Postoperative Respiratory Failure and Treatment

Abstract

After thoracic surgery lobar atelectasis, pneumonia, or the need for more than 24 h of mechanical ventilation occurs with an incidence of 22-25%, while respiratory failure requiring mechanical ventilation for more than 48 h occurs 3-10% of the time. These severe complications occur more frequently in patients undergoing more major procedures or resections such as esophagogastrectomy, lung volume reduction, and pneumonectomy. Preoperative risk factors as discussed in Chap. 2 are a major determinant of postoperative respiratory failure; intra- and postoperative complications such as atelectasis, pulmonary edema, and mechanical complications (e.g., bronchopleural fistula, lung torsion, pneumothorax) are also contributing factors. Measures to prevent or reduce atelectasis, to help mobilize secretions, and provision of adequate analgesia are essential to reduce respiratory deterioration after thoracic surgery. When respiratory failure appears to be developing, less invasive modes of respiratory assist such as high-flow nasal cannula or facemask continuous positive-pressure or bi-level support may reduce the need for intubation. When mechanical ventilation is required, a lung-protective mode with reduced tidal volumes and adequate PEEP should be employed. This is especially true when acute respiratory distress syndrome (ARDS) occurs, a complication with high mortality. Tracheostomy, performed when ventilator weaning appears to be unlikely within 7-10 days, can provide significant improvement in patient comfort and reduced need for sedation, facilitating mobility and weaning.