Effect of Incentive Spirometry on Postoperative Hypoxemia and Pulmonary Complications After Bariatric Surgery: A Randomized Clinical Trial

Effectiveness of a Modified Nurse-Led COUGH Bundle for Obese Patients After Bariatric Surgery

BACKGROUND

Obesity commonly affects postsurgical pulmonary outcomes and is associated with increased oxygen usage, length of recovery and hospital stay, discharge to high levels of care, cost, morbidity, and mortality.

LOCAL PROBLEM

No standardized pulmonary care bundle for obese patients after bariatric surgery was available in the postanesthesia care unit (PACU) at a hospital in Singapore.

METHODS

This quality improvement project was a prospective, single-cohort, pre- and posttest intervention design with 151 patients recruited.

INTERVENTIONS

Teaching and implementation of a modified nurse-led COUGH bundle was carried out on obese patients after their bariatric surgery.

RESULTS

Postbariatric surgery patients with the nurse-led COUGH bundle had significantly less consumption of oxygen in the PACU and step-down units. The PACU and hospital length of stay were also reduced.

CONCLUSIONS

The modified nurse-led COUGH bundle can reduce patients' oxygen usage and hospital stay after their bariatric surgery.

Association Between Visceral Fat Area and Glycated Hemoglobin in Type 2 Diabetics: A Retrospective Study

Introduction

Obesity is a risk factor for the development of type 2 diabetes (T2DM) as well as its associated metabolic complications. Central obesity, characterized by an increased visceral fat area (VFA), is contributed to the development of T2DM. However, the relationship between VFA and HbA1c is not particularly clear.

Methods

A total of 3173 patients with T2DM participated in the study at the Metabolic Management Center (MMC), with anthropometric and biochemical measurements recorded. To examine the association between HbA1c and VFA, fitting curves were plotted, facilitating a comprehensive observation of their relationship.

Results

HbA1c was inversely associated with VFA (β -1.79, 95% CI -2.34~-1.24, P < 0.001). The fitted curve shows that VFA increased with the increase of HbA1c when it was less than 8.62%. When it was greater than 8.62%, VFA decreased as HbA1c increased. Using linear inflection point analysis, we found that its inflection point interval falls within 8.36%~8.88%.

Conclusion

VFA was positively associated with HbA1c in individuals with T2DM. Furthermore, the relationship between the two variables was an inverted U-shaped association.

Prehabilitation: a narrative review focused on exercise therapy for the prevention of postoperative pulmonary complications following lung resection

Extensive preventive strategies in the perioperative period are popular worldwide. Novel "prehabilitation" approaches are being defined for every individual surgical discipline. With intention to reduce perioperative morbidity, "prehabilitation" was developed to increase "physical wellness" considering exercise capacity, nutritional status, and psychological support. Thus, prehabilitation could be well-suited for patients undergoing lung cancer surgery. Theoretically, improving physical condition may increase the chances of having a better post-operative course, especially among frail patients. In this review, we describe the concept of prehabilitation with possible benefits, its role in the Enhanced Recovery After Surgery protocols, and its potential for the future.

Incentive spirometry is an effective strategy to improve the quality of postoperative care in patients

Postoperative pulmonary complications (PPCs) most commonly occur after thoracic surgery. Not only prolonged hospital stay and increased financial expenses but also morbidity and even mortality may be troublesome for those with PPCs. Herein, we aimed to conduct a comprehensive systematic review and meta-analysis of available data to examine the effectiveness of incentive spirometry (IS) to reduce PPCs and shorten hospital stay. This systematic review and meta-analysis included 5 randomized controlled trials (RCT) and 3 retrospective cohort study (10,322 patients in total) in PubMed, Embase and Cochrane Library until September 31, 2021. We assessed the clinical efficacy of IS using length of hospital stay, PPCs, postoperative pneumonia, and postoperative atelectasis with meta-analysis, meta-regression and trial sequential analysis (TSA). With this meta-analysis, the length of hospital stay in patients undergoing IS was significantly shorter (1.8 days) than that in patients not receiving IS (MD = -1.80, 95% CI = -2.95 to -0.65). Patients undergoing IS also had reduced risk of PPCs (32%) and postoperative pneumonia (17.9%) with statistical significance than patients not undergoing IS (PPC: OR = 0.68, 95% CI = 0.51-0.90) (Pneumonia: OR = 0.821, 95% CI = 0.677-0.995).In meta-regression, the benefits of undergoing IS in patients with preoperative predicted FEV1 of <80% in a linear fashion with decreasing PPCs. IS is an effective modality to improve the quality of postoperative care for patients after pulmonary resection, compared with the control group without using IS; and applying IS has favorable outcomes of shorter length of hospital stay (1.8 days) and lower occurrence of PPCs (32% of risk reduction), which are conclusive and robust based on our validation via TSA. Moreover, the IS device is more beneficial for patients with preoperative predicted FEV1 of <80% than that in others.

