recommendations for the evaluation of the risk of pulmonary complications in anesthesia and surgery

1. Raccomandazioni per la valutazione
preoperatoria dei pazienti adulti per
chirurgia non cardiaca:
blocco II con enfasi sulle malattie
respiratorie
Claudio Melloni
libero professionista
2011-2012

2. • Qaseem A, Snow V, Fitterman N, et al. Risk
assessment for and strategies to reduce
perioperative pulmonary complications for
patients undergoing noncardiothoracic surgery: a
guideline from the American College of
Physicians. Ann Intern Med 2006; 144:575–580.
• Smetana GW, Lawrence VA, Cornell JE.
Preoperative pulmonary risk stratification for
noncardiothoracic surgery: systematic review for
the American College of Physicians. Ann Intern
Med 2006; 144:581–595.

3. Pulmonary complications risk:
Pneumonia,respiratory
insufficiency….

4. • Risk Assessment for and Strategies To Reduce
Perioperative Pulmonary Complications for Patients
Undergoing Noncardiothoracic Surgery: A Guideline
from the American College of Physicians
• Amir Qaseem, MD, PhD, MHA; Vincenza Snow, MD;
Nick Fitterman, MD; E. Rodney Hornbake, MD; Valerie
A. Lawrence, MD; Gerald W. Smetana, MD; Kevin
Weiss, MD, MPH; Douglas K. Owens, MD, MS, for the
Clinical Efficacy Assessment Subcommittee of the
American College of Physicians*
Annals of Internal medicine 18 April 2006 | Volume
144 Issue 8 | Pages 575-580

5. Relazione fra ASA PS e complicanze
polmonari

6. Strategie tese alla riduzione delle complicanze postop
• Lawrence VA, Cornell JE, Smetana GW. Strategies to reduce postoperative pulmonary
complications after noncardiothoracic surgery: systematic review for the American
College of Physicians. Ann Intern Med. 2005;144:596-608.
• Tutte le tecniche di espansione polmonare :
– spirometria incentiva
– terapia fisica
– provocazione della tosse
– drenaggio posturale
– percussione e vibrazione
– Aspirazione
– Deambulazione
– IPPB
– CPAP
• hanno dimostrato superiorità rispetto ai controlli dopo chirurgia
addominale.
• Non differenze fra le diverse modalità di espansione ,né dalla loro
combinazione.

7. decompressione nasogastrica selettiva
• effettuata nei pazienti con PONV ,incapaci di assumere nutrizione orale o con
distensione addominale
– diminuisce la frequenza di polmonite ed atelettasia
nei confronti della decompressione con sondino
routinaria ,finche cioè non ritorni la motilità
gastrointestinale.
– Cheatham ML, Chapman WC, Key SP, Sawyers JL. A meta-analysis of selective
versus routine nasogastric decompression after elective laparotomy. Ann Surg.
1995;221:469-76.
– Nelson R, Tse B, Edwards S. Systematic review of prophylactic nasogastric decompression
after abdominal operations. Br J Surg. 2005;92:673-80.
– Nelson R, Edwards S, Tse B. Prophylactic nasogastric decompression after
abdominal surgery. Cochrane Database Syst Rev. 2005.

8. Pneumonia risk

9. Development and Validation of a Multifactorial Risk Index for
Predicting Postoperative Pneumonia after Major Noncardiac
Surgery . Arozullah AM, Khuri SF, HendersonWG, Daley J. Ann
Intern Med. 2001;135:847-857
• Background: Pneumonia is a common postoperative complication associated with substantial morbidity and mortality.
• Objective: To develop and validate a preoperative risk index for predicting postoperative pneumonia.
• Design: Prospective cohort study with outcome assessment based on chart review.
• Setting: 100 Veterans Affairs Medical Centers performing major surgery.
• Patients: The risk index was developed by using data on 160 805 patients undergoing major noncardiac surgery bet ween 1
September 1997 and 31 August 1999 and was validated by using data on 155 266 patients undergoing surgery between 1
September 1995 and 31 August 1997. Patients with preoperative pneumonia, ventilator dependence, and pneumonia that
developed after postoperative respiratory failure were excluded.
• Measurements: Postoperative pneumonia was defined by using the Centers for Disease Control and Prevention definition
of nosocomial pneumonia.
• Results: A total of 2466 patients (1.5%) developed pneumonia, and the 30-day postoperative mortality rate was 21%. A
postoperative pneumonia risk index was developed that included type of surgery (abdominal aortic aneurysm repair,
thoracic, upper abdominal, neck, vascular, and neurosurgery), age, functional status, weight loss, chronic obstructive
pulmonary disease, general anesthesia,
• impaired sensorium, cerebral vascular accident, blood urea nitrogen level, transfusion, emergency surgery, long-term
steroid use, smoking, and alcohol use. Patients were divided into five risk classes by using risk index scores. Pneumonia
rates were 0.2% among those with 0 to 15 risk points, 1.2% for those with 16 to 25 risk points, 4.0% for those with 26 to
40 risk points, 9.4% for those with 41 to 55 risk oints, and 15.3% for those with more than 55 risk points. The C-statistic
was 0.805 for the development cohort and 0.817 for the validation cohort.
• Conclusions: The postoperative pneumonia risk index identifies patients at risk for postoperative neumonia and may be
useful in guiding perioperative respiratory care.

10. Development and Validation of a Multifactorial Risk Index for
Predicting Postoperative Pneumonia after Major Noncardiac Surgery . Arozullah AM, Khuri SF, Henderson
WG, Daley J. Ann Intern Med. 2001;135:847-857
Risk of postop
pneumonia

11. Risk factors for postop pneumonia
Development and Validation of a Multifactorial Risk Index for
Predicting Postoperative Pneumonia after Major Noncardiac Surgery . Arozullah AM, Khuri SF, HendersonWG,
Daley J. Ann Intern Med. 2001;135:847-857
• Long-term steroid use
• Age >60 years
• dependent functional status,
• weight loss greater than 10% of body mass in the previous 6
months
• recent alcohol use.
• Recent smoking
• history of chronic obstructive pulmonary disease
• history of cerebral vascular accident with a residual deficit
• impaired sensorium.

