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Background Esophageal and gastric cancer surgery are associated with considerable morbidity, specifically postoperative pulmonary complications (PPCs), potentially accentuated by underlying challenges with malnutrition and cachexia affecting respiratory muscle mass. Physiotherapy regimens aim to increase the respiratory muscle strength and may prevent postoperative morbidity. Objective The aim of this study was to assess the impact of physiotherapy regimens in patients treated with esophagectomy or gastrectomy. Methods An electronic database search was performed in the MEDLINE, EMBASE, CENTRAL, CINAHL and Pedro databases. A meta-analysis was performed to assess the impact of physiotherapy on the functional capacity, incidence of PPCs and postoperative morbidity, in-hospital mortality rate, length of hospital stay (LOS) and health-related quality of life (HRQoL). Results Seven randomized controlled trials (RCTs) and seven cohort studies assessing prehabilitation totaling 960 patients, and five RCTs and five cohort studies assessing peri- or postoperative physiotherapy with 703 total patients, were included. Prehabilitation resulted in a lower incidence of postoperative pneumonia and morbidity (Clavien–Dindo score ≥ II). No difference was observed in functional exercise capacity and in-hospital mortality following prehabilitation. Meanwhile, peri- or postoperative rehabilitation resulted in a lower incidence of pneumonia, shorter LOS, and better HRQoL scores for dyspnea and physical functioning, while no differences were found for the QoL summary score, global health status, fatigue, and pain scores. Conclusion This meta-analysis suggests that implementing an exercise intervention may be beneficial in both the preoperative and peri- or postoperative periods. Further investigation is needed to understand the mechanism through which exercise interventions improve clinical outcomes and which patient subgroup will gain the maximal benefit.

Rationale: Poor preoperative physical fitness and respiratory muscle weakness are associated with postoperative pulmonary complications (PPCs) that result in prolonged hospital length of stay and increased mortality.Objectives: To examine the effect of preoperative exercise training on the risk of PPCs across different surgical settings.Methods: We searched MEDLINE, Web of Science, Embase, the Physiotherapy Evidence Database, and the Cochrane Central Register, without language restrictions, for studies from inception to July 2020. We included randomized controlled trials that compared patients receiving exercise training with those receiving usual care or sham training before cardiac, lung, esophageal, or abdominal surgery. PPCs were the main outcome; secondary outcomes were preoperative functional changes and postoperative mortality, cardiovascular complications, and hospital length of stay. The study was registered with PROSPERO (International Prospective Register of Systematic Reviews).Results: From 29 studies, 2,070 patients were pooled for meta-analysis. Compared with the control condition, preoperative exercise training was associated with a lower incidence of PPCs (23 studies, 1,864 patients; relative risk, 0.52; 95% confidence interval [CI], 0.41 to 0.66; grading of evidence, moderate); Trial Sequential Analysis confirmed effectiveness, and there was no evidence of difference of effect across surgeries, type of training (respiratory muscles, endurance or combined), or preoperative duration of training. At the end of the preoperative period, exercise training resulted in increased peak oxygen uptake (weighted mean difference [WMD], +2 ml/kg/min; 99% CI, 0.3 to 3.7) and higher maximal inspiratory pressure (WMD, +12.2 cm H 2 O; 99% CI, 6.3 to 18.2). Hospital length of stay was shortened (WMD, -2.3 d; 99% CI, -3.82 to -0.75) in the intervention group, whereas no difference was found in postoperative mortality.Conclusions: Preoperative exercise training improves physical fitness and reduces the risk of developing PPCs while minimizing hospital resources use, regardless of the type of intervention and surgery performed.Systematic review registered with https://www.crd.york.ac.uk/prospero/ (CRD 42018096956).

The prophylaxis of ventilator-associated lung injury (VALI) and postoperative pulmonary complications (PPC) is of utmost importance to reduce complications both in the perioperative period of major surgery and in the intensive care unit (ICU).Protective approach to mechanical ventilation comprises a wide range of measures reducing the damage of the lung tissue associated with the stress and strain phenomena. The implementation of the strategy of high positive end-expiratory pressure (PEEP) in combination with alveolar recruitment maneuver has numerous limitations and requires further personalized approaches.When lung injury is self-induced by a patient, it becomes an important contributor to VALI and should be timely diagnosed and prevented both before initiation of mechanical support and during the restoration of spontaneous breathing. This review highlights the key mechanisms of VALI and current understanding of protective ventilation. The concept of damaging energy as well as approaches to the personalized optimization of respiratory settings are discussed in detail. Particular attention is paid to the prognostication of the risk factors of VALI and PPC.

Introduction: Major cardiothoracic or abdominal surgery can lead to the development of postoperative pulmonary complications (PPC), associated with increased morbidity and prolonged length of hospital stay. Preventive chest physiotherapy is routinely provided, but optimization of treatment strategies is needed to improve patient outcome and resource utilization. Objective: To develop a preoperative risk prediction scorelr to assist clinical decision-making regarding physiotherapy interventions. Methods: A prospective observational single-center study included 339 of 577 eligible patients admitted for major elective cardiothoracic or abdominal surgery. Primary outcome measure was PPC amendable to chest physiotherapy. Results: A total of 113 patients (33.3%) developed a PPC. Logistic regression modeling identified four independent predictors of PPC presented with odds ratio (OR) and 95% confidence interval. Reduced lung function (FEV 1 > 50% to 1 ≤ 50% OR 4.7 (1.4;16.0)), Recent unintended weight loss OR 4.5 (1.1; 18.7), Sternotomy OR 3.5 (2.0; 6.0) and Thoraco-abdominal incision OR 4.5 (2.1; 10.1). Based on assigned point values, a score dividing patients into three risk groups was developed. The score had moderate discrimination (c-statistic 0.70). Conclusion: By following recommended guidelines (TRIPOD) a preoperative risk prediction score including four predictors of PPC was developed. External validation of the score is currently being investigated.

The objective : basing on published data, to highlight the main issues of preparation of patients with concomitant lung pathology and a high risk of developing postoperative pulmonary complications for planned surgical interventions. Results : changes made to international guidelines over the past 5 years based on evidenc e-b ased studies and met a-a nalyzes have been analyzed. The article presents data on preoperative management of patients with concomitant lung pathologies and a high risk of postoperative pulmonary complications, assessment of the risk of developing these complications based on evaluation of the functional status of patients. It analyzes the contemporary recommendations on the perioperative prevention of pulmonary complications, the use of physical exercises and respiratory gymnastics in the perioperative period in patients with a high risk of postoperative pulmonary complications. It is concluded that the implementation of comprehensive strategy aimed at reducing the risk of pulmonary complications should ensure decrease in their frequency and mortality due to them.

Background The prospective observational European multicentre cohort study (POPULAR) of postoperative pulmonary complications (NCT01865513) did not demonstrate that adherence to the recommended train-of-four ratio (TOFR) of 0.9 before extubation was associated with better pulmonary outcomes from the first postoperative day up to hospital discharge. We re-analysed the POPULAR data as to whether there existed a better threshold for TOFR recovery before extubation to reduce postoperative pulmonary complications in patients who had quantitative neuromuscular monitoring (87% acceleromyography). Methods To identify the optimal TOFR, the complete case cohort of patients with quantitative neuromuscular monitoring (n=3150) was split into several pairs of sub-cohorts related to TOFR values from 0.86 to 0.96; values of 0.97 and higher could not be used as the sub-cohorts were too small. The optimal TOFR was considered to have the lowest P-value from multivariate logistic regression calculated for each of the TOFR values. Data are presented as adjusted absolute risk reduction or median difference with 95% confidence interval. Results Extubating patients with TOFR >0.95 rather than >0.9 reduced the adjusted risk of postoperative pulmonary complications by 3.5% (0.7–6.0%) from that reported in POPULAR (11.3%). Increasing the recommended TOFR from 0.9 to 0.95 reduced the adjusted risk by 4.9% (1.2–8.5%). Sub-cohorts resulting from 1:1 propensity score matching revealed that sugammadex had been given in higher doses by 0.30 (0.13–0.48) mg kg−1 in the sub-cohort with TOFR > 0.95. Conclusions A post hoc analysis of patients receiving quantitative monitoring of neuromuscular function suggests that postoperative pulmonary complications are reduced for TOFR > 0.95 before tracheal extubation compared with TOFR > 0.9. Trial registration number NCT01865513.

