Perioperative Respiratory Risk and Pulmonary Protection in Upper Abdominal Surgery: From Early Prediction to Stepwise Ventilatory Support
DOI:
https://doi.org/10.64784/339Palabras clave:
postoperative pulmonary complications, upper abdominal surgery, lung-protective ventilation, perioperative care, respiratory failure, noninvasive ventilation, preoperative physiotherapy, inspiratory muscle training, ARISCAT, postoperative respiratory supportResumen
Pleuropulmonary complications remain a frequent cause of morbidity after upper abdominal surgery and are associated with prolonged hospitalization, greater need for respiratory support, and delayed postoperative recovery. This study analyzed current evidence regarding the prediction, prevention, and stepwise management of postoperative pulmonary complications in adult patients undergoing major upper abdominal procedures. A structured integrative review was conducted using the Scientific Method, incorporating randomized clinical trials, observational studies, systematic reviews, meta-analyses, and relevant multicenter investigations. The evidence was organized into three main domains: perioperative risk prediction, preventive respiratory strategies, and escalation of postoperative respiratory support. The results showed that variables such as low preoperative oxygen saturation, advanced age, recent respiratory infection, anemia, prolonged surgery, emergency procedures, and upper abdominal incisions contribute to increased pulmonary risk. Preoperative physiotherapy and inspiratory muscle training were associated with reductions in postoperative respiratory complications in selected populations. Intraoperatively, lung-protective ventilation based on lower tidal volumes and individualized assessment of PEEP, respiratory compliance, and driving pressure was associated with improved pulmonary outcomes, whereas routine use of high PEEP did not consistently reduce complications. Postoperatively, prophylactic CPAP did not demonstrate universal benefit, while noninvasive ventilation reduced re-intubation and healthcare-associated infections in patients with established hypoxemic respiratory failure. Overall, the findings support a multimodal, risk-adapted, and stepwise perioperative strategy integrating early risk identification, pulmonary protection, postoperative surveillance, and timely escalation of respiratory support.
Referencias
• Abbott, T. E. F., Fowler, A. J., Pelosi, P., Gama de Abreu, M., Møller, A. M., Canet, J., Creagh-Brown, B., Mythen, M., Gin, T., Lalu, M. M., Futier, E., Grocott, M. P. W., Schultz, M. J., & Pearse, R. M. (2018). A systematic review and consensus definitions for standardised end-points in perioperative medicine: Pulmonary complications. British Journal of Anaesthesia, 120(5), 1066–1079. DOI: 10.1016/j.bja.2018.02.007.
• Assouline, B., Cools, E., Schorer, R., Kayser, B., Elia, N., & Licker, M. (2021). Preoperative exercise training to prevent postoperative pulmonary complications in adults undergoing major surgery: A systematic review and meta-analysis with trial sequential analysis. Annals of the American Thoracic Society, 18(4), 678–688. DOI: 10.1513/AnnalsATS.202002-183OC.
• Boden, I., Skinner, E. H., Browning, L., Reeve, J., Anderson, L., Hill, C., Robertson, I. K., Story, D., & Denehy, L. (2018). Preoperative physiotherapy for the prevention of respiratory complications after upper abdominal surgery: Pragmatic, double blinded, multicentre randomised controlled trial. BMJ, 360, j5916. DOI: 10.1136/bmj.j5916.
• Canet, J., Gallart, L., Gomar, C., Paluzie, G., Vallès, J., Castillo, J., Sabaté, S., Mazo, V., Briones, Z., & Sanchis, J. (2010). Prediction of postoperative pulmonary complications in a population-based surgical cohort. Anesthesiology, 113(6), 1338–1350. DOI: 10.1097/ALN.0b013e3181fc6e0a.
• Futier, E., Constantin, J.-M., Paugam-Burtz, C., Pascal, J., Eurin, M., Neuschwander, A., Marret, E., Beaussier, M., Gutton, C., Lefrant, J.-Y., Allaouchiche, B., Verzilli, D., Leone, M., De Jong, A., Bazin, J.-E., Pereira, B., & Jaber, S. (2013). A trial of intraoperative low-tidal-volume ventilation in abdominal surgery. The New England Journal of Medicine, 369(5), 428–437. DOI: 10.1056/NEJMoa1301082.
• Garg, S., Govindaraj, V., Dwivedi, D. P., Raja, K., & Theerthar, E. P. (2025). Postoperative pulmonary complications in patients undergoing upper abdominal surgery: Risk factors and predictive models. Monaldi Archives for Chest Disease, 95(1). DOI: 10.4081/monaldi.2024.2915.
• Ge, X., Wang, W., Hou, L., Yang, K., & Fa, X. (2018). Inspiratory muscle training is associated with decreased postoperative pulmonary complications: Evidence from randomized trials. The Journal of Thoracic and Cardiovascular Surgery, 156(3), 1290–1300.e5. DOI: 10.1016/j.jtcvs.2018.02.105.
