A 67-year-old male comes to the clinic for medical clearance prior to an elective abdominal aortic aneurysm repair. He denies any cough, shortness of breath or chest pain. He has coronary artery disease, diabetes and hypertension. He does not use tobacco, alcohol or drugs. His blood pressure is 120/76 mm Hg, pulse is 60/min, and respirations are 14/min. Examination shows no abnormalities, except prominent epigastric pulsations. Which of the following interventions would be most helpful in preventing postoperative pneumonia in this patient?
This patient has numerous risk factors for postoperative pneumonia. His age, poor health, and scheduled long invasive surgery put him at increased risk. Postoperative measures used to decrease the risk of pneumonia are aimed at encouraging lung expansion. These include incentive spirometry, deep breathing exercises, continuous positive airway pressure, and intermittent positive pressure breathing. Of these, incentive spirometry has been shown to be the most effective, and is thus the first line preventive measure.
(Choice A) Albuterol inhalers are used preoperatively in patients with COPD or asthma, exhibiting dyspnea or wheezing. This treatment is unnecessary for a patient without preexisting pulmonary disease.
(Choice B) Prophylactic antibiotics prior to surgery are only used in patients with evidence of preexisting respiratory infection. The use of antibiotics in patients without respiratory infection has not been shown to improve outcomes, and may increase the risk of developing antibiotic-resistant pneumonia.
(Choice D) Continuous positive airway pressure (CPAP), like incentive spirometry, promotes lung expansion postoperatively. However, it is more costly and has a higher rate of complications than incentive spirometry. For these reasons, CPAP is used only in patients who develop pulmonary complications in spite of incentive spirometry.
(Choice E) By controlling pain and encouraging early ambulation, intercostal nerve blocks have shown some efficacy in preventing postoperative pulmonary complications. The findings have been most pronounced in patients under age 50, and with subcostal incisions.
Educational objective:
Postoperative pulmonary complications are common, particularly in patients with known risk factors. These risk factors include smoking, preexisting pulmonary disease, age >50, thoracic or abdominal surgery, surgery lasting >3 hours, and poor general health. Postoperative measures such as incentive spirometry and deep breathing exercises are used to prevent such complications and improve outcomes by promoting lung expansion.