138 MINERVA ANESTESIOLOGICA February 2010

REVI EW
Postoperative pulmonary complications
J. CANET, V. MAZO
Department of Anesthesiology, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, Spain
Postoperative pulmonary complications (PPC)
account for a substantial proportion of morbidi-
ty and mortality related to surgery and anesthesia
and lead to longer hospital stays.
1
The aim of this review is to describe the cur-
rent evidence underpinning our understanding of
PPC and to highlight measuresthat might become
necessary at different points during the course of
perioperative care.
Definition and incidence of PPC
There is no standard definition of PPC.Most
investigators include postoperative pneumonia
(confirmed or suspected), respiratory failure (usu-
ally defined as the need for ventilatory support)
and bronchospasm, but analysis of the literature
shows that other complications, such as unex-
plained fever, excessive bronchial secretions, pro-
ductive cough, abnormal breath sounds, atelecta-
sis or hypoxemia, may also be included. The inci-
dence of PPC varies depending on the clinical
treatment setting, the kind of surgery studied, and
the definition of PPC used. For all of these rea-
sons, incidence rates vary dramatically, ranging
from 2% to 40%.
2
Causes of PPC
The factors affecting the development of PPC
are related to the prior health status of the patient
and the effects of anesthesia and surgical trau-
ma. The synergy between these factors deter-
mines risk.
3
General health status
The patients overall health has a strong influ-
ence on the development of complications. Pre-
existing disorders that affect normal respiratory
and cardiovascular function and those associated
with an abnormal immune response favor the
development of complications.
ABSTRACT
Postoperative pulmonary complications(PPC) account for a substantial portion of the risksrelated to surgery and
anesthesia and are a source of postoperative morbidity, mortality and longer hospital stays. The current basisfor our
understanding of the nature of PPC isweak; only a small number of high-quality studiesare available, a uniform def-
inition hasnot emerged, and studieshave focused on specific patientsand kindsof surgeries. Current evidence sug-
geststhat risk factorsfor PPC are related to the patientshealth statusand the particular anesthetic and surgical pro-
cedureschosen. Age, general co-morbidity, pre-existing respiratory and cardiac diseases, the use of general anesthesia
and the overall surgical insult. are the most significant factorsassociated with complications. Election of anesthetic tech-
nique, postoperative analgesia and physical therapy seem to be the preventive measuresthat are best supported by evi-
dence. (Minerva Anestesiol 2010;76:138-43)
Key words: Postoperative complications, Pulmonary atelectasis, Smoking, Continuous positive airway pressure,
Analgesia.
MINERVA MEDICA COPYRIGHT