• Güldner, A., Kiss, T., Serpa Neto, A., Hemmes, S. N. T., Canet, J., Spieth, P. M., Rocco, P. R. M., Schultz, M. J., Pelosi, P., & Gama de Abreu, M. (2015). Intraoperative protective mechanical ventilation for prevention of postoperative pulmonary complications: A comprehensive review of the role of tidal volume, positive end-expiratory pressure, and lung recruitment maneuvers. Anesthesiology, 123(3), 692–713. DOI: 10.1097/ALN.0000000000000754.
• Katsura, M., Kuriyama, A., Takeshima, T., Fukuhara, S., & Furukawa, T. A. (2015). Preoperative inspiratory muscle training for postoperative pulmonary complications in adults undergoing cardiac and major abdominal surgery. Cochrane Database of Systematic Reviews, 2015(10), CD010356. DOI: 10.1002/14651858.CD010356.pub2.
• Kendall, F., Oliveira, J., Peleteiro, B., Pinho, P., & Bastos, P. T. (2018). Inspiratory muscle training is effective to reduce postoperative pulmonary complications and length of hospital stay: A systematic review and meta-analysis. Disability and Rehabilitation, 40(8), 864–882. DOI: 10.1080/09638288.2016.1277396.
• Kokotovic, D., Berkfors, A., Gögenur, I., Ekeloef, S., & Burcharth, J. (2021). The effect of postoperative respiratory and mobilization interventions on postoperative complications following abdominal surgery: A systematic review and meta-analysis. European Journal of Trauma and Emergency Surgery, 47(4), 975–990. DOI: 10.1007/s00068-020-01522-x.
• LAS VEGAS Investigators. (2017). Epidemiology, practice of ventilation and outcome for patients at increased risk of postoperative pulmonary complications: LAS VEGAS—An observational study in 29 countries. European Journal of Anaesthesiology, 34(8), 492–507. DOI: 10.1097/EJA.0000000000000646.
• Miskovic, A., & Lumb, A. B. (2017). Postoperative pulmonary complications. British Journal of Anaesthesia, 118(3), 317–334. DOI: 10.1093/bja/aex002.
• Mo, J., Wang, D., Xiao, J., Chen, Q., An, R., & Liu, H. L. (2024). Effects of lung protection ventilation strategies on postoperative pulmonary complications after noncardiac surgery: A network meta-analysis of randomized controlled trials. BMC Anesthesiology, 24(1), 346. DOI: 10.1186/s12871-024-02737-w.
• Odor, P. M., Bampoe, S., Gilhooly, D., Creagh-Brown, B., & Moonesinghe, S. R. (2020). Perioperative interventions for prevention of postoperative pulmonary complications: Systematic review and meta-analysis. BMJ, 368, m540. DOI: 10.1136/bmj.m540.
• PRISM Trial Group. (2021). Postoperative continuous positive airway pressure to prevent pneumonia, re-intubation, and death after major abdominal surgery (PRISM): A multicentre, open-label, randomised, phase 3 trial. The Lancet Respiratory Medicine, 9(11), 1221–1230. DOI: 10.1016/S2213-2600(21)00089-8.
• PROVE Network Investigators for the Clinical Trial Network of the European Society of Anaesthesiology. (2014). High versus low positive end-expiratory pressure during general anaesthesia for open abdominal surgery (PROVHILO trial): A multicentre randomised controlled trial. The Lancet, 384(9942), 495–503. DOI: 10.1016/S0140-6736(14)60416-5.
• Serpa Neto, A., Schultz, M. J., & Gama de Abreu, M. (2015). Intraoperative ventilation strategies to prevent postoperative pulmonary complications: Systematic review, meta-analysis, and trial sequential analysis. Best Practice & Research Clinical Anaesthesiology, 29(3), 331–340. DOI: 10.1016/j.bpa.2015.09.002.
• Serpa Neto, A., Hemmes, S. N. T., Barbas, C. S. V., Beiderlinden, M., Fernandez-Bustamante, A., Futier, E., Gajic, O., El-Tahan, M. R., Al Ghamdi, A. A., Günay, E., Jaber, S., Kokulu, S., Kozian, A., Licker, M., Lin, W.-Q., Maslow, A. D., Memtsoudis, S. G., Reis Miranda, D., Moine, P., … Schultz, M. J. (2016). Association between driving pressure and development of postoperative pulmonary complications in patients undergoing mechanical ventilation for general anaesthesia: A meta-analysis of individual patient data. The Lancet Respiratory Medicine, 4(4), 272–280. DOI: 10.1016/S2213-2600(16)00057-6.
• Sullivan, K. A., Churchill, I. F., Hylton, D. A., & Hanna, W. C. (2021). Use of incentive spirometry in adults following cardiac, thoracic, and upper abdominal surgery to prevent post-operative pulmonary complications: A systematic review and meta-analysis. Respiration, 100(11), 1114–1127. DOI: 10.1159/000517012.