Effect of post-extubation high-flow nasal cannula combined with respiratory training versus conventional oxygen therapy on postoperative pulmonary complications in patients after major abdominal surgery: protocol for a single-centre randomized controlled trial

BACKGROUND

Nearly 234 million patients undergo surgery each year, and 1.3 million among them develop complications. Patients undergoing major upper abdominal surgery (operation time > 2 h) have a really high incidence of postoperative pulmonary complications (PPCs). The occurrence of PPCs seriously affects the outcomes of patients. High-flow nasal cannula (HFNC) is as effective as noninvasive ventilation (NIV) in preventing postoperative hypoxaemia and respiratory failure. Respiratory training using positive expiratory pressure (PEP) Acapella (Choice) has been shown to help patients with rapid recovery from postoperative atelectasis. However, no relevant randomized controlled studies have been conducted to clarify the effect of HFNC combined with respiratory training in the prevention of PPCs. This study aims to investigate whether the use of HFNC combined with respiratory training could reduce the incidence of PPCs within 7 days after major upper abdominal surgery compared to that with conventional oxygen therapy (COT).

METHODS

This is a randomized controlled single-centre trial. A total of 328 patients who undergo major abdominal surgery will be included. Subjects who fulfil the eligible criteria will be randomly assigned into the combination treatment group (Group A) or COT group (Group B) after extubation. The interventions will begin within 30 min of extubation. Patients in Group A will receive HFNC for at least 48 h and respiratory training three times a day for at least 72 h. Patients in Group B will receive oxygen therapy through a nasal catheter or mask for at least 48 h. Our primary endpoint is the incidence of PPCs within 7 days, and the secondary outcome measures include 28-day mortality, reintubation rate, length of hospital stay, and all-cause mortality within 1 year.

DISCUSSION

This trial would help provide evidence on the effectivity of applying HFNC combined with respiratory training for the prevention of PPCs in patients undergoing major upper abdominal surgery. The objective of this study is to determine the optimal treatment approach to improve the prognosis of patients undergoing surgery.

TRIAL REGISTRATION

ChiCTR2100047146. Registered on 8 June 2021. Retrospectively registered.

Efficacy of prophylactic high-flow nasal cannula therapy for postoperative pulmonary complications after pediatric cardiac surgery: a prospective single-arm study

PURPOSE

This study investigated the incidence of postoperative pulmonary complications (PPC) when high-flow nasal cannula therapy (HFNC) is used prophylactically after pediatric cardiac surgery, and evaluated its efficacy.

METHODS

This was a single-arm prospective interventional study that was conducted in a tertiary teaching hospital with eight beds in the pediatric cardiac ICU after approval by the Ethics Committee. One-hundred children under the age of 48 months who were scheduled for cardiac surgery for congenital heart disease were recruited. HFNC was used for 24 h after extubation at a 2 L/kg/min flow rate. The primary outcome was the incidence of PPC within 48 h after extubation. PPC was defined as atelectasis and acute respiratory failure meeting certain criteria. We considered prophylactic HFNC as effective if the prevalence of PPC was < 10%, based on previous reports of reintubation rates of 6%-9% after pediatric cardiac surgery.

RESULTS

A total of 91 patients were finally included in the analysis. The incidence of PPC within 48 h after extubation was 18.7%, whereas atelectasis was observed in 13.2%, and acute respiratory failure in 8.8%. Reintubation rate within 48 h after extubation was 0%.

CONCLUSIONS

We found the incidence of PPC with prophylactic HFNC after planned extubation after pediatric cardiac surgery. However, the incidence was > 10%; therefore, we could not demonstrate its efficacy in this single-arm study. Further studies are needed to investigate whether the HFNC could be adapted as first-line oxygen therapy after pediatric cardiac surgery.

