POST OPERATIVE PULMONARY COMPLICATIONS

Chris Wasson St3 Anaesthesia

• PPC’s• Audit project• interventions• iCough bundle• summary• questions/discussion

What are PPCs?• Respiratory failure• Atelectasis• Acute lung injury• Pneumonia• Pneumothorax• Pneumonitis• Exacerbation COPD

Why are they important• Common; incidence of 1.2 – 10.9%• Increased mortality – 10.7%• Increased ICU stay• Increased Hospital day 8-14 days• Increased hospital costs -75%

Risk factors• Patient• Surgical• Anaesthetic

Pathophysiology

Project• Prospective cohort• January to June• 100 major cases followed up for 10 post operative days

Aims• Identify rate of PPC• Identify high risk groups

Data collected• AGE• Pre-op functional status• ASA score• BMI• OSA• Congestive heart failure hx [use NYHA if known or mild,

moderate, severe]• Cigarette use• Asthma/COPD• Diabetes [IDDM/NIDDM]

Post operative pneumonia• Temp >38.5• Wheeze• New onset purulent sputum• WCC and CRP• CXR• Anti-biotics• New nebs

Cohort• 102 patients• Male 62 Female 40• Average age 62.1ASA:

I – 11II – 41III – 47IV - 3

Patient Characteristics• 32% overweight• 20.5% obese• 21.6% smokers• 32.3% ex smokers• 21 patients with prior respiratory disease• 17 diabetics

Surgical factors• Elective – 83• Emergency – 19• Average duration of surgery 208 minutes

Speciality• General – 35• HPB – 25• Upper GI – 13• Vascular – 11• Urology – 8• Gynae – 7• Transplant – 3

Results• Rate of PPC 20.5%• Rate of post op pneumonia 14.7%

Analysis• Rate pneumonia 14.7%• Per specialty:

• 14.3 % general• 27.3% vascular• 30.8% upper GI• 14.3% gynaecology• 0% transplant

Asa• 1 – 0%• 2 – 9.8%• 3 – 21.3%• 4 – 33.3%

• Emergency - 10.2%• Elective – 15.7%• EX-smoker – 21.9%• Smoker 27%• Non-smoker – 3.8%• Overweight – 12.5%• Obese – 14.6%• Diabetes – 23.5%

analysis• Pulmonary disease – 33.3 %• Upper abdominal incision – 19.4%• Elective surgical time – 232 minutes• Epidural 45%

• 26% in epidural group• 5.4% in non epidural group• 80% post op pneumonia had epidural

At risk groups• ASA 3• Prolonged surgery (>180 minutes)• Pre existing pulmonary disease• Upper abdominal incision• Diabetics• Smoking history

What to do about it?

Bundles• Simple• Inexpensive• Implementable• Easily audited

Examples• VAP• Central line – matching Michigan• Sepsis 6 - Rivers

Interventions• “Manchester Respiratory Intervention”

• Pre operative• Peri operative• Post operative

Pre operative• Patient education• Teeth brushing• Chlorhexidine mouthwash• Pulmonary optomisation

Peri operative• Polyurethane tapered tube• Sub glottic suctioning

Post operative• iCOUGH

ICOUGH

Bundle of preventative measures for PPC's

• Boston Medical Centre USA, Aug 2010

• All general and vascular surgical patients

• Post op pneumonia 2.55% down to 1.62%

• Unplanned intubations 1.98% down to 1.16%

6 Elements

I - Incentive spirometry

C - Cough/deep breathing exercises

O - Oral Care 

U - Understanding/education

G - Getting out of bed

H - Head of bed elevation

Important ICOUGH Features

• Bundle of simple nursing/physio interventions

• Basic and inexpensive• Estimated cost of PPC per patient between £4000 - £16 000• Length of hospital stay increased by 8-14days

