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Preoperative Assessment of Pulmonary Risk* FREE TO VIEW

Mark K. Ferguson, MD, FCCP
Author and Funding Information

*From the Department of Surgery, the University of Chicago, Chicago, IL.

Correspondence to: Mark K. Ferguson, MD, FCCP, 5841 S Maryland Ave MC5035, Chicago, IL 60637; e-mail: mferguso@surgery.bsd.uchicago.edu



Chest. 1999;115(suppl_2):58S-63S. doi:10.1378/chest.115.suppl_2.58S
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Published online

Study objectives: A summary of current modalities for and the utility of preoperative assessment of pulmonary risk.

Design: Review of recent literature published in the English language.

Setting: Not applicable.

Patients or participants: Patients who undergo elective cardiothoracic or abdominal operations.

Interventions: Not applicable.

Measurements and results: Postoperative pulmonary complications occur after 25 to 50% of major surgical procedures. The accuracy of the preoperative assessment of the risk of such complications is only fair. The routine assessment for all preoperative patients includes age, general physiologic status, and the nature of the planned operation. Specific tests such as measurement of spirometric values and diffusing capacity are indicated routinely only for patients who are candidates for major lung resection or esophagectomy.

Conclusions: Pulmonary complications are an important form of postoperative morbidity after major cardiothoracic and abdominal operations. The appropriate preoperative assessment of the risk of such complications is well defined for lung resection and esophagectomy operations, but it requires refinement for general surgical and cardiovascular operations.

Pulmonary complications are the most common form of postoperative morbidity experienced by patients who undergo general surgical abdominal procedures and thoracotomy, and frequently occur after cardiac surgical operations. The cost of postoperative pulmonary complications was well recognized at the beginning of the 20th century, at which time a number of clinical reviews identified the mortality rate associated with the development of postoperative pneumonia among > 40,000 patients to be in excess of 40%.18 In addition to pneumonia, postoperative pulmonary complications include massive lobar collapse due to mucus plugging of a central airway, pneumonitis, atelectasis, and a combination of one or more of these or other less common problems that results in respiratory insufficiency.

Because of the high incidence of these complications and their associated costs such as prolonged hospital stay and mortality, substantial effort has been made during the 20th century to predict which patients are at increased risk for developing such complications and to identify techniques that can be used to prevent them. This article will focus on methods that are currently used to predict which patients are at increased risk for postoperative pulmonary complications and mortality.

A prescient commentary in 1910 by W. Pasteur9 pointed the direction to our current understanding of the etiology of postoperative pulmonary complications. He noted that “when the true history of postoperative lung complications comes to be written, active collapse of the lung, from deficiency of inspiratory power, will be found to occupy an important position among determining causes.”9Most postoperative pulmonary complications develop as a result of changes in lung volumes that occur in response to dysfunction of muscles of respiration and other changes in chest wall mechanics. Abdominal and thoracic surgical procedures cause large reductions in vital capacity and smaller but crucial reductions in functional residual capacity (FRC), which has been recognized for decades as the single most important lung volume measurement involved in the etiology of respiratory complications.10Although no consistent changes occur in FRC after nonabdominal, nonthoracic surgery, FRC decreases after lower abdominal operations by 10 to 15%, by 30% after upper abdominal operations, and by 35% after thoracotomy and lung resection.1116 Other factors that decrease FRC include the supine position, obesity, the presence of ascites, the development of peritonitis, and general anesthesia.

The other important element in the etiology of postoperative respiratory complications is the closing volume (CV), which is the lung volume at which the flow from the dependent parts of the lungs stops during expiration because of airway closure. Factors that promote an increase in CV include advanced age, tobacco use, fluid overload, bronchospasm, and the presence of airway secretions.

Under normal circumstances, FRC is about 50% and CV is about 30% of total lung capacity. When FRC is reduced or CV is increased, portions of the lung are subject to premature airway closure and atelectasis. This causes ventilation-perfusion mismatch resulting in hypoxemia and promotes the trapping of secretions resulting in pneumonitis, all of which may combine to cause respiratory insufficiency.