Analysis of the impact of ERAS-based respiratory function training on older patients’ ability to prevent pulmonary complications after abdominal surgery

BACKGROUND

In China, as the population grows older, the number of elderly people who have died from respiratory problems has increased.

AIM

To investigate whether enhanced recovery after surgery (ERAS)-based respiratory function training may help older patients who had abdominal surgery suffer fewer pulmonary problems, shorter hospital stays, and improved lung function.

METHODS

The data of 231 elderly individuals having abdominal surgery was retrospectively analyzed. Based on whether ERAS-based respiratory function training was provided, patients were divided into ERAS group (n = 112) and control group (n = 119). Deep vein thrombosis (DVT), pulmonary embolism (PE), and respiratory tract infection (RTI) were the primary outcome variables. Secondary outcome variables included the Borg score Scale, FEV1/FVC and postoperative hospital stay.

RESULTS

The percentage of 18.75% of ERAS group participants and 34.45% of control group participants, respectively, had respiratory infections (P = 0.007). None of the individuals experienced PE or DVT. The ERAS group’s median postoperative hospital stay was 9.5 d (3-21 d) whereas the control groups was 11 d (4-18 d) (P = 0.028). The Borg score decreased on the 4^th d following surgery in the ERAS group compared to the 2^nd d prior (P = 0.003). The incidence of RTIs was greater in the control group than in the ERAS group among patients who spent more than 2 d in the hospital before surgery (P = 0.029).

CONCLUSION

ERAS-based respiratory function training may reduce the risk of pulmonary complications in older individuals undergoing abdominal surgery.

Postoperative prophylactic intermittent noninvasive ventilation versus usual postoperative care for patients at high risk of pulmonary complications: a multicentre randomised trial

BACKGROUND

Pulmonary complications are an important cause of morbidity and mortality after surgery. We evaluated the clinical effectiveness of noninvasive ventilation (NIV) in preventing postoperative acute respiratory failure.

METHODS

This is an open, multicentre randomised trial that included patients at high risk of postoperative pulmonary complications after elective or semi-urgent surgery with an Assess Respiratory Risk in Surgical Patients in Catalonia (ARISCAT) score ≥45. Patients were randomly assigned to intermittent prophylactic face-mask NIV for 6-8 h day^-1 or usual postoperative care. The primary outcome was in-hospital acute respiratory failure within 7 days after surgery. Patients who underwent surgery and postoperative extubation were included in the modified intended-to-treat analysis. Results are presented as n (%) and odds ratios (ORs) with 95% confidence intervals.

RESULTS

Between November 2017 and October 2019, 266 patients were randomised and 253 included in the main analysis. Of these, 203 (80.2%) were male with a mean age of 68 (11) yr and an ARISCAT score of 53 (6); 237 subjects (93.7%) underwent cardiac or thoracic surgery. There were 125 patients allocated to prophylactic NIV and 128 to usual care. Unplanned treatment termination occurred in 58 subjects in the NIV group, which was linked to NIV discomfort for 36 subjects. There was no difference in the incidence of the primary outcome of postoperative acute respiratory failure between treatment groups (NIV: 30 of 125 subjects [24.0%] vs usual care: 35 of 128 subjects [27.3%]; OR 0.97 [0.90-1.04]; P=0.54).

CONCLUSIONS

Prophylactic NIV was difficult to implement after high-risk surgery because of low patient compliance. Prophylactic NIV did not prevent acute respiratory failure.

CLINICAL TRIAL REGISTRATION

NCT03629431 and EudraCT 2017-001011-36.

A Scoring Tool That Identifies the Need for Positive-Pressure Ventilation and Determines the Effectiveness of Allocated Respiratory Therapy

BACKGROUND

Hospital-acquired pneumonia (HAP) and the need for positive-pressure ventilation (PPV) are significant postoperative pulmonary complications (PPCs) that increase patients' lengths of stay, mortality, and costs. Current tools used to predict PPCs use nonmodifiable preoperative factors; thus, they cannot assess provided respiratory therapy effectiveness. The Respiratory Assessment and Allocation of Therapy (RAAT) tool was created to identify HAP and the need for PPV and assist in assigning respiratory therapies. This study aimed to assess the RAAT tool's reliability and validity and determine if allocated respiratory procedures based on scores prevented HAP and the need for PPV.

