Preoperative Spine Evaluation and Assessment

5. Preoperative Pulmonary Evaluation and Optimization

Recommendations

Question 1:

What preoperative patient factors are associated with increased risk of postoperative pulmonary adverse events in patients undergoing spine surgery?

Recommendation:

Clinicians should consider risk factors associated with increased risk of postoperative pulmonary adverse events [functional dependence, advanced age, chronic obstructive pulmonary disease (COPD), congestive heart failure, weight loss, and obstructive sleep apnea] when determining patient suitability for spine surgery and counsel at risk patients about the potential for postoperative pulmonary adverse events. Strength of Recommendation: Grade B

Question 2:

What preoperative diagnostic studies of pulmonary function predict risk of postoperative pulmonary adverse events in patients undergoing spine surgery?

Recommendation:

There is insufficient evidence to support the efficacy of any preoperative pulmonary test on predicting risk of postoperative pulmonary adverse events in patients undergoing elective spine surgery. However, the task force recommends that clinicians perform the appropriate preoperative pulmonary tests based on the clinical presentation of active pulmonary symptoms or to confirm a suspected pulmonary disease. Strength of Recommendation: Grade Insufficient

Question 3:

Do preoperative pulmonary interventions reduce the risk of postoperative pulmonary adverse events in patients undergoing spine surgery?

Recommendation:

There is insufficient evidence regarding preoperative pulmonary interventions to reduce the risk of postoperative pulmonary adverse events in patients undergoing spine surgery. However, the task force recommends that clinicians proceed with the appropriate preoperative pulmonary interventions to treat active pulmonary symptoms or suspected pulmonary disease. Strength of Recommendation: Grade Insufficient

Overview

Postoperative pulmonary adverse events are serious complications that can lead to increased morbidity and mortality. Recent studies demonstrated up to a 10-fold increase in mortality in the first 30 days after surgery in patients who experience a postoperative pulmonary adverse event. Pulmonary complications are 1 of 4 patient safety indicators leading to 68% of all reported patient safety postoperative events.¹ Recent literature has identified several patient risk factors for postoperative pulmonary complications (e.g., pneumonia, reintubation, prolonged ventilation, and venous thromboembolism), with many commonly occurring because of advanced age and associated comorbid medical conditions in patients who are undergoing elective spine surgery. There are no current recommendations for preoperative pulmonary evaluation and management of patients undergoing elective spine surgery.

The aim of this guideline is to determine preoperative risk factors for perioperative and postoperative pulmonary adverse events and to determine the optimal preoperative evaluation and management of at-risk patients.

There is substantial evidence for multiple preoperative patient factors that predict an increased risk of a postoperative pulmonary adverse event. Individuals with these risk factors (functional dependence, advanced age [≥65 years], chronic obstructive pulmonary disease, congestive heart failure, weight loss, and obstructive sleep apnea) who are undergoing spine surgery should be counseled regarding the potential increased risk of a perioperative and postoperative pulmonary adverse events. There is insufficient evidence to support any specific preoperative diagnostic test for predicting the risk of postoperative pulmonary adverse events or any treatment intervention that reduces risk. It is suggested, however, to consider appropriate preoperative pulmonary diagnostic testing and treatment to address active pulmonary symptoms of existing or suspected disease.

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