12. Fattori di rischio per la polmonite postop:paziente
Development and Validation of a Multifactorial Risk Index for
Predicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M. Arozullah, MD, MPH;
Shukri F. Khuri, MD; William G. Henderson, PhD; and Jennifer Daley, MDAnn Intern Med. 2001;135:847-857
• Somministrazione di steroidi a lungo termine
• Età>60 anni
• Stato funzionale dipendente
• Perdita di peso > 10% della massa coroorea nei 6 mesi
precedenti
• uso recente di alcohol
• Fumo recente
• Storia di COPD
• Storia di accidente cerebrovascolare con deficit residuo.
• Disturbo di coscienza

13. Fattori di rischio per la polmonite postop:interventi
Development and Validation of a Multifactorial Risk Index for
Predicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M. Arozullah, MD, MPH;
Shukri F. Khuri, MD; William G. Henderson, PhD; and Jennifer Daley, MDAnn Intern Med. 2001;135:847-
857
• abdominal aortic aneurysm repair
• thoracic,
• neck,
• upper abdominal
• peripheral vascular surgery
• neurosurgery

14. Am J Respir Crit Care Med. 2005 Mar 1;171(5):514-7. Incidence of
and risk factors for pulmonary complications after nonthoracic
surgery.McAlister FA, Bertsch K, Man J, Bradley J, Jacka M
• Identifica come fattori di rischio:
– l’età>65 anni
– il fumo(> 40 pacchetti/anno)
– la diminuzione del FEV1
– Diminuzione del FVC e del FEV1/FVC
– la durata dell’anestesia >2.5 hr
– storia di COPD
– tosse produttiva giornaliera
– incisione nell’addome sup
– presenza di un SNG.
• Solo 4 sono indipendenti dopo una analisi
multivariata: età,test alla tosse
positivo,presenza periop del SNG e la
durata dell’anestesia.

15. a preoperative risk index for
predicting postoperative respiratory
failure (PRF).

16. Ahsan M. Arozullah, Jennifer Daley, William G. Henderson, Shukri F. Khuri, for the National Veterans
Administration Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative
Respiratory Failure in Men After Major Noncardiac Surgery. ANNALS OF SURGERY Vol.
232, No. 2, 242–253
• Objective
• To develop and validate a preoperative risk index for predicting
postoperative respiratory failure (PRF).
• prospective cohort study
• 44 Veterans Affairs Medical Centers (n 5 81,719) were used to
develop the models. Cases from 132 Veterans Affairs Medical
Centers (n 5 99,390) were used as a validation sample.
• PRF was defined as mechanical ventilation for more than 48 hours
after surgery or reintubation and mechanical ventilation after
postoperative extubation.
• Ventilator-dependent, comatose, do not,resuscitate, and female
patients were excluded.
• respiratory care.

17. Multifactorial Risk Index for Predicting Postoperative Respiratory
Failure in Men After Major Noncardiac Surgery Ahsan M. Arozullah, Jennifer Daley,
William G. Henderson, Shukri F. Khuri, for the National Veterans Administration Surgical Quality Improvement Program Multifactorial Risk Index for Predicting
Postoperative Respiratory Failure in Men After Major Noncardiac Surgery. ANNALS OF SURGERY Vol. 232, No. 2, 242–253
• Results
• PRF developed in 2,746 patients (3.4%).
• The respiratory failure risk index was developed from a simplified logistic
regression model and included:
– abdominal aortic aneurysm repair,
– thoracic surgery,
– neurosurgery,
– upper abdominal surgery,
– Peripheral vascular surgery,
– neck surgery
– emergency surgery,
– albumin level l< than 30 g/L,
– BUN> 30 mg/dL,
– dependent functional status,
– chronic obstructive pulmonary disease,
– age>60

18. Indici prognostici di insuff resp postop: Ahsan M. Arozullah, MD, MPH,*
Jennifer Daley, MD,† William G. Henderson, PhD,‡ and Shukri F. Khuri, MD,§ for the National Veterans Administration
Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in
Men After Major Noncardiac Surgery. ANNALS OF SURGERY Vol. 232, No. 2, 242–253
– Aneurismectomia aorta addominale,
– Chir toracica
– neurochir,
– Chir addominale maggiore
– Chir vascolare periferica
– Chir del collo
– Chir in emergenza ,
– Livelli di albumina < 30 g/L,
– BUN > 30 mg/dL,
– Dipendenza funzionale,
– COPD (chronic obstructive pulmonary disease)
– Età >60

19. Probability of PRF, postoperative resp failure
AhsanM. Arozullah, MD, MPH,* Jennifer Daley, MD,† William G. Henderson, PhD,‡ and Shukri F. Khuri, MD,§ for the National Veterans Administration
Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major Noncardiac Surgery.
ANNALS OF SURGERY Vol. 232, No. 2, 242–253
• Classe punti probab PRF
• 1 <=10 0.5%
• 2 11–19 2.2%-1.8%
• 3 20–27 5.3%- 4.2%
• 4 28–40 10%-11.9%
• 5 . >40 30.9% -26.6%

20. A comparison of risk factors for postoperative pneumonia and respiratory failure
Ahsan M. Arozullah, MD, MPH,* Jennifer Daley, MD,† William G. Henderson, PhD,‡ and Shukri F. Khuri, MD,§ for the National Veterans Administration Surgical
Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major Noncardiac Surgery. ANNALS OF
SURGERY Vol. 232, No. 2, 242–253
&
Ahsan M. Arozullah, MD, MPH; Shukri F. Khuri, MD; William G. Henderson, PhD; and Jennifer Daley, MD.Development and Validation of a Multifactorial Risk
Index for Predicting Postoperative Pneumonia after Major Noncardiac Surgery Ann Intern Med. 2001;135:847-857

21. How should respiratory disease and obstructive sleep
apnoea syndrome be assessed?
• Spirometry
• Many studies on spirometry and pulmonary function
• tests relate to lung resection surgery or cardiac surgery
• and have been published mainly more than 10 years
• ago; therefore, they have been excluded from this
• review.
• Spirometry has value in diagnosing obstructive lung
• disease, but it has not been shown to translate into
• effective risk prediction for individual patients. In
• addition, there are no data indicating a prohibitive
• threshold for spirometric values below which the risk
• for surgery would be unacceptable. Changes in clinical
• management due to findings from preoperative spirometry
• were also not reported. One study (published in 2000) looked at 460 patients who
• underwent abdominal surgery. The authors reported that
• a predicted FEV1 of less than 61%, and a PaO2 less than
• 9.3 kPa (70mmHg), the presence of ischaemic heart
• disease and advanced age, each were independent risk
• factors for postoperative pulmonary complications (level
• of evidence: 2).47

22. • Chest radiography
• Chest radiographs are ordered frequently as part of a
• routine preoperative evaluation. The evidence is poor
• and the related articles again mostly date before 2000
• and, therefore, were not addressed in this review. However,
• chest radiographs are not predictive of postoperative
• pulmonary complications in a high percentage of
• patients. A change in management or cancellation
• of elective surgery was reported in only a fraction of
• patients.48,49
• A meta-analysis in 2006 on the value of routine preoperative
• testing identified eight studies published
• between 1980 and 2000 in which the corresponding
• authors looked at the impact of chest radiographs on a
• change on perioperative management. In only 3% of the
• cases in these studies, the chest radiograph influenced the
• management, even though 23.1% of preoperative chest
• radiographs in that sample were abnormal (level of evidence:
• 1þ).44
• In a systematic review from 2005, the diagnostic yield of
• chest radiographs increased with age. However, most of
• the abnormalities consisted of chronic disorders such as
• cardiomegaly and chronic obstructive pulmonary disease
• (up to 65%). The rate of subsequent investigations was
• highly variable (4–47%). When further investigations
• were performed, the proportion of patients who had a
• change in management was low (10% of investigated
• patients). Postoperative pulmonary complications were
• also similar between patients who had preoperative chest
• radiographs (12.8%) and patients who did not (16%)
• (level of evidence: 1þ).50

