Point-of-Care Guides

Predicting the Risk of Postoperative Pulmonary Complications

 

Am Fam Physician. 2019 Oct 15;100(8):499-501.

Author disclosure: No relevant financial affiliations.

Clinical Question

What is the best approach to evaluate postoperative pulmonary risk?

Evidence Summary

The incidence of pulmonary complications following major surgery is estimated to be 1% to 23%, with the risk varying based on patient factors and the type of surgery.1 Postoperative pulmonary complications include pneumonia, tracheobronchitis, pulmonary edema, pulmonary embolism, atelectasis, pleural effusion, pneumothorax, bronchospasm, aspiration, respiratory failure, and acute respiratory distress syndrome. Postoperative pulmonary complications increase 30-day and 90-day mortality, making pulmonary risk stratification an important part of the primary care preoperative assessment.1,2

Several tools have been developed to stratify patients according to their risk of postoperative pulmonary complications. The ARISCAT (Assess Respiratory Risk in Surgical Patients in Catalonia Tool) was derived using a Spanish registry to predict postoperative pulmonary pneumonia.3 A trial that externally validated the ARISCAT using a larger, European data registry showed that the tool performed differently in different geographic populations, calling into question its application in a U.S. population without specific validation.46

The Respiratory Failure Risk Index was derived from the National Veterans Affairs Surgical Quality Improvement Program.7 Because it was created using mostly male veteran patients, it is unclear whether this tool would be generalizable to a broader patient population.

Two other risk stratification tools have been developed using data from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP). The NSQIP Pneumonia Risk Tool and the NSQIP Respiratory Failure Risk Tool predict the risk of developing pneumonia and respiratory failure within 30 days of surgery.2,8 Both tools were developed using a comprehensive data registry from the American College of Surgeons that included more than 180 hospitals. A 2007 data set (211,410 patients) and 2008 data set (257,385 patients) were used for derivation and validation, respectively.

Registry patients included males and females, patients undergoing cardiothoracic and noncardiothoracic surgeries, and patients undergoing emergent and nonemergent procedures.2,8 The type of surgery had the greatest impact on the risk of developing postoperative respiratory failure or pneumonia. The high C statistics for both tools (0.855 for pneumonia, 0.897 for postoperative respiratory failure) indicate excellent discrimination (the ability to distinguish between patients who do and do not develop a complication, where 0.5 is worst and 1.0 is best).2,8

The NSQIP tools use clinical data that are easily accessible preoperatively and do not require additional blood tests or imaging. Both risk tools include the type of surgery, the patient's functional status (best level of self-care demonstrated by the patient within the 30 days prior to surgery9), American Society of Anesthesiology class,10  and the presence or absence of sepsis (Table 12,8). The Respiratory Failure Risk Tool also includes whether it is an emergency, and the Pneumonia Risk Tool also includes patient age and smoking status and whether the patient has chronic obstructive pulmonary disease. Adding to the ease of use for physicians, these risk tools are available as online calculators, such as at https://www.mdcalc.com/gupta-postoperative-respiratory-failure-risk and https://www.mdcalc.com/gupta-postoperative-pneumonia-risk, and in the QxMD smartphone app (https://qxmd.com/calculate/calculator_261/postoperative-respiratory-failure-risk-calculator).

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TABLE 1.

Factors Required to Predict Postoperative Pulmonary Complications

FactorsPostoperative respiratory failure predictionPostoperative pneumonia prediction

Type of surgery

 Anorectal

X

X

 Aortic

X

X

 Bariatric

X

X

 Brain

X

X

 Breast

X

X

 Cardiac

X

X

 Ears, nose, throat

X

X

 Foregut/hepatopancreatobiliary

X

X

 Gallbladder, appendix, adrenal, and spleen

X

X

 Hernia (ventral, inguinal, femoral)

X

X

 Intestinal

X

X

 Neck (thyroid and parathyroid)

