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Postoperative pulmonary complications (PPC) are common and increase morbidity, length of stay, and mortality. They are even more morbid than postoperative cardiac complications. Among patients who suffer a PPC, 30-day mortality increases from 0.2–3% to 14–30%.1

An assessment of the risk of PPC should be part of every preoperative evaluation. The principal clinically important PPC are pneumonia, respiratory failure, and atelectasis requiring intervention. In this chapter, we outline preoperative general pulmonary risk assessment and perioperative interventions to mitigate the risk of PPC. This discussion applies to noncardiothoracic surgery as the risk factors for PPC differ for cardiac surgery and lung resection surgery. Furthermore, risk assessment and management for sleep apnea is discussed in a separate chapter.


It is customary to divide risk factors for PPC into those that are intrinsic to the procedure itself (procedure-related risk factors) and those due to inherent comorbidities in the patient (patient-related risk factors). Procedure-related risk factors dominate this assessment. In this regard, the preoperative pulmonary evaluation differs from a preoperative cardiac risk assessment where patient-related factors are more important than those intrinsic to the procedure itself.

Patient-Related Risk Factors

While intuitive in some respects, certain patient-related risk factors are more important than others. Table 15-1 lists the most commonly identified risk factors. In contrast to the estimation of cardiac risk, the risk of PPC due to age holds true even after multivariable adjustment for those conditions that are more common in older persons. The risk is particularly high for patients 70 years of age or older. Therefore, even otherwise healthy older patients should be counseled about PPC risks and clinicians should consider this factor during the preoperative evaluation.

TABLE 15-1Risk Factors for Postoperative Pulmonary Complications

The other most important patient-related risk factor that persists after adjustment for confounders is the American Society of Anesthesiologists’ (ASA) physical status classification (see chapter on anesthesiology). ASA class of 3–5 (on a scale of 1–5) confers increased risk. The ASA classification is based on the estimation of overall level of chronic illness and comorbid conditions.

Other important patient-related risk factors are ...

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