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Background: Statins possess pleiotropic effects, which potentially benefit noncardiovascular conditions. Previous work suggests that statins reduce inflammation and prevent acute respiratory distress syndrome and infections. However, there is a paucity of data regarding potential benefits of statins on respiratory and infectious complications, particularly after noncardiac surgery. We therefore evaluated respiratory and other complications in noncardiac surgery patients taking or not taking statins preoperatively., Methods: We obtained data from the Cleveland Clinic Perioperative Health Documentation System and evaluated medical records of 92,139 inpatients who had noncardiac surgery. Among these, 31,719 patients took statins preoperatively. Statin patients were compared to nonstatin patients on incidence of intraoperative use of albuterol and postoperative respiratory complications for primary analysis. Infectious complications, cardiovascular complications, in-hospital mortality, and duration of hospitalization were compared for secondary analyses, using inverse probability of treatment weighting to control for potential confounding., Results: Statin use was associated with lower odds of intraoperative albuterol treatment (odds ratio [OR] = 0.89; 97.5% confidence interval [CI], 0.82-0.97; P = .001; number needed to treat [NNT] = 216). Postoperative respiratory complications were also less common (OR = 0.82; 98.75% CI, 0.78-0.87; P < .001). Secondarily, statin use was associated with lower odds of infections, cardiovascular complications, in-hospital mortality, and shorter duration of hospitalization. The interaction between statin use and sex was significant (with significance criteria P < .10) for all primary and secondary outcomes except intraoperative use of albuterol., Conclusions: Preoperative statin use in noncardiac surgical patients was associated with slightly reduced odds of postoperative respiratory, infectious, and cardiovascular complications. However, the NNTs were high. Thus, despite the fact that statins appeared to be associated with lower odds of various complications, especially cardiovascular complications, our results do not support using statins specifically to reduce noncardiovascular complications after noncardiac surgery., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2020 International Anesthesia Research Society.)

Artificial intelligence and machine learning are rapidly expanding fields with increasing relevance in anesthesia and, in particular, airway management. The ability of artificial intelligence and machine learning algorithms to recognize patterns from large volumes of complex data makes them attractive for use in pediatric anesthesia airway management. The purpose of this review is to introduce artificial intelligence, machine learning, and deep learning to the pediatric anesthesiologist. Current evidence and developments in artificial intelligence, machine learning, and deep learning relevant to pediatric airway management are presented. We critically assess the current evidence on the use of artificial intelligence and machine learning in the assessment, diagnosis, monitoring, procedure assistance, and predicting outcomes during pediatric airway management. Further, we discuss the limitations of these technologies and offer areas for focused research that may bring pediatric airway management anesthesiology into the era of artificial intelligence and machine learning., (© 2019 John Wiley & Sons Ltd.)

Background: Compared with historic ventilation strategies, modern lung-protective ventilation includes lower tidal volumes (VT), lower driving pressures, and application of positive end-expiratory pressure (PEEP). The contributions of each component to an overall intraoperative protective ventilation strategy aimed at reducing postoperative pulmonary complications have neither been adequately resolved, nor comprehensively evaluated within an adult cardiac surgical population. The authors hypothesized that a bundled intraoperative protective ventilation strategy was independently associated with decreased odds of pulmonary complications after cardiac surgery., Methods: In this observational cohort study, the authors reviewed nonemergent cardiac surgical procedures using cardiopulmonary bypass at a tertiary care academic medical center from 2006 to 2017. The authors tested associations between bundled or component intraoperative protective ventilation strategies (VT below 8 ml/kg ideal body weight, modified driving pressure [peak inspiratory pressure - PEEP] below 16 cm H2O, and PEEP greater than or equal to 5 cm H2O) and postoperative outcomes, adjusting for previously identified risk factors. The primary outcome was a composite pulmonary complication; secondary outcomes included individual pulmonary complications, postoperative mortality, as well as durations of mechanical ventilation, intensive care unit stay, and hospital stay., Results: Among 4,694 cases reviewed, 513 (10.9%) experienced pulmonary complications. After adjustment, an intraoperative lung-protective ventilation bundle was associated with decreased pulmonary complications (adjusted odds ratio, 0.56; 95% CI, 0.42-0.75). Via a sensitivity analysis, modified driving pressure below 16 cm H2O was independently associated with decreased pulmonary complications (adjusted odds ratio, 0.51; 95% CI, 0.39-0.66), but VT below 8 ml/kg and PEEP greater than or equal to 5 cm H2O were not., Conclusions: The authors identified an intraoperative lung-protective ventilation bundle as independently associated with pulmonary complications after cardiac surgery. The findings offer insight into components of protective ventilation associated with adverse outcomes and may serve as targets for future prospective interventional studies investigating the impact of specific protective ventilation strategies on postoperative outcomes after cardiac surgery.

