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INTRODUCTION

Hospitalists are frequently called upon to provide perioperative care to a broad spectrum of surgical patients, in either a consultative or a comanagement role. Although historically much emphasis has been placed on postoperative cardiac complications, postoperative pulmonary complications are known to occur with equal or greater frequency and contribute substantially to morbidity, mortality, and health care costs. Broadly defined, postoperative pulmonary complications are conditions affecting the respiratory tract that adversely influence the clinical course of patients after surgery. The Confederate general, Thomas “Stonewall” Jackson, wounded in the Battle of Chancellorsville in 1863, was perhaps the earliest recorded victim of a postoperative pulmonary complication, dying of pneumonia 8 days after the successful amputation of his left arm. It is estimated that over 1 million patients undergoing nonthoracic surgery in the United States annually experience postoperative pulmonary complications. Pulmonary complications produce the highest attributable costs among common categories of postoperative complications and can result in a fivefold increase in the median cost of an operation. The presence of pulmonary complications after major surgery increased 30-day mortality from 2% to 22%, and 1-year mortality from 8.7% to 45.9% based on data from the National Surgical Quality Improvement Program (NSQIP). The most important postoperative pulmonary complications are atelectasis, pneumonia, respiratory failure, and exacerbation of underlying chronic lung disease, although earlier studies have also included transient and self-limited clinical findings. A general principle is that the closer the operative site is to the diaphragm, the higher the likelihood of postoperative pulmonary complications. Interventions to reduce the incidence of these complications depend on the aggressive application of preventive measures to high-risk patients. Obstructive sleep apnea in particular has received greater recognition as a frequently undiagnosed and prevalent condition in surgical patients that increases pulmonary risk. Programs such as the NSQIP allow institutions to track their performance and engage in quality improvement in this area. Anticipation, early diagnosis and prompt effective therapies form the next line of defense in treating postsurgical complications once they occur. Studies of hospital mortality associated with inpatient surgery suggest the variation between institutions is explained more by their ability to “rescue” patients from complications when they occur rather than differences in incidence. This chapter focuses on the pathogenesis, early recognition, and evidence-based treatment of common postoperative pulmonary complications.

PRACTICE POINT

  • A general principle to predicting the risk of postoperative pulmonary complications is that the closer the operative site is to the diaphragm, the higher the likelihood of complications.

ATELECTASIS

Atelectasis, or reversible alveolar collapse, is a common perioperative phenomenon and occurs in 90% of patients receiving general anesthesia. Computed tomographic (CT) studies have demonstrated collapse of 15% to 20% of the lung volume near the diaphragm. Dr William Pasteur, a Swiss physician practicing in England in the early part of the last century, wrote extensively on the postoperative lung and noted, “when the true history of postoperative lung complications comes to be written, active ...

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