Vol. 76 - No. 2 MINERVA ANESTESIOLOGICA 139

POSTOPERATIVE PULMONARY COMPLICATIONS CANET
General anesthesia
General anesthesia has biological effects on the
respiratory system and also results in mechanical
and functional changes that enhance those effects.
These effects begin with anesthetic induction and
can extend into the postoperative period. General
anesthesia reduces functional residual capacity,
with an immediate and universal development of
atelectasis in the dependent regions of the lung
through three mechanisms: compression of lung
tissue, absorption of alveolar air, and impairment
of surfactant function. The resulting ventilation-
perfusion mismatch leads to increased shunt, dead
space and hypoxemia. Anesthetics, analgesics and
other perioperative drugs affect the central regu-
lation of breathing, changing the neural drive of the
upper airway and chest wall muscles and further
contributing to PPC. Overall, the intensity and
coordination of the activities of several muscle
groups and the preservation of biological mecha-
nisms in the lung are the keys to shifting the bal-
ance toward recovery rather than severe respira-
tory complications.
4, 5
Additionally, immunosup-
pressive effects due to anesthesia
6
and intraopera-
tive transfusion have also been invoked as con-
tributors to poor postoperative outcome.
7
Surgical trauma
The type of surgical insult contributes greatly to
the development of PPC.
3
All thoracic and abdom-
inal surgery involves trauma near the diaphragm,
resulting in at least three types of trauma. The first
is functional disruption of respiratory muscle
movements, caused by incisions. The second is
the effect of postoperative pain in limiting respi-
ratory motion. The third is the reflex inhibition
of the phrenic nerve and other nerves that inner-
vate respiratory muscles, a result of stimulating
the viscera by mechanical traction. As a conse-
quence, in the postoperative period, normal respi-
ratory muscle activity, particularly that of the
diaphragm, is disrupted.
8
Factors related
4
to the degree of surgical insult,
such as level of aggressiveness, procedure duration
or amount of blood lost, may by themselves
increase the risk of PPC or may interact with the
local effects described above. The postoperative
immune response is extremely complex and has
detrimental procoagulant and immunosuppres-
sive effects. Proinflammatory cytokines, especial-
ly tumor necrosis factor and interleukin-6, are
major players because of their roles in the systemic
inflammatory response syndrome and multiple
organ dysfunction after trauma. Again, immune
depression, in this case provoked by the surgical
insult, may be invoked as a mediator that increas-
es the risk of postoperative respiratory infection
and other complications.
4
Preoperative management
Preoperative assessment includes taking a med-
ical history, paying close attention to preexisting
respiratory diseases, smoking, respiratory symp-
TABLE I.Significant risk factorsaccordingthesystematic review of theAmerican Collegeof Physicians.
6
A (good evidence)
B (fair evidence)
Cardiac failure
ASA class2
Advanced age
COPD
Functional dependence
Weight loss
Impaired sensorium
Cigarette use
Alcohol use
Aortic aneurysm
Thoracic surgery
Abdominal surgery
Upper abdominal surgery
Neurosurgery
Prolonged surgery (>3h)
Head and neck surgery
Emergency surgery
Vascular surgery
General anaesthesia
Transfusion
Low serum albumin
Chest X-ray
Blood urea
Level of evidence Patient Procedure Laboratory test
MINERVA MEDICA COPYRIGHT

CANET POSTOPERATIVE PULMONARY COMPLICATIONS

140 MINERVA ANESTESIOLOGICA February 2010
toms and any medications that have been given
for respiratory disorders. A positive cough test
(performed by having the patient take a deep
breath and cough once, with a positive finding
defined as repeated coughing after the first cough)
has been demonstrated as a predictor of PPC.
9
The cough test is easy to perform and could pos-
sibly indicate some degree of airway hyperreactiv-
ity and hypersecretion. With the exception of
assessment prior to lung resection surgery, there
is no evidence that routine chest radiographs
10
or
pulmonary function tests are beneficial.
11
The first step in respiratory management is to
identify the preoperative risk factorsassociated with
PPC. Table I showsfactorswith good (level A) or fair
(level B) evidence according to a systematic review
by the American College of Physicians.
11
The same
meta-analysis shows that there is fair or good evi-
dence that diabetes, obesity, asthma, and hip, gyne-
cological and urologic surgery do not increase the
risk of PPC. Obstructive sleep apnea syndrome has
also not been definitively implicated in an increased
risk of PPC. Predictive indices for postoperative
pneumonia
12
(Table II) and respiratory failure
13
have been developed within the context of the US
National Veterans Affairs Improvement Program
for identifying high-risk patients. However, although
these studies included the largest known samples
with regard to PPC, the patients were mostly male
veterans who were far from representative of a gen-
eral surgical population.
Preventivemeasures
SMOKING CESSATION
Several studies have analyzed the beneficial
effects of preoperative smoking cessation as well as
how long before surgery the patient should quit
smoking.
14
This is an important step, and patients
should be informed about how quitting will
decrease their perioperative risk. The degree of
benefit will depend on three factors: the amount
of lifetime smoking (pack-years), how long the
patient has been abstinent, and age at the moment
of smoking cessation. There is no clear evidence
regarding whether risk for PPC derivesfrom smok-
ing per se or is due to the comorbidity that smok-
ing generates. Nonetheless, preoperative absti-
nence should be recommended and an abstinence
period of at least 4-6 weeks seems to be the most
beneficial.
15
The following evidence and patho-
physiologic reasoning supports this advice:
16
the effects that are attributable to carbon
monoxide and nicotine disappear during the first
12-48 hours of abstinence;
at one week after smoking cessation, airway
reactivity is significantly reduced;
at two weeksafter smoking cessation, sputum
volume isreduced by half and declinessteadily over
a six-week period. It isnot clear whether thetransient
increase in cough and sputum production during
the first two weeks increases the risk for PPC.
In addition, observational studies suggest that
patients are more prone to quitting smoking per-
manently after undergoing surgery.
17
For this rea-
son, it is very important to be aware that the pre-
operative visit is a window of opportunity for
encouraging patients to quit smoking through
counseling.
18
Parents should also be warned about
TABLE II.PostoperativePneumonia Risk Index.
Perioperativerisk factor point value
Type of surgery
Abdominal aortic aneurysm repair 15
Thoracic 14
Upper abdominal 10
Neck 8
Neurosurgery 8
Vascular 3
Age
>80 yr 17
70-79 yr 13
60-69 yr 9
50-59 yr 4
Functional status
Totally dependent 10
Partially dependent 6
Weight loss>10% in past six months 7
History of chronic obstructive pulmonary disease 5
General anesthesia 4
Impaired sensorium 4
History of cerebrovascular accident 4
Blood urea
<8 mg/dL 4
22-30 mg/dL 2
30 mg/dL 3
Blood transfusion >4 U 3
Emergency surgery 3
Steroid use for chronic condition 3
Current smoker within one year 3
Alcohol intake >two drinks/day in past two weeks 2
Pneumonia risk: 0-15 points, 0.24%; 16-25 points, 1.18%; 26-40
points, 4.6%; 41-55 points, 10.8%; >55 points, 15.9%. From Arozullah
AM et al.
12
MINERVA MEDICA COPYRIGHT