Abdominal surgeries are the most common operative procedures including a wide range of both emergency and elective surgical interventions. Postoperative Pulmonary Complications (PPCs) following upper abdominal surgery are the most common surgical complications. The combined effect of surgical trauma and anaesthesia results in reduced lung volumes and respiratory muscle dysfunction. Chest physical therapy is widely recommended to prevent and treat PPCs, using a wide variety of techniques and devices, including incentive spirometry, continuous positive airway pressure, positive expiratory pressure, intrapulmonary percussive ventilation and Inspiratory Muscle Training (IMT) using a pressure threshold device that targets the muscles of inspiration. The present narrative review aims to examine the available literature to evaluate whether preoperative respiratory muscle training is effective on pulmonary function test, Respiratory Muscle Strength (RMS) and preventing PPCs after abdominal surgery. A computer-based literature search was done using the PubMed, PubMed Central, Science direct and Google Scholar. Relevant articles with full text published in English from 1995 to 2021 were screened and included. Studies were included which had preoperative physiotherapy techniques on patients undergoing abdominal surgery. Editorials, commentaries, discussion papers, conference abstracts, reviews and duplicates were excluded. After screening, only studies with full text articles were included that comprised of 9 relevant articles. It is imperative to discover the probable outcome of preoperative respiratory exercise training. Hence, a review could be helpful in delivering a perception about which exercise program could cause improved and enhanced postoperative outcome.

Journal of Medical Bioscience, 4, 1, 025-035

ObjectiveThis study aimed to create a prediction model of postoperative pulmonary complications for the patients with emergency cerebral hemorrhage surgery.MethodsPatients with hemorrhage surgery who underwent cerebral hemorrhage surgery were included and divided into two groups: patients with or without pulmonary complications. Patient characteristics, previous history, laboratory tests, and interventions were collected. Univariate and multivariate logistic regressions were used to predict postoperative pulmonary infection. Multiple machine learning approaches have been used to compare their importance in predicting factors, namely K-nearest neighbor (KNN), stochastic gradient descent (SGD), support vector classification (SVC), random forest (RF), and logistics regression (LR), as they are the most successful and widely used models for clinical data.ResultsThree hundred and fifty four patients with emergency cerebral hemorrhage surgery between January 1, 2017 and December 31, 2020 were included in the study. 53.7% (190/354) of the patients developed postoperative pulmonary complications (PPC). Stepwise logistic regression analysis revealed four independent predictive factors associated with pulmonary complications, including current smoker, lymphocyte count, clotting time, and ASA score. In addition, the RF model had an ideal predictive performance.ConclusionsAccording to our result, current smoker, lymphocyte count, clotting time, and ASA score were independent risks of pulmonary complications. Machine learning approaches can also provide more evidence in the prediction of pulmonary complications.

Introduction: The role of intraoperative ventilation strategies in subjects undergoing surgery is still contested. This meta-analysis study was performed to assess the relationship between the low tidal volumes strategy and conventional mechanical ventilation in subjects undergoing surgery.Methods: A systematic literature search up to December 2020 was performed in OVID, Embase, Cochrane Library, PubMed, and Google scholar, and 28 studies including 11,846 subjects undergoing surgery at baseline and reporting a total of 2,638 receiving the low tidal volumes strategy and 3,632 receiving conventional mechanical ventilation, were found recording relationships between low tidal volumes strategy and conventional mechanical ventilation in subjects undergoing surgery. Odds ratio (OR) or mean difference (MD) with 95% confidence intervals (CIs) were calculated between the low tidal volumes strategy vs. conventional mechanical ventilation using dichotomous and continuous methods with a random or fixed-effect model.Results: The low tidal volumes strategy during surgery was significantly related to a lower rate of postoperative pulmonary complications (OR, 0.60; 95% CI, 0.44–0.83, p < 0.001), aspiration pneumonitis (OR, 0.63; 95% CI, 0.46–0.86, p < 0.001), and pleural effusion (OR, 0.72; 95% CI, 0.56–0.92, p < 0.001) compared to conventional mechanical ventilation. However, the low tidal volumes strategy during surgery was not significantly correlated with length of hospital stay (MD, −0.48; 95% CI, −0.99–0.02, p = 0.06), short-term mortality (OR, 0.88; 95% CI, 0.70–1.10, p = 0.25), atelectasis (OR, 0.76; 95% CI, 0.57–1.01, p = 0.06), acute respiratory distress (OR, 1.06; 95% CI, 0.67–1.66, p = 0.81), pneumothorax (OR, 1.37; 95% CI, 0.88–2.15, p = 0.17), pulmonary edema (OR, 0.70; 95% CI, 0.38–1.26, p = 0.23), and pulmonary embolism (OR, 0.65; 95% CI, 0.26–1.60, p = 0.35) compared to conventional mechanical ventilation.Conclusions: The low tidal volumes strategy during surgery may have an independent relationship with lower postoperative pulmonary complications, aspiration pneumonitis, and pleural effusion compared to conventional mechanical ventilation. This relationship encouraged us to recommend the low tidal volumes strategy during surgery to avoid any possible complications.

ObjectivesCough impairment may lead to excessive accumulation of pulmonary secretions and increase the risk of postoperative pulmonary complications (PPCs). Peak expiratory flow (PEF) is a sensitive indicator of cough ability. We aimed to investigate the correlation between PEF and PPCs for lung cancer patients undergoing lobectomy or segmental resection for improved risk assessment.MethodsThis retrospective study assessed 560 patients with non-small cell lung cancer admitted for surgery between January 2014 to June 2016. The measurements of PEF were performed before surgery and the clinical outcomes were recorded, including PPCs, postoperative hospital stay, hospitalization costs, and other variables.ResultsPreoperative PEF was significantly lower in PPCs group compared to non-PPCs group (294.2 ± 95.7 vs. 363.0 ± 105.6 L/min, P < 0.001). Multivariable regression analysis showed that high PEF (OR=0.991, 95%CI: 0.988-0.993, P < 0.001) was an independent protective factor for PPCs. According to the receiver operating characteristic (ROC) curve, a PEF value of 250 L/min was selected as the optimal cutoff value in female patients, and 320 L/min in male patients. Patients with PEF under cutoff value of either sex had higher PPCs rate and unfavorable clinical outcomes.ConclusionsPreoperative PEF was found to be a significant predictor of PPCs for surgical lung cancer patients. It may be beneficial to consider the cutoff value of PEF in perioperative risk assessment.

Mechanical ventilation (MV) is still necessary in many surgical procedures; nonetheless, intraoperative MV is not free from harmful effects. Protective ventilation strategies, which include the combination of low tidal volume and adequate positive end expiratory pressure (PEEP) levels, are usually adopted to minimize the ventilation-induced lung injury and to avoid post-operative pulmonary complications (PPCs). Even so, volutrauma and atelectrauma may co-exist at different levels of tidal volume and PEEP, and therefore, the physiological response to the MV settings should be monitored in each patient. A personalized perioperative approach is gaining relevance in the field of intraoperative MV; in particular, many efforts have been made to individualize PEEP, giving more emphasis on physiological and functional status to the whole body. In this review, we summarized the latest findings about the optimization of PEEP and intraoperative MV in different surgical settings. Starting from a physiological point of view, we described how to approach the individualized MV and monitor the effects of MV on lung function.

Background Postoperative pulmonary complications (PPCs) often occur after cardiac operations and are a leading cause of morbidity, inhibit oxygenation, and increase hospital length of stay and mortality. Although clinical evidence for PPCs prevention is often unclear and crucial, measures occur to reduce PPCs. One device usually used for this reason is incentive spirometry (IS). The aim of the study is to evaluate the effect of preoperative incentive spirometry to prevent postoperative pulmonary complications, improve postoperative oxygenation, and decrease hospital stay following coronary artery bypass graft (CABG) surgery patients. Methods This was a clinical randomized prospective study. A total of 80 patients were selected as candidates for CABG at An-Najah National University Hospital, Nablus-Palestine. Patients had been randomly assigned into two groups: incentive spirometry group (IS), SI performed before surgery (study group) and control group, preoperative spirometry was not performed. The 40 patients in each group received the same protocol of anesthesia and ventilation in the operating room. Result The study findings showed a significant difference between the IS and control groups in the incidence of postoperative atelectasis. There were 8 patients (20.0%) in IS group and 17 patients (42.5%) in the control group (p = 0.03). Mechanical ventilation duration was significantly less in IS group. The median was four hours versus six hours in the control group (p p p Conclusion Preoperative incentive spirometry for two days along with the exercise of deep breathing, encouraged coughing, and early ambulation following CABG are in connection with prevention and decreased incidence of atelectasis, hospital stay, mechanical ventilation duration and improved postoperative oxygenation with better pain control. A difference that can be considered both significant and clinically relevant. Trial registration Thai Clinical Trials Registry: TCTR20201020005. Registered 17 October 2020—retrospectively registered.

