From the Guidelines
A standard preoperative pulmonary evaluation should include a thorough history and physical examination, focusing on respiratory symptoms, exercise tolerance, and risk factors for pulmonary complications, as recommended by the American College of Physicians 1. The evaluation process should identify patients at higher risk for postoperative pulmonary complications, such as those undergoing prolonged surgery, abdominal surgery, thoracic surgery, or having a low serum albumin level (<35 g/L) 1.
- Key components of the evaluation include:
- Assessing for risk factors, such as a history of chronic obstructive pulmonary disease or asthma
- Measuring serum albumin levels in patients with suspected hypoalbuminemia or risk factors for perioperative pulmonary complications
- Considering preoperative spirometry and chest radiography in patients with known pulmonary disease or asthma, but not as a routine measure for all patients 1
- Patients at higher risk for postoperative pulmonary complications should receive postoperative procedures, including deep breathing exercises or incentive spirometry, and selective use of a nasogastric tube, as needed 1. Recent guidelines also suggest using a dedicated score for preoperative pulmonary risk evaluation and individualized mechanical ventilation to improve respiratory function and prevent postoperative pulmonary complications 1.
- Optimization measures before surgery may include:
- Smoking cessation
- Bronchodilator therapy for patients with obstructive lung disease
- Treatment of respiratory infections
- Preoperative pulmonary rehabilitation for patients with moderate to severe lung disease These evaluations and optimization measures help identify patients at risk for postoperative complications and allow for appropriate perioperative management strategies to minimize pulmonary complications.
From the Research
Standard Preoperative Pulmonary Evaluation Recommendations
The standard preoperative pulmonary evaluation is crucial for identifying patients at risk of postoperative pulmonary complications (PPCs) and optimizing their health before surgery 2, 3, 4, 5, 6.
- Risk Factors: Patient-related risk factors, such as age, obesity, smoking history, and underlying respiratory diseases, and procedure-related risk factors, like upper abdominal or thoracic surgery, should be assessed 3, 6.
- Clinical Examination and Laboratory Tests: A thorough clinical examination supported by appropriate laboratory tests, including pulmonary function testing, chest radiographs, and quantitative perfusion scans, can help guide the clinician in providing optimal perioperative care 2, 4, 6.
- Optimization of Pulmonary Comorbidities: Optimization of pulmonary comorbidities, smoking cessation, and correction of anemia are essential risk-mitigation strategies 5.
- Preventive Strategies: Intra-operative preventive strategies, such as lung-protective ventilation, moderate PEEP application, and conservative use of neuromuscular blocking drugs, can reduce the risk of PPCs 5.
- Postoperative Care: Postoperative early mobilization, chest physiotherapy, oral care, and appropriate analgesia can speed up recovery 5.
- High-Risk Patients: High-risk patients should receive inspiratory muscle training prior to surgery, and there should be a focus to minimize surgery time 5.
- Preoperative Preparation: Prevention of postoperative pulmonary complications should begin with discontinuation of smoking at least 8 weeks prior to surgery, and preoperative chest physiotherapy, including incentive spirometry, is clearly beneficial in high-risk patients 6.