23. Assessment of patients with obstructive sleep apnoea
syndrome
• OSAS has been identified as an independent risk factor
• for airway management difficulties in the immediate
• postoperative period.44 In a cohort study from 2008, it
• was been demonstrated that patients classified as OSAS
• risk have more airway-obstructive events postoperatively
• and more periods of desaturations (SpO2 less than 90%) in
• the first 12 h postoperatively (level of evidence: 2þ).51
• Data are scarce regarding the overall pulmonary complication
• rate. One case–control study with matched
• patients undergoing hip or knee replacement surgery
• reported that serious complications after surgery, such
• as unplanned days in ICU, tracheal reintubations and
• cardiac events, occurred significantly more often in
• patients with OSAS (24% compared with 9% of matched
• control patients) (level of evidence: 2þ).52 A recentcohort study also reported that postoperative cardiorespiratory
• complications were associated with a score
• indicating the existence of OSAS (level of evidence:
• 2þ).53
• OSAS patients have been identified as having a higher
• risk of difficult airway management (level of evidence:
• 2þ).54 The American Society of Anesthesiologists
• addressed this issue in 2006 with practice guidelines
• including assessment of patients for possible OSAS
• before surgery and suggested careful postoperative
• monitoring for those suspected to be at high risk.55
• Therefore, the question of how to correctly identify
• patients with OSAS or at risk for OSAS is of importance.
• Of the 25 eligible studies on that topic published between
• 2000 and June 2010, 10 dealt with measures to correctly
• identify patients with risk factors for OSAS. The ‘gold
• standard’ for diagnosis of sleep apnoea is an overnight
• sleep study (polysomnography). However, such testing is
• time consuming, expensive and unsuitable for screening
• purposes. The literature indicates that the most widely
• used screening tool for detecting sleep apnoea is the Berlin
• questionnaire (level of evidence: 2).53,56,57 Overnight
• pulse oximetry may be an additional alternative to detect
• sleep apnoea (level of evidence: 2þþ).

24. • Clin Respir J. 2011 Oct;5(4):219-26. doi: 10.1111/j.1752-699X.2010.00223.x. Epub 2010 Sep 22.
• Clinical and functional prediction of moderate to severe obstructive sleep apnoea.
• Bucca C, Brussino L, Maule MM, Baldi I, Guida G, Culla B, Merletti F, Foresi A, Rolla G, Mutani R, Cicolin A.
• Source
• Dipartimento di Scienze Biomediche e Oncologia Umana, Università di Torino, Italia. caterina.bucca@unito.it
• Abstract
• INTRODUCTION:
• Upper airway inflammation and narrowing are characteristics of obstructive sleep apnoea (OSA). Inflammatory markers have been found to be
increased in exhaled breath and induced sputum of patients with OSA.
• OBJECTIVES:
• The aim of this study was to investigate if the measurement of exhaled nitric oxide (F(ENO) ), as marker of airway inflammation, together with the
forced mid-expiratory/mid-inspiratory airflow ratio (FEF(50) /FIF(50) ), as marker of upper airway narrowing, may help to predict OSA.
• METHODS:
• Two hundred one consecutive outpatients with suspected OSA were prospectively studied between January 2004 and December 2005. All patients
underwent clinical examination, spirometry with measurement of FEF(50) /FIF(50) , maximum inspiratory pressure, arterial blood gas analysis,
exhaled nitric oxide (F(ENO) ) and overnight polysomnography. Linear regression models were used to evaluate the effect of measured variables on
the apnoea-hypopnoea index (AHI). Models were cross-validated by bootstrapping.
• RESULTS:
• Most of the patients were obese and had severe OSA. FEF(50) /FIF(50) , F(ENO) and an interaction term between smoking and F(ENO) contributed
significantly to the predictive model for AHI, in addition to age, neck circumference, body mass index and carboxyhaemoglobin saturation. A
nomogram to predict AHI was obtained, which converted the effect of each covariate in the model to a 0-100 scale. The nomogram showed a good
predictive ability for AHI values between 25 and 64.
• CONCLUSIONS:
• The measurement of F(ENO) and of FEF(50) /FIF(50) improves the ability to predict OSA and may be used to identify patients who require a sleep
study

25. • Will optimisation and/or treatment alter outcome and if so,
• what intervention and at what time should it be done in the
• presence of respiratory disease, smoking and obstructive
• sleep apnoea?
• Incentive spirometry and chest physical therapy
• Most of the relevant studies deal with physical therapy
• after the operation. Although relevant from a clinical
• point of view, a systematic review from 2009 could not
• show a benefit from incentive spirometry on postoperative
• pulmonary complications after upper abdominal
• surgery, as the methodological quality of the included
• studies was only moderate and RCTs were lacking.59
• When it comes to preoperative optimisation, there are
• only limited data on possible effects of chest physical
• therapy or incentive spirometry for optimisation in noncardiothoracic
• surgery. In a randomised trial of 50 patients
• scheduled for laparoscopic cholecystectomy, patients in
• one group were instructed to carry out incentive spirometry
• repeatedly for 1 week before surgery, whereas in
• the control group, incentive spirometry was carried out
• only during the postoperative period. Lung function tests
• were recorded at the time of pre-anaesthetic evaluation,
• on the day before the surgery, postoperatively at 6, 24 and
• 48 h, and at discharge. Significant improvement in lung
• function tests were seen at all study time points after
• preoperative incentive spirometry compared with patients
• in the control group (level of evidence: 2þ).60

26. • Nutrition
• Patients with severe pulmonary disease and many
• other causes may present for surgery with a very poornutritional status. This may be detrimental for two
• reasons. First, muscle mass may be diminished. This
• may lead to an early loss of muscle strength following
• only a few days of immobilisation or assisted ventilation
• in ICUs. Second, serum albumin concentrations are often
• reduced. This can lead to severe problems with oncotic
• pressure and fluid shifts. A low serum albumin level
• (<30 g l1) has been found to be an independent risk
• factor for postoperative pulmonary complications (level
• of evidence: 2þ).61 In some cases (urgent or emergency
• operations), an improvement in the nutritional status is
• often impossible. In scheduled elective surgery on the
• contrary, improvements in nutritional status may be of
• benefit. However, there are only limited and conflicting
• data in this regard in the non-cardiothoracic surgery
• literature in the last 10 years under review (level of
• evidence: 2).62,63

27. Smoking cessation
• Smoking is a known risk factor for impaired woundhealing
• and postoperative surgical sites of infection. A
• RCT of smoking cessation in 120 patients found a significantly
• reduced incidence of wound-related complications
• in the intervention (smoking cessation) group
• (5 vs. 31%, P¼0.001) (level of evidence: 1).23
• In 27 eligible studies, 17 articles addressed the issue of
• preoperative smoking cessation. Aspects such as duration
• of cessation necessary, methods to motivate cessation and
• impact on complications were covered. In a RCT (smoking
• cessation 4 weeks prior surgery vs. control group with
• no smoking cessation), an intention-to-treat analysis
• showed that the overall complication rate in the control
• group was 41% and in the intervention group 21%
• (P¼0.03). Relative risk reduction for the primary outcome
• of any postoperative complication was 49% and
• number-needed-to-treat was five (95% CI 3–40) (level of
• evidence: 1).64