The incidence of postoperative pulmonary complications after thoracotomy and lung resection is about 30% and is related not only to the removal of lung tissue but is also caused by alterations in chest wall mechanics due to the thoracotomy itself.1721 All spirometric measurements fall precipitously immediately postoperatively and do not return toward normal until 6 to 8 weeks postoperatively.16

Knowledge about the utility of preoperative assessment of the lung resection candidate was first developed in the 1950s and further refinement has taken place since then (Table 1). Early methods of evaluating risk included the measurement of bellows function of the lungs such as maximum voluntary ventilation and FRC.22The latter continues to be important for this purpose. Air flow parameters that are useful include FEV1 and forced expiratory flow rate in the middle 50% of the forced expiratory flow curve.24

Because raw spirometric values are relatively inaccurate for surgical candidates at the far ends of the body mass spectrum, further refinement of these measurements has included expressing them as a percentage of predicted based on patient age, sex, and height.22,2425 The calculation of postoperative predicted values for both spirometric raw numbers and percentage of predicted values has further increased the accuracy of spirometry as a preoperative tool for evaluating pulmonary risk preoperatively.2527 This calculation is usually performed by estimating the number of functional lung segments that will remain postoperatively. Quantitative ventilation-perfusion scans used to assess regional lung function have aided considerably in the calculation of predicted postoperative spirometric function in patients who are considered borderline candidates for operation based on standard techniques.2829

In addition to these standard methods, other measures of gas exchange and oxygen consumption have also proved useful in the preoperative assessment of risk. These include clinical assessments such as the 6-min walk distance and stair climbing effort and laboratory measures of exercise capacity such as maximum oxygen consumption during exercise (V̇o2max).3033 All have shown some promise in the prediction of postoperative pulmonary complications and, in some settings, postoperative mortality. Measurement of gas exchange capacity using diffusing capacity of the lung for carbon monoxide (Dlco) has proved to be an independent and useful means of estimating operative risk for patients undergoing major lung resection. Preoperative raw values or values expressed as a percent of predicted (Dlco%) as well as calculated postoperative values expressed as a percent of predicted function have all been shown to be useful, although the best value to use is the calculated postoperative Dlco expressed as a percent of predicted (ppoDlco%).,26,3435 In patients preselected as adequate candidates for lung resection on the basis of spirometry, the risk of pulmonary complications is best defined by patient age and ppoDlco%.,35 A direct comparison between the use of Dlco% and V̇o2max revealed that Dlco% was a better predictor of pulmonary complications after lung resection.,21

There have been important advances in the selection and postoperative care of the lung resection patient since the time most of the data noted previously were derived. Postoperative analgesia with epidural catheters or patient-controlled delivery devices has substantially reduced surgical pain. Vigorous pulmonary toilet exercises are used more routinely and frequently. Experience in lung volume reduction surgery and lung transplantation has increased our knowledge of how to treat critically ill patients with end-stage emphysema. There have also been changes in the way in which lung resection operations are performed. The use of muscle-sparing thoracotomy reduces postthoracotomy pain, retains shoulder girdle muscle strength, and may permit improved spirometric function in the early postoperative period compared with a standard lateral thoracotomy.17,36 Further improvements such as these may be evident with additional experience using thoracoscopic lung resection techniques.

At the present time, the risk of postoperative pulmonary complications in the candidate for lung resection should be evaluated with age and performance status during the initial history and physical examination. Based on the extent of planned lung resection, postoperative predicted spirometry and diffusing capacity are calculated (Table 1). For high-risk patients, an additional assessment of V̇o2max may be useful. Conclusions about the utility of muscle-sparing and thoracoscopic approaches await further data.

The incidence of pulmonary complications after cardiac surgical procedures is high and includes pneumonitis, bronchospasm, or lobar collapse in 40%, prolonged mechanical ventilation in 5 to 10%, and generalized respiratory dysfunction in most patients who undergo cardiopulmonary bypass.3739 The etiology of pulmonary complications in patients who undergo cardiac surgery has some factors that are similar to those that have been identified for pulmonary complications that develop after lung resection, specifically alterations in chest wall mechanics due to the incision. FRC is decreased by nearly 20% at the time of hospital discharge but is normal at 3 months after the operation. Interestingly, whether an internal mammary artery is used for bypass grafting has an important impact on respiratory function postoperatively. Increasing age and the use of an internal mammary artery graft have significant and independent negative impacts on spirometric values postoperatively.4041 In contrast to lung resection patients, however, the prediction of pulmonary complications after cardiac surgery is not aided by preoperative measurement of lung volumes and flows.37

