Prediction tools• CXRLow yield in in patient without risk factorsIn a systematic review of 14 studies abnormal CXR lead

to Rx change in 10% of cases without changing PPC rate.

• ABG Cardiac, thoracic, abdominal surgeries Pts who have SOB or smokers Pt with abnormal pulse oximetry

Prediction tools

• Cardiopulmonary Exercise Testing Purely lung resection surgery

MVO2 maximum oxygen consumption

MVO2 > 20ml/kg low risk

MVO2 < 10 ml/kg very high risk

• Stair climbing Prospective study in 110 pts who underwent high risk procedures

thoracotomy , sternotomy or upper abd sx

7 Flights of stairs each flight consists of 18 steps

Cardioplumonary complications & mortalityGirisch et al Chest 2001

Girisch et al Chest 2001Girisch et al Chest 2001

Girisch et al Chest 2001Girisch et al Chest 2001

Lung ResectionThe risks associated with thoracotomy can be divided into 2 categories:

I- short-term riskperioperative morbidity and mortality

II- long-term riskactivity limitation resulting from loss of lung reserve.

Low RiskFEV1 (Forced Expiratory Volume in one second ) 1.2 L

Predicted postoperative FEV1.8 L or 40% predicted

MVV ( Maximum Voluntary Ventilation) 50% predicted

High Risk PCO2 45 or PO2 50

Predicted Postoperative FEV1 0.7 L 40% predicted

Poor exercise performance

Rilley Chest 1999

American College Of Chest Physician Guidelines 2007

Preventive Measures

• Incentive spirometry & deep breathing exercises

Meta-analysis of 14 studies of incentive spirometry & deep-breathing exercises Vs no intervention

odds ratios of 0.44 and 0.43 for PPC

Preoperative education reduces PPC to a greater degree than instruction that begins after surgery

Arch Phys Med Rehab 1985 & AmRev Respir Dis 1984

Preventive Measures

Non invasive positive pressure ventilation • Prospective study of 72 post abdominal Sx pts with acute

hypoxic failure were treated with escalating PSV /PEEP to achieve target tidal volume of 8-10 ml/kg .

• 48/72 (67%) avoided intubation

• LOS was shorter 17 days Vs 34 days

• Mortality was less 6% Vs 29%

• 10/72 had esophageal & gastric surgery no leak

Jaber Chest oct 2005

To put everything together

Sematana NEJM 2007

Take Home Message

• Conducting detailed history taking & physical examination should be the first screening tool

• Investigations selection had to tailored to detected abnormalities

• Risk factors for PPC are either patient or procedure related. It could be modifiable or non modifiable

• The variation in definition of PPC & patient population lead to different reported rate of PPC

• All prediction tools of PPC have not been validated after being derived further studies is needed

ThanksThe more you know the more you realize

how much you don’t know