28. SMOKING

29. Cochrane Database Syst Rev. 2010 Jul 7;(7):CD002294.
Interventions for preoperative smoking cessation.
Thomsen T, Villebro N, Møller AM.
• Five trials examined the effect of smoking intervention on
postoperative complications.
• Pooled risk ratios were 0.70 (95% CI 0.56 to 0.88) for
developing any complication; and 0.70 (95% CI 0.51 to 0.95)
for wound complications.
• Exploratory subgroup analyses showed a significant effect
of intensive intervention on any complications; RR 0.42
(95% CI 0.27 to 0.65) and on wound complications RR 0.31
(95% CI 0.16 to 0.62).
• For brief interventions the effect was not statistically
significant but CIs do not rule out a clinically significant
effect (RR 0.96 (95% CI 0.74 to 1.25) for any complication,
RR 0.99 (95%CI 0.70 to 1.40) for wound complications).

30. Cochrane Database Syst Rev. 2010 Jul 7;(7):CD002294.
Interventions for preoperative smoking cessation.
Thomsen T, Villebro N, Møller AM.

31. Cochrane Database Syst Rev. 2010 Jul 7;(7):CD002294.
Interventions for preoperative smoking cessation.
Thomsen T, Villebro N, Møller AM.

32. A U T H O R S ’ C O N C L U S I O N S Cochrane
Database Syst Rev. 2010 Jul 7
Implications for practice
• The results of this updated reviewindicate that preoperative smoking
intervention is beneficial for changing smoking behaviour
perioperatively and in the long term, and for reducing the
incidence of complications.
• Exploratory subgroup analyses of two smaller trials suggest that intensive
intervention over a period of four to eight weeks before surgery and including
NRT,may support smoking cessation and reduce postoperative morbidity.
• Six trials testing brief interventions, on the other hand, increased smoking cessation
• at the time of surgery but failed to detect a statistically significant effect on
postoperative morbidity.
• Based on this evidence, intensive interventions for 4-8 weeks before surgery, and
including NRT, appear relevant for patients scheduled to undergo surgery 4 weeks or
more after diagnosis.
• We suggest that smokers scheduled for surgery less than 4 weeks after diagnosis, like
all smokers, be advised to quit and offered effective interventions, including
behavioural support and pharmacotherapy.

33. Biblio :23,27,29,64,65
• Theadom A, Cropley M. Effects of preoperative smoking cessation on the
• incidence and risk of intraoperative and postoperative complications in
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• cessation interventions on postoperative complication and smoking
• cessation. Br J Surg 2009; 96:451–461.
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34. Carboxyhemoglobin in smokers and a
preoperative smoking cessation.
• Benefivi dell’astiennza dal fumo(oltre quelli
visti sulle Ko periop)
• .miglioramento della funzione mcucocilaire
nasale
• Diminuzione della Carbossi Hb e CO

35. • Eur J Anaesthesiol. 2010 Sep;27(9):812-8.
• Assessment of carbon monoxide values in smokers: a comparison of carbon monoxide in expired air and carboxyhaemoglobin in arterial blood.
• Andersson MF, Møller AM.
• Source
• Department of Anaesthesiology, Herlev University Hospital, Copenhagen, Denmark. mf_andersson@hotmail.com
• Abstract
• BACKGROUND AND OBJECTIVE:
• Smoking increases perioperative complications. Carbon monoxide concentrations can estimate patients' smoking status and might be relevant in
preoperative risk assessment. In smokers, we compared measurements of carbon monoxide in expired air (COexp) with measurements of
carboxyhaemoglobin (COHb) in arterial blood. The objectives were to determine the level of correlation and to determine whether the methods
showed agreement and evaluate them as diagnostic tests in discriminating between heavy and light smokers.
• METHODS:
• The study population consisted of 37 patients. The Micro Smokerlyzer was used to measure COexp; it measures COexp in parts per million (ppm) and
converts it to the percentage of haemoglobin combined with carbon monoxide (%Hb). COHb in arterial blood was measured by the ABL 725.
Correlation analysis and Bland-Altman analysis were performed, and 2 x 2 contingency tables and receiver operating characteristic curve analysis
were conducted.
• RESULTS:
• The correlation between the methods was high (rho = 0.964). Bland-Altman analysis demonstrated that the Micro Smokerlyzer underestimated
COHb values. The areas under the receiver operating characteristic curves were 0.746 (ABL 725) and 0.754 (Micro Smokerlyzer) and, by comparison,
no statistically significant difference was found (P = 0.815).
• CONCLUSION:
• The two methods showed a high level of correlation, but poor agreement. The Micro Smokerlyzer systematically underestimated COHb values and, in
order to avoid this, we suggested an alternative algorithm for converting COexp from ppm to %Hb. The ABL 725 and Micro Smokerlyzer were fair
diagnostic tests in distinguishing between heavy and light smokers, but the longer the patients' smoking cessation time, the poorer the ability as
diagnostic tests.

36. • Regul Toxicol Pharmacol. 2010 Jul-Aug;57(2-3):241-6. Epub 2010 Mar 15.
• Acute effects of cigarette smoking on pulmonary function.
• Unverdorben M, Mostert A, Munjal S, van der Bijl A, Potgieter L, Venter C, Liang Q, Meyer B, Roethig HJ.
• Source
• Altria Client Services, Research Development & Engineering, Richmond, VA 23234, USA. sbu135@live.com
• Abstract
• INTRODUCTION:
• Chronic smoking related changes in pulmonary function are reflected as accelerated decrease in FEV1 although histologic changes occur in the
peripheral bronchi earlier. More sensitive pulmonary function parameters might mirror those early changes and might show a dose response.
• METHODS:
• In a randomized three-period cross-over design 57 male adult conventional cigarette (CC)-smokers (age: 45.1+/-7.1 years) smoked either CC (tar:11
mg, nicotine:0.8 mg, carbon monoxide:11 mg [Federal Trade Commission (FTC)]), or used as a potential reduced-exposure product the electrically
heated smoking system (EHCSS) (tar:5 mg, nicotine:0.3 mg, carbon monoxide:0.45 mg (FTC)) or did not smoke (NS). After each 3-day exposure
period, hematology and exposure parameters were determined preceding body plethysmography.
• RESULTS:
• Cigarette smoke exposure was significantly (p<0.0001) higher in CC than in EHCSS and in NS: (carboxyhemoglobin: CC: 6.4+/-1.9%; EHCSS: 1.3+/-
0.6%; NS: 0.5+/-0.3%; serum nicotine: CC: 18.9+/-7.4 ng/ml; EHCSS: 8.4+/-4.3 ng/ml; NS: 1.2+/-1.6 ng/ml). Significantly lower in CC than in EHCSS and
NS were specific airway conductance (0.22+/-0.09; 0.25+/-0.12; 0.25+/-0.1 1/cmH(2)O x s; CC vs EHCSS: p<0.05; CC vs NS: p<0.01), forced expiratory
flow 25% (7.6+/-1.7; 7.8+/-1.7; 7.9+/-1.7 L/s; CC vs EHCSS or NS: p<0.01). Thoracic gas volume (5.1+/-1; 5+/-1.1; 5+/-1.1L/min) changed
insignificantly.
• CONCLUSION:
• The data indicate acute and reversible effects of cigarette smoke exposures and no-smoking on mid to small size pulmonary airways in a dose
dependent manner

