Table 1.

Strategies to minimize postoperative respiratory complications

Intraoperative considerations
Factor	Improved outcome	Favorable strategy	Respiratory complication	Study cohort	Reference
Ventilation
Protective lung ventilation	Major PRC, hospital length of stay	PEEP ≥ 5 cmH2O, median tidal volume ≤10 ml/kg of predicted body weight, median plateau pressure ≤30 cmH2O	Pulmonary edema, respiratory failure, pneumonia, and reintubation	Noncardiac surgery with endotracheal intubation; major abdominal surgery	Ladha et al. [25▪▪], de Jong et al. [26▪▪]
Oxygen toxicity	Major PRC, mortality, and ICU admission	Low intraoperative inspiratory oxygen fraction (mean of 0.31)	Respiratory failure, reintubation, pulmonary edema, and pneumonia	Noncardiac surgery	Staehr-Rye et al. [28▪]
Recruitment maneuvers and PEEP titration	Lung volumes, respiratory system elastance, and oxygenation	A recruitment maneuver followed by end-expiratory pressure titration	–	Critically ill, mechanically ventilated, morbidly obese (BMI > 35) patients	Pirrone et al. [27▪]
Surgical factors
Laparoscopic vs. open surgery	PRC	Laparoscopic surgical approach	Pleural effusion, respiratory insufficiency, ARDS, pulmonary infection, and pulmonary embolism	Major hepatectomy surgery	Fuks et al. [43▪▪]
Anesthetic factors
Fluid administration	Length of stay, costs, postoperative ileus, pneumonia, major PRC, 30-day mortality and renal complications	Moderate/goal-directed fluid administration	Respiratory failure, reintubation, pulmonary edema, and pneumonia	In patients undergoing colon, rectal, hip, or knee surgery; 12 liberal fluid therapy RCTs; noncardiac surgery	Shin et al. [37▪▪]; Thacker et al. [39▪]; Corcoran et al. [38]
Dose of NMBAs and neostigmine	PRC	Low-dose use of NMBAs, proper neostigmine reversal (≤60 μg/kg after recovery of train-of-four count of 2)	Respiratory failure, reintubation, pulmonary edema, and pneumonia	Noncardiac surgery with NMBA use	McLean et al. [31▪▪]
Use of NMBA, and neostigmine	Oxygen desaturation and reintubation	No use of intermediate-acting NMBA and neostigmine	SpO2 < 90% with a decrease in oxygen saturation after extubation of >3%; reintubation	Noncardiac surgery	Grosse-Sundrup et al. [30]
Dose of inhalational anesthetics	Major PRC, mortality, hospital length of stay, costs	High-dose inhalational anesthetic	Respiratory failure, reintubation, pulmonary edema, and pneumonia	Noncardiac surgery with inhalational anesthetic use	Grabitz et al. [29▪▪]
Neuraxial anesthesia	Morbidity and mortality	Use of neuraxial blockade with epidural or spinal anesthesia	Pulmonary embolism, pneumonia, and respiratory depression	Randomized surgical cases with or without neuraxial anesthesia	Rodgers et al. [41]
Dose of opioids	30-day readmission	Low-dose intraoperative opioid	Respiratory failure, reintubation, pulmonary edema, and pneumonia	Noncardiac surgery	Grabitz et al. [40]
Postoperative considerations
Admission to ICU	Hospital length of stay, PRC, and costs	Optimal decision of postoperative ICU vs. ward admission	Respiratory failure, reintubation, pulmonary edema, and pneumonia	Noncardiac and nontransplant surgery	Thevathasan et al. [44▪]
Monitoring on surgical floor	Rescue events and transfers to ICU	Appropriate postoperative monitoring (e.g., pulse oximetry)	–	Orthopedic surgery	Taenzer et al. [45]
Postoperative analgesia	Opioid-induced respiratory depression	Opioid-sparing analgesia	Respiratory depression	Surgical patients with acute pain	Lee et al. [46▪▪]
CPAP	AHI, oxygen desaturations, mean oxygen saturation, and opioid-induced respiratory depression	CPAP treatment in postanesthesia care unit	Apnea–hypopnea index and oxygen desaturation	Bariatric surgery	Zaremba et al. [47▪▪]
Upright positioning	Pharyngeal collapsibility	Postural change from supine to sitting	–	Patients with OSA	Tagaito et al. [48]
Fowler's position	Apnea–hypopnea index, oxygen saturation <90%	Elevated body position	Apnea–hypopnea index, oxygen saturation <90%	OB, postdelivery	Zaremba et al. [49▪]
Avoid reintubation in surgical ICU patients	Reintubation	Avoid elevated blood urea nitrogen, low hemoglobin, and muscle weakness in SICU patients	Reintubation	Surgical ICU patients (noncardiac)	Piriyapatsom et al. [50▪▪], Farhan et al. [51]
Early mobilization in the ICU	Length of stay in the ICU, functional mobility at hospital discharge	Early, goal-directed mobilization using an interprofessional approach of closed-loop communication and SOMS algorithm	–	ICU patients, mechanically ventilated (<48 h; expected to require ≥24 h)	Schaller et al. [53▪▪]

ARDS, acute respiratory distress syndrome; CPAP, continuous positive airway pressure; NMBA, neuromuscular blocking agent; PEEP, positive end-expiratory pressure; PRC, postoperative respiratory complication; RCT, randomized controlled trial.