Two unique factors contribute to the development of pulmonary complications after cardiac surgery. The first of these is the use of topical slush to protect the myocardium, which results in phrenic nerve paralysis in > 30% of patients compared with an incidence of < 5% in patients in whom no topical slush is used. The use of slush is also associated with an incidence of left lower lobe collapse of > 80% compared with only 32% in patients in whom no slush is used.42

The other unique factor that is associated with the development of pulmonary complications is the use of cardiopulmonary bypass. Within 24 h of surgery, there is a reduction in arterial oxygen tension of > 30%, an increase in the alveolar-arterial oxygen gradient of > 150%, and an increase in the pulmonary shunt fraction from a baseline of 3% to 19%. These changes only partially resolve by the end of the first postoperative week and eventually return to baseline values after 6 weeks.39 The only predictor of this complication is a preoperative abnormality of the alveolar-arterial oxygen gradient. The presumed etiology of this profound dysfunction is the activation of a multitude of inflammatory mediators in addition to the factors mentioned above.

The overall preoperative assessment of pulmonary risk in a patient who is to undergo cardiac surgery is based more on the planned operation and less on the patient’s preoperative status than for any other preoperative assessment. Issues of critical importance other than patient age and performance status are the choice of conduit if the patient is having coronary artery bypass grafting, the technique used for myocardial protection, and possibly the duration of cardiopulmonary bypass. Whether the minimally invasive approaches to bypass grafting and valve repair or replacement will reduce the incidence of postoperative pulmonary complications is as yet unknown.

Postoperative pulmonary complications occur in 25 to 50% of patients after esophagectomy.4345 These complications arise from a number of factors, including the type of incision used, the extent of mediastinal dissection, the development of a recurrent laryngeal nerve injury that may impair coughing efficiency postoperatively, and the presence of an intrathoracic reconstructive organ or pleural effusion that may directly impair ventilation in the early postoperative period.

The risk of pulmonary complications after esophagectomy is predicted on the basis of a number of preoperative factors, including patient age, spirometric values, diffusing capacity, performance status, nutritional status, and a diagnosis of COPD.4345 Intraoperative factors also strongly predict the likelihood of pulmonary complications. An increase in complications is associated with an increased volume of blood loss, use of the substernal rather than the posterior mediastinal route for esophageal reconstruction, and routine use of ventilatory support rather than early extubation postoperatively.4344,46 The type of incision used to perform the resection is also a predictor of the likelihood of postoperative pulmonary complications. Use of an isolated left thoracotomy results in fewer complications than does an Ivor Lewis approach combining a right thoracotomy and laparotomy. The Ivor Lewis approach is associated with fewer complications than is a transhiatal approach, in which a laparotomy and cervical incision are performed and no thoracotomy is necessary.44,47 The development of pulmonary complications is associated with a sevenfold increase in the risk of operative mortality, and pulmonary complications account for 40 to 60% of operative mortality.4345,48

Because of the high incidence of pulmonary complications and associated operative mortality after esophagectomy, a thorough preoperative evaluation of pulmonary risk is appropriate in candidates for esophagectomy. The evaluation should include a general assessment of age, performance and nutritional status, measurement of spirometric values, and an assessment of diffusing capacity. Knowledge of the planned approach to resection and the route to be used for reconstruction will also provide useful information regarding the risk of postoperative pulmonary complications.

The incidence of pulmonary complications after abdominal surgery is about 30%, a frequency that is high enough to have stimulated considerable research into the etiology of this problem.4953 In addition to dysfunction of abdominal wall musculature, the supine position, the development of ascites, and other factors that reduce FRC postoperatively after laparotomy, abdominal surgery has the unique propensity to impair diaphragmatic function, an effect that further contributes to the reduction in FRC. Transdiaphragmatic pressure decreases by almost 70% on the first postoperative day and does not return to normal until at least 1 week postopera-tively.54 Adequate relief of postoperative pain does not reduce this impairment that appears to result from dysfunction of the diaphragm itself rather than from phrenic nerve or central neural sources. Upper abdominal operations are associated with substantially worse diaphragmatic function postoperatively than are lower abdominal operations, and the risk of postoperative pulmonary complications is accordingly higher by a factor of 1.5.50