37. • J Clin Gastroenterol. 2007 Feb;41(2):211-5.
• Carboxyhemoglobin and its correlation to disease severity in cirrhotics.
• Tran TT, Martin P, Ly H, Balfe D, Mosenifar Z.
• Source
• Department of Medicine, Cedars Sinai Medical Center, Los Angeles, CA, USA. TranT@cshs.org
• Abstract
• GOAL:
• To assess the correlation of serum carboxyhemoglobin (CO-Hb) to severity of liver disease as compared with Model for End Stage Liver Disease
(MELD) score, Child Pugh score, and clinical parameters.
• BACKGROUND:
• There are 2 sources of carbon monoxide (CO) in humans, exogenous sources include those such as tobacco smoke and inhaled motor vehicle
exhaust. The endogenous source is via the heme-oxygenase pathway, in which a heme molecule is broken down into biliverdin with release of an
iron (Fe) and CO molecule. Normal serum CO-Hb levels in nonsmokers is 0% to 1.5% and 4% to 9% in smokers. Activity of the heme-oxygenase
pathway may be increased in the cirrhotic patient, as measured indirectly by exhaled CO and serum CO-Hb. This may be due to alterations in vascular
tone in the splanchnic circulation in cirrhotics that may lead to elevated CO production. One published study also showed that those with
spontaneous bacterial peritonitis had higher levels of both CO and CO-Hb. The MELD score uses prothrombin time (INR), creatinine, and bilirubin in
the prediction of short-term mortality in decompensated cirrhotics while awaiting liver transplant. Measurement of endogenous CO-Hb may
correlate to severity of liver disease.
• STUDY:
• Retrospective analysis was done of 113 adult patients who were evaluated for liver transplantation between September 1996 and July 2003 and had
pulmonary function testing with CO-Hb as part of their evaluation. We excluded any patients with a history of smoking. Clinical parameters used for
comparison included grade of esophageal varices (n=75), spleen size (n=51) measured on abdominal ultrasound or computed tomography scan,
aminotransferases, and disease duration. Serum CO-Hb levels were measured from whole blood, sent refrigerated to ARUP laboratories (Salt Lake
City, UT) and analyzed via spectrophotometry. Bivariate analysis was performed by means of the Pearson product moment correlation.
• RESULTS:
• The mean CO-Hb level was 2.1%, which is higher than the expected normal population controls. No correlation was found, however, with MELD
score, Child Turcotte Pugh score, or other biochemical or clinical measurements of disease severity.
• CONCLUSIONS:
• Although CO and CO-Hb production may be increased in the cirrhotic patient, in this study no correlation was found to disease severity as measured
by the MELD score. Further studies are needed to assess the role of CO in other complications of cirrhosis including infection and circulatory
dysfunction.
• PMID: 17245222 [PubMed - indexed for MEDLINE]

38. • Scand J Public Health. 2006;34(6):609-15.
• COHb% as a marker of cardiovascular risk in never smokers: results from a population-based cohort study.
• Hedblad B, Engström G, Janzon E, Berglund G, Janzon L.
• Source
• Department of Clinical Sciences in Malmö, Epidemiological Research Group, Lund University, Malmö University Hospital, Malmö, Sweden.
Bo.Hedblad@med.lu.se
• Abstract
• AIM:
• Carbon monoxide (CO) in blood as assessed by the COHb% is a marker of the cardiovascular (CV) risk in smokers. Non-smokers exposed to tobacco
smoke similarly inhale and absorb CO. The objective in this population-based cohort study has been to describe inter-individual differences in COHb%
in never smokers and to estimate the associated cardiovascular risk.
• METHODS:
• Of the 8,333 men, aged 34-49 years, from the city of Malmö, Sweden, 4,111 were smokers, 1,229 ex-smokers, and 2,893 were never smokers.
Incidence of CV disease was monitored over 19 years of follow up.
• RESULTS:
• COHb% in never smokers ranged from 0.13% to 5.47%. Never smokers with COHb% in the top quartile (above 0.67%) had a significantly higher
incidence of cardiac events and deaths; relative risk 3.7 (95% CI 2.0-7.0) and 2.2 (1.4-3.5), respectively, compared with those with COHb% in the
lowest quartile (below 0.50%). This risk remained after adjustment for confounding factors.
• CONCLUSION:
• COHb% varied widely between never-smoking men in this urban population. Incidence of CV disease and death in non-smokers was related to
COHb%. It is suggested that measurement of COHb% could be part of the risk assessment in non-smoking patients considered at risk of cardiac
disease. In random samples from the general population COHb% could be used to assess the size of the population exposed to second-hand smoke.

39. • BMC Public Health. 2006 Jul 18;6:189.
• Carboxyhaemoglobin levels and their determinants in older British men.
• Whincup P, Papacosta O, Lennon L, Haines A.
• Source
• Division of Community Health Sciences, St George's, University of London, London SW17 0RE, UK. pwhincup@sgul.ac.uk
• Abstract
• BACKGROUND:
• Although there has been concern about the levels of carbon monoxide exposure, particularly among older people, little is known about COHb levels
and their determinants in the general population. We examined these issues in a study of older British men.
• METHODS:
• Cross-sectional study of 4252 men aged 60-79 years selected from one socially representative general practice in each of 24 British towns and who
attended for examination between 1998 and 2000. Blood samples were measured for COHb and information on social, household and individual
factors assessed by questionnaire. Analyses were based on 3603 men measured in or close to (< 10 miles) their place of residence.
• RESULTS:
• The COHb distribution was positively skewed. Geometric mean COHb level was 0.46% and the median 0.50%; 9.2% of men had a COHb level of 2.5%
or more and 0.1% of subjects had a level of 7.5% or more. Factors which were independently related to mean COHb level included season (highest in
autumn and winter), region (highest in Northern England), gas cooking (slight increase) and central heating (slight decrease) and active smoking, the
strongest determinant. Mean COHb levels were more than ten times greater in men smoking more than 20 cigarettes a day (3.29%) compared with
non-smokers (0.32%); almost all subjects with COHb levels of 2.5% and above were smokers (93%). Pipe and cigar smoking was associated with more
modest increases in COHb level. Passive cigarette smoking exposure had no independent association with COHb after adjustment for other factors.
Active smoking accounted for 41% of variance in COHb level and all factors together for 47%.
• CONCLUSION:
• An appreciable proportion of men have COHb levels of 2.5% or more at which symptomatic effects may occur, though very high levels are
uncommon. The results confirm that smoking (particularly cigarette smoking) is the dominant influence on COHb levels.