Postoperative pulmonary complications are associated with an increase in mortality, morbidity and healthcare utilisation. The Agency for Healthcare Research and Quality recommends risk assessment for postoperative respiratory complications in patients undergoing surgery. In this hospital registry study of adult patients undergoing non-cardiac surgery between 2005 and 2017 at two independent healthcare networks, a prediction instrument for early postoperative tracheal re-intubation was developed and externally validated. This was based on the development of the Score for Prediction Of Postoperative Respiratory Complications. For predictor selection, stepwise backward logistic regression and bootstrap resampling were applied. Development and validation cohorts were represented by 90,893 patients at Partners Healthcare and 67,046 patients at Beth Israel Deaconess Medical Center, of whom 699 (0.8%) and 587 (0.9%) patients, respectively, had their tracheas re-intubated. In addition to five pre-operative predictors identified in the Score for Prediction Of Postoperative Respiratory Complications, the final model included seven additional intra-operative predictors: early post-tracheal intubation desaturation; prolonged duration of surgery; high fraction of inspired oxygen; high vasopressor dose; blood transfusion; the absence of volatile anaesthetic use; and the absence of lung-protective ventilation. The area under the receiver operating characteristic curve for the new score was significantly greater than that of the original Score for Prediction Of Postoperative Respiratory Complications (0.84 [95%CI 0.82-0.85] vs. 0.76 [95%CI 0.75-0.78], respectively; p < 0.001). This may allow clinicians to develop and implement strategies to decrease the risk of early postoperative tracheal re-intubation., (© 2019 Association of Anaesthetists.)

Background: The impact of cardiorespiratory comorbidity on operative outcomes after esophagectomy remains controversial. This study investigated the effect of cardiorespiratory comorbidity on postoperative complications for patients treated for esophageal or gastroesophageal junction cancer., Patients and Methods: A European multicenter cohort study from five high-volume esophageal cancer centers including patients treated between 2010 and 2017 was conducted. The effect of cardiorespiratory comorbidity and respiratory function upon postoperative outcomes was assessed., Results: In total 1590 patients from five centers were included; 274 (17.2%) had respiratory comorbidity, and 468 (29.4%) had cardiac comorbidity. Respiratory comorbidity was associated with increased risk of overall postoperative complications, anastomotic leak, pulmonary complications, pneumonia, increased Clavien-Dindo score, and critical care and hospital length of stay. After neoadjuvant chemoradiotherapy, respiratory comorbidity was associated with increased risk of anastomotic leak [odds ratio (OR) 1.83, 95% confidence interval (CI) 1.11-3.04], pneumonia (OR 1.65, 95% CI 1.10-2.47), and any pulmonary complication (OR 1.52, 95% CI 1.04-2.22), an effect which was not observed following neoadjuvant chemotherapy or surgery alone. Cardiac comorbidity was associated with increased risk of cardiovascular and pulmonary complications, respiratory failure, and Clavien-Dindo score ≥ IIIa. Among all patients, forced expiratory volume in 1 s (FEV1)/forced vital capacity (FVC) ratio > 70% was associated with reduced risk of overall postoperative complications, cardiovascular complications, atrial fibrillation, pulmonary complications, and pneumonia., Conclusions: The results of this study suggest that cardiorespiratory comorbidity and impaired pulmonary function are associated with increased risk of postoperative complications after esophagectomy performed in high-volume European centers. Given the observed interaction with neoadjuvant approach, these data indicate a potentially modifiable index of perioperative risk.

Objectives: Emphysema is one of the main causes of respiratory complications in patients operated on for lung cancer. We have used three-dimensional computed tomography (3D CT) for surgical simulations, as well as for depicting emphysematous areas as low attenuation areas (LAAs) and visual scores based on the Goddard classification (Goddard score), which is a visual scale of the area of vascular disruption and LAA for each lung field. This study aimed to investigate the effectiveness of the 3D CT function for assessing emphysema severity and its association with respiratory complications., Methods: The study included 504 lung cancer patients who had preoperative 3D CT from October 2010 to March 2015. Goddard score and LAA% (LAA/total lung volume) were measured using 3D CT data. The relationship between respiratory complications and independent variables was investigated., Results: Postoperative respiratory complications were observed in 69 (13.6%) patients. The receiver operating characteristic curves for respiratory complications determined using the Goddard score and LAA% dichotomized at each cut-off level (1 and 0.7%, respectively) showed that the events were observed in 32% of the patients with a Goddard score ≥1 and in 25% of the patients with an LAA% ≥0.7. On multivariable analyses, the Goddard score was significantly correlated with postoperative respiratory complications (P < 0.001)., Conclusions: Preoperative measurement of the Goddard score and LAA% using 3D CT in patients with lung cancer, particularly with the coexistence of emphysema, was beneficial for predicting postoperative respiratory complications.