The accurate preoperative prediction of pulmonary risk associated with abdominal surgery has been somewhat elusive. The use of spirometry to assess which patients are at greatest risk has enjoyed widespread popularity, but its predictive value when used routinely is unproved.55 Clinical factors that have been shown to be useful in the prediction of postoperative pulmonary complications include a history of smoking, chronic bronchitis, airflow obstruction, obesity, and a prolonged preoperative hospital stay.50,5657 The presence of colonizing bacteria in the stomach and the use of nasogastric intubation increase the specific risk of postoperative pneumonia.50,58Smaller incisions and the use of laparoscopic techniques promise to reduce the incidence of pulmonary complications by preventing substantial reductions in pulmonary function postoperatively, but the data supporting these outcomes are scant at the present time.59 The most important predictive factors appear to be the overall condition of the patient (based on the classification of the American Society of Anesthesiologists) and patient age.52

Based on available information, the preoperative evaluation of pulmonary risk in the candidate for abdominal surgery should include an assessment of patient age, general performance status, relative weight, pulmonary comorbid conditions, the planned operation, and the incision that is to be used. Spirometry is indicated in patients in whom severe pulmonary dysfunction is evident as a means to assess whether a period of pulmonary rehabilitation is indicated to improve the preoperative pulmonary condition prior to an elective operation.

Table Graphic Jump Location
Table 1. Preoperative Tests for Assessing Pulmonary Risk Prior to Major Lung Resection
Armstrong, GE (1906) Lung complaints after operations with anaesthesia.BMJ1,1141-1142
 
Bancroft, FW A review of the postoperative cases of pneumonia in the second surgical service of the New York Hospital.Med Record1916;89,583
 
Lawen.. Uber lungenkomplikationen nach bauchoperationen.Zentralbl Chir1907;34,96-97
 
Beckman, EH Complications following surgical operations.Surg Gynecol Obstet1914;18,551-555
 
Booth, LS Discussion of LeWald LT. Differential diagnosis between pneumonia and acute appendicitis made by roentgen examination before physical signs of pneumonia obtained.Med Record1916;89,582-583
 
Cutler, EC, Morton, JJ Postoperative pulmonary complications.Surg Gynecol Obstet1917;25,621-649
 
Whipple, AO A study of postoperative pneumonitis.Surg Gynecol Obstet1918;26,29-47
 
Cleveland, M Further studies in postoperative pneumonitis.Surg Gynecol Obstet1919;28,282-293
 
Pasteur, W Active lobar collapse of the lung after abdominal operations.Lancet1910;2,1080-1083
 
Beecher, HK The measured effect of laparotomy on the respiration.J Clin Invest1933;12,639-650
 
Ali, J, Weisel, RD, Layug, AB, et al Consequences of postoperative alterations in respiratory mechanics.Am J Surg1974;128,376-382
 
Meyers, JR, Lembeck, L, O’Kane, H, et al Changes in functional residual capacity of the lung after operation.Arch Surg1975;110,576-583
 
Alexander, JI, Spence, AA, Parikh, RK, et al The role of airway closure in postoperative hypoxaemia.Br J Anaesth1973;45,34-40
 
Vaughan, RW, Wise, L Choice of abdominal operative incision in the obese patient: a study using blood gas measurements.Ann Surg1975;181,829-835
 
Craig, DB Postoperative recovery of pulmonary function.Anesth Analg1981;60,46-52
 
Bastin, R, Moraine, J-J, Bardocsky, G, et al Incentive spirometry performance.Chest1997;111,559-563
 
Hazelrigg, SR, Landreneau, RJ, Boley, TM, et al The effect of muscle-sparing versus standard posterolateral thoracotomy on pulmonary function, muscle strength, and postoperative pain.J Thorac Cardiovasc Surg1991;101,394-401
 
Busch, E, Verazin, G, Antkowiak, JG, et al Pulmonary complications in patients undergoing thoracotomy for lung carcinoma.Chest1994;105,760-766
 
Bolliger, CT, Wyser, C, Roser, H, et al Lung scanning and exercise testing for the prediction of postoperative performance in lung resection candidates at increased risk for complications.Chest1995;108,341-348
 
Epstein, SK, Faling, J, Daly, BDT, et al Inability to perform bicycle ergometry predicts increased morbidity and mortality after lung resection.Chest1995;107,311-316
 
Wang, J, Ultman, R, Olak, J, et al Prospective trial of diffusing capacity and oxygen consumption in the prediction of pulmonary complications after lung resection.Chest1997;112,153S
 
Gaensler, EA, Cugell, DW, Lindgren, I, et al The role of pulmonary insufficiency in mortality and invalidism following surgery for pulmonary tuberculosis.J Thorac Cardiovasc Surg1955;29,163-187
 