40. • Br J Clin Pharmacol. 2008 Jan;65(1):30-9. Epub 2007 Aug 31.
• Population pharmacokinetic analysis of carboxyhaemoglobin concentrations in adult cigarette smokers.
• Cronenberger C, Mould DR, Roethig HJ, Sarkar M.
• Source
• Projections Research Inc., Phoenixville, PA, USA.
• Abstract
• AIMS:
• To develop a population-based model to describe and predict the pharmacokinetics of carboxyhaemoglobin (COHb) in adult smokers.
• METHODS:
• Data from smokers of different conventional cigarettes (CC) in three open-label, randomized studies were analysed using NONMEM (version V, Level
1.1). COHb concentrations were determined at baseline for two cigarettes [Federal Trade Commission (FTC) tar 11 mg; CC1, or FTC tar 6 mg; CC2]. On
day 1, subjects were randomized to continue smoking their original cigarettes, switch to a different cigarette (FTC tar 1 mg; CC3), or stop smoking.
COHb concentrations were measured at baseline and on days 3 and 8 after randomization. Each cigarette was treated as a unit dose assuming a
linear relationship between the number of cigarettes smoked and measured COHb percent saturation. Model building used standard methods.
Model performance was evaluated using nonparametric bootstrapping and predictive checks.
• RESULTS:
• The data were described by a two-compartment model with zero-order input and first-order elimination with endogenous COHb. Model parameters
included elimination rate constant (k(10)), central volume of distribution (Vc/F), rate constants between central and peripheral compartments (k(12)
and k(21)), baseline COHb concentrations (c0), and relative fraction of carbon monoxide absorbed (F1). The median (range) COHb half-lives were 1.6
h (0.680-2.76) and 30.9 h (7.13-367) (alpha and beta phases, respectively). F1 increased with increasing cigarette tar content and age, whereas k(12)
increased with ideal body weight.
• CONCLUSION:
• A robust model was developed to predict COHb concentrations in adult smokers and to determine optimum COHb sampling times in future studies

41. • Respirology. 2011 Jul;16(5):849-55. doi: 10.1111/j.1440-1843.2011.01985.x.
• Reversibility of impaired nasal mucociliary clearance in smokers following a smoking cessation programme.
• Ramos EM, De Toledo AC, Xavier RF, Fosco LC, Vieira RP, Ramos D, Jardim JR.
• Source
• Department of Physiotherapy, São Paulo State University (UNESP), Presidente Prudente, São Paulo, Brazil. ercy@fct.unesp.br
• Abstract
• BACKGROUND AND OBJECTIVE:
• Smoking cessation (SC) is recognized as reducing tobacco-associated mortality and morbidity. The effect of SC on nasal mucociliary clearance (MC) in
smokers was evaluated during a 180-day period.
• METHODS:
• Thirty-three current smokers enrolled in a SC intervention programme were evaluated after they had stopped smoking. Smoking history,
Fagerström's test, lung function, exhaled carbon monoxide (eCO), carboxyhaemoglobin (COHb) and nasal MC as assessed by the saccharin transit
time (STT) test were evaluated. All parameters were also measured at baseline in 33 matched non-smokers.
• RESULTS:
• Smokers (mean age 49 ± 12 years, mean pack-year index 44 ± 25) were enrolled in a SC intervention and 27% (n = 9) abstained for 180 days, 30% (n =
11) for 120 days, 49.5% (n = 15) for 90 days or 60 days, 62.7% (n = 19) for 30 days and 75.9% (n = 23) for 15 days. A moderate degree of nicotine
dependence, higher education levels and less use of bupropion were associated with the capacity to stop smoking (P < 0.05). The STT was prolonged
in smokers compared with non-smokers (P = 0.002) and dysfunction of MC was present at baseline both in smokers who had abstained and those
who had not abstained for 180 days. eCO and COHb were also significantly increased in smokers compared with non-smokers. STT values decreased
to within the normal range on day 15 after SC (P < 0.01), and remained in the normal range until the end of the study period. Similarly, eCO values
were reduced from the seventh day after SC.
• CONCLUSIONS:
• A SC programme contributed to improvement in MC among smokers from the 15th day after cessation of smoking, and these beneficial effects
persisted for 180 days

42. Optimisation in obstructive sleep apnoea syndrome
• improve or optimise an OSAS patient’s perioperative
physical status:
– preoperative continuous positive airway pressure (CPAP)
or bi-level positive airway pressure;
– preoperative use of oral appliances for mandibular
advancement;
– or preoperative weight loss.
• There is insufficient literature(ESA 2011) to evaluate
the impact of any of these measures on perioperative
outcomes, although expert opinion recommends these
interventions (level of evidence:4).
• BP control???

43. Recommendations:ESA 2011
(1) Preoperative diagnostic spirometry in non-cardiothoracic patients cannot be
recommended to evaluate the risk of postoperative complications (grade of
ecommendation:D).
(2) Routine preoperative chest radiographs rarely alter perioperative management of these
cases. Therefore, it cannot be recommended on a routine basis (grade of recommendation:
B).
(3) Preoperative chest radiographs have a very limited value in patients older than 70 years
with established risk factors (grade of recommendation: A).
(4) Patients with OSAS should be evaluated carefully for a potential difficult airway and
special attention is advised in the immediate postoperative period (grade of
recommendation: C).
(5) Specific questionnaires to diagnose OSAS can be recommended when polysomnography is
not available (grade of recommendation: D).
(6) Use of CPAP perioperatively in patients with OSAS may reduce hypoxic events (grade of
recommendation:D).
(7) Incentive spirometry preoperatively can be of benefit in upper abdominal surgery to avoid
postoperative pulmonary complications (grade of recommendation:D).
(8) Correction of malnutrition may be beneficial (grade of recommendation: D).
(9) Smoking cessation before surgery is recommended. It must start early (at least 6–8 weeks
prior to surgery, 4 weeks at a minimum) (grade of recommendation: B).A short-term
cessation is only beneficial to reduce the amount of carboxyhaemoglobin in the blood in
heavy smokers (grade of recommendation: D).