METHODS

Electronic medical record data for nonintubated surgical ICU subjects scored with the RAAT tool were pulled from July 1, 2015-January 31, 2016, using a consecutive sampling technique. Sensitivity, specificity, and jackknife analysis were generated based on total RAAT scores. A unit-weighted analysis and mean differences of consecutive RAAT scores were analyzed with RAAT total scores ≥ 10 and the need for PPV.

RESULTS

The first or second RAAT score of ≤ 5 (unlikely to receive PPV) and ≥ 10 (likely to receive PPV) provided a sensitivity of 0.833 and 0.783 and specificity of 0.761 and 0.804, respectively. Jackknifed sensitivity and specificity for identified cutoffs above were 0.800-0.917 and 0.775-0.739 for the first RAAT score and 0.667-0.889 and 0.815-0.79 for the second RAAT score. The initial RAAT scores of ≥ 10 predicted the need for PPV (P < .001) and was associated with higher in-hospital mortality (P < .001). Mean differences between consecutive RAAT scores revealed decreasing scores did not need PPV.

CONCLUSIONS

The RAAT scoring tool demonstrated an association with the need for PPV using modifiable factors and appears to provide a quantitative method of determining if allocated respiratory therapy is effective.

Pulmonary Complications Are a Strong Independent Predictor of 30-Day Mortality Following Elective Bariatric Surgery

OBJECTIVE

Pulmonary complications in patients with obesity carry a high morbidity and mortality. An analysis of the MBSAQIP database was performed to determine the effect of post-operative pulmonary complications on patients undergoing elective bariatric surgery, with the primary outcome of 30-day mortality.

METHODS

We extracted data from the MBSAQIP database from 2015 to 2019 on patients who underwent elective Roux-en-Y gastric bypass or sleeve gastrectomy. Pulmonary complications were defined as prolonged ventilation, pneumonia, unplanned intubation, pulmonary embolism, and coma past 24 h (with the assumption of this being due to hypercapnia). Data on post-operative complications and 30-day mortality was extracted. To determine the effect of pulmonary complications on 30-day mortality, a multivariable logistic regression model was developed.

RESULTS

Pulmonary complications were associated with a near 50-fold increased odds of 30-day mortality (OR 47.1; 95%, 38.6-57.5; p < 0.0001). Pulmonary complications were also associated with higher rates of anastomotic leaks (9.5% vs. 0.3%; p < 0.0001), post-operative bleeding (13.7% vs. 0.9%; p < 0.0001), cardiac complications (6.6% vs. 0.0%; p < 0.0001), post-operative AKIs (9.6% vs. 0.1%; p < 0.0001), incidence of deep SSI (9.4% vs. 0.2%; p < 0.0001), incidence of post-operative sepsis (6.2% vs. 0.1%; p < 0.0001), and incidence of Clostridioides difficile (2.0% vs. 0.1%; p < 0.0001).

CONCLUSION

Pulmonary complications after elective bariatric surgery are a strong predictor of 30-day mortality. Patients who experience pulmonary complications have a higher incidence of co-morbidities and unfavorable baseline patient characteristics, and thus, likely form a unique subset of the bariatric patient population.

Perioperative care for major elective surgery: a survey of Brazilian physiotherapists

Abstract Introduction: Major surgeries are highly complex procedures and have a higher incidence of respiratory morbidity and mortality compared to other types of surgery. Postoperative pulmonary complications (PPC) are common after such surgeries and are associated with increased hospital stay, health care costs and surgical patient mortality. Objective: To investigate the most commonly used physical therapy techniques for the prevention and treatment of PPC among thoracic and abdominal surgery patients in all regions of Brazil. Methods: A total of 489 randomly selected physiotherapists who provided perioperative care for patients undergoing elective abdominal, thoracic or cardiac surgeries participated in this study. A questionnaire with nine questions about routine care and therapeutic choices for the surgical population was developed and assessed by 10 specialists before being administered to the physiotherapists. Results: Among the physiotherapists (63% with at least 5 years of experience with surgical patients), 50.9% considered the patient’s surgical risk in their treatment either always or often. A total of 53.8% patients were treated by the physiotherapist following a physician’s prescription. The most mentioned physical therapy techniques used to prevent PPC were postoperative mobilization/exercises (59.3%), postoperative lung expansion (52.8%), and preoperative advice (50.7%). In addition, 80.6% of the physiotherapists believe that incentive spirometry prevents PPC, while 72.8% expected this effect from positive airway pressure devices. Conclusion: Most physiotherapists in Brazil who work with surgical patients offer preoperative professional advice, use postoperative early mobilization and lung expansion techniques to prevent PPC, and consider the patient's surgical risk during treatment. In addition, some physical therapy sessions are routinely performed preoperatively.