Boushy, SF, Billig, DM, North, LB, et al Clinical course related to preoperative and postoperative pulmonary function in patients with bronchogenic carcinoma.Chest1971;59,383-391
 
Olsen, GN, Block, AJ, Swenson, EW, et al Pulmonary function evaluation of the lung resection candidate: a prospective study.Am Rev Respir Dis1975;111,379-387
 
Putnam, JB, Jr, Lammermeier, DE, Colon, R, et al Predicted pulmonary function and survival after pneumonectomy for primary lung carcinoma.Ann Thorac Surg1990;49,909-915
 
Markos, J, Mullan, BP, Hillman, DR, et al Preoperative assessment as a predictor of mortality and morbidity after lung resection.Am Rev Respir Dis1989;139,902-910
 
Wahi, R, McMurtrey, MJ, DeCaro, LF, et al Determinants of perioperative morbidity and mortality after pneumonectomy.Ann Thorac Surg1989;48,33-37
 
Ali, MK, Ewer, MS, Atallah, MR, et al Regional and overall pulmonary function changes in lung cancer.J Thorac Cardiovasc Surg1983;86,1-8
 
Bria, WF, Kanarek, DJ, Kazemi, H Prediction of postoperative pulmonary function following thoracic operations.J Thorac Cardiovasc Surg1983;86,186-192
 
Marshall, MC, Olsen, GN The physiologic evaluation of the lung resection candidate.Clin Chest Med1993;14,305-320
 
Olsen, GN, Bolton, JW, Weiman, DS, et al Stair climbing as an exercise test to predict the postoperative complications of lung resection.Chest1991;99,587-590
 
Smith, TP, Kinasewitz, GT, Tucker, WY, et al Exercise capacity as a predictor of postthoracotomy morbidity.Am Rev Respir Dis1984;129,730-734
 
Bechard, D, Wetstein, L Assessment of exercise oxygen consumption as preoperative criterion for lung resection.Ann Thorac Surg1987;44,344-349
 
Ferguson, MK, Little, L, Rizzo, L, et al Diffusing capacity predicts morbidity and mortality after pulmonary resection.J Thorac Cardiovasc Surg1988;96,894-900
 
Ferguson, MK, Reeder, LB, Mick, R Optimizing selection of patients for major lung resection.J Thorac Cardiovasc Surg1995;109,275-283
 
Lemmer, JH, Jr, Gomez, MN, Symreng, T, et al Limited lateral thoracotomy.Arch Surg1990;125,873-877
 
Warner, MA, Divertie, MB, Tinker, JH Preoperative cessation of smoking and pulmonary complications in coronary artery bypass patients.Anesthesiology1984;60,380-383
 
Hammermeister, KE, Burchfiel, C, Johnson, R, et al Identification of patients at greatest risk for developing major complications at cardiac surgery.Circulation1990;82 (suppl IV),IV-380–IV-389
 
Taggart, DP, El-Fiky, M, Carter, R, et al Respiratory dysfunction after uncomplicated cardiopulmonary bypass.Ann Thorac Surg1993;56,1123-1128
 
Shapira, N, Zabatino, SM, Ahmed, S, et al Determinants of pulmonary function in patients undergoing coronary bypass operations.Ann Thorac Surg1990;50,268-273
 
Berrizbeitia, LD, Tessler, S, Jacobowitz, IJ, et al Effect of sternotomy and coronary bypass surgery on postoperative pulmonary mechanics.Chest1989;96,873-876
 
Efthimiou, J, Butler, J, Woodham, C, et al Diaphragm paralysis following cardiac surgery: role of phrenic nerve cold injury.Ann Thorac Surg1991;52,1005-1008
 
Law, SYK, Fok, M, Wong, J Risk analysis in resection of squamous cell carcinoma of the esophagus.World J Surg1994;18,339-346
 
Ferguson, MK, Martin, TR, Reeder, LB, et al Determinants of pulmonary complications following esophagectomy. Peracchia, A Rosati, R Bonavina, Let al eds.Recent advances in diseases of the esophagus1996,527-532 Monduzzi Editore. Milan, Italy:
 
Hennessy, TPJ Respiratory complications in oesophageal surgery. Peracchia, A Rosati, R Bonavina, Let al eds.Recent advances in diseases of the esophagus1996,533-535 Monduzzi Editore. Milan, Italy:
 
