmonary risk, routine total enteral or parenteral nutrition does not reduce risk (1 meta-analysis, 3 additional RCTs). Enteral formulations designed to improve immune status (immunonutrition) may prevent postoperative pneumonia (1 meta-analysis, 1 additional RCT).
The overall quality of the literature was fair: Ten of 20 RCTs and 6 of 11 systematic reviews were good quality.
Few interventions have been shown to clearly or possibly reduce postoperative pulmonary complications.
Table 1. Randomized, Controlled Trials of Combined Intraoperative Anesthesia and Postoperative Analgesia
Table 2. Summary of Results of Meta-Analysis of 12 Randomized, Controlled Trials for Laparoscopic Operations Relative to Open Operations for Colorectal Cancer
Table 3. Meta-Analyses and Randomized, Controlled Trials of Lung Expansion Interventions To Prevent Postoperative Pulmonary Complications
Table 4. Strength of the Evidence for Specific Interventions To Reduce the Risk for Postoperative Pulmonary Complications
The In the Clinic® slide sets are owned and copyrighted by the American College of Physicians (ACP). All text, graphics, trademarks, and other intellectual property incorporated into the slide sets remain the sole and exclusive property of the ACP. The slide sets may be used only by the person who downloads or purchases them and only for the purpose of presenting them during not-for-profit educational activities. Users may incorporate the entire slide set or selected individual slides into their own teaching presentations but may not alter the content of the slides in any way or remove the ACP copyright notice. Users may make print copies for use as hand-outs for the audience the user is personally addressing but may not otherwise reproduce or distribute the slides by any means or media, including but not limited to sending them as e-mail attachments, posting them on Internet or Intranet sites, publishing them in meeting proceedings, or making them available for sale or distribution in any unauthorized form, without the express written permission of the ACP. Unauthorized use of the In the Clinic slide sets will constitute copyright infringement.
Department of Anesthesiology and Reanimation. Hospital General Universitario de Elche (Spain)
April 22, 2006
Strategies to Reduce Postoperative Pulmonary Complications after Noncardiothoracic Surgery
Dr. Lawrence and colleagues (1) write that "Evidence on intraoperative epidural anesthesia and postoperative epidural analgesia is insufficient". However, they affirm that "Good evidence suggests that lung expansion therapy reduces postoperative pulmonary risk after abdominal surgery".
The use of postoperative lung expansion therapy (incentive spirometry, deep breathing exercises, and continuous positive airway pressure) may be very difficult because of pain. Epidural analgesia has been shown to reduce postoperative pain, improve gastrointestinal function and reduce the incidence of serious complications (2,3).
The authors state that the risk for epidural bleeding due to postoperative epidural catheters may influence decisions about modalities for pain control and thromboembolism prophylaxis. They don't consider that epidural analgesia permits early mobilization programmes, avoiding immobility.
In our hospital anesthesiologists provide critical care for surgical patients; the use of epidural analgesia provides them safe analgesia, avoiding opioids which are known to produce ileus and ease development of hyperalgesia (4).
If the authors haven't found evidence that epidural analgesia reduces postoperative pulmonary complications, they must admit that epidural analgesia does reduce pain, allowing lung expansion therapies and early mobilization programmes which have shown to reduce length of hospital stay (5).
1. Lawrence VA, Cornell JE, Smetana GW. Strategies To Reduce Postoperative Pulmonary Complications after Noncardiothoracic Surgery: Systematic Review for the American College of Physicians. Ann Intern Med. 2006;144:596-608. [PMID:16618957]
2. Carli F, Mayo N, Klubien K, Schricker T, Trudel J, Belliveau P. Epidural analgesia enhances functional exercise capacity and health- related quality of life after colonic surgery: results of a randomized trial. Anesthesiology 2002;97:540"“549. [PMID:12218518]
3. Rodgers A, Walker N, Schug S,McKee A, KehletH, van Zundert A et al. Reduction of postoperative mortality and morbidity with epidural or spinal anaesthesia: results from overview of randomised trials. BMJ 2000;321:1493. [PMID: 11118174]
4. Angst MS, Clark JD. Opioid-induced hyperalgesia: a qualitative systematic review. Anesthesiology. 2006;104:570-87. [PMID:16508405]
5. Anderson AD, McNaught CE, MacFie J, Tring I, Barker P, Mitchell CJ. Randomized clinical trial of multimodal optimization and standard perioperative surgical care. Br J Surg. 2003;90:1497-504. [PMID:14648727]
Valerie A. Lawrence, John E. Cornell, Gerald W. Smetana. Strategies To Reduce Postoperative Pulmonary Complications after Noncardiothoracic Surgery: Systematic Review for the American College of Physicians. Ann Intern Med. 2006;144:596–608. doi: 10.7326/0003-4819-144-8-200604180-00011
Download citation file:
Published: Ann Intern Med. 2006;144(8):596-608.
Guidelines, Pulmonary/Critical Care.
Results provided by:
Copyright © 2017 American College of Physicians. All Rights Reserved.
Print ISSN: 0003-4819 | Online ISSN: 1539-3704
Conditions of Use