Positive Expiratory Pressure Therapy on Oxygen Saturation and Ventilation After Abdominal Surgery: A Randomized Controlled Trial

Objective

To evaluate the immediate effects of positive expiratory pressure therapy on oxygen saturation and ventilation after abdominal surgery.

Background

Positive expiratory pressure therapy to treat postoperative hypoxia is widespread, despite a lack of evidence of effect.

Methods

This randomized, sham-controlled, crossover trial investigated adults 1-2 days after abdominal surgery at Umeå University Hospital, Sweden. The intervention was positive expiratory pressure of 10-15 cm H2O. The control was a sham device. The investigations were ended with deep-breathing maneuvers. Outcomes were the gradient of changes in peripheral oxygen saturation and transcutaneous carbon-dioxide partial pressure (PtcCO2).

Results

Eighty patients were included and randomized and 76 patients were analyzed. Oxygen saturation increased from a baseline mean of 92% to 95%, P < 0.001, during positive expiratory pressure breathing, while PtcCO2 decreased from a mean of 36 to 33 mm Hg, P < 0.001. This was followed by apnea, oxygen desaturations to a mean of 89%, P < 0.001, and increased PtcCO2 before returning to baseline values. The changes in oxygen saturation and PtcCO2 did not differ from sham breathing or deep-breathing maneuvers.

Conclusions

Positive expiratory pressure breathing after abdominal surgery improves oxygen saturation during the maneuver because of hyperventilation, but it is followed by apnea, hypoventilation, and oxygen desaturation. The effect is not different from the expiration to a sham device or hyperventilation. It is time to stop positive expiratory pressure therapy after abdominal surgery, as there is no evidence of effect in previous trials, apart from the adverse effects reported here.

Nurse-guided incentive spirometry use and postoperative pulmonary complications among cardiac surgery patients: A randomized controlled trial

AIMS

To assess the effect of nurse-guided use of incentive spirometer on postoperative oxygenation and pulmonary complications after coronary artery bypass graft surgery.

BACKGROUND

Deep breathing exercises have been shown to improve postoperative lung expansion and reduce pulmonary complications. An incentive spirometer is a deep breathing exercises device that imitates continuous sigh-like maximal inspiration.

DESIGN

Randomized control trial, two groups nonblinded parallel design.

METHODS

A total of n = 89 eligible patients were randomized to either control or intervention group. Patients in the intervention group received bihourly nurse-guided incentive spirometry for 48-h postextubation. The endpoints were: the number and duration of hypoxic events during the first 24-hr postsurgery, pneumonia and pulmonary function parameters. Data were collected May to September 2019.

RESULTS

Patients in the intervention group had a significantly lower mean number of hypoxic events with shorter duration and shorter length of stay in the hospital and the ICU. Patients in the intervention group also had greater postoperative forced expiratory volume in 1 second.

CONCLUSION

Nurse-guided use of the incentive spirometer reduces the risk of pulmonary complications and hospital length of stay after cardiac surgery.

Objective postoperative pain assessment using incentive spirometry values: a prospective observational study

Aim: Determine if incentive spirometry (IS) values correlate with postoperative pain control. Design: Prospective observational study. Setting & participants: A total of 100 patients undergoing major abdominal procedures at the University of North Carolina Medical Center. Interventions: Patients studied as a single cohort. All patients received thoracic epidural analgesia preoperatively. Outcome: Preoperative and daily postoperative numeric pain scores, subjective pain description and IS values were collected for all patients. Results: There was a strong correlation with IS values relative to baseline for both the numeric pain scores (p < 0.0001), postoperative day (p < 0.0001) and the subjective pain score (p < 0.0007). Conclusion: IS values are an objective surrogate data point for pain control after surgery, particularly when followed over time and compared with a preoperative baseline value.