Objectives The aim of this study was to determine the effects of escalation of respiratory support and prolonged postoperative invasive ventilation on patient-centered outcomes, and identify perioperative factors associated with these 2 respiratory complications. Design A retrospective cohort analysis of cardiac surgical patients admitted to the cardiothoracic intensive care unit (ICU) between August 2015 and January 2018. Escalation of respiratory support was defined as “unplanned continuous positive airway pressure,” “non-invasive ventilation,” or “reintubation” after surgery; prolonged invasive ventilation was defined as “invasive ventilation beyond the first 12 hours following surgery.” The primary endpoint was the composite of escalation of respiratory support and prolonged ventilation. Setting Tertiary cardiothoracic ICU. Participants A total of 2,098 patients were included and analyzed. Interventions None. Measurements and Main Results The composite of escalation of support or prolonged ventilation occurred in 509 patients (24.3%). Patients who met the composite had higher mortality (2.9% v 0.1%; p < 0.001) and longer median [interquartile range] length of ICU (2.1 [1.0-4.9] v 0.9 [0.8-1.0] days; p < 0.0001) and hospital (10.6 [8.0-16.0] v 7.2 [6.2-10.0] days; p < 0.0001) stay. Hypoxemia and anemia on admission to ICU were the only 2 factors independently associated with the need for escalation of respiratory support or prolonged invasive ventilation. Conclusions Escalation of respiratory support or prolonged invasive ventilation is frequently seen in cardiac surgery patients and is highly associated with increased mortality and morbidity. Hypoxemia and anemia on admission to the ICU are potentially modifiable factors associated with escalation of respiratory support or prolonged invasive ventilation.

У пацієнтів з гострою абдомінальною патологією середнього і високого хірургічного ризику загальна частота післяопераційних легеневих ускладнень становить 10,5%, з них 80,9% всіх випадків пов'язаноз пневмонією. У пацієнтів середнього хірургічного ризику режим інфузійної терапії впливає на частоту виникнення післяопераційних легеневих ускладнень як: ліберальний режим супроводжується розвитком інтерстиціального набряку, збільшенням позасудинної рідини в легенях помірного ступеня і частотою розвитку легеневих ускладнень у 16%, рестриктивний режим зберігає об'єм інтерстиції в межах норми весь післяопераційний період і знижує ризики легеневих ускладнень до 6%. У пацієнтів високого хірургічного ризику згострою абдомінальною патологією післяопераційний період ускладнюється розвитком легеневих ускладнень у 10% випадків через збільшення інтерстиціального обсягу і легеневої позасудинної рідини легкого ступеня у першу добу при цілеспрямованому режимі інфузійної терапії, обмеження розвитку інтерстиціального набряку весь післяопераційний період при рестриктивному режимі інфузійної терапії. In patients with acute abdominal pathology of middle and high surgical risk the overall incidence of postoperative pulmonary complications is 10.5%, of which 80.9% of all cases are associated with pneumonia. Moderate surgical risk patients had a different infusion therapy's affects to the development of postoperative pulmonary complications;a liberal regime is accompanied by the development of interstitial edema, increased extravascular fluid in the lungs and incidence of pulmonary complications in 16%, restrictive mode preserves the volume of the interstices within the boundaries of the rules during postoperative period and reduces the risks of pulmonary complications to 6%. High surgical risk patients with acute abdominal pathology,postoperative period is complicated by development of pulmonary complications in 10% of cases due to increased interstitial volume and pulmonary extravascular fluid mild in the first day when targeted mode of infusion therapy limitsthe development of interstitial edema during all the postoperative period in the restrictive mode of infusion therapy.

Introduction: A lot of clinical studies have shown that during prolonged surgery protective ventilation strategy, including low tidal volume, PEEP and recruitment maneuvers (RM) can reduce the rate of postoperative pulmonary complications, which are the second most common cause for postoperative mortality. Therefore, it is important to investigate clinical methods for preventing them. The strategy of protective ventilation is easy and safe for the patients and inexpensive for application during prolonged surgery. Aims: The objective of this trial was to study whether application of PEEP in patients during prolonged gynecological surgery could decrease the postoperative complications. Material and Methods: We compared the rates of postoperative complications in patients after prolonged open gynecological surgery, who were divided into 2 groups – group A, which was the control group on non-protective ventilation (35 patients) and group B on protective ventilation (35 patients). The patients in the control group were ventilated with tidal volume (VT) of 8-10 ml/kg without PEEP and RM; the patients in group B were ventilated with VT = 6-8 ml/kg according to their Predicted Body Weight, with a PEEP of 6 cm H2O and RM, which consisted of applying continuous positive airway pressure of 30 cm H2O for 30 seconds. RM was performed after intubation, after every disconnection from ventilator and before extubation. The study was successfully performed without a need for a change in the type of ventilation strategy because of hypoxia or hemodynamic instability. Statistical nonparametric test (e.g. chi-square) was applied. Results: Total rate of all postoperative complications observed in both groups was 27,1%. We found a significant relationship between application of PEEP and lower rates of postoperative pulmonary complications in group A (39,4%) compared to group B (12,1%), lower rate of respiratory failure (33,3% in group A vs. 9,1% in group B -) and atelectasis (21,2% in group A vs. 0% in group B). Conclusion: The protective ventilation strategy (low VT, PEEP and RM) in patients during prolonged gynecological surgery can reduce the rate of postoperative pulmonary complications such as respiratory failure and atelectasis.

Objectives To determine whether driving pressure and expiratory flow limitation are associated with the development of postoperative pulmonary complications (PPCs) in cardiac surgery patients. Design Prospective cohort study. Setting University Hospital San Raffaele, Milan, Italy. Participants Patients undergoing elective cardiac surgery. Measurements and Main Results The primary endpoint was the occurrence of a predefined composite of PPCs. The authors determined the association among PPCs and intraoperative ventilation parameters, mechanical power and energy load, and occurrence of expiratory flow limitation (EFL) assessed with the positive end-expiratory pressure test. Two hundred patients were enrolled, of whom 78 (39%) developed one or more PPCs. Patients with PPCs, compared with those without PPCs, had similar driving pressure (mean difference [MD] –0.1 [95% confidence interval (CI), –1.0 to 0.7] cmH2O, p = 0.561), mechanical power (MD 0.5 [95% CI, –0.3 to 1.1] J/m, p = 0.364), and total energy load (MD 95 [95% CI, –78 to 263] J, p = 0.293), but they had a higher incidence of EFL (51% v 38%, p = 0.005). Only EFL was associated independently with the development of PPCs (odds ratio 2.46 [95% CI, 1.28-4.80], p = 0.007). Conclusions PPCs occurred frequently in this patient population undergoing cardiac surgery. PPCs were associated independently with the presence of EFL but not with driving pressure, total energy load, or mechanical power.

Background The influence of sugammadex for reversal of neuromuscular block (NMB) on postoperative pulmonary complications (PPCs), compared with neostigmine, remains to be determined. We performed a meta-analysis of randomized controlled trials (RCTs) to compare the incidence of PPCs between patients who received sugammadex versus neostigmine. Methods Relevant studies were obtained by searching the PubMed, Embase, and Cochrane Library databases. A random effects model incorporating the potential heterogeneity was used to pool the results. Results Fourteen RCTs including 1478 adult patients who underwent surgeries with general anesthesia were included, and of these, 753 received sugammadex and 725 received neostigmine for reversal of NMB. The pooled results showed that sugammadex was associated with a lower risk of overall PPCs compared to neostigmine (odds ratio [OR]: 0.62, 95% confidence interval [CI]: 0.43–0.89, p = 0.01; I2 = 0%). This finding remained consistent after exclusion of two studies with potential overlapping events (OR: 0.58, 95% CI: 0.36–0.96, p = 0.03; I2=9%). Stratified analyses according to the categories of PPCs showed that sugammadex was associated with a significantly lower risk of postoperative respiratory failure (OR: 0.60, 95% CI: 0.38–0.97, p = 0.04; I2 = 0%) but not of postoperative pulmonary infection (OR: 0.79, p = 0.71), atelectasis (OR: 0.78, p = 0.33), or pneumothorax (OR: 0.87, p = 0.79). Conclusions Compared with neostigmine, the use of sugammadex for reversal of NMB was associated with a lower risk of PPCs, mainly due to a lower incidence of postoperative respiratory failure with the use of sugammadex.

Background The study aimed to evaluate the outcomes following the implementation of enhanced recovery after surgery (ERAS) for patients undergoing lung cancer surgery. Method A retrospective cohort study involving 1749 patients with lung cancer undergoing pulmonary resection was conducted. The patients were divided into two time period groups for analysis (routine pathway and ERAS pathway). Logistic regression analysis was performed to assess the risks of developing postoperative pulmonary complications. Results Among the 1749 patients, 691 were stratified into the ERAS group, and 1058 in to the routine group. The ERAS group presented with shorter postoperative in-hospital length of stay (LOS) (4.0 vs 6.0, P Conclusion Implementation of an ERAS pathway shows improved postoperative outcomes, including shortened LOS, lower in-hospital costs, and reduced occurrence of PPCs, providing benefits to the postoperative recovery of patients with lung cancer undergoing surgical treatment.