Background: While mortality and adverse perioperative events after noncardiac surgery in children with a broad range of congenital cardiac lesions have been investigated using large multiinstitutional databases, to date single-center studies addressing adverse outcomes in children with congenital heart disease (CHD) undergoing noncardiac surgery have only included small numbers of patients with significant heart disease. The primary objective of this study was to determine the incidences of perioperative cardiovascular and respiratory events in a large cohort of patients from a single institution with a broad range of congenital cardiac lesions undergoing noncardiac procedures and to determine risk factors for these events., Methods: We identified 3010 CHD patients presenting for noncardiac procedures in our institution over a 5-year period. We collected demographic information, including procedure performed, cardiac diagnosis, ventricular function as assessed by echocardiogram within 6 months of the procedure, and classification of CHD into 3 groups (minor, major, or severe CHD) based on residual lesion burden and cardiovascular functional status. Characteristics related to conduct of anesthesia care were also collected. The primary outcome variables for our analysis were the incidences of intraoperative cardiovascular and respiratory events. Univariable and multivariable logistic regressions were used to determine risk factors for these 2 outcomes., Results: The incidence of cardiovascular events was 11.5% and of respiratory events was 4.7%. Univariate analysis and multivariable analysis demonstrated that American Society of Anesthesiologists (≥3), emergency cases, major and severe CHD, single-ventricle physiology, ventricular dysfunction, orthopedic surgery, general surgery, neurosurgery, and pulmonary procedures were associated with perioperative cardiovascular events. Respiratory events were associated with American Society of Anesthesiologists (≥4) and otolaryngology, gastrointestinal, general surgery, and maxillofacial procedures., Conclusions: Intraoperative cardiovascular events and respiratory events in patients with CHD were relatively common. While cardiovascular events were highly associated with cardiovascular status, respiratory events were not associated with cardiovascular status.

Background: Limited evidence suggests that children have a lower incidence of perioperative respiratory adverse events when intravenous propofol is used compared with inhalational sevoflurane for the anesthesia induction. Limiting these events can improve recovery time as well as decreasing surgery waitlists and healthcare costs. This single center open-label randomized controlled trial assessed the impact of the anesthesia induction technique on the occurrence of perioperative respiratory adverse events in children at high risk of those events., Methods: Children (N = 300; 0 to 8 yr) with at least two clinically relevant risk factors for perioperative respiratory adverse events and deemed suitable for either technique of anesthesia induction were recruited and randomized to either intravenous propofol or inhalational sevoflurane. The primary outcome was the difference in the rate of occurrence of perioperative respiratory adverse events between children receiving intravenous induction and those receiving inhalation induction of anesthesia., Results: Children receiving intravenous propofol were significantly less likely to experience perioperative respiratory adverse events compared with those who received inhalational sevoflurane after adjusting for age, sex, American Society of Anesthesiologists physical status and weight (perioperative respiratory adverse event: 39/149 [26%] vs. 64/149 [43%], relative risk [RR]: 1.7, 95% CI: 1.2 to 2.3, P = 0.002, respiratory adverse events at induction: 16/149 [11%] vs. 47/149 [32%], RR: 3.06, 95% CI: 1.8 to 5. 2, P < 0.001)., Conclusions: Where clinically appropriate, anesthesiologists should consider using an intravenous propofol induction technique in children who are at high risk of experiencing perioperative respiratory adverse events., Visual Abstract: An online visual overview is available for this article at http://links.lww.com/ALN/B725.

Background: Limited information exists about the epidemiology and outcome of surgical patients at increased risk of postoperative pulmonary complications (PPCs), and how intraoperative ventilation was managed in these patients., Objectives: To determine the incidence of surgical patients at increased risk of PPCs, and to compare the intraoperative ventilation management and postoperative outcomes with patients at low risk of PPCs., Design: This was a prospective international 1-week observational study using the 'Assess Respiratory Risk in Surgical Patients in Catalonia risk score' (ARISCAT score) for PPC for risk stratification., Patients and Setting: Adult patients requiring intraoperative ventilation during general anaesthesia for surgery in 146 hospitals across 29 countries., Main Outcome Measures: The primary outcome was the incidence of patients at increased risk of PPCs based on the ARISCAT score. Secondary outcomes included intraoperative ventilatory management and clinical outcomes., Results: A total of 9864 patients fulfilled the inclusion criteria. The incidence of patients at increased risk was 28.4%. The most frequently chosen tidal volume (VT) size was 500 ml, or 7 to 9 ml kg predicted body weight, slightly lower in patients at increased risk of PPCs. Levels of positive end-expiratory pressure (PEEP) were slightly higher in patients at increased risk of PPCs, with 14.3% receiving more than 5 cmH2O PEEP compared with 7.6% in patients at low risk of PPCs (P < 0.001). Patients with a predicted preoperative increased risk of PPCs developed PPCs more frequently: 19 versus 7%, relative risk (RR) 3.16 (95% confidence interval 2.76 to 3.61), P < 0.001) and had longer hospital stays. The only ventilatory factor associated with the occurrence of PPCs was the peak pressure., Conclusion: The incidence of patients with a predicted increased risk of PPCs is high. A large proportion of patients receive high VT and low PEEP levels. PPCs occur frequently in patients at increased risk, with worse clinical outcome., Trial Registration: The study was registered at Clinicaltrials.gov, number NCT01601223.