Incentive Spirometry for Prevention of Postoperative Pulmonary Complications After Thoracic Surgery

Incentive spirometry is frequently used after thoracic surgery as an adjunct to physiotherapy. Despite its widespread use, it has remained challenging to demonstrate a clinical benefit in terms of either incidence of postoperative pulmonary complications or hospital stay. In this literature review, we have observed that, although there is no study supporting clinical benefit in the thoracic surgical patient population generally, there is now emerging evidence of benefit in higher-risk patient populations such as those with COPD. There is an indication that incentive spirometry can lead to a reduction in the incidence of postoperative pulmonary complications in these patients. The problem with studies published to date is that there are many limitations, not least of which is the challenge of achieving patient adherence with performing incentive spirometry as prescribed. Despite the lack of evidence, there remains an appetite for persevering with incentive spirometry in the postoperative thoracic surgical patient because it is a relatively inexpensive intervention that motivates many patients to perform regular breathing exercises long after the therapist has moved on to the next patient.

Incentive spirometry to prevent pulmonary complications after chest trauma: a retrospective observational study

Aim

Pulmonary complications (PCs) are a major cause of poor prognosis in chest trauma. Evidence on the effectiveness of incentive spirometry (IS) in trauma is scarce. This study investigated the effectiveness of IS in preventing PCs in patients with chest trauma with rib fractures.

Methods

This retrospective observational study analyzed the data obtained from the electronic medical records of patients with chest trauma with rib fractures admitted between 2011 and 2019. We included patients 18 years of age or older with risk of worsening respiratory failure. Early IS was the primary exposure and PCs (pulmonary infection or respiratory failure requiring escalating oxygen therapy) were the primary outcomes. Secondary outcomes were length of hospital stay, duration of oxygenation therapy, and adverse events of IS. Logistic regression analysis with a propensity score was used.

Results

We extracted 514 patients from the electronic medical records; 299 patients were included. The early IS group had a higher proportion of hypoxemia at admission, opioid analgesia use, invasive positive pressure ventilation, and respiratory physiotherapy. The severity of trauma was higher in the early IS group. There was no significant difference in the occurrence of the PCs between groups (adjusted odds ratio 0.71; 95% confidence interval, 0.24–2.16). No statistical differences were seen in the secondary outcomes.

Conclusion

For patients with chest trauma with rib fractures at risk of worsening respiratory failure, IS early after injury did not reduce the rate of PCs. No adverse event of IS was observed and IS was shown to be safe.

The effect of postoperative respiratory and mobilization interventions on postoperative complications following abdominal surgery: a systematic review and meta-analysis

PURPOSE

Up to 30% of patients undergoing abdominal surgery suffer from postoperative pulmonary complications. The purpose of this systematic review and meta-analyses was to investigate whether postoperative respiratory interventions and mobilization interventions compared with usual care can prevent postoperative complications following abdominal surgery.

METHODS

The review was conducted in line with PRISMA and GRADE guidelines. MEDLINE, Embase, and PEDRO were searched for randomized controlled trials and observational studies comparing postoperative respiratory interventions and mobilization interventions with usual care in patients undergoing abdominal surgery. Meta-analyses with trial sequential analysis on the outcome pulmonary complications were performed. Review registration: PROSPERO (identifier: CRD42019133629) RESULTS: Pulmonary complications were addressed in 25 studies containing 2068 patients. Twenty-three studies were included in the meta-analyses. Patients predominantly underwent open elective upper abdominal surgery. Postoperative respiratory interventions consisted of expiratory resistance modalities (CPAP, EPAP, BiPAP, NIV), assisted inspiratory flow modalities (IPPB, IPAP), patient-operated ventilation modalities (spirometry, PEP), and structured breathing exercises. Meta-analyses found that ventilation with high expiratory resistance (CPAP, EPAP, BiPAP, NIV) reduced the risk of pulmonary complications with OR 0.42 (95% CI 0.18-0.97, p = 0.04, I² = 0%) compared with usual care, however, the trial sequential analysis revealed that the required information size was not met. Neither postoperative assisted inspiratory flow therapy, patient-operated ventilation modalities, nor breathing exercises reduced the risk of pulmonary complications.

CONCLUSION

The use of postoperative expiratory resistance modalities (CPAP, EPAP, BiPAP, NIV) after abdominal surgery might prevent pulmonary complications and it seems the preventive abilities were largely driven by postoperative treatment with CPAP.

