A is a 68-year-old man with severe chronic obstructive pulmonary disease (COPD), coronary artery disease, peripheral vascular disease, hypertension, hypercholesterolemia, and ongoing tobacco use who needs surgery for presumed colon cancer.In December 2005, Mr A underwent a colonoscopy for a single episode of melena. The colonoscopy revealed a malignant-appearing, friable infiltrative sigmoid mass. A previous routine colonoscopy performed in 2001 had revealed only 2 small polyps: a right-sided small adenoma and a left-sided small hyperplastic polyp. Since the recent colonoscopy, Mr A has seen 2 general surgeons who have both recommended that he proceed with resection of the mass.Mr A smokes 1 to 2 packs per day, although he has been trying to cut down; he has a 75-pack-year history of smoking. He produces copious gray sputum in the morning; his chronic cough has not changed in the past several months. He has tried to quit smoking with the aid of a nicotine patch, but his periods of abstinence have been short. A trial of bupropion was limited by dysphoria. His recent attempts to quit have been limited in part by his increased stress level around the new diagnosis of near-certain cancer. He has numerous recent episodes of "bronchitis" and upper respiratory tract infection (URI) for which he has been treated with short courses of oral steroids and antibiotics. He has infrequent episodes of angina in a stable pattern. His exercise is limited by his peripheral vascular disease. He can walk 50 to 100 yards before his calves ache and he must stop to rest. Mr A's past medical history is significant for COPD with numerous hospitalizations but no intubations. Magnetic resonance imaging has shown evidence of lacunar strokes. Mr A is a 68-year-old man with a history of melena who was found to have a mass in his colon that was suspicious for possible malignancy. His 75-pack-year smoking history has resulted in a chronic daily cough and the diagnosis of chronic obstructive pulmonary disease. On physical examination, he has wheezes, decreased breath sounds, and a prolonged expiratory phase; his forced expiratory volume in the first second (FEV 1 ) is 1.34 L (47% predicted). Mr A needs surgery for potentially curative treatment for presumed colon cancer, but he is understandably worried about the effect of his lung disease on his surgical risk. In particular, he is worried that he may not be able to be weaned off the ventilator after surgery. This discussion reviews the important patient-and procedure-related risk factors for pulmonary complications after surgery, the role of preoperative testing, and the evidence supporting strategies to reduce the risk of pulmonary complications as they apply to Mr A.