What are the optimum components in a care bundle aimed at reducing post-operative pulmonary complications in high-risk patients?

Abstract

BackgroundPost-operative pulmonary complications (POPC) are common, predictable and associated with increased morbidity and mortality, independent of pre-operative risk. Interventions to reduce the incidence of POPC have been studied individually, but the use of a care bundle has not been widely investigated. The purpose of our work was to use Delphi consensus methodology and an independently chosen expert panel to formulate a care bundle for patients identified as being at high of POPC, as preparation towards an evaluation of its effectiveness at reducing POPC.MethodsWe performed a survey of members of the ESICM POIC section to inform a Delphi consensus and to share their opinions on a care bundle to reduce POPC, the POPC-CB. We formed a team of 36 experts to participate in and complete an email-based Delphi consensus over three rounds, leading to the formulation of the POPC-CB.ResultsThe survey had 362 respondents and informed the design of the Delphi consensus. The Delphi consensus resulted in a proposed POPC-CB that incorporates components before surgery-supervised exercise programmes and inspiratory muscle training, during surgery, low tidal volume ventilation with individualised PEEP (positive end-expiratory pressure), use of routine monitoring to avoid hyperoxia and efforts made to limit neuromuscular blockade, and post-operatively, deep breathing exercises and elevation of the head of the bed.ConclusionA care bundle has been suggested for evaluation in surgical patients at high risk of POPC. Evaluation of feasibility of both implementation and effectiveness is now indicated.

Perioperative interventions for prevention of postoperative pulmonary complications: systematic review and meta-analysis

“…Despite care bundles being strongly endorsed for prevention of ventilator associated pneumonia in intensive care,144145 evidence for equivalent non-ventilator bundles in perioperative patient care to prevent PPCs is still uncertain 146. An international Delphi consensus process considered which interventions might best be combined to reduce PPCs,147 and a UK based, patient centred quality improvement project (ERAS+) used a PPC reduction care bundle with notable success 148. To date, these care bundles have predominantly included relatively simple and inexpensive interventions, often with imperfect evidence of efficacy.…”

A case for inspiratory muscle training in SCI: potential role as a preventative tool in infectious respiratory diseases like COVID-19

“…In addition to providing evidence for feasibility, the observed improvements in pulmonary function may provide a preventive health benefit. IMT has been used to prepare individuals for surgery and reduce instances of post-surgical pulmonary compromise, including pneumonia [29][30][31][32]. Additionally, Boswell-Ruys et al recently reported the results of a 6-week supervised RMT randomized clinical trial, which showed that individuals with SCI in the intervention group experienced significantly fewer respiratory complications in the following year than participants with SCI undergoing sham treatment [33].…”

Anesthetic management of geriatric patients

“…The ACS best practice guidelines for PPC detailed risk factors and strategies to prevent complications. A 2018 expert survey including 362 respondents suggested a care bundle composed of factors before surgery, i.e., supervised exercise programs and inspiratory muscle training; factors during surgery, i.e., low tidal volume ventilation (6-8 ml/kg) with individualized positive end-expiratory pressure (PEEP) of 5-8 cmH 2 O and repeated recruitment maneuvers, use of routine monitoring to avoid hyperoxia, and efforts to limit neuromuscular blockade; and post-operative factors, i.e., deep breathing exercises and elevation of the head of the bed [115].…”