What are the recommendations for post-operative pulmonary hygiene?

Post-Operative Pulmonary Hygiene Recommendations

All patients at high risk for postoperative pulmonary complications should receive multimodal pulmonary hygiene including deep breathing exercises or incentive spirometry, early mobilization, and selective use of nasogastric tubes to reduce morbidity and mortality. 1

Risk Assessment for Pulmonary Complications

Before implementing pulmonary hygiene measures, identify patients at higher risk:

• Patient-related risk factors:

  • Chronic obstructive pulmonary disease 1
  • Age >60 years 1
  • American Society of Anesthesiologists (ASA) class II or greater 1
  • Functionally dependent status 1
  • Congestive heart failure 1
  • Low serum albumin (<35 g/L) 1

• Surgery-related risk factors:

  • Prolonged surgery (>3 hours) 1
  • Abdominal, thoracic, neurosurgery, head and neck, vascular surgery 1
  • Emergency surgery 1
  • General anesthesia 1

Core Pulmonary Hygiene Interventions

1. Deep Breathing Exercises

• Instruct patients to perform deep breathing exercises hourly while awake 1
• Recommended frequency: 30 deep breaths per hour shows better oxygenation outcomes than 10 breaths per hour 2
• Technique: Patient should take slow, deep breaths, hold for 3-5 seconds, and exhale slowly 3
• Duration: Continue for at least the first 2-3 postoperative days 2

2. Early Mobilization

• Begin as soon as medically indicated after surgery 1
• Progress from moving in bed to sitting, standing, and walking 1
• Combine with breathing exercises for optimal effect 1

3. Incentive Spirometry

• Use for patients at high risk for pneumonia 1
• Instruct patients to use hourly while awake 4
• May be used in combination with deep breathing exercises 4
• Note: When added to a comprehensive multimodal approach, the additional benefit may be limited 1

4. Coughing Techniques

• Teach supported coughing (splinting incision site) 1
• Include as part of multimodal management 1

5. Nasogastric Tube Management

• Use selectively rather than routinely 1, 4
• Indications: Postoperative nausea/vomiting, inability to tolerate oral intake, or symptomatic abdominal distention 1

6. Patient Positioning

• Elevate head of bed 30-45 degrees for patients at high risk for aspiration 1
• Particularly important for patients with enteral feeding tubes 1

Special Considerations

For Thoracic Surgery Patients

• Implement postoperative multimodal physiotherapy combining early mobilization, breathing exercises, and bronchial drainage techniques 1
• Consider positive expiratory pressure (PEP) devices on a case-by-case basis, but not as isolated therapy 1, 2
• Ensure adequate pain management to facilitate effective deep breathing 1

For Cardiac Surgery Patients

• Consider using positive expiratory pressure (PEP) devices with pressures between 2-20 cm H₂O 5
• Chlorhexidine oral rinse (0.12%) during perioperative period for cardiac surgery patients 1

Implementation Tips

• Preoperative education is essential for patients at high risk for complications 1
• Ensure proper technique through demonstration and supervision 3
• Monitor compliance with breathing exercises as adherence affects outcomes 2
• Continue breathing exercises after discharge for high-risk patients, though optimal duration varies 5

Common Pitfalls to Avoid

• Relying solely on one intervention (e.g., incentive spirometry alone) instead of a multimodal approach 1
• Delaying mobilization which can increase risk of complications 1
• Inadequate pain control limiting effective deep breathing and coughing 1
• Routine use of nasogastric tubes which may increase pulmonary complications 1, 4
• Overreliance on preoperative spirometry or chest radiography for risk prediction 1