Background Secondary lung injury is the most common non-neurological complication after traumatic brain injury (TBI). Lung-protective ventilation (LPV) has been proven to improve perioperative oxygenation and lung compliance in some critical patients. This study aimed to investigate whether intraoperative LPV could improve respiratory function and prevent postoperative complications in emergency TBI patients. Methods Ninety TBI patients were randomly allocated to three groups (1:1:1): Group A, conventional mechanical ventilation [tidal volume (VT) 10 mL/kg only]; Group B, small VT (8 mL/kg) + positive end-expiratory pressure (PEEP) (5 cmH2O); and Group C, small VT (8 mL/kg) + PEEP (5 cmH2O) + recruitment maneuvers (RMs). The primary outcome was the incidence of total postoperative pulmonary complications; Secondary outcomes were intraoperative respiratory mechanics parameters and serum levels of brain injury markers, and the incidence of each postoperative pulmonary and neurological complication. Results Seventy-nine patients completed the final analysis. The intraoperative PaO2 and dynamic pulmonary compliance of Groups B and C were higher than those of Group A (P = 0.028; P = 0.005), while their airway peak pressure and plateau pressure were lower than those of group A (P = 0.004; P = 0.005). Compared to Group A, Groups B and C had decreased 30-day postoperative incidences of total pulmonary complications, hypoxemia, pulmonary infection, and atelectasis (84.0 % vs. 57.1 % vs. 53.8 %, P = 0.047; 52.0 % vs. 14.3 % vs. 19.2 %, P = 0.005; 84.0 % vs. 50.0 % vs. 42.3 %, P = 0.006; 24.0 % vs. 3.6 % vs. 0.0 %, P = 0.004). Moreover, intraoperative hypotension was more frequent in Group C than in Groups A and B (P = 0.007). At the end of surgery, the serum levels of glial fibrillary acidic protein and ubiquitin carboxyl-terminal hydrolase isozyme L1 in Group B were lower than those in Groups A and C (P = 0.002; P Conclusions Continuous intraoperative administration of small VT + PEEP is beneficial to TBI patients. Additional RMs can be performed with caution to prevent disturbances in the stability of cerebral hemodynamics. Trial registration Chinese Clinical Trial Registry (ChiCTR2000038314), retrospectively registered on September 17, 2020.

Background: International data on the epidemiology, ventilation practice, and outcomes in patients undergoing abdominal robotic-assisted surgery (RAS) are lacking. The aim of the study was to assess the incidence of postoperative pulmonary complications (PPCs), and to describe ventilator management after abdominal RAS. Methods: This was an international, multicentre, prospective study in 34 centres in nine countries. Patients >= 18 yr of age undergoing abdominal RAS were enrolled between April 2017 and March 2019. The Assess Respiratory Risk in Surgical Patients in Catalonia (ARISCAT) score was used to stratify for higher risk of PPCs (>= 26). The primary outcome was the incidence of PPCs. Secondary endpoints included the preoperative risk for PPCs and ventilator management. Results: Of 1167 subjects screened, 905 abdominal RAS patients were included. Overall, 590 (65.2%) patients were at increased risk for PPCs. Meanwhile, 172 (19%) patients sustained PPCs, which occurred more frequently in 132 (22.4%) patients at increased risk, compared with 40 (12.7%) patients at lower risk of PPCs (absolute risk difference: 12.2% [95% confidence intervals (CI), 6.8-17.6%]; P

Background and Aims: Induction of general anaesthesia is associated with development of atelectasis in the lungs, which may further lead to postoperative pulmonary complications. Inverse ratio ventilation (IRV) has shown to improve oxygenation and minimise further lung injury in patients with acute respiratory distress syndrome. We evaluated the safety and effectiveness of IRV on intraoperative respiratory mechanics and postoperative pulmonary function tests (PFTs). Methods: In a prospective, controlled study, 128 consecutive patients with normal preoperative PFTs who underwent elective laparoscopic cholecystectomy were randomised into IRV and conventional ventilation groups. Initially, all patients were ventilated with settings of tidal volume 8 mL/kg, respiratory rate 12/min, inspiratory/expiratory ratio (I: E) = 1:2, positive end expiratory pressure = 0. Once the pneumoperitoneum was created, the conventional group patients were continued to be ventilated with same settings. However, in the IRV group, I: E ratio was changed to 2:1. Peak pressure (Ppeak), Plateau pressure (Pplat) and lung compliance were measured. Haemodynamic parameters and arterial blood gas values were also measured. PFTs were repeated in postoperative period. Statistical tool included Chi-square test. Results: There was no significant difference in PFTs in patients who underwent IRV as compared to conventional ventilation [forced vital capacity (FVC) 2.52 ± 0.13 versus 2.63 ± 0.16, P = 0.28]. The Ppeak (cmH2O) and Pplat (cmH2O) were statistically lower in IRV patients [Ppeak 21.4 ± 3.4 versus 22.4 ± 4.2, P = 0.003] [Pplat 18.7 ± 2.4 versus 19.9.4 ± 3.2, P = 0.008]. There was no significant difference in lung compliance and oxygenation intraoperatively. Conclusion: Intraoperative IRV led to reduced airway pressures; however, it did not prevent deterioration of PFTs in postoperative period.

Objective To observe spirometry and its correlation with postoperative pulmonary complications in cardiac surgery patients. Study design Prospective observational study Place and duration of the study Chaudhary Pervaiz Elahi Institute of Cardiology (CPEIC) Multan, from January 1, 2017, to June 30, 2020 Methodology Written informed consent was taken from 357 patients. Spirometry was performed in all the patients using the conventional method. Baseline data, including gender, age, body mass index (BMI), living area, smoking history, known lung illness, six-minute walk distance, predicted forced vital capacity (FVC) %, predicted forced expiratory volume in one second (FEV1) %, and type of the procedure such as aortic valve replacement (AVR), coronary artery bypass grafting (CABG), double-valve replacement (DVR), and mitral valve replacement (MVR) were documented for all the patients. Outcome data included postoperative ICU length of stay (LOS), respiratory failure, respiratory infection, atelectasis, and mortality. Results The most common procedure was CABG and MVR proceeded by n=254 (71.1%) and n=83 (23.2%) patients, respectively. Postoperative complications, such as respiratory failure, respiratory infection, and atelectasis, was noted in n=29 (8.1%), n=28 (7.8 %), and n=127 (35.6 %) patients, respectively, while n=5 (1.4%) patients died. Conclusion Deranged pulmonary function tests (PFTs) are associated with poor prognosis following elective cardiac surgery in terms of postoperative pulmonary complications such as pulmonary infection, respiratory failure, and atelectasis. There is a significant difference in percentage predicted of FVC and FEV1 in patients who developed atelectasis and respiratory tract infection.

Introduction: Postoperative pulmonary complications (PPCs) are common and associated with increased morbidity, mortality, and medical cost. They are gaining increasing concerns among patients receiving neurological surgery. Chronic obstructive pulmonary disease (COPD) affect a large section of whole population and is also one of the risk factors of PPCs in the perioperative setting. Ipratropium bromide is the inhalation solution for the treatment of COPD. Studies showed the perioperative nebulization of ipratropium bromide could increase the lung function and decrease the incidence of postoperative pneumonia in COPD patients underwent thoracic surgery. The purpose of this study is to investigate the effect of perioperative nebulization of ipratropium bromide on PPCs in COPD patients underwent neurosurgical surgery. Methods and analysis: This study is a multicenter retrospective study in China. Patients who meet the inclusion/exclusion criteria are selected from 7 neurosurgical centers in China. According to whether ipratropium bromide is used in perioperative period, the patients are divided into exposure group and control group. The primary outcome is the incidence of postoperative pneumonia. Secondary outcomes are unplanned intubation, postoperative mechanical ventilation ≥ 48 hours, respiratory failure, atelectasis, death, and length of stay. Ethics and dissemination: This study was approved by the ethics committee (EC) of the School of Public Health, Fudan University, Shanghai, China. Waived by the ethics committee, no written consent form was obtained since we used the registry data. The study results will be communicated via publication. Trial Registration Number: ChiCTR1900022552.

