Role of Preoperative Cessation of Smoking and Other Factors in Postoperative Pulmonary Complications: A Blinded Prospective Study of Coronary Artery Bypass Patients

https://doi.org/10.1016/S0025-6196(12)65337-3Get rights and content

The association between preoperative smoking cessation and postoperative pulmonary morbidity was studied prospectively in 200 consecutive patients undergoing an elective coronary artery bypass surgical procedure. Detailed respiratory, cardiovascular, and smoking histories were elicited. Preoperative arterial blood gas analyses and bedside spirometry were performed. Urinary cotinine levels were measured to verify smoking histories. During spirometry, severe angina developed in seven patients, who were hence excluded from the study; one patient died of hemorrhage intraoperatively. An observer unaware of patients' preoperative histories assessed the remaining 192 patients throughout the intraoperative and postoperative periods for pulmonary complications. Postoperative pulmonary complications occurred in a third of the current smokers. Patients who had stopped smoking for 2 months or less had a pulmonary complication rate almost 4 times that of patients who had stopped for more than 2 months (57.1% versus 14.5%). Patients who had stopped smoking for more than 6 months had rates similar to those who had never smoked (11.1% and 11.9%, respectively). Preoperative pulmonary dysfunction, increased pack-years of smoking, prolonged surgical time, and the use of enflurane were independently associated with postoperative pulmonary morbidity (P<0.05). We concluded that smoking cessation should occur at least 2 months preoperatively to maximize the reduction of postoperative respiratory complications.

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METHODS

From October 1986 to March 1987, 200 consecutive informed and consenting patients undergoing elective coronary artery bypass grafting were studied. Detailed cigarette smoking and cardiopulmonary histories were elicited, and bedside measurements of arterial blood gases, spirometry, and urinary cotinine were performed. Study patients were assessed immediately postoperatively, on postoperative days one and seven, and on the day of hospital dismissal for the development of postoperative respiratory

RESULTS

The characteristics of 192 study patients are shown in Table 1. Of the initial 200 patients, 7 patients were eliminated from the study because of onset of angina during bedside spirometry. Also excluded from analysis was one patient who died of massive hemorrhage intraoperatively.

Postoperative pulmonary complications occurred in 36 patients (18.7%) (Table 2), 14 of whom had multiple complications. Of these complications, 83% occurred within 48 hours postoperatively, and 95% occurred within 96

DISCUSSION

Preoperative cessation of smoking for less than 2 months in patients undergoing coronary artery bypass grafting does not seem to decrease postoperative respiratory morbidity below that found in current smokers. Supportive evidence has shown that improvement in ciliary15 and small airway function16, 17 and a decrease in production of sputum4 occur slowly for a period of weeks after cigarette smoking is stopped. Therefore, the risk of postoperative pulmonary complications remains high in patients

ACKNOWLEDGMENT

We thank Kris D. Hammel, R.R.T., R.P.F.T., and Peggy A. Hauswald, C.R.T.T., for help with data collection and performance of spirometry testing, Julie M. Vogen for assistance in preparing the manuscript, and Mary M. Ho for assistance with analysis of the data.

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    Current address: St. Francis Hospital and Medical Center, Topeka, Kansas.

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