Bartels, H, Stein, HJ, Siewert, JR Early extubation versus prolonged ventilation after esophagectomy: a randomized prospective study. Peracchia, A Rosati, R Bonavina, Let al eds.Recent advances in diseases of the esophagus1996,537-539 Monduzzi Editore. Milan, Italy:
 
Stark, SP, Romberg, MS, Pierce, GE, et al Transhiatal versus transthoracic esophagectomy for adenocarcinoma of the distal esophagus and cardia.Am J Surg1996;172,478-482
 
Ferguson, MK, Martin, TR, Reeder, LB, et al Mortality after esophagectomy: risk factor analysis.World J Surg1997;21,599-604
 
Lyager, S, Wernberg, M, Rajani, N, et al Can postoperative pulmonary conditions be improved by treatment with the Bartlett-Edwards incentive spirometer after upper abdominal surgery?Acta Anaesthesiol Scand1979;23,312-319
 
Mitchell, C, Garrahy, P, Peake, P Postoperative respiratory morbidity: identification and risk factors.Aust N Z J Surg1982;52,203-209
 
Celli, BR, Rodriguez, KS, Snider, GL A controlled trial of intermittent positive pressure breathing, incentive spirometry, and deep breathing exercises in preventing pulmonary complications after abdominal surgery.Am Rev Respir Dis1984;130,12-15
 
Hall, JC, Tarala, RA, Hall, JL, et al A multivariate analysis of the risk of pulmonary complications after laparotomy.Chest1991;99,923-927
 
Kocabas, A, Kara, K, Ozgur, G, et al Value of preoperative spirometry to predict postoperative pulmonary complications.Respir Med1996;90,25-33
 
Simonneau, G, Vivien, A, Sartene, R, et al Diaphragm dysfunction induced by upper abdominal surgery.Am Rev Respir Dis1983;128,899-903
 
Lawrence, VA, Page, CP, Harris, GD Preoperative spirometry before abdominal operations.Arch Intern Med1989;149,280-285
 
Garibaldi, RA, Britt, MR, Coleman, ML, et al Risk factors for postoperative pneumonia.Am J Med1981;70,677-680
 
Dilworth, JP, White, RJ Postoperative chest infection after upper abdominal surgery: an important problem for smokers.Respir Med1992;86,205-210
 
Ephgrave, KS, Kleiman-Wexler, R, Pfaller, M, et al Postoperative pneumonia: a prospective study of risk factors and morbidity.Surgery1993;114,815-821
 
McMahon, AJ, Russell, IT, Ramsay, G, et al Laparoscopic and minilaparotomy cholecystectomy: a randomized trial comparing postoperative pain and pulmonary function.Surgery1994;115,533-539
 

Figures

Tables

Table Graphic Jump Location
Table 1. Preoperative Tests for Assessing Pulmonary Risk Prior to Major Lung Resection

References

Armstrong, GE (1906) Lung complaints after operations with anaesthesia.BMJ1,1141-1142
 
Bancroft, FW A review of the postoperative cases of pneumonia in the second surgical service of the New York Hospital.Med Record1916;89,583
 
Lawen.. Uber lungenkomplikationen nach bauchoperationen.Zentralbl Chir1907;34,96-97
 
Beckman, EH Complications following surgical operations.Surg Gynecol Obstet1914;18,551-555
 
Booth, LS Discussion of LeWald LT. Differential diagnosis between pneumonia and acute appendicitis made by roentgen examination before physical signs of pneumonia obtained.Med Record1916;89,582-583
 
Cutler, EC, Morton, JJ Postoperative pulmonary complications.Surg Gynecol Obstet1917;25,621-649
 
Whipple, AO A study of postoperative pneumonitis.Surg Gynecol Obstet1918;26,29-47
 
Cleveland, M Further studies in postoperative pneumonitis.Surg Gynecol Obstet1919;28,282-293
 
Pasteur, W Active lobar collapse of the lung after abdominal operations.Lancet1910;2,1080-1083
 
Beecher, HK The measured effect of laparotomy on the respiration.J Clin Invest1933;12,639-650
 
Ali, J, Weisel, RD, Layug, AB, et al Consequences of postoperative alterations in respiratory mechanics.Am J Surg1974;128,376-382
 
Meyers, JR, Lembeck, L, O’Kane, H, et al Changes in functional residual capacity of the lung after operation.Arch Surg1975;110,576-583
 