Background: Respiratory adverse events are commonly observed after adenotonsillectomy in children with sleep-disordered breathing. Preoperative prediction of these events enhances quality of care and resource management in facilities while encouraging precautions against them. Red cell distribution width, a measure of erythrocyte size variability, has recently been linked to adverse outcomes in a variety of disorders. Red cell distribution width has also been found to be associated with severity of obstructive sleep apnea in adults due to hypoxia-mediated inflammation., Aim: The objective of this study was to evaluate whether elevated red cell distribution width is associated with postoperative respiratory adverse events in children with symptoms of sleep-disordered breathing., Methods: A prospective, observational, assessor-blinded study was conducted with consecutive children undergoing elective adenotonsillectomy for treatment of sleep-disordered breathing. Under general anesthesia, adenoidectomy was performed by curettage, and tonsillectomy was carried out by dissection. The primary outcome was the occurrence of an adverse event during emergence or in the postanesthesia care unit (PACU)., Results: Among 287 patients, with mean ± sd age 7.49 ± 3.21, the frequency of respiratory complications during emergence was 62 (22.30%) and in PACU was 56 (20.14%). Mean ± sd red cell distribution width was 14.36 ± 1.06 in patients with complications and higher than that in those without complications 13.53 ± 0.59. Red cell distribution width had an adjusted odds ratio 7.28 (95% CI: 4.30-13.28) and area under the curve value 0.74 (95% CI: 0.67-0.81) to predict postoperative complications. A cutoff value for red cell distribution width was found to be 14.7., Conclusion: Our study showed that preoperative elevated red cell distribution width is associated with an increased risk of respiratory adverse events in children undergoing adenotonsillectomy for sleep-disordered breathing., (© 2017 John Wiley & Sons Ltd.)