Background Postoperative pulmonary complications (PPCs) seems to be high in patients undergoing pelvic and sacrum tumor resection assisted by abdominal aortic balloon occlusion. We hypothesized that the accumulative occlusion time (AOT) of the abdominal aortic balloon may be predictive of PPCs. The objective of the study was to identify the influence of AOT on PPCs. Methods Retrospectively analyzed perioperative factors of 584 patients who underwent pelvic and sacrum tumor resection assisted by abdominal aortic balloon occlusion in our hospital from January 1, 2016 to December 31, 2018. PPCs including suspected pulmonary infection, atelectasis, pulmonary edema, pleural effusion, respiratory failure were clinically diagnosed. Perioperative parameters among patients with and without PPCs were compared. A receiver operating characteristic (ROC) analysis was conducted to evaluate the discriminative power of AOT with regard to PPCs. A multivariate logistic-regression model was finally established to identify independent risk factors for PPCs. Results The incidence of PPCs was 15.6% (91 patients). The median AOT in PPCs group was significantly higher than that in non-PPCs group (P P P = 0.046; odds ratio (OR) = 2.074), age (P < 0.001; OR = 1.032), ASA grade III (P = 0.015; OR = 3.264), and estimated blood loss (P = 0.022; OR = 1.235) were independent risk factors of PPCs by multivariate logistic regression analysis. Conclusion The incidence of PPCs in patients undergoing the pelvic and sacrum tumor surgery assisted by abdominal aortic balloon occlusion was 15.6%. AOT ≥ 119 min was an independent predictor for PPCs. Surgeons should strive to minimize the AOT within 2 h.

Background Limited information is available regarding intraoperative ventilator settings and the incidence of postoperative pulmonary complications (PPCs) in patients undergoing neurosurgical procedures. The aim of this post-hoc analysis of the 'Multicentre Local ASsessment of VEntilatory management during General Anaesthesia for Surgery' (LAS VEGAS) study was to examine the ventilator settings of patients undergoing neurosurgical procedures, and to explore the association between perioperative variables and the development of PPCs in neurosurgical patients. Methods Post-hoc analysis of LAS VEGAS study, restricted to patients undergoing neurosurgery. Patients were stratified into groups based on the type of surgery (brain and spine), the occurrence of PPCs and the assess respiratory risk in surgical patients in Catalonia (ARISCAT) score risk for PPCs. Results Seven hundred eighty-four patients were included in the analysis; 408 patients (52%) underwent spine surgery and 376 patients (48%) brain surgery. Median tidal volume (V-T) was 8 ml [Interquartile Range, IQR = 7.3-9] per predicted body weight; median positive end-expiratory pressure (PEEP) was 5 [3 to 5] cmH(2)0. Planned recruitment manoeuvres were used in the 6.9% of patients. No differences in ventilator settings were found among the sub-groups. PPCs occurred in 81 patients (10.3%). Duration of anaesthesia (odds ratio, 1.295 [95% confidence interval 1.067 to 1.572]; p = 0.009) and higher age for the brain group (odds ratio, 0.000 [0.000 to 0.189]; p = 0.031), but not intraoperative ventilator settings were independently associated with development of PPCs. Conclusions Neurosurgical patients are ventilated with low V-T and low PEEP, while recruitment manoeuvres are seldom applied. Intraoperative ventilator settings are not associated with PPCs.

Background: The use of positive end-expiratory pressure (PEEP) can have an important role as one of the ways to prevent and treat atelectasis, but it seems that there is still no consensus about its beneficial level. The aim of this study was to determine the effect of different levels of PEEP on the incidence of atelectasis after heart surgery. Methods: This is a double-blind randomized controlled trial that was adopted from a research project recorded in the Iranian Registry of Clinical Trials. This paper is the result of a research project undertaken at Fatemeh Zahra Hospital (Mazandaran Heart Center) in 2015. 180 patients underwent open heart surgery were selected and were divided randomly into three groups: control, PEEP=8, and PEEP=10 (60 in each group). The patients in the two PEEP8 and PEEP10 intervention groups separately received 8 cm H2O and 10 cm H2O PEEP, respectively, 30 minutes after admission to the ICU for 4 hours and then received 5 cm H2O PEEP until extubation. Atelectasis was examined two hours after the extubation and on the third day after surgery. Results: The incidence rates of atelectasis two hours after extubation on the first day of surgery were 22 (36.7%), 20 (33.3%) and 10 (16.7%) patients in the control, PEEP8 and PEEP10 groups, respectively. The differences were statistically significant among the three groups (p=0.035). The incidence rates of atelectasis on the third day after surgery were 39 (65%), 36 (60%) and 21 (35%) patients in the control, PEEP8 and PEEP10 groups, respectively. The differences were also statistically significant among the three groups (p=0.003). Conclusion: The use of 10 cm H2O PEEP can lead to a reduction in the incidence of atelectasis, intubation time at the ICU and length of ICU and hospital stay. Given that this level of PEEP is effective, this method is recommended to be used in postoperative care of patients.

Postoperative pulmonary complications (PPCs) occur frequently and are associated with substantial morbidity and mortality. Evidence suggests that reduction of PPCs can be accomplished by using lung-protective ventilation strategies intraoperatively, but a consensus on perioperative management has not been established. We sought to determine recommendations for lung protection for the surgical patient at an international consensus development conference. Seven experts produced 24 questions concerning preoperative assessment and intraoperative mechanical ventilation for patients at risk of developing PPCs. Six researchers assessed the literature using questions as a framework for their review. The modified Delphi method was utilised by a team of experts to produce recommendations and statements from study questions. An expert consensus was reached for 22 recommendations and four statements. The following are the highlights: (i) a dedicated score should be used for preoperative pulmonary risk evaluation; and (ii) an individualised mechanical ventilation may improve the mechanics of breathing and respiratory function, and prevent PPCs. The ventilator should initially be set to a tidal volume of 6-8 ml kg-1 predicted body weight and positive end-expiratory pressure (PEEP) 5 cm H2O. PEEP should be individualised thereafter. When recruitment manoeuvres are performed, the lowest effective pressure and shortest effective time or fewest number of breaths should be used. ispartof: BJA: British Journal of Anaesthesia vol:123 issue:6 pages:898-913 ispartof: location:England status: Published online

Background Metabolic syndrome (MetS) is defined as an accumulation of risk factors that include chronic hypertension, dyslipidaemia, insulin resistance and obesity and leads to an increased risk for diabetes, cardiovascular disease and stroke. MetS is widespread and estimated to affect up to a quarter of the global population. Patients with MetS who undergo surgery are associated with an increased risk of postoperative complications when compared with patients with a non-MetS profile. An emerging body of literature points to MetS being associated with a greater risk of postoperative pulmonary complications (PPC) in the surgical patient. PPC are associated with increased postoperative morbidity and mortality, Intensive care unit (ICU) admission, length of stay (ICU and hospital), health care costs, resource usage, unplanned re-intubation and prolonged ventilatory time. Methods/design We will search for relevant studies in the following electronic bibliographic databases: EMBASE, MEDLINE, Cumulative Index to Nursing and Allied Health Literature (CINAHL) and Scopus as well as scan the reference lists of included studies for potential additional literature. Two authors will independently screen titles and abstracts to identify potentially relevant studies for inclusion based on predefined inclusion and exclusion criteria. The Cochrane Collaboration Review Manager (Review Manager 5) statistical software will be used to conduct this systematic review and meta-analysis and generate forest plots to demonstrate comparison of findings across studies included for meta-analysis. Subgroup and sensitivity analysis will be performed to assess the heterogeneity of included studies. A descriptive synthesis of the statistical data will be provided to summarise the results and findings of the systematic review and meta-analysis. Discussion This review will be the first to report and summarise the risk for and incidence of PPC in adult patients with MetS undergoing surgery across a range of surgical specialities. The results have the potential to inform the development of evidenced-based interventions to improve the management of PPC in the surgical patient with MetS. Findings from this systematic review and meta-analysis will inform a subsequent Delphi study on priorities and responses to PPC in patients with MetS. We will also disseminate our results through publication in scientific peer-reviewed journals, conference presentations and promotion throughout our network of surgical safety champions in clinical settings. Systematic review registration PROSPERO CRD42019120279.

BackgroundUse of minimally invasive surgical techniques for lung resection surgery (LRS), such as video-assisted thoracoscopy (VATS), has increased in recent years. However, there is little information about the best anesthetic technique in this context. This surgical approach is associated with a lower intensity of postoperative pain, and its use has been proposed in programs for enhanced recovery after surgery (ERAS). This study compares the severity of postoperative complications in patients undergoing LRS who have received lidocaine intraoperatively either intravenously or via paravertebral administration versus saline.Methods/designWe will conduct a single-center randomized controlled trial involving 153 patients undergoing LRS through a thoracoscopic approach. The patients will be randomly assigned to one of the following study groups: intravenous lidocaine with more paravertebral thoracic (PVT) saline, PVT lidocaine with more intravenous saline, or intravenous remifentanil with more PVT saline. The primary outcome will be the comparison of the postoperative course through Clavien-Dindo classification. Furthermore, we will compare the perioperative pulmonary and systemic inflammatory response by monitoring biomarkers in the bronchoalveolar lavage fluid and blood, as well as postoperative analgesic consumption between the three groups of patients. We will use an ANOVA to compare quantitative variables and a chi-squared test to compare qualitative variables.DiscussionThe development of less invasive surgical techniques means that anesthesiologists must adapt their perioperative management protocols and look for anesthetic techniques that provide good analgesic quality and allow rapid rehabilitation of the patient, as proposed in the ERAS protocols. The administration of a continuous infusion of intravenous lidocaine has proven to be useful and safe for the management of other types of surgery, as demonstrated in colorectal cancer. We want to know whether the continuous administration of lidocaine by a paravertebral route can be substituted with the intravenous administration of this local anesthetic in a safe and effective way while avoiding the risks inherent in the use of regional anesthetic techniques. In this way, this technique could be used in a safe and effective way in ERAS programs for pulmonary resection.Trial registrationEudraCT, 2016–004271-52; ClinicalTrials.gov,NCT03905837. Protocol number IGGFGG-2016 version 4.0, 27th April 2017.

