There has been increased focus on the need for higher-quality, safer, and more appropriate care in hospitals nationwide. One of the most important components of this mission is to reduce the risk of complications after surgery. Postoperative pulmonary complications (PPCs) are considered modifiable adverse clinical events. Anticipating and preventing these problems have become key measures of the quality and safety of hospital care in the United States. “PPCs are a major contributor to the overall risk in many types of surgery and have been associated with considerable morbidity and mortality,” says Aryeh Shander, MD, FCCP, FCCM. “Despite this, awareness of the consequences and prevention of PPCs remain relatively low.”
In 2009, 15 experts in the fields of surgery, anesthesiology or critical care, internal and hospital medicine, and health services with experience in managing PPCs were convened in a patient safety summit. This resulted in a paper published in the September 2011 issue of Critical Care Medicine. Dr. Shander, lead author of the paper, says “we wanted to enhance and increase physician awareness of PPCs, recommend strategies to reduce the impact of these complications, provide information to catch patients at increased risk, and identify patients who would benefit from preventive interventions and more intensive monitoring.”
Defining Pulmonary Complications
PPCs are broadly defined as conditions affecting the respiratory tract that can adversely influence the clinical course of patients after surgery. “PPCs have a multifactorial etiology and are associated with many preoperative, intraoperative, and postoperative risk factors,” explains Dr. Shander. “Several independent risk factors for PPCs have been identified [Table 1], but more research is needed in this area. Increasing awareness and recognition of these known risk factors, however, is important considering the large scope of PPCs.”
Although many factors are associated with PPCs, Dr. Shander says it remains challenging for clinicians to define and quantify their total burden. For example, it is often difficult to determine whether coded complications are actually present on admission. Furthermore, clinical evidence supporting a specific PPC diagnosis may be limited or absent. All of this may result in inaccurate reporting and uncertainty about the validity of a diagnosis. “Despite these limitations, it’s well established that PPCs are common events that represent a significant economic problem,” says Dr. Shander. “As the U.S. government continues to seek out measures of preventable complications as part of reimbursement, it’s becoming increasingly important to recognize and optimize the management of PPCs.”
To effectively reduce the impact of PPCs, preoperative identification of patients at risk and subsequent modification of risk factors are required. This must occur within the constraints of complex patient care, economics, and other limiting factors. “PPCs substantially increase the use of healthcare resources because they’re associated with increased morbidity, mortality, and hospital length of stay,” adds Dr. Shander. “Need for rehospitalization and cost of service are important benchmarks that gauge quality of care. Reducing PPC-related morbidity and associated costs could both enhance patient outcomes and alleviate financial resources for hospitals.”
Preventing Post-Op Pulmonary Complications
Several preoperative interventions, including smoking cessation, nutritional supplementation, and pulmonary rehabilitation, have been recommended to decrease the risk of PPCs (Table 2). Postoperative interventions to reduce the risk of PPCs during mechanical ventilation include chest physical therapy, intermittent positive pressure breathing, intermittent suction, bronchodilators, positive end-expiratory pressure valves, and inhaled mucolytics. These interventions are commonly used together but appear to have less of an impact when used individually, according to some studies.
The patient safety summit participants advocated using mechanical ventilation for more than 48 hours after surgery as a measurable marker of PPC risk. They noted that is an unequivocal marker that may also facilitate tracking of the effect of risk-reducing interventions and strategies on clinical outcomes over time. “Furthermore,” says Dr. Shander, “there’s a need to develop educational programs and communication tools to raise awareness about PPCs among all perioperative care providers.”
Reducing Risk of Pulmonary Complications
Taking a coordinated perioperative approach has the potential to significantly decrease risk for PPCs. “Much of the additional costs incurred by PPCs is avoidable or preventable, but it requires teamwork,” Dr. Shander says. “It’s also important that we take all the necessary steps to decrease the incidence of PPCs as far as possible. By developing protocols and interventions, we can optimize our ability to address this important public health issue. We need to continue researching modifiable risks for PPCs and target interventions that address them. Only with more data and research will we be able to truly decrease the incidence, morbidity, mortality, and cost of PPCs.”
Readings & Resources (click to view)
Shander A, Fleisher LA, Barie PS, et al. Clinical and economic burden of postoperative pulmonary complications: Patient safety summit on definition, risk-reducing interventions, and preventive strategies. Crit Care Med. 2011;39:2163-2172. Available at: http://journals.lww.com/ccmjournal/pages/articleviewer.aspx?year=2011&issue=09000&article=00018&type=abstract.
Qaseem A, Snow V, Fitterman N, et al. Risk assessment for and strategies to reduce perioperative pulmonary complications for patients undergoing non-cardiothoracic surgery: a guideline from the American College of Physicians. Ann Intern Med. 2006;144:575-580.
Bapoje SR, Whitaker JF, Schulz T, et al. Preoperative evaluation of the patient with pulmonary disease. Chest. 2007;132:1637-1645
Lawrence VA, Cornell JE, Smetana GW, et al. Strategies to reduce postoperative pulmonary complications after non-cardiothoracic surgery: systematic review for the American College of Physicians. Ann Intern Med. 2006;144:596-608.
Smetana GW, Lawrence VA, Cornell JE, et al. Preoperative pulmonary risk stratification for non-cardiothoracic surgery: systematic review for the American College of Physicians. Ann Intern Med. 2006;144:581-595.