Vol. 76 - No. 2 MINERVA ANESTESIOLOGICA 141

POSTOPERATIVE PULMONARY COMPLICATIONS CANET
the consequences of smoking for their children
who are about to undergo surgery.
PATIENTSWITH A CHRONIC PULMONARY DISEASE
Patientswith a chronic pulmonary disease, espe-
cially those with some degree of bronchial hyper-
reactivity, might benefit from starting preopera-
tive bronchodilator therapy or increasing the ther-
apy dosage.
19
Extra vigilance is needed for patients
who have suffered an acute respiratory exacerba-
tion, including influenza; in cases of elective sur-
gery, cancellation might be advisable.
PREOPERATIVE PHYSICAL THERAPY
There is no clinical evidence supporting rou-
tine preoperative physiotherapy, even in high-risk
patients.
3
However, therapy may be advisable in
specific cases to reduce bronchial secretions and
to teach breathing techniques that can be used
postoperatively.
NUTRITION
A low preoperative albumin concentration has
been shown to be a good predictor of PPC;
20, 21
for
thisreason, it would seem advisable for patientswho
are severely undernourished to receive preoperative
nutritional supplements. However, thereisno proven
advantage to total parenteral nutrition over enteral
nutrition or even no supplementation.
21
Intraoperative management
Anesthetic technique
No evidence currently provides strong support
for recommending one anesthetic technique over
another in order to reduce the incidence of PPC.
If avoidance of general anesthesia is feasible, this
precaution might be advisable in patients at high
risk for PPC in order to reduce the formation of
atelectases. The only measure proven to be bene-
ficial is the avoidance of long-acting neuromus-
cular blocking drugs (e.g., pancuronium),
21 ,22
the
likely mechanism being the association between
residual muscle paralysis and PPC.
22
Ventilatory management
There is no consensus on how to ventilate
patients during surgery to reduce the risk of PPC.
In general, a low tidal volume strategy is advised
for all patients
23
, and therapeutic strategies for
preventing and treating atelectasis should be
planned for those at higher risk.
24, 25
It has been
shown that the incidence of atelectasis can be
reduced by using positive airway pressure, either
as positive end-expiratory pressure (PEEP)
26
or
continuous pressure (CPAP), even before anes-
thetic induction
27
and intraoperative recruitment
maneuvers.
28
The application of intraoperative
positive pressure in obese patients
26
or in specific
surgical procedures
29
also reduces the incidence of
atelectasis. No clear recommendation regarding
intraoperative ventilatory management for reduc-
ing the incidence of PPC has emerged, however.
Further prospective studies are needed.
Fluid therapy
It has been suggested that perioperative fluid
overloading might increase the risk of PPC, but
no evidence has been found to support this
assumption in a general surgical population.
30
An
association between transfusion and PPC has been
demonstrated,
12
however; therefore, it seemsadvis-
able to avoid transfusion if possible.
Surgical management
Risk factors related to the type of surgery play
a large role in promoting PPC.
3, 11
To some extent,
these factors can be mitigated by surgeons, and
this possibility should be discussed whenever
patients are at high risk for complications.
Measures to apply might include: 1) avoiding
emerging surgical techniques whenever possible;
2) reducing surgical aggressiveness and duration if
possible; and 3) using minimally invasive surgery
(e.g., laparoscopic surgery) whenever possible.
Postoperative management
Postoperativeanalgesia
The most important measure to implement
postoperatively to reduce the incidence of PPC is
the provision of adequate analgesia. Postoperative
epidural or intravenous patient-controlled anal-
gesia both seem to be superior to on-demand deliv-
ery of opioidsin preventing PPCs.
21, 31
The epidur-
al route of administration seems to be superior to
MINERVA MEDICA COPYRIGHT