Objectives: Postoperative pulmonary complications (PPC) are among the most common complications after noncardiac surgery. Men, smokers, and elderly patients with chronic obstructive pulmonary disease or heart failure are more likely to experience PPC. The majority of patients undergoing vascular surgery belong in these categories and are at higher risk of developing PPC. Moreover, the surgical site is one of the most important risk factors associated with PPC, and aortic surgery carries the highest risk. The aim of this systematic review was to obtain an additional understanding of the real incidence of PPC after open abdominal aortic surgery and the impact of PPC on survival., Design: Systematic review and meta-analysis., Setting: Hospitals PARTICIPANTS: Patients who underwent open abdominal aortic surgery., Interventions: None., Measurements and Main Results: A literature search was performed on BioMedCentral, PubMed, Embase, and the Cochrane Register of clinical trials. All prospective or retrospective studies reporting data on PPC after open abdominal aortic surgery were included. Co-primary endpoints were the PPC rate and the correlation between PPC and perioperative mortality. The secondary endpoint was the difference in the PPC rate and mortality between elective and urgent surgery. Data on 269,637 patients from 213 studies were analyzed. The overall median incidence of PPC was 10.3% (interquartile range 5.55%-19.1%). Pneumonia, respiratory insufficiency, prolonged mechanical ventilation, need for unplanned mechanical ventilation, atelectasis, acute respiratory distress syndrome, pulmonary edema, and pleural effusions were the most common PPC reported in the literature. Occurrence of PPC was associated with postoperative mortality (r = 0.65, p<0.01) and was significantly higher in urgent procedures (p<0.001)., Conclusions: Incidence of PPC after open abdominal aortic surgery is high and is associated with increased postoperative morbidity and mortality., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background: Residual neuromuscular blockade (RNMB) has been linked to adverse respiratory events (AREs) in the postanesthetic care unit (PACU). However, these events are often not attributed to RNMB by anesthesiologists because they may also be precipitated by other factors including obstructive sleep apnea, opioids, or hypnotic agents. Many anesthesiologists believe RNMB occurs infrequently and is rarely associated with adverse outcomes. This study evaluated the prevalence and predictors of RNMB and AREs., Methods: This prospective cohort study included 599 adult patients undergoing general anesthesia who received neuromuscular blocking agents. Baseline demographic, surgical, and anesthetic variables were collected. RNMB was defined as a train-of-four ratio below 0.90 measured by electromyography on admission to the PACU. AREs were defined based on the modified Murphy's criteria., Results: RNMB was present in 186 patients (31% [95% confidence interval (CI), 27%-35%]) on admission to the PACU. One or more AREs were experienced by 97 patients (16% [95% CI 13-19]). AREs were more frequent in patients with RNMB (21% vs 14%, P = .033). RNMB was significantly associated with age (adjusted relative risk [RR], 1.17 [95% CI, 1.06-1.29] per 10-year increase), type of operation (adjusted RR, 0.59 [95% CI, 0.34-0.99] for laparoscopic surgery compared with open abdominal surgery), and duration of operation (adjusted RR, 0.59 [95% CI, 0.39-0.86] for ≥90 minutes compared with <90 minutes). Using multivariate logistic regression, AREs were found to be independently associated with decreased level of consciousness (adjusted RR, 4.76 [95% CI, 1.49-6.76] for unrousable/unconscious compared with alert/awake) and lower core temperature (adjusted RR, 1.43 [95% CI, 1.04-1.92] per 1°C decrease). Although univariate analysis found a significant association between AREs and RNMB, the significance became borderline after adjusting for other covariates (adjusted RR, 1.46 [95% CI, 0.99-2.08])., Conclusions: The prevalence of RNMB in the PACU was >30%. Older age, open abdominal surgery, and duration of operation <90 minutes were associated with increased risk of RNMB in our patients. Our RR estimate for AREs was highest for depressed level of consciousness. When AREs occur in the PACU, potentially preventable causes including RNMB, hypothermia, and reduced level of consciousness should be readily identified and treated appropriately. Delaying extubation until the patient is awake and responsive may reduce AREs.

The preoperative respiratory evaluation aims at predicting the occurrence of postoperative respiratory complications (PORC), such as: atelectasis, pulmonary infection (bronchitis and pneumonia), acute ventilatory distress, pleural effusion, prolonged mechanical ventilation, exacerbation of chronic respiratory disease and bronchospasm. The incidence of (PORC) all surgeries combined is 6.8%. Individual surgical and anesthetic factors are impacting on the occurrence of PORC. Simple scores, including anamnestic data, clinical examination and some biological parameters were validated to assess the risk of PORC depending on the type of surgery. Data from standard pulmonary function tests (PFT) is of little use to estimate the individual risk of PORC. Most of the time, PFT abnormal parameters only confirm the clinical assessment of the severity of the illness. PFT may however be useful to confirm an improvement in the clinical condition of the patient related to the preoperative preparation. Specialized EFR, including standardized testing efforts are sometimes required in the case of lung reduction surgery. These specialized explorations can predict lung function and post-interventional pulmonary oxygenation and ensure that these are viable., (Copyright © 2014 Société française d’anesthésie et de réanimation (Sfar). Published by Elsevier SAS. All rights reserved.)

Background: In the absence of formal polysomnography (PSG), many children with symptoms of sleep-disordered breathing (SDB) go unrecognized and thus may be at risk for perioperative respiratory adverse events (PRAE)., Objectives: To develop a simple practical tool to identify children with symptoms consistent with SDB who may be at risk for PRAE., Methods: Three-hundred and thirty-seven parents of children scheduled for surgery completed the Sleep-Related Breathing Disorder (SRBD) questionnaire. Data regarding the incidence and severity of PRAE including airway obstruction and laryngospasm, were collected prospectively., Results: Thirty-two (9.5%) children had a confirmed diagnosis of SDB by PSG and 90 (26.7%) had symptoms consistent with SDB based on the SRBD questionnaire. Principal component analysis identified five symptoms from the SRBD questionnaire that were strongly predictive of PRAE and which were incorporated into the STBUR tool (Snoring, Trouble Breathing, Un-Refreshed). The likelihood of PRAE was increased by threefold (positive likelihood ratio 3.06 [1.64-5.96] in the presence of any 3 STBUR symptoms and by tenfold when all five symptoms were present (9.74 [1.35-201.8]). In comparison, the likelihood of PRAE based on a PSG-confirmed diagnosis of SDB was 2.63 (1.17-6.23)., Conclusions: Children presenting for surgery with symptoms consistent with SDB may be at risk for PRAE. It is important therefore that anesthesia providers identify these individuals prior to surgery to avoid potential complications. The STBUR questionnaire appears promising as a simple, clinically useful tool for identifying children at risk for PRAE. Further studies to validate the STBUR questionnaire as a diagnostic tool may be warranted., (© 2013 Blackwell Publishing Ltd.)