44. FINE
Segue lavori in dettaglio….

45. Development and Validation of a Multifactorial Risk Index for
Predicting Postoperative Pneumonia after Major Noncardiac Surgery
Ahsan M. Arozullah, MD, MPH; Shukri F. Khuri, MD; William G.
Henderson, PhD; and Jennifer Daley, MDAnn Intern Med. 2001;135:847-857
• Postoperative pulmonary complications are associated
• with substantial morbidity and mortality. It has
• been estimated that nearly one fourth of deaths occurring
• within 6 days of surgery are related to postoperative
• pulmonary complications (1). Postoperative infections
• are also a major source of the morbidity and mortality
• associated with undergoing surgery. Pneumonia is the
• most serious postoperative complication that is included
• in both of these categories. Pneumonia ranks as the
• third most common postoperative infection, behind urinary
• tract and wound infection (2). According to the
• National Nosocomial Infection Surveillance system,
• pneumonia occurred in 18% of patients after surgery
• (3). Postoperative pneumonia occurs in 9% to 40% of
• patients, and the associated mortality rate is 30% to
• 46%, depending on the type of surgery (1, 4).
• Previous studies of risk factors used various definitions
• of postoperative pulmonary complications. Atelectasis
• (1, 4–7), postoperative pneumonia (1–2, 4–6,
• 8–11), the acute respiratory distress syndrome (9, 12),
• and postoperative respiratory failure (6, 9, 11, 13) have
• been classified as postoperative pulmonary complications.
• Although the clinical significance of each of these
• complications varies greatly, they were grouped together
• as a single outcome in previous studies (6). Some studies
• were limited to examination of risk factors in patients
• undergoing abdominal or thoracic procedures or in patients
• with specific medical conditions, such as chronic
• obstructive pulmonary disease (2, 4, 6, 10–12, 14).
• These studies were often based on a small sample from
• one institution, and studies of independent samples did
• not validate their findings (15, 16

46. Table 1. Definition of Postoperative
PneumoniaDevelopment and Validation of a Multifactorial Risk Index for
Predicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M. Arozullah, MD, MPH;
Shukri F. Khuri, MD; William G. Henderson, PhD; and Jennifer Daley, MDAnn Intern Med. 2001;135:847-857
• Patient met one of the following two criteria postoperatively:
• 1. Rales or dullness to percussion on physical examination of chest AND any
of the following:
• New onset of purulent sputum or change in character of sputum
• Isolation of organism from blood culture
• Isolation of pathogen from specimen obtained by transtracheal aspirate,
bronchial brushing, or biopsy
• 2. Chest radiography showing new or progressive infiltrate, consolidation,
cavitation, or pleural effusion AND any of the following:
• New onset of purulent sputum or change in character of sputum.
• Isolation of organism from blood culture.
• Isolation of pathogen from specimen obtained by transtracheal aspirate,
bronchial brushing, or biopsy
• Isolation of virus or detection of viral antigen in respiratory secretions
• Diagnostic single antibody titer (IgM) or fourfold increase in paired serum
samples (IgG) for pathogen
• Histopathologic evidence of pneumonia

48. Postoperative pneumonia risk indexDevelopment and
Validation of a Multifactorial Risk Index for
Predicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M. Arozullah, MD, MPH; Shukri F. Khuri, MD;
William G. Henderson, PhD; and Jennifer Daley, MDAnn Intern Med. 2001;135:847-857

49. Development and Validation of a Multifactorial Risk Index for
Predicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M.
Arozullah, MD, MPH; Shukri F. Khuri, MD; William G. Henderson, PhD; and Jennifer
Daley, MDAnn Intern Med. 2001;135:847-857
• DISCUSSION
• Our results confirm several previously described risk
• factors for postoperative pneumonia, including the type
• of surgery performed. The patient-specific risk factors
• were related to general health and immune status, respiratory
• status, neurologic status, and fluid status. These
• risk factors were used to develop a preoperative risk assessment
• model for predicting postoperative pneumonia,
• the postoperative pneumonia risk index.
• We found that patients undergoing abdominal aortic
• aneurysm repair; thoracic, neck, upper abdominal, or
• peripheral vascular surgery; or neurosurgery had an increased
• likelihood of developing postoperative pneumonia.
• Previous studies focused on the increased incidence
• of postoperative pulmonary complications in patients
• undergoing these types of surgery (2, 4, 5, 8, 9, 11, 12,
• 14, 29). Impairment of normal swallowing and respiratory
• clearance mechanisms may be responsible for some
• of the increased risk in these patients.

50. Patient specific risk factor for postop pneumonia
Development and Validation of a Multifactorial Risk Index for
Predicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M. Arozullah, MD, MPH; Shukri F.
Khuri, MD; William G. Henderson, PhD; and Jennifer Daley, MDAnn Intern Med. 2001;135:847-857
• Long-term steroid use (30)
• Age older than 60 years (2, 4, 5, 11, 12)
• dependent functional status,
• weight loss greater than 10% of body mass in the previous 6 months
• recent alcohol use.
• Further studies are needed to assess the effect of interventions, such as preoperative
optimization of nutritional status and perioperative physical therapy, in reducing the
incidence of postoperative pneumonia.
• Our definition of current smoking included patients who smoked up to 1 year before surgery.
Before 1995, the NSQIP definition for “current smoking” was smoking in the 2 weeks before
surgery. Using this definitio n,we found that smoking was not significantly associated with
postoperative mortality or overall morbidity (22, 23). On closer examination, it appeared that
sicker patients tended to quit smoking more than 2 weeks before surgery and were therefore
being classified as nonsmokers. To capture the effect of recent smoking, the NSQIP definition
was modified in September 1995 to include patients who smoked up to 1 year before
surgery.

51. Development and Validation of a Multifactorial Risk Index for
Predicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan
M. Arozullah, MD, MPH; Shukri F. Khuri, MD; William G. Henderson, PhD;
and Jennifer Daley, MDAnn Intern Med. 2001;135:847-857
• Recent smoking and history of chronic obstructive
• pulmonary disease were previously found to be pulmonary
• risk factors for postoperative pneumonia (2, 4,
• 9–12, 14). Chumillas and colleagues (31) found that
• preoperative and postoperative respiratory rehabilitation
• protected against postoperative pulmonary complications
• in moderate-risk and high-risk patients undergoing
• upper abdominal surgery. Use of an incentive spirometer
• or intermittent positive-pressure breathing and control
• of pain that interferes with coughing and deep
• breathing have been recommended for preventing postoperative
• pneumonia in high-risk patients (32).

52. Development and Validation of a Multifactorial Risk Index for
Predicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan
M. Arozullah, MD, MPH; Shukri F. Khuri, MD; William G. Henderson, PhD;
and Jennifer Daley, MDAnn Intern Med. 2001;135:847-857
• We found two risk factors related to neurologic status:
• history of cerebral vascular accident with a residual
• deficit and impaired sensorium. Previously identified
• neurologic risk factors for postoperative pneumonia
included
• impaired cognitive function (4). These risk factors
• are often associated with a decreased ability to protect
• one’s airway and may increase the risk for
• aspiration. Other risk factors related to aspiration in
previous
• studies included the use of nasogastric tubes and
• H2 receptor antagonists (6).