Background Postoperative pulmonary complications (PPCs) after thoracoscopic surgery are common. This retrospective study aimed to develop a nomogram to predict PPCs in thoracoscopic surgery. Methods A total of 905 patients who underwent thoracoscopy were randomly enrolled and divided into a training cohort and a validation cohort at 80%:20%. The training cohort was used to develop a nomogram model, and the validation cohort was used to validate the model. Univariate and multivariable logistic regression were applied to screen risk factors for PPCs, and the nomogram was incorporated in the training cohort. The discriminative ability and calibration of the nomogram for predicting PPCs were assessed using C-indices and calibration plots. Results Among the patients, 207 (22.87%) presented PPCs, including 166 cases in the training cohort and 41 cases in the validation cohort. Using backward stepwise selection of clinically important variables with the Akaike information criterion (AIC) in the training cohort, the following seven variables were incorporated for predicting PPCs: American Society of Anesthesiologists (ASA) grade III/IV, operation time longer than 180 min, one-lung ventilation time longer than 60 min, and history of stroke, heart disease, chronic obstructive pulmonary disease (COPD) and smoking. With incorporation of these factors, the nomogram achieved good C-indices of 0.894 (95% confidence interval (CI) [0.866–0.921]) and 0.868 (95% CI [0.811–0.925]) in the training and validation cohorts, respectively, with well-fitted calibration curves. Conclusion The nomogram offers good predictive performance for PPCs after thoracoscopic surgery. This model may help distinguish the risk of PPCs and make reasonable treatment choices.

Highlights • To investigate the effects of respiratory physiotherapy after lung resection surgery on mortality rate within 30 days after surgery. • Postoperative pulmonary complications within 30 days after surgery. • Length of stay in hospital postoperatively., Background The main treatment of lung cancer (stage 1 and 2) is lung resection surgery. The risk of postoperative pulmonary complications is high and therefore standard postoperative care involves respiratory physiotherapy. The purpose of this systematic review is to create an overview of the evidence on respiratory physiotherapy after lung resection surgery on mortality rate (within 30 days) and postoperative pulmonary complications. Methods and analysis The review will include randomized or quasi-randomized controlled studies investigating the effect of all types of respiratory physiotherapy on mortality and postoperative pulmonary complications after lung resection surgery. Furthermore, the effect of respiratory physiotherapy is evaluated on secondary outcomes such as length of hospital stay, lung volumes and function, and adverse events. The method of the planned review is described in this paper. The literature search will include the databases PubMed, Cochrane (Central), Embase, Cinahl and PEDro. The literature search is being performed in 2017. If meta-analyses are not undertaken, a narrative synthesis of the available data will be provided. The protocol was registered in PROSPERO on the 10th of October 2016 (registration number CRD42016048956). Ethics and dissemination Conclusion of this systematic review is expected available in the second half of 2017.

Tae Hoon Kim, Jae Seung Lee, Sei Won Lee, Yeon-Mok Oh Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea Abstract: Postoperative pulmonary complications (PPCs) are one of the most important causes of postoperative morbidity and mortality after abdominal surgery. Although chronic obstructive pulmonary disease (COPD) has been considered a risk factor for PPCs, it remains unclear whether mild-to-moderate COPD is a risk factor. This retrospective cohort study included 387 subjects who underwent abdominal surgery with general anesthesia in a tertiary referral hospital. PPCs included pneumonia, pulmonary edema, pulmonary thromboembolism, atelectasis, and acute exacerbation of COPD. Among the 387 subjects, PPCs developed in 14 (12.0%) of 117 patients with mild-to-moderate COPD and in 13 (15.1%) of 86 control patients. Multiple logistic regression analysis revealed that mild-to-moderate COPD was not a significant risk factor for PPCs (odds ratio [OR] =0.79; 95% confidence interval [CI] =0.31–2.03; P=0.628). However, previous hospitalization for respiratory problems (OR =4.20; 95% CI =1.52–11.59), emergency surgery (OR =3.93; 95% CI =1.75–8.82), increased amount of red blood cell (RBC) transfusion (OR =1.09; 95% CI =1.05–1.14 for one pack increase of RBC transfusion), and laparoscopic surgery (OR =0.41; 95% CI =0.18–0.93) were independent predictors of PPCs. These findings suggested that mild-to-moderate COPD may not be a significant risk factor for PPCs after abdominal surgery.Keywords: postoperative pulmonary complications, spirometry, risk factor, abdominal surgery, postoperative complications, postoperative care

Patients with pulmonary hypertension are at increased risk for postoperative pulmonary complications (PPCs). Herein, we review PPCs in pulmonary hypertension patients undergoing non-cardiac procedures under general anesthesia. The medical records of pulmonary hypertension patients who underwent surgery with general anesthesia between 2010 and 2017 were reviewed for PPCs. In addition we reviewed nursing-documented respiratory depressive episodes in the post-anesthesia care unit to assess the associations between these episodes and later PPCs. There were 20 PPCs among 128 patients who underwent 197 procedures (10.2 per 100 surgeries) [95% CI 6.7–15.2]. Of these, 5 occurred during anesthesia recovery and 15 following anesthesia recovery. Three-quarters of the PPCs occurred within 24 postoperative hours. All the PPCs were severe. The frequency of PPCs was significantly higher in those who experienced respiratory depression during anesthesia recovery vs. in those who did not (5/17, 29% vs. 10/175, 6%; odds ratio 5.15, 95% CI 1.58–16.81, p = 0.007). Increased PPC rates were observed among patients who were current/previous smokers and who routinely use benzodiazepines, and among those undergoing emergent surgery. With treatment, all PPCs resolved. The rate of PPCs in the population of contemporary surgical pulmonary hypertension patients was 10.2%, and three-quarters occurred during first 24 postoperative hours. Patients who had respiratory depression during anesthesia recovery were 5-fold more likely to experience later PPCs.

Background There is no consensus on the ventilation management during cardiopulmonary bypass (CPB), and the anesthesiologists or the surgeons usually ventilate the lungs with different ventilation strategies or keep them static. Better outcomes are more likely to occur when the ventilation is administered during CPB according to the existing literatures. However, the use of high fraction of inspired oxygen (FiO2) is debatable in cardiac surgery. And the potential effects of strategies combining low tidal volume (VT) ventilation with different FiO2 during CPB on postoperative pulmonary complications (PPCs) are unclear. Design The VONTCPB trial is a single-center, prospective, double-blinded, randomized, controlled trial. We are going to recruit total 420 elective cardiac surgery patients with median sternotomy under CPB, who will be equally randomized into three different ventilation strategy groups: NoV, LOV and HOV. (1) The NoV group receives no mechanical ventilation during CPB; (2) the LOV group receives a low VT of 3-4 ml/kg of ideal body weight (IBW) with the respiratory rate (RR) of 10–12 acts/min, and the positive end-expiratory pressure (PEEP) of 5–8 cmH2O during CPB; the FiO2 is 30%; (3) the HOV group receives a low VT of 3-4 ml/kg of IBW with the RR of 10–12 acts/min, and the PEEP of 5–8 cmH2O during CPB; the FiO2 is 80%. The primary endpoints are the incidence of the composite of PPCs and the PPCs score. The secondary endpoints refer to the incidence of the oxygenation index (PaO2/FiO2 ratio)

BACKGROUND: Chronic obstructive pulmonary disease (COPD) patients are at an increased risk of postoperative pulmonary complications (PPCs). The purpose of this study is to evaluate the risks and benefits associated with preoperative steroids in COPD patients. METHODS: The National Surgical Quality Improved Program database was used to identify 92 COPD patients who underwent surgery at the American University of Beirut Medical Center between 2009 and 2013. COPD was diagnosed based on postbronchodilator forced expiratory volume in 1 s to forced vital capacity ratio

Objectives This meta-analysis aimed to demonstrate the impact of preoperative exercise therapy on surgical outcomes in patients with lung cancer and COPD. Pulmonary function and muscle capacity were investigated to explore their potential links with outcome improvements after exercise. Methods Articles were searched from PubMed, Embase, and the Cochrane Library with criteria of lung cancer patients with or without COPD, undergoing resection, and receiving preoperative exercise training. Key outcomes were analyzed using meta-analysis. Results Seven studies containing 404 participants were included. Patients receiving preoperative exercise training had a lower incidence of postoperative pulmonary complications (PPCs; OR 0.44, 95% CI 0.27–0.71) and shorter length of hospital stay (standardized mean difference −4.23 days, 95% CI −6.14 to −2.32 days). Exceptionally, pneumonia incidence remained unchanged. Patients with COPD could not obviously benefit from exercise training to reduce PPCs (OR 0.44, 95% CI 0.18–1.08), but still might achieve faster recovery. No significant difference in pulmonary function was observed between the two groups. However, 6MWD and VO2 peak were significantly improved after exercise training. Conclusion Preoperative exercise training may reduce PPCs for lung cancer patients. However, for patients with COPD undergoing lung cancer resection, the role of exercise is uncertain, due to limited data, which calls for more prospective trials on this topic. Rehabilitation exercise strengthens muscle capacity, but does not improve impaired pulmonary function, which emphasizes the possible mechanism of the protocol design.