Objective: To (1) assess upper airway function by videoendoscopy in horses performing poorly after laryngoplasty and (2) establish whether dynamic collapse of the left arytenoid can be predicted by the degree of resting postsurgical abduction., Study Design: Case series., Animals: Horses that had left laryngoplasty (n=45)., Methods: Medical records (June 1993-December 2007) of horses evaluated for abnormal respiratory noise and/or poor performance after laryngoplasty were reviewed. Horses with video recordings of resting and exercising upper airway endoscopy were included and postsurgical abduction categorized. Horses with immediate postoperative endoscopy recordings were also evaluated and postsurgical abduction categorized. Relationships between resting postsurgical abduction and historical information with exercising endoscopic findings were examined., Results: Dynamic collapse of the left arytenoid cartilage was probable in horses with no postsurgical abduction and could not be predicted in horses with grade 3 or 4 postsurgical abduction. Respiratory noise was associated with upper airway obstruction but was not specific for arytenoid collapse. Most horses with a left vocal fold had billowing of the fold during exercise. Other forms of dynamic collapse involved the right vocal fold, aryepiglottic folds, corniculate process of left arytenoid cartilage, dorsal displacement of soft palate, and pharyngeal collapse. Complex obstructions were observed in most examinations and in all horses with exercising collapse of the left arytenoid cartilage., Conclusions: There was no relationship between exercising collapse of the left arytenoid cartilage and grade 3 or 4 postsurgical abduction but was likely in horses with no abduction., (© Copyright 2010 by The American College of Veterinary Surgeons.)

Background: Laparoscopic gastrectomy (LAG) is recognized as a less invasive surgery, but no advantage in terms of respiratory function recovery has been demonstrated. We investigated respiratory function recovery in the early period after LAG compared with open gastrectomy (OG) for measuring the recovery of oxygen saturation level (SaO(2))., Methods: The study population comprised 454 patients who underwent distal gastrectomy or total gastrectomy for preoperatively diagnosed T1N0 gastric cancer: 192 underwent laparoscopy-assisted distal gastrectomy (LADG), 190 underwent open distal gastrectomy (ODG), 42 underwent laparoscopy-assisted total gastrectomy (LATG), and 30 underwent open total gastrectomy (OTG)., Results: The number of days until SaO(2) reached 95% or higher in room air was significantly smaller in the LADG group (1.54 days) than in the ODG group (1.81 days; p = 0.010) and also significantly smaller in the LATG group (1.48 days) than in the OTG group (2.03 days; p = 0.043)., Conclusions: LAG patients recovered their oxygenation earlier than OG patients. The laparoscopic procedure might confer a respiratory benefit for gastrectomy patients.

Background: Tracheoesophageal fistula (TEF) is the most common congenital tracheal abnormality, frequently associated with esophageal atresia. Respiratory symptoms are associated with all types of TEF, even after surgical repair of the fistula. Gastroesophageal reflux (GER) with aspiration of gastric contents, structural instability of the airways (tracheomalacia), abnormal respiratory epithelium, abnormal esophageal motility, recurrent TEF, and esophageal stenosis contribute to postsurgical complications., Methods: We review 7 patients between 4 and 14 years of age with a history of TEF repair and persistent or worsening respiratory symptoms despite conventional airway clearance techniques and treatment of GER., Results: Bronchoscopic evaluation in all 7 patients revealed tracheomalacia and a diverticulum on the posterior wall of the trachea at the fistula repair site., Conclusion: We hypothesize that the diverticula impaired airway clearance and contributed to persistent respiratory symptoms. Possible mechanisms for the diverticulum contributing to poor airway clearance include facilitating the pooling of secretions and acting as a "barrier" to the lower airway clearance mechanism. The diagnosis of a diverticulum should be considered early in patients with persistent respiratory symptoms after management of GER and tracheomalacia. Early obliteration of tracheal diverticula might improve respiratory status in some patients.