• Effective in reducing PPCs 

• Implemented through check-lists

• Easy to measure effectiveness and re-audit

ICOUGH Development

Audit of the pre-intervention practices of nurses and physios

Set up a multi-disciplinary pulmonary care working group

Development of ICOUGH bundle

Programmes of education for doctors, nurses, physios and patients

Preparation of check-list bundle

Audit of post intervention practices

Patient Audit• 50 patients over 6 week period + followed them daily• Post-op HDU following major surgery• Average duration of surgery 3h 30min

No PPC

PPC

24%

76%

PPC Incidence

Pneumonia

Atelectasis

Pnemothorax

Pleural Ef-fusion

Types of PPC

8 patients2

11

Education and MobilisationEducationWere risks of PPCs and preventative measures explained? 

Yes - 36%

No or couldn’t remember - 64%

ACTION : Educate all patients on risks or and measures to prevent PPCs

Mobilisation

Good early mobilisation – 22%

Partial mobilisation – 40%

Little or no early mobilisation – 38%

ACTION: Promote early and regular mobilisation (chair and/or walking)

Oral Hygiene and Deep Breathing

Oral Hygiene

Tooth brushing ≥ 2/day - 70%

Tooth brushing < 2/day - 24%

Data not available - 6%

ACTION: Implement consistent oral hygiene regime for all patients

Deep breathing

≥ once every 2h - 56%

< once every 2h - 40%

Data not available - 4%

ACTION: To standardise the deep breathing regimes for patients and

to regularly prompt patients

Incentive Spirometer and Position

Incentive Spirometer

Only 20% of patients received an incentive spirometer

and instructions on how to use it

ACTION: To issue incentive spirometers before surgery and

educate patients in their use and benefits

Position

The head of the bed was elevated by 30 degrees or more

for all patients for which is was appropriate

ACTION: None

Other ICOUGH Research

Vancouver General Hospital, Nov 2012

The results for their "ICOUGH" compliance were:   Measure                             % patients Vancouver % patients MRI  Incentive spirometry                       17%  20%   Deep Breathing (≥1/2h)                  52%  56%  Oral Care                                        60%  70%  Understanding/education                21%  36%  Get out of bed                                17% into a chair  62%                                                    76% walking   Head of bed elevation                     48%  100%

What Should Happen Next? 1. Decide on whether to implement ICOUGH

2. If yes - Create an implementation plan

3. Identify any obstacles and involve all staff in addressing these

4. Regularly monitor the PPC incidence

5. Review the handover from HDU to wards

Potential Barriers to Implementation

Examples of Potential Barriers

• Work load on the nursing staff • Lack of chairs/space for chairs• Mobilisation of patients with attachments • Need for help in manual handling of patients

Manchester Respiratory Intervention

Preoperative

• Lung optimisation

• Patient Education

• Oral Decontamination

Intraoperative

• Prevent aspiration

• Endotracheal tube design

• Cuff pressure monitoring

Postoperative

• HDU ICOUGH + fluid limitation

• Critical care surgical pathway

• Surgical ward ICOUGH

Thank You

Other PPC Prevention Bundles

• NICE (UK)                                          2008 

• British Society of Antimicrobial Chemotherapy                  2008 

• Scottish Intensive Care Society                                         2008 

• European HAP Working Group                                          2008 

• Canadian Clinical Trials Group                                          2008 

• American Society for Critical Care                                     2008 

• Institute for Healthcare Improvement (US)                        2006 

• American Thoracic Society                                                2005 

• Center for Disease Control (US)                                        2003

References• Peri-operative Respiratory Complications and the

Post-operative Consequences – Atelectasis and Risk Factors Paolo Pelosi and Cesare Gregoretti

• Polyurethane cuffed endotracheal tubes to prevent early postoperative pneumonia after cardiac surgery: A pilot study Stijn Blot Jan Poelaert, Pieter Depuydt, Annick De Wolf, Stijn Van de Velde, Ingrid Herck J Thorac Cardiovasc Surg 2008;135:771-776

What’s new in the prevention of ventilator-associated pneumonia?

Stijn Blot1, Jordi Rello2, and Dirk Vogelaers1