Retrospective studies have shown that smoking cessation reduced the incidence of pulmonary complications, but only if it was initiated at least 1–2 months before surgery. A meta-analysis of randomized trials found that preoperative smoking cessation programs reduced both pulmonary and surgical wound complications, especially if smoking cessation was initiated at least 4 weeks prior to surgery. The preoperative period may be an optimal time to initiate smoking cessation efforts. A systematic review found that smoking cessation programs started in a preoperative evaluation clinic increased the odds of abstinence at 3–6 months by nearly 60%. Smoking cessation less than 1 month before surgery does not appear to increase the risk of postoperative complications.
The incidence of postoperative pulmonary complications in patients with COPD or asthma may be reduced by preoperative optimization of pulmonary function. Patients who are wheezing should receive preoperative therapy with bronchodilators and, in certain cases, corticosteroids. Antibiotics may be beneficial for patients with COPD with increased sputum production or purulence. Patients receiving oral theophylline should continue taking the medication perioperatively. A serum theophylline level should be measured to rule out toxicity.
Postoperative risk reduction strategies have centered on promoting lung expansion through the use of incentive spirometry, continuous positive airway pressure (CPAP), intermittent positive-pressure breathing (IPPB), and deep breathing exercises. Although trial results have been mixed, all these techniques have been shown to reduce the incidence of postoperative atelectasis and, in a few studies, to reduce the incidence of other postoperative pulmonary complications. In most comparative trials, these methods were equally effective. Given the higher cost of CPAP and IPPB, incentive spirometry and deep breathing exercises are the preferred methods for most patients. Multi-component respiratory care programs may be particularly beneficial. One program termed “I COUGH”—an acronym for Incentive spirometry, Coughing and deep breathing, Oral care, Understanding (patient education), Get out of bed (early ambulation), and Head of bed elevation—reduced the rates of pneumonia and unplanned intubation after general and vascular surgery.