Background: Patients with obstructive sleep apnea are at risk for perioperative morbidity. The authors used a screening prediction model for obstructive sleep apnea to generate a sleep apnea clinical score (SACS) that identified patients at high or low risk for obstructive sleep apnea. This was combined with postanesthesia care unit (PACU) monitoring with the aim of identifying patients at high risk of postoperative oxygen desaturation and respiratory complications., Methods: In this prospective cohort study, surgical patients with a hospital stay longer than 48 h who consented were enrolled. The SACS (high or low risk) was calculated; all patients were monitored in the PACU for recurrent episodes of bradypnea, apnea, desaturations, and pain-sedation mismatch. All patients underwent pulse oximetry postoperatively; complications were documented. Chi-square, two-sample t test, and logistic regression were used for analysis. The oxygen desaturation index (number of desaturations per hour) was calculated. Oxygen desaturation index and incidence of postoperative cardiorespiratory complications were primary endpoints., Results: Six hundred ninety-three patients were enrolled. From multivariable logistic regression analysis, the likelihood of a postoperative oxygen desaturation index greater than 10 was increased with a high SACS (odds ratio = 1.9, P < 0.001) and recurrent PACU events (odds ratio = 1.5, P = 0.036). Postoperative respiratory events were also associated with a high SACS (odds ratio = 3.5, P < 0.001) and recurrent PACU events (odds ratio = 21.0, P < 0.001)., Conclusions: Combination of an obstructive sleep apnea screening tool preoperatively (SACS) and recurrent PACU respiratory events was associated with a higher oxygen desaturation index and postoperative respiratory complications. A two-phase process to identify patients at higher risk for perioperative respiratory desaturations and complications may be useful to stratify and manage surgical patients postoperatively.

A predictive role of volume-velocity (VV) indices of ventilation in prognosis of respiratory complications after radical surgeries for non-small cell carcinoma of the lung was evaluated. It is demonstrated that decreased VV indices of ventilation before surgery directly correlate with a respiratory complication rate after surgery. New methods of diagnosis of ventilation disorders and of monitoring are regarded as promising.

Background and Purpose: To determine the association between structural cardiac changes and postoperative respiratory complications after adenotonsillectomy for obstructive breathing during sleep., Patients and Methods: Forty-eight children, ages 2-18 years, undergoing adenotonsillectomy for obstructive breathing during sleep were recruited for this case control study. The case group consisted of 24 children with postoperative respiratory complications after adenotonsillectomy who also had an echocardiogram. An equal number of children without postoperative respiratory complications after adenotonsillectomy were recruited as controls. Left ventricular mass (LVM) was calculated from 2D guided M mode echocardiographic measurements of the left ventricle. Left ventricular mass index (LVMI) was calculated as left ventricular mass/height(2.7). Left ventricular hypertrophy (LVH) was defined as LVMI index greater than the 95th percentile for age. The two groups were compared for demographic variables and cardiac structure., Results: The two groups did not significantly differ by age, height, gender or racial distribution. LVH and right ventricular (RV) dimension greater than the 95th percentile for age remained significantly associated with the occurrence of postoperative respiratory complications after controlling for body mass index (BMI) Z score, age, gender, race, systolic and diastolic blood pressure., Conclusions: The increased prevalence of structural cardiac changes in the group with complications (P<0.01) suggests an underlying cardiac origin for postoperative respiratory complications in this group of children.

Background: Pulmonary complications remain a leading cause of morbidity after major abdominal operations., Objective: To compare pulmonary function and the frequency of pulmonary complications after laparoscopic cholecystectomy (LC) and open cholecystectomy (OC)., Methods: Fifty-five patients with symptomatic gallstone disease undergoing elective cholecystectomy (LC 40, OC 15) under general anesthesia were evaluated using pulmonary function tests (forced vital capacity [FVC], forced expiratory volume at 1 second [FEV1], and forced expiratory flow at 25% to 75% [FEF25% -75%], chest X-ray and pulse oximetry before and after surgery., Results: FVC, FEV1 and FEF25% -75% decreased by 21.5%, 21.2% and 30.3%, respectively, on postoperative day 1 following LC, and by 44.3%, 46.2% and 58.3%, respectively, after OC. Chest X-ray showed atelectasis in 15% of patients undergoing LC and 45% of those with OC., Conclusion: Impairment in pulmonary function after LC was less marked than after OC.

Background: Postoperative respiratory disturbances may be the result either of depression of respiratory drive, or alteration of respiratory pattern., Methods: Using an inductance plethysmograph, we continuously recorded the breathing in 52 patients for 4 h after major thoracic, abdominal, and body surface surgery. The ventilatory response to hypercapnia was measured preoperatively, and at the start and end of the observation period., Results: From a variety of statistical measures of respiratory depression, it was found that the occurrence of apnoeas (breath times >10 s), did not correlate with measures of respiratory drive, or with dose or route of administration of opioid, site of surgery, pain, or drowsiness. Instead, the incidence of apnoeas correlated most closely with measures of respiratory pattern (standard deviation of breath times (r=0.72), the mean breath time (r=0.63), approximate entropy of the breath times (r= -0.32)). Twenty-nine percent of patients had some breath times (Ttot) longer than 20 s., Conclusion: We would conclude that changes in respiratory pattern are not closely correlated with changes in traditional measures of respiratory drive.