X

X

 Nonesophageal thoracic

X

X

 Obstetric/gynecologic

X

X

 Orthopedic and nonvascular extremity

X

X

 Other abdominal

X

X

 Peripheral vascular

X

X

 Skin

X

X

 Spine

X

X

 Urologic

X

X

 Vein

X

X

American Society of Anesthesiology class*

 Normal healthy patient

X

X

 Patient with mild systemic disease

X

X

 Patient with severe systemic disease

X

X

 Patient with severe systemic disease that is a constant threat to life

X

X

 Moribund patient who is not expected to survive without the surgery

X

X

Functional status†

 Totally dependent

X

X

 Partially dependent

X

X

 Totally independent

X

X

Sepsis

 Preoperative systemic inflammatory response syndrome

X

X

 Preoperative septic shock

X

X

 Preoperative sepsis

X

X

 None

X

X

Emergency case

 Yes

X

 No

X

Age (in years)

X

COPD

 GOLD stage 2–4

X

 Without COPD

X

Smoking

 Yes

Address correspondence to Pete Yunyongying, MD, FACP, at pete.yunyongying@carle.com. Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

References

show all references

1. Miskovic A, Lumb AB. Postoperative pulmonary complications. Br J Anaesth. 2017;118(3):317–334....

2. Gupta H, Gupta PK, Schuller D, et al. Development and validation of a risk calculator for predicting postoperative pneumonia. Mayo Clin Proc. 2013;88(11):1241–1249.

3. Canet J, Gallart L, Gomar C, et al.; ARISCAT Group. Prediction of postoperative pulmonary complications in a population-based surgical cohort. Anesthesiology. 2010;113(6):1338–1350.

4. Russotto B, Sabaté S, Canet J; PERISCOPE Group of the European Society of Anaesthesiology (ESA) Clinical Trial Network. Development of a prediction model for postoperative pneumonia: a multicentre prospective observational study. Eur J Anaesthesiol. 2019;36(2):93–104.

5. Mazo V, Sabaté S, Canet J, et al. Prospective external validation of a predictive score for postoperative pulmonary complications. Anesthesiology. 2014;121(2):219–231.

6. Bevacqua BK. Pre-operative pulmonary evaluation in the patient with suspected respiratory disease. Indian J Anaesth. 2015;59(9):542–549.

7. Arozullah AM, Daley J, Henderson WG, et al. Multifactorial risk index for predicting postoperative respiratory failure in men after major noncardiac surgery. Ann Surg. 2000;232(2):242–253.

8. Gupta H, Gupta PK, Fang X, et al. Development and validation of a risk calculator predicting postoperative respiratory failure. Chest. 2011;140(5):1207–1215.

9. American College of Surgeons National Quality Improvement Program. Surgical risk calculator. Accessed July 31, 2019. https://riskcalculator.facs.org/RiskCalculator/PatientInfo.jsp

10. American Society of Anesthesiologists. ASA physical status classification system. Accessed July 31, 2019. https://www.asahq.org/standards-and-guidelines/asa-physical-status-classification-system

11. Neto AS, da Costa LGV, Hemmes SNT, et al. The LAS VEGAS risk score for prediction of postoperative pulmonary complications: an observational study. Eur J Anaesthesiol. 2018;35(9):691–701.

12. Kor DJ, Warner DO, Alsara A, et al. Derivation and diagnostic accuracy of the surgical lung injury prediction model. Anesthesiology. 2011;115(1):117–128.

13. Brueckmann B, Villa-Uribe JL, Bateman BT, et al. Development and validation of a score for prediction of postoperative respiratory complications. Anesthesiology. 2013;118(6):1276–1285.

This guide is one in a series that offers evidence-based tools to assist family physicians in improving their decision-making at the point of care.

This series is coordinated by Mark H. Ebell, MD, MS, deputy editor for evidence-based medicine.

A collection of Point-of-Care Guides published in AFP is available at https://www.aafp.org/afp/poc.

 

 

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