A multifactorial score (FLAM score) was developed to standardize postoperative respiratory evaluation and to test the hypothesis that significant respiratory changes are evident at least 24 hours before the onset of pulmonary complications.
The FLAM score, created in 2002, is based on 3 main parameters (dyspnea, chest X-ray, delivered oxygen) and 4 minor parameters (auscultation, cough, quality of bronchial secretions, and quantity of bronchial secretions). To validate the FLAM score, we prospectively calculated scores during the first postoperative week in 300 consecutive patients submitted to posterolateral thoracotomy.
Sixty patients (20%) developed pulmonary complications during the postoperative period. In uncomplicated patients (n=240), the highest FLAM score (mean 5.03 ± 2.16) was recorded on the first postoperative day (POD), with progressive decline to POD7 (mean 2.41 ± 1.84). By contrast, the FLAM score progressively increased in complicated patients until POD4 (mean 13.5 ± 11.9). FLAM scores in patients with complications were significantly higher (p<0.05) at least 24 hours before the onset of complication, compared to FLAM scores in uncomplicated patients. ROC curve analysis showed that a FLAM score of 7 identified patients likely to develop a pulmonary complication with a good specificity (87.4% and 90% respectively on POD2 and POD3). Based on the highest FLAM scores recorded for each patient during the first postoperative week, 4 risk classes were identified: class I (FLAM 0-7) without respiratory morbidity; class II (FLAM 8-14); 40% risk of respiratory complications but no mortality; class III (FLAM 15-21), 8.3% postoperative mortality; and class IV (FLAM > 21), 22.2% postoperative mortality.
Changes in FLAM score were evident at least 24 hours before the onset of pulmonary complications, with the exception of those patients who develop complications on POD1.
The FLAM score can be used to categorize patients according to risk of respiratory morbidity and mortality and could be a useful tool in the postoperative management of patients undergoing thoracotomy.FLAM Peak ValuenRespiratory ComplicationsRespiratory FailureDeath0 - 72031 (0.5%)008 - 146027 (45%)2 (3.3%)015 - 211918 (94.7%)7 (36.8%)3 (15.7%)> 211818 (100%)9 (50%)6 (30%)
Francesco Leo, None.