Objective: To determine risk factors predictive of outcomes to aid in the cost-effective preoperative evaluation and postoperative management of patients who are undergoing tonsillectomy and adenoidectomy for obstructed breathing during sleep., Design: A historical cohort study with a nested case-control analysis that examined risk factors associated with postoperative respiratory complications., Setting: Children's Medical Center of Dallas, Dallas, Tex, which is a pediatric referral hospital for secondary and tertiary pediatric care with both private and university-appointed physicians., Patients: A convenience sample of 355 patients who were undergoing tonsillectomy and adenoidectomy for obstructed breathing during sleep throughout a 1-year period., Intervention: None., Main Outcome Measure: The occurrence of postoperative complications, including airway obstruction, apneas with oxygen desaturations, airway interventions (e.g., endotracheal intubation), or administration of supplemental oxygen, as they related to associated medical conditions (e.g., cerebral palsy or prematurity) and diagnostic tests (e.g., chest x-ray film and electrocardiogram)., Results: Five associated medical conditions (cerebral palsy; seizures; age, < or = 3 years; congenital heart disease; and prematurity) were identified as important predictors of a complicated postoperative course using stepwise logistic regression analysis. Those children with an abnormal chest x-ray film or electrocardiogram were also identified as having an associated medical condition that was predictive of postoperative complications., Conclusions: Children with 1 or more of the associated risk factors identified should be considered candidates for postoperative inpatient observation. A preoperative chest x-ray film and electrocardiogram were found to be of little predictive value, and they are probably not cost-effective screening tests for postoperative respiratory complications.

Thoracic impedance (TTI) and rib cage inductance band (IB) signals were measured in 10 patients during the first night after abdominal surgery, and compared by successive correlation of the change in each signal. Poor matching of the signals occurred, on average, for 94 min either because of movement of differences in the waveform. There were frequent episodes of transient poor correlation, generally associated with transient respiratory disturbance, predominantly airway obstruction (58%). Thoracic impedance measurements are simpler than inductance band methods for detecting rib cage movement and may be useful for large studies of respiratory abnormalities in patients after operation.

New York Heart Association (NYHA) functional classification of cardiac patients is assessed by subjective impairment of respiratory reserve. We objectively studied pulmonary function by spirometry in 31 random patients (average age 27.2 years) with rheumatic mitral valve (MV) disease undergoing open surgery (7 reconstruction, 24 replacement) preoperatively, predischarge and at 3 month follow-up. Better preoperative spirometric parameters were observed in class II nonsmoker patients with smaller cardiothoracic ratio (CTR) and normal pulmonary artery pressure (PAP). After surgery mean PAP decreased to 19.0 +/- 6.7 mmHg, MV gradient dropped to 3.4 +/- 2.9 mmHg, average CTR decreased to 52.3 /- 5.5%. MV area increased significantly from 0.8 +/= 0.49 to 2.45 +/- 1.23 cm2. Forced vital capacity (FVC), forced expiratory volume in one second FEV1), flow rates at 25%-75% of expired vital capacity (FEF 25-75%) and maximum voluntary ventilation (MVV) decreased significantly in all patients at discharge. Prolonged postoperative ventilatory support over 10 hours led to markedly reduced predischarge FVC, FEV1, FEF50, MVV and maximum mid expiratory flow rate (MMEFR). Prolonged cardiopulmonary bypass over 80 minutes caused further decrease in FVC. After 3 months all these parameters improved in all above the preoperative level but remained below the predicted values. Despite improvement in NYHA class, impaired spirometry was observed in 11 patients. Functional or hemodynamic improvement did not correlate with spirometric changes.

A study was carried out assessing the practical use of a simple system of scoring information which can help in making a diagnosis or establishing a prognosis in an individual patient. The system was introduced in 1984 for use in gastroenterology, but it can be employed in a wide range of medical and surgical settings. This series was concerned with predicting postoperative respiratory complications in a group of elderly surgical patients. The system combines elements from Baye's theorem and logistic regression, though no mathematical knowledge is required to apply it in clinical practice. The method by which results are presented is easy to understand, yet at the same time more complex ideas such as conflict of evidence and doubt may be embraced if the clinician so desires.

Spirometry was carried out before and after operation in groups of patients undergoing three preselected surgical procedures. The patterns of impairment of pulmonary function in each group are discussed. Only in patients undergoing inguinal herniorrhaphy was spirometry of value in determining an 'at-risk' group for the development of respiratory complications. Discrimination was optimal on the 1st postoperative day, making it possible for 70% of patients to be discharged from hospital 48 h after this operation with little risk of subsequent respiratory complications.