Alexander, JI, Spence, AA, Parikh, RK, et al The role of airway closure in postoperative hypoxaemia.Br J Anaesth1973;45,34-40
 
Vaughan, RW, Wise, L Choice of abdominal operative incision in the obese patient: a study using blood gas measurements.Ann Surg1975;181,829-835
 
Craig, DB Postoperative recovery of pulmonary function.Anesth Analg1981;60,46-52
 
Bastin, R, Moraine, J-J, Bardocsky, G, et al Incentive spirometry performance.Chest1997;111,559-563
 
Hazelrigg, SR, Landreneau, RJ, Boley, TM, et al The effect of muscle-sparing versus standard posterolateral thoracotomy on pulmonary function, muscle strength, and postoperative pain.J Thorac Cardiovasc Surg1991;101,394-401
 
Busch, E, Verazin, G, Antkowiak, JG, et al Pulmonary complications in patients undergoing thoracotomy for lung carcinoma.Chest1994;105,760-766
 
Bolliger, CT, Wyser, C, Roser, H, et al Lung scanning and exercise testing for the prediction of postoperative performance in lung resection candidates at increased risk for complications.Chest1995;108,341-348
 
Epstein, SK, Faling, J, Daly, BDT, et al Inability to perform bicycle ergometry predicts increased morbidity and mortality after lung resection.Chest1995;107,311-316
 
Wang, J, Ultman, R, Olak, J, et al Prospective trial of diffusing capacity and oxygen consumption in the prediction of pulmonary complications after lung resection.Chest1997;112,153S
 
Gaensler, EA, Cugell, DW, Lindgren, I, et al The role of pulmonary insufficiency in mortality and invalidism following surgery for pulmonary tuberculosis.J Thorac Cardiovasc Surg1955;29,163-187
 
Boushy, SF, Billig, DM, North, LB, et al Clinical course related to preoperative and postoperative pulmonary function in patients with bronchogenic carcinoma.Chest1971;59,383-391
 
Olsen, GN, Block, AJ, Swenson, EW, et al Pulmonary function evaluation of the lung resection candidate: a prospective study.Am Rev Respir Dis1975;111,379-387
 
Putnam, JB, Jr, Lammermeier, DE, Colon, R, et al Predicted pulmonary function and survival after pneumonectomy for primary lung carcinoma.Ann Thorac Surg1990;49,909-915
 
Markos, J, Mullan, BP, Hillman, DR, et al Preoperative assessment as a predictor of mortality and morbidity after lung resection.Am Rev Respir Dis1989;139,902-910
 
Wahi, R, McMurtrey, MJ, DeCaro, LF, et al Determinants of perioperative morbidity and mortality after pneumonectomy.Ann Thorac Surg1989;48,33-37
 
Ali, MK, Ewer, MS, Atallah, MR, et al Regional and overall pulmonary function changes in lung cancer.J Thorac Cardiovasc Surg1983;86,1-8
 
Bria, WF, Kanarek, DJ, Kazemi, H Prediction of postoperative pulmonary function following thoracic operations.J Thorac Cardiovasc Surg1983;86,186-192
 
Marshall, MC, Olsen, GN The physiologic evaluation of the lung resection candidate.Clin Chest Med1993;14,305-320
 
Olsen, GN, Bolton, JW, Weiman, DS, et al Stair climbing as an exercise test to predict the postoperative complications of lung resection.Chest1991;99,587-590
 
Smith, TP, Kinasewitz, GT, Tucker, WY, et al Exercise capacity as a predictor of postthoracotomy morbidity.Am Rev Respir Dis1984;129,730-734
 
Bechard, D, Wetstein, L Assessment of exercise oxygen consumption as preoperative criterion for lung resection.Ann Thorac Surg1987;44,344-349
 
Ferguson, MK, Little, L, Rizzo, L, et al Diffusing capacity predicts morbidity and mortality after pulmonary resection.J Thorac Cardiovasc Surg1988;96,894-900
 
Ferguson, MK, Reeder, LB, Mick, R Optimizing selection of patients for major lung resection.J Thorac Cardiovasc Surg1995;109,275-283
 
Lemmer, JH, Jr, Gomez, MN, Symreng, T, et al Limited lateral thoracotomy.Arch Surg1990;125,873-877
 
Warner, MA, Divertie, MB, Tinker, JH Preoperative cessation of smoking and pulmonary complications in coronary artery bypass patients.Anesthesiology1984;60,380-383
 
