Do smokers require preoperative steroids and nebulization prior to anesthesia?

Preoperative Management for Smokers Before Anesthesia

Smokers do not routinely require preoperative steroids and nebulization prior to anesthesia, but they should quit smoking at least 4 weeks before surgery to reduce respiratory and wound-healing complications.

Smoking Cessation Recommendations

Smoking significantly increases the risk of postoperative complications, particularly respiratory and wound-healing issues. The evidence provides clear guidance on managing smokers before surgery:

• Smoking cessation should begin at least 4 weeks before surgery to effectively reduce respiratory complications 1, 2, 3
• Shorter periods of smoking cessation (less than 4 weeks) have not consistently demonstrated reduced complications 1, 3
• Abstinence of at least 3-4 weeks is needed to reduce wound-healing complications 3

Optimal Approach to Smoking Cessation

For maximum effectiveness, smoking cessation interventions should include:

• Intensive counseling combined with nicotine replacement therapy (NRT) 1, 4
• Weekly counseling sessions when possible 4
• Pharmacologic support options including:
  • Nicotine replacement therapy
  • Bupropion
  • Varenicline 4, 5

Evidence Against Routine Preoperative Steroids and Nebulization

The guidelines do not recommend routine preoperative steroids or nebulization for smokers prior to anesthesia. Instead, they emphasize smoking cessation as the primary intervention 1.

Timing Considerations

The timing of smoking cessation is critical:

• 4-8 weeks of abstinence is necessary to reduce respiratory complications 1, 3
• Smokers who quit more than 4 weeks before surgery had significantly lower risks of respiratory complications (RR 0.77; 95% CI 0.61 to 0.96) 3
• Smokers who quit more than 8 weeks before surgery showed even greater reduction in respiratory complications (RR 0.53; 95% CI 0.37 to 0.76) 3

Common Pitfalls and Caveats

1. Misconception about short-term cessation: There is a common concern that short-term smoking cessation (less than 4 weeks) might paradoxically increase pulmonary complications due to increased mucous production. However, evidence shows that short-term cessation does not increase the risk of postoperative respiratory complications 3.

2. Delaying surgery: The limitations of the evidence base make it impossible to estimate the relative impact of prioritizing abstinence over the practicalities of procedure scheduling. The data do not support delaying lung cancer surgery to pursue smoking cessation prior to resection 1.

3. Inadequate cessation support: Simply advising patients to quit without providing structured support is insufficient. Intensive interventions that include counseling and pharmacotherapy are most effective 1, 4.

Practical Implementation

For patients identified as smokers before surgery:

1. Screen all surgical patients for tobacco use
2. Recommend smoking cessation at least 4 weeks before elective surgery
3. Provide intensive counseling and nicotine replacement therapy
4. Consider pharmacologic support with bupropion or varenicline
5. Do not routinely prescribe preoperative steroids or nebulization unless specifically indicated for other respiratory conditions

This approach aligns with the Enhanced Recovery After Surgery (ERAS) society recommendations and other evidence-based guidelines, prioritizing interventions that have demonstrated improvements in postoperative outcomes.