53. •APPENDIX: DEFINITIONS OF RISK FACTORS IN THE
POSTOPERATIVE PNEUMONIA RISK INDEX
Type of Surgery Development and Validation of a Multifactorial Risk Index for
Predicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M. Arozullah, MD, MPH; Shukri F. Khuri,
MD; William G. Henderson, PhD; and Jennifer Daley, MDAnn Intern Med. 2001;135:847-857
• Abdominal aortic aneurysm repair: Surgeries to repair ruptured or unruptured aortic
aneurysm involving only abdominal incisions.
• Neck surgery: Surgeries related to the thyroid, parathyroid,and larynx; tracheostomy; cervical
and axillary lymph node excision; and cervical and axillary lymphadenectomy.
• Neurosurgery: Application of a halo, central nervous system injection, central nervous system
drainage, creation of a bur hole,craniectomy, craniotomy, arteriovenous malformation or
aneurysm repair, stereotaxis, neurostimulator placement, skull repair, and cerebral spinal
fluid shunt.
• Thoracic surgery: Esophageal resection, esophageal repair, mediastinoscopy, pleural biopsy,
pneumocentesis, chest wall excision, incision and drainage of neck and thorax, excision of
neck and thorax, repair of fractured ribs, diaphragmatic hernia repair, bronchoscopy,
catheterization of trachea, trachea repair, thoracotomy, pericardium, pacemaker placement,
heart wound repair, valve repair, thoracic or abdominothoracic aortic aneurysm repair,
• and pulmonary artery procedures.
• Upper abdominal surgery: Gastrectomy; vagotomy; intestinal surgery; partial hepatectomy;
subfascial abdominal excision; splenectomy; excision of abdominal masses; laparoscopic
appendectomy and cholecystectomy; shunt insertion; ventral, umbilical and spigelian hernia
repair; and liver, gallbladder, and pancreas surgery.
• Vascular surgery: Any surgery related to the arteries or veins except central nervous
system aneurysm or abdominal aortic aneurysm repair

54. APPENDIX: DEFINITIONS OF RISK FACTORS IN THE
POSTOPERATIVE PNEUMONIA RISK INDEX:
Functional StatusDevelopment and Validation of a Multifactorial Risk Index for
Predicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M. Arozullah, MD, MPH; Shukri F. Khuri, MD;
William G. Henderson, PhD; and Jennifer Daley, MDAnn Intern Med. 2001;135:847-857
• Functional status: The level of self-care demonstrated by the patient on
admission to the hospital, reflecting his or her prehospitalization
functional status.
• Totally dependent: The patient cannot perform any activities of daily living
for himself or herself; includes patients who are totally dependent on
nursing care, such as a dependent nursing home patient.
• Partially dependent: The patient requires use of equipment or devices plus
assistance from another person for some activities of daily living. Patients
admitted from a nursing home setting who are not totally dependent
would fall into this category, as would any patient who requires kidney
dialysis or home ventilator support yet maintains some independent
function.
• Independent: The patient is independent in activities of daily living;
ncludes those who are able to function independently with a prosthesis,
equipment, or devices.

55. APPENDIX: DEFINITIONS OF RISK FACTORS IN THE
POSTOPERATIVE PNEUMONIA RISK INDEX:
Other…..
Development and Validation of a Multifactorial Risk Index for
Predicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M. Arozullah, MD, MPH; Shukri F. Khuri, MD;
William G. Henderson, PhD; and Jennifer Daley, MDAnn Intern Med. 2001;135:847-857
• History of chronic obstructive pulmonary disease: The patient has chronic obstructive
pulmonary disease resulting in functional disability, hospitalization in the past to treat
chronic obstructive pulmonary disease, need for bronchodilator therapy with oral or
inhaled agents, or FEV1 of less than 75% of predicted value.
• Patients excluded from this category were those in whom the only pulmonary disease was
acute asthma, an acute and chronic inflammatory disease of the airways resulting in
bronchospasm.
• History of cerebrovascular accident: The patient has a history of cerebrovascular accident
(embolic, thrombotic, or hemorrhagic) with persistent motor, sensory, or cognitive
dysfunction.
• Impaired sensorium: The patient is acutely confused or delirious and responds to verbal or
mild tactile stimulation; patient with mental status changes or delirium in the context of
the current illness. Patients with chronic mental status changes secondary to chronic
mental illness or chronic dementing llnesses were excluded from this category.
• Steroid use for chronic condition: The patient has required the regular administration of
parenteral or oral corticosteroid medication in the month before admission. Patients using
only topical, rectal, or inhalational corticosteroids were excluded from this category.

56. Ahsan M. Arozullah, MD, MPH,* Jennifer Daley, MD,† William G. Henderson, PhD,‡ and Shukri F. Khuri, MD,§ for the National Veterans
Administration Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major
Noncardiac Surgery. ANNALS OF SURGERY Vol. 232, No. 2, 242–253

57. Ahsan M. Arozullah, MD, MPH,* Jennifer Daley, MD,† William G. Henderson, PhD,‡ and Shukri F. Khuri, MD,§ for the National Veterans
Administration Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After
Major Noncardiac Surgery. ANNALS OF SURGERY Vol. 232, No. 2, 242–253

58. Ahsan M. Arozullah, MD, MPH,* Jennifer Daley, MD,† William G. Henderson, PhD,‡ and Shukri F.
Khuri, MD,§ for the National Veterans Administration Surgical Quality Improvement Program
Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major
Noncardiac Surgery. ANNALS OF SURGERY Vol. 232, No. 2, 242–253
• The most common postoperative complications in phase I were
postoperative pneumonia (3.6%), urinary tract infection (3.5%), and
respiratory failure (3.4%). Notably, two of the top three postoperative
complications were pulmonary complications.
• The 30-day death rate for patients with PRF was 27% versus 1% for
patients without PRF.
• In contrast, cardiac arrest requiring cardiopulmonary resuscitation
occurred in 1.5% of total patients; myocardial infarction occurred in only
0.7% of patients.
• Thirty-seven percent of patients with PRF had the inability to be
extubated, 29% had unplanned intubation, and 34% had both.
• For all three groups, the most commonly associated postoperative
complications were pneumonia, pulmonary edema, systemic sepsis, and
cardiac arrest.
• The 30-day death rate was 31% for reintubation patients and 23% for
patients with the inability to be extubated.

59. Ahsan M. Arozullah, MD, MPH,* Jennifer Daley, MD,† William G. Henderson, PhD,‡ and Shukri F.
Khuri, MD,§ for the National Veterans Administration Surgical Quality Improvement Program
Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major
Noncardiac Surgery. ANNALS OF SURGERY Vol. 232, No. 2, 242–253
• Despite these limitations, the respiratory failure risk index may be helpful to
clinicians and researchers in targeting perioperative testing and respiratory care to
high-risk patients.
• Prior studies have been limited to patients undergoing specific types of
operations2–7,9,10 or patients with particular risk factors.1,10
• The respiratory failure risk index is unique in that it includes several patient-specific
and operation- specific risk factors simultaneously, allowing for an accurate
assessment of the preoperative risk of PRF associated with each individual risk
factor.
• We found that the type of surgery performed has the highest associated risk for
developing PRF and that the major patient-specific risk factors are related to
general health status, renal and fluid status, and respiratory status.
• We hope that an increased awareness of the importance of postoperative
pulmonary complications will develop through the clinical use of the respiratory
failure risk index. We also hope that by using the models developed in this study,
researchers will be able to evaluate future interventions aimed at reducing the
rate of PRF.