Effects of Depth of Anesthesia Monitored by IoC on Patients Undergoing Laparoscopic Radical Resection of Colorectal Cancer

Index of consciousness (IoC) consisting of IoC1 and IoC2, is a new analgesia monitoring indicator in anesthesia evaluation in the laparoscopic radical resection of colorectal cancer. Although the precise anesthetic dosage adjusted by IoC1 has been confirmed to enhance the recovery and reduce the complications of anesthesia, the most appropriate range of IoC2 during anesthesia remains unclear. To investigate the correlation between IoC2 and peri-operative indicators of patients during laparoscopic radical resection of colorectal cancer, the current randomized, controlled, and single-blinded clinical trial was performed. Participants were divided randomly into three groups with different anesthesia depth monitored by IoC2 during their laparoscopic radical resections. Primary outcomes included the dosage of remifentanil. Secondary outcomes included other physiological indexes and complications. The remifentanil dosage and the awakening time increased as IoC2 decreased. The incidences of hypotension and hypoxemia decreased with the elevated IoC2, but the risk of intra-operative awareness also increased. The impact caused by anesthesia to the immune system and health-related life quality of the patients descended with reduced anesthetic level. The IoC2 range of 35–45 could represent the most appropriate anesthetic depth during laparoscopic radical resection, which provides a new perspective for the clinical treatment of colon cancer.

Thoracic complications in bariatric surgery patients

Obesity is a health issue that can lead to medical and psychological problems. Recently, bariatric surgery has become the best choice for treatment of selected candidates. As the number of bariatric surgeries increases, various related postoperative complications are being encountered. Most studies have been concerned with abdominal complications and thoracic complications were beyond their scope. The aim of this report was to review thoracic complications following bariatric surgery, in terms of incidence, management, and outcome. A literature search of English language published data concerning thoracic complications related to or following bariatric surgery was performed in November 2018. A total of 10,145 results were found. After screening titles and abstracts, 10,060 noneligible publications were excluded. Eighty-five publications were potentially eligible and their full texts were analyzed. After excluding overlapping series of patients, 44 studies were selected. These included 934 patients. Females accounted for 87.9% of the included patients. Ages ranged between 21 and 64 years (mean 43.86 ± 4.4 years). Most frequently encountered complications were esophageal (80.84%) followed by pulmonary (17.45%). The majority of esophageal complications were functional (82.38%) in contrast to the pulmonary type that were mostly organic (87.73%). There were 5 documented deaths. We concluded that thoracic complications are not infrequent after bariatric surgery. Esophageal and pulmonary are the most common thoracic complications reported. The outcome is usually favorable. Mortality may be avoided when complications are detected early and well-managed.

Incentive Spirometry After Lung Resection: A Randomized Controlled Trial

BACKGROUND

Incentive spirometry (IS) is thought to reduce the incidence of postoperative pulmonary complications (PPC) after lung resection. We sought to determine whether the addition of IS to routine physiotherapy following lung resection results in a lower rate of PPC, as compared with physiotherapy alone.

METHODS

A single-blind prospective randomized controlled trial was conducted in adults undergoing lung resection. Individuals with previous lung surgery or home oxygen were excluded. Participants randomized to the control arm (PHY) received routine physiotherapy alone (deep breathing, ambulation and shoulder exercises). Those randomized to the intervention arm (PHY/IS) received IS in addition to routine physiotherapy. The trial was powered to detect a 10% difference in the rate of PPC (β = 80%). Student's t test and chi-square were utilized for continuous and categorical variables, respectively, with a significance level of p = 0.05.

RESULTS

A total of 387 participants (n = 195 PHY/IS; n = 192 PHY) were randomized between 2014 and 2017. Baseline characteristics were comparable for both arms. The majority of patients underwent a pulmonary lobectomy (PHY/IS = 59.5%, PHY = 61.0%; p = 0.84), with no difference in the rates of minimally invasive and open procedures. There were no differences in the incidence of PPC at 30 days postoperatively (PHY/IS = 12.3%, PHY = 13.0%; p = 0.88). There were no differences in rates of pneumonia (PHY/IS = 4.6%, PHY = 7.8%; p = 0.21), mechanical ventilation (PHY/IS = 2.1%, PHY = 1.0%; p = 0.41), home oxygen (PHY/IS = 13.8%, PHY = 14.6%; p = 0.89), hospital length of stay (PHY/IS = 4 days, PHY = 4 days; p = 0.34), or rate of readmission to hospital (PHY/IS = 10.3%, PHY = 9.9%; p = 1.00).

CONCLUSIONS

The addition of IS to routine postoperative physiotherapy does not reduce the incidence of PPC after lung resection.