Background Data on high-flow nasal oxygen after thoracic surgery are limited and confined to the comparison with low-flow oxygen. Different from low-flow oxygen, Venturi masks provide higher gas flow at a predetermined fraction of inspired oxygen (FiO2). We conducted a randomized trial to determine whether preemptive high-flow nasal oxygen reduces the incidence of postoperative hypoxemia after lung resection, as compared to Venturi mask oxygen therapy. Methods In this single-center, randomized trial conducted in a teaching hospital in Italy, consecutive adult patients undergoing thoracotomic lung resection, who were not on long-term oxygen therapy, were randomly assigned to receive high-flow nasal or Venturi mask oxygen after extubation continuously for two postoperative days. The primary outcome was the incidence of postoperative hypoxemia (i.e., ratio of the partial pressure of arterial oxygen to FiO2 (PaO2/FiO2) lower than 300 mmHg) within four postoperative days. Results Between September 2015 and April 2018, 96 patients were enrolled; 95 patients were analyzed (47 in high-flow group and 48 in Venturi mask group). In both groups, 38 patients (81% in the high-flow group and 79% in the Venturi mask group) developed postoperative hypoxemia, with an unadjusted odds ratio (OR) for the high-flow group of 1.11 [95% confidence interval (CI) 0.41–3] (p = 0.84). No inter-group differences were found in the degree of dyspnea nor in the proportion of patients needing oxygen therapy after treatment discontinuation (OR 1.34 [95% CI 0.60–3]), experiencing pulmonary complications (OR 1.29 [95% CI 0.51–3.25]) or requiring ventilatory support (OR 0.67 [95% CI 0.11–4.18]). Post hoc analyses revealed that PaO2/FiO2 during the study was not different between groups (p = 0.92), but patients receiving high-flow nasal oxygen had lower arterial pressure of carbon dioxide, with a mean inter-group difference of 2 mmHg [95% CI 0.5–3.4] (p = 0.009), and were burdened by a lower risk of postoperative hypercapnia (adjusted OR 0.18 [95% CI 0.06–0.54], p = 0.002). Conclusions When compared to Venturi mask after thoracotomic lung resection, preemptive high-flow nasal oxygen did not reduce the incidence of postoperative hypoxemia nor improved other analyzed outcomes. Further adequately powered investigations in this setting are warranted to establish whether high-flow nasal oxygen may yield clinical benefit on carbon dioxide clearance. Trial registration ClinicalTrials.gov, NCT02544477. Registered 9 September 2015. Electronic supplementary material The online version of this article (10.1186/s13054-019-2361-5) contains supplementary material, which is available to authorized users.

Background and objective The prevalence of lung cancer has been increasing in healthy elderly patients with preserved pulmonary function and without underlying lung diseases. We aimed to determine the prevalence of and risk factors for postoperative pulmonary complications (PPCs) in healthy elderly patients with non-small cell lung cancer (NSCLC) to select optimal candidates for surgical resection in this subpopulation. Methods We included 488 patients older than 70 years with normal spirometry results who underwent curative resection for NSCLC (stage IA-IIB) between 2012 and 2016. Results The median (interquartile range) age of our cohort was 73 (71–76) years. Fifty-two patients (10.7%) had PPCs. Severe PPCs like acute respiratory distress syndrome, pneumonia, and respiratory failure had prevalences of 3.7, 3.7, and 1.4%, respectively. Compared to patients without PPCs, those with PPCs were more likely to be male and current smokers; have a lower body mass index (BMI), higher American Society of Anesthesiologists (ASA) classification, more interstitial lung abnormalities (ILAs), and higher emphysema index on computed tomography (CT); and have undergone pneumonectomy or bilobectomy (all p

PURPOSE: The purpose of this review was to investigate the effect of respiratory physiotherapy after lung resection on mortality, postoperative pulmonary complications (PPC), length of stay, lung volumes, and adverse events.MATERIAL AND METHODS: Randomized or quasi-randomized controlled trials were searched in CENTRAL, PubMed, EMBASE, Cinahl, PEDro, and hand searching of related studies. Various respiratory physiotherapy interventions were compared to standard care, sham treatment, or no treatment. Two reviewers assessed eligibility and quality of studies using Cochrane guidelines. Meta-analyses were undertaken on subgroups of intervention.RESULTS: Various types of positive pressure breathing, deep breathing exercises, and strength and aerobic exercises as a supplement to standard care did not show any significant effect over standard care in preventing mortality or PPC, reducing length of stay, or improving lung volumes.CONCLUSION: Prophylactic continuous positive airway pressure does not seem to affect rate of mortality and PPC, when compared with standard care embodying respiratory physiotherapy such as airway clearance techniques and assistance with early ambulation. However, further research is still needed to make a final conclusion. The effect of standard respiratory physiotherapy as a package is still unknown, and may or may not be effective in preventing PPC among patients undergoing lung resection.

Objective: The aim of this clinical trial is to examine whether it is possible to reduce postoperative complications using an individualized perioperative ventilatory strategy versus using a standard lung-protective ventilation strategy in patients scheduled for thoracic surgery requiring one-lung ventilation. Design: International, multicenter, prospective, randomized controlled clinical trial. Setting: A network of university hospitals. Participants: The study comprises 1,380 patients scheduled for thoracic surgery. Interventions: The individualized group will receive intraoperative recruitment maneuvers followed by individualized positive end-expiratory pressure (open lung approach) during the intraoperative period plus postoperative ventilatory support with high-flow nasal cannula, whereas the control group will be managed with conventional lung-protective ventilation. Measurements and Main Results: Individual and total number of postoperative complications, including atelectasis, pneumothorax, pleural effusion, pneumonia, acute lung injury; unplanned readmission and reintubation; length of stay and death in the critical care unit and in the hospital will be analyzed for both groups. The authors hypothesize that the intraoperative application of an open lung approach followed by an individual indication of high-flow nasal cannula in the postoperative period will reduce pulmonary complications and length of hospital stay in high-risk surgical patients. (C) 2019 Published by Elsevier Inc.

Objective To compare the analgesic effects of patient-controlled intravenous analgesia (PCA) with hydromorphone and sufentanil after thoracic surgery on postoperative pulmonary complications (PPCs). Methods A total of 142 patients who were scheduled for thoracic surgery were randomly allocated to receive PCA with hydromorphone (group A: experimental group): hydromorphone 0.2 mg/kg + dezocine 0.5 mg/kg + ramosetron 0.6 mg diluted with normal saline to 200 mL; or with sufentanil (group B: control group): sufentanil 3.0μg/kg + dezocine 0.5 mg/kg + ramosetron 0.6 mg diluted with normal saline to 200 mL. The parameters of intravenous analgesia pump were set as background dose 4 ml/h, PCA dose 1 mL, locking time 15 min. Pain NRS (numerical rating scale), Ramsay sedation score, nausea or vomiting score were evaluated at 0 h, 6 h, 12 h, 24 h, 48 h after operation. The cases of PPCs (atelectasis, pulmonary infection, respiratory failure), CRP (C-reaction protein) and inflammatory cells (white cell count and percentage of neutrophils) and blood gas analysis at 12 h after operation, length of ICU and postoperative stay were recorded for each patient. Results Data of 136 patients were analyzed. Compared with group B (4[IQR:2,2]), the pain NRS in group A (2[IQR:4,4]) was significantly lower at 6 h after operation (P = 0.000). The CRP in group A (69.79 ± 32.13 mg/L) were lower than group B (76.76 ± 43.42 mg/L) after operation, but the difference was not significant (P = 0.427). No difference of nausea or vomiting was found between group A (7.3%) and group B (5.8%) postoperatively (P = 0.999). The PPCs were happened in 11 patients in group A (16.2%) and 22 patients in group B (32.4%) and the difference between two groups was significant (P = 0.027). Seven patients in group A (10.3%) and eighteen patients in group B (26.5%) had clinical evidence of pneumonia and the difference between two groups was significant (P = 0.014). The length of ICU and postoperative stay in group A were 2.73 h and 1.82 days less than group B respectively but the differences were not significant (P = 0.234, P = 0.186 respectively). Conclusion Compared with sufentanil, hydromorphone may provide better postoperative analgesic effect with less pulmonary complications for patients undergoing thoracic surgery, and it may accelerate patients’ rehabilitation. Trial registration Randomized Controlled Trials ChiCTR1800014282c. Registered 3 January 2018.