Hammermeister, KE, Burchfiel, C, Johnson, R, et al Identification of patients at greatest risk for developing major complications at cardiac surgery.Circulation1990;82 (suppl IV),IV-380–IV-389
 
Taggart, DP, El-Fiky, M, Carter, R, et al Respiratory dysfunction after uncomplicated cardiopulmonary bypass.Ann Thorac Surg1993;56,1123-1128
 
Shapira, N, Zabatino, SM, Ahmed, S, et al Determinants of pulmonary function in patients undergoing coronary bypass operations.Ann Thorac Surg1990;50,268-273
 
Berrizbeitia, LD, Tessler, S, Jacobowitz, IJ, et al Effect of sternotomy and coronary bypass surgery on postoperative pulmonary mechanics.Chest1989;96,873-876
 
Efthimiou, J, Butler, J, Woodham, C, et al Diaphragm paralysis following cardiac surgery: role of phrenic nerve cold injury.Ann Thorac Surg1991;52,1005-1008
 
Law, SYK, Fok, M, Wong, J Risk analysis in resection of squamous cell carcinoma of the esophagus.World J Surg1994;18,339-346
 
Ferguson, MK, Martin, TR, Reeder, LB, et al Determinants of pulmonary complications following esophagectomy. Peracchia, A Rosati, R Bonavina, Let al eds.Recent advances in diseases of the esophagus1996,527-532 Monduzzi Editore. Milan, Italy:
 
Hennessy, TPJ Respiratory complications in oesophageal surgery. Peracchia, A Rosati, R Bonavina, Let al eds.Recent advances in diseases of the esophagus1996,533-535 Monduzzi Editore. Milan, Italy:
 
Bartels, H, Stein, HJ, Siewert, JR Early extubation versus prolonged ventilation after esophagectomy: a randomized prospective study. Peracchia, A Rosati, R Bonavina, Let al eds.Recent advances in diseases of the esophagus1996,537-539 Monduzzi Editore. Milan, Italy:
 
Stark, SP, Romberg, MS, Pierce, GE, et al Transhiatal versus transthoracic esophagectomy for adenocarcinoma of the distal esophagus and cardia.Am J Surg1996;172,478-482
 
Ferguson, MK, Martin, TR, Reeder, LB, et al Mortality after esophagectomy: risk factor analysis.World J Surg1997;21,599-604
 
Lyager, S, Wernberg, M, Rajani, N, et al Can postoperative pulmonary conditions be improved by treatment with the Bartlett-Edwards incentive spirometer after upper abdominal surgery?Acta Anaesthesiol Scand1979;23,312-319
 
Mitchell, C, Garrahy, P, Peake, P Postoperative respiratory morbidity: identification and risk factors.Aust N Z J Surg1982;52,203-209
 
Celli, BR, Rodriguez, KS, Snider, GL A controlled trial of intermittent positive pressure breathing, incentive spirometry, and deep breathing exercises in preventing pulmonary complications after abdominal surgery.Am Rev Respir Dis1984;130,12-15
 
Hall, JC, Tarala, RA, Hall, JL, et al A multivariate analysis of the risk of pulmonary complications after laparotomy.Chest1991;99,923-927
 
Kocabas, A, Kara, K, Ozgur, G, et al Value of preoperative spirometry to predict postoperative pulmonary complications.Respir Med1996;90,25-33
 
Simonneau, G, Vivien, A, Sartene, R, et al Diaphragm dysfunction induced by upper abdominal surgery.Am Rev Respir Dis1983;128,899-903
 
Lawrence, VA, Page, CP, Harris, GD Preoperative spirometry before abdominal operations.Arch Intern Med1989;149,280-285
 
Garibaldi, RA, Britt, MR, Coleman, ML, et al Risk factors for postoperative pneumonia.Am J Med1981;70,677-680
 
Dilworth, JP, White, RJ Postoperative chest infection after upper abdominal surgery: an important problem for smokers.Respir Med1992;86,205-210
 
Ephgrave, KS, Kleiman-Wexler, R, Pfaller, M, et al Postoperative pneumonia: a prospective study of risk factors and morbidity.Surgery1993;114,815-821
 
McMahon, AJ, Russell, IT, Ramsay, G, et al Laparoscopic and minilaparotomy cholecystectomy: a randomized trial comparing postoperative pain and pulmonary function.Surgery1994;115,533-539
 
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