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
- Patients with the following risk factors should receive pre- and postoperative interventions to reduce pulmonary complications: chronic obstructive pulmonary disease, age >60 years, American Society of Anesthesiologists (ASA) class II or greater, functionally dependent status, congestive heart failure, and low serum albumin (<35 g/L) 2, 1
- Procedures associated with higher risk include: prolonged surgery (>3 hours), abdominal surgery, thoracic surgery, neurosurgery, head and neck surgery, vascular surgery, aortic aneurysm repair, emergency surgery, and general anesthesia 2
- Obesity and mild/moderate asthma are not significant risk factors for postoperative pulmonary complications 2
Core Pulmonary Hygiene Interventions
- Deep breathing exercises: Instruct patients to perform 30 deep breaths per hour while awake to improve oxygenation outcomes 1, 3
- Early mobilization: Begin as soon as medically indicated after surgery, progressing from moving in bed to sitting, standing, and walking 1
- Incentive spirometry: Recommended for high-risk patients, to be used hourly while awake, in combination with deep breathing exercises 1, 4
- Supported coughing: Teach patients to splint incision sites when coughing, particularly for those with respiratory complications 1
- Selective nasogastric tube use: Only as needed for postoperative nausea/vomiting, inability to tolerate oral intake, or symptomatic abdominal distention 2, 1
Special Considerations
- For thoracic surgery patients: Implement postoperative multimodal physiotherapy combining early mobilization, breathing exercises, and bronchial drainage techniques 1
- For cardiac surgery patients: Consider positive expiratory pressure (PEP) devices on a case-by-case basis and ensure adequate pain management to facilitate effective deep breathing 1, 3
- For cardiac surgery patients: Use chlorhexidine oral rinse (0.12%) during the perioperative period 1
Implementation Best Practices
- Provide preoperative education for patients at high risk for complications 1
- Ensure proper technique through demonstration and supervision 1
- Higher frequency of deep breathing exercises (30 breaths hourly vs. 10 breaths hourly) significantly improves oxygenation in the early postoperative period 3
- Consider postponing surgery in patients with respiratory infections or inadequately treated respiratory disease until these conditions are fully treated 5
Common Pitfalls to Avoid
- Relying solely on one intervention (e.g., incentive spirometry alone) instead of a multimodal approach 1
- Delaying mobilization 1
- Inadequate pain control, which can impair effective deep breathing 1, 6
- Routine use of nasogastric tubes 2, 1
- Overreliance on preoperative spirometry or chest radiography for risk prediction 2, 1
- Failing to recognize the importance of pulmonary complications, which contribute similarly to morbidity, mortality, and length of stay as cardiac complications 2