Background Patients undergoing cardiac surgery with cardiopulmonary bypass are at an increased risk of developing postoperative pulmonary complications, potentially leading to excess morbidity and mortality. It is likely that pulmonary ischemia-reperfusion (IR) injury during cardiopulmonary bypass is a major contributor to perioperative lung injury. Therefore, interventions that can minimize IR injury would be valuable in reducing the excess burden of this potentially preventable disease process. Volatile anesthetics including sevoflurane have been shown in both preclinical and human trials to effectively limit pulmonary inflammation in a number of settings including ischemia-reperfusion injury. However, this finding has not yet been demonstrated in the cardiac surgery population. The Anesthetics to Prevent Lung Injury in Cardiac Surgery (APLICS) trial is a randomized, controlled trial investigating whether sevoflurane anesthetic maintenance can modulate pulmonary inflammation occurring during cardiac surgery with cardiopulmonary bypass, and whether this potential effect can translate to a reduction in postoperative pulmonary complications. Methods APLICS is a prospective, randomized controlled trial of adult cardiac surgical patients. Subjects will be randomized to receive intraoperative anesthetic maintenance with either sevoflurane or propofol. Patients in both groups will be ventilated according to protocols intended to minimize the influences of ventilator induced lung injury and hyperoxia. Bronchoalveolar lavage (BAL) and blood sampling will take place after anesthetic induction and between two to four hours after pulmonary reperfusion. The primary outcome is a difference between groups in the incidence of inflammatory lung injury, defined by an increase in post-bypass BAL concentrations of TNFα. Secondary outcomes will include additional relevant BAL and systemic inflammatory markers and the incidence of postoperative pulmonary complications. Discussion APLICS investigates whether anesthetic choice can influence lung inflammation and pulmonary outcomes following cardiac surgery with cardiopulmonary bypass. A positive result from this trial would add to the growing body of evidence describing the lung protective properties of the volatile anesthetics and potentially reduce unnecessary morbidity for cardiac surgery patients. Trial Registration ClinicalTrials.gov identifier NCT02918877, registered on September 29, 2016. KEYWORDS Inflammatory lung injury, volatile anesthetics, cardiac surgery, postoperative pulmonary complications, TNFα.

Background Ulinastatin can prevent the perioperative increase in proinflammatory cytokines for lung resection surgery; however, its impact on early clinical outcomes remains unknown. Methods The study enrolled 108 non-small cell lung cancer (NSCLC) patients who were randomly allocated into two groups: ulinastatin (group U) and control (group C). Patients in group U ( n = 52) were continuously intravenously infused with ulinastatin at a rate of 20 000 U/kg/hour for the first hour after anesthesia induction, and then at a rate of 5000 U/kg/hour until the conclusion of surgery. Patients in group C ( n = 56) received an equivalent volume of normal saline. The primary outcome was to record the postoperative pulmonary complications that occurred during hospital stay. Other clinical courses, such as hospital mortality, blood loss, respiratory parameters, postoperative chest drainage, and duration of intensive care unit and postoperative hospital stay, were also observed and analyzed. Results There were no significant differences between the two groups in early postoperative pulmonary complications, hospital mortality, blood loss, or other perioperative laboratory values, except for the duration of postoperative chest drainage and serum creatinine level. The frequency of pulmonary complications was lower in patients treated with ulinastatin compared with the control (38.46% in group U vs. 48.21% in group C). Conclusion Administration of high-dose ulinastatin during surgery did not reduce postoperative pulmonary complications, hospital mortality, or hospital stay for patients undergoing lung radical thoracotomy. However, a protective trend of ulinastatin was observed.

Patients with chronic obstructive pulmonary disease (COPD) exhibit airflow limitation and suboptimal lung function, and they are at high risk of developing postoperative pulmonary complications (PPCs). We aimed to determine the factors that would decrease PPC risk in patients with COPD. We retrospectively analyzed 419 patients with COPD who were registered in our institutional PPC database and had undergone an abdominal surgery under general anesthesia. PPCs comprised respiratory failure, pleural effusion, atelectasis, respiratory infection, and bronchospasm, the presence or type of PPC was diagnosed by respiratory physicians and recorded in the database before this study. Binary logistic regression was used for statistical analysis. Of the 419 patients, 121 patients (28.8%) experienced 200 PPCs. Multivariable analysis showed three modifiable anesthetic factors that could decrease PPC risk: low tidal volume ventilation, restricted fluid infusion, and sugammadex-induced neuromuscular blockade reversal. We found that the 90-day mortality risk was significantly greater in patients with PPC than in those without PPC (5.8% vs. 1.3%, p = 0.016). Therefore, PPC risk in patients with COPD can be decreased if low tidal volume ventilation, restricted fluid infusion, and sugammadex-induced reversal during abdominal surgery are efficiently managed, as these factors result in decreased postoperative mortality.

Supplemental Digital Content is available in the text, Background: Since postoperative pulmonary complications are one of the main causes of morbidity and mortality in patients undergoing lung resection surgery, we performed a meta-analysis to compare the incidence of postoperative pulmonary complications and hospital death, and the length of hospital stay in patients who received nonintubated or intubated anesthesia during thoracoscopic surgery for lung resection and further explore the tricks in nonintubated anesthesia. Methods: PubMed, Embase, and Cochrane Library were searched from inception to September 2017. We included eligible research comparing nonintubated anesthesia with intubated anesthesia in thoracoscopic surgery for lung resection. The primary outcomes involved postoperative pulmonary complications, hospital death, and hospital stay. The rates and causes of conversion from nonintubated anesthesia to intubated anesthesia were also analyzed. Results: After screening through 754 potentially relevant articles, we included 3 randomized controlled trials and 7 observational studies with 1138 patients. There was no perioperative mortality in 2 groups. The nonintubated group revealed comparable postoperative pulmonary complications (OR = 0.57; P = .07; P for heterogeneity = .49, I2 = 0%) and shorter hospital stay (WMD = −1.10; P

Postoperative pulmonary complications are common after cardiothoracic surgery and are associated with adverse outcomes. The ability to detect postoperative pulmonary complications using chest X-rays is limited, and this technique requires radiation exposure. Little is known about the diagnostic accuracy of lung ultrasound for the detection of postoperative pulmonary complications after cardiothoracic surgery, and we therefore aimed to compare lung ultrasound with chest X-ray to detect postoperative pulmonary complications in this group of patients. We performed this prospective, observational, single-centre study in a tertiary intensive care unit treating adult patients who had undergone cardiothoracic surgery. We recorded chest X-ray findings upon admission and on postoperative days 2 and 3, as well as rates of postoperative pulmonary complications and clinically-relevant postoperative pulmonary complications that required therapy according to the treating physician as part of their standard clinical practice. Lung ultrasound was performed by an independent researcher at the time of chest X-ray. We compared lung ultrasound with chest X-ray for the detection of postoperative pulmonary complications and clinically-relevant postoperative pulmonary complications. We also assessed inter-observer agreement for lung ultrasound, and the time to perform both imaging techniques. Subgroup analyses were performed to compare the time to detection of clinically-relevant postoperative pulmonary complications by both modalities. We recruited a total of 177 patients in whom both lung ultrasound and chest X-ray imaging were performed. Lung ultrasound identified 159 (90%) postoperative pulmonary complications on the day of admission compared with 107 (61%) identified with chest X-ray (p < 0.001). Lung ultrasound identified 11 out of 17 patients (65%) and chest X-ray 7 out of 17 patients (41%) with clinically-relevant postoperative pulmonary complications (p < 0.001). The clinically-relevant postoperative pulmonary complications were detected earlier using lung ultrasound compared with chest X-ray (p = 0.024). Overall inter-observer agreement for lung ultrasound was excellent (κ = 0.907, p < 0.001). Following cardiothoracic surgery, lung ultrasound detected more postoperative pulmonary complications and clinically-relevant postoperative pulmonary complications than chest X-ray, and at an earlier time-point. Our results suggest lung ultrasound may be used as the primary imaging technique to search for postoperative pulmonary complications after cardiothoracic surgery, and will enhance bedside decision making.