CANET POSTOPERATIVE PULMONARY COMPLICATIONS

142 MINERVA ANESTESIOLOGICA February 2010
others for delivering opioids in terms of prevent-
ing PPCs, and epidural analgesia by itself may fur-
ther reduce PPC.
32
Evidence regarding postoper-
ative epidural analgesia remains insufficient, how-
ever. A greater number of high-quality trials are
needed to accurately assessthe whether thismodal-
ity is superior to others in reducing PPC rates.
Postoperativelungexpansion measures
Lung expansion techniques include incentive
spirometry, chest physical therapy, deep breath-
ing exercises, postural drainage, and CPAP. There
is evidence that for patients undergoing thoracic
and abdominal surgery, any type of lung expan-
sion intervention isbetter than none.
21, 33
However,
no single modality is better than any other, and
combining methods does not provide additional
risk reduction.
34, 35
Local treatment protocols may
already be available for specific high-risk patient
groups. Simple measures (positioning, mobiliza-
tion, hydration, cough stimulation, ambulation,
sleep) are probably best for reducing the incidence
of complications.
Nasogastric tube
Routine placement of nasogastric tubes refers
to their use after surgery until the return of gas-
trointestinal motility. A meta-analysis examined
evidence of selective versus routine nasogastric
decompression after elective laparotomy,
36
find-
ing that a tube should be introduced if the patient
has postoperative nausea or vomiting, is unable
to tolerate oral intake, or there is symptomatic
abdominal distension. Patients receiving selective
nasogastric decompression have been found to
possess a significantly lower rate of pneumonia
and atelectasis with no difference in aspiration
rates. It should be noted, however, that nasogastric
tube placement impairs the cough reflex and pro-
vides a more direct pathway for oro-pharyngeal
bacteria to the lungs, thuspotentially increasing res-
piratory tract infections.
Treatment of PPC
Early postoperative hypoxemia isvery common,
especially in those patients and surgical settings
in which there is a greater risk of atelectasis.
37
Postoperative oxygen therapy should not be used
routinely. Routine continuous pulse oximetry dur-
ing the first postoperative hours, with a target of
maintaining 92% or greater saturation, isone selec-
tive strategy. Any method of oxygen administration
alleviates hypoxemia efficiently.
38
Late postoperative hypoxemia is a result of per-
sistent atelectasis and the development of respira-
tory infection and failure. In high-risk patients,
early application of CPAP may prevent the devel-
opment of severe hypoxemia after elective major
abdominal surgery.
39
If a PPC is suspected, arte-
rial blood gas assessment, sputum culture, chest
x-rays and an electrocardiogram should be
ordered. Aggressive treatment is encouraged, to
take advantage of the combination of antibiotics,
physical therapy and ventilatory support. When
acute postoperative respiratory failure develops,
non-invasive continuous positive airway pressure
is the first-choice method for ventilatory support,
to avoid reintubation.
40
If respiratory failure pro-
gresses, however, and acute lung injury is demon-
strated, invasive mechanical ventilation may be
required.
40
Conclusions
PPCs are often life threatening, as shown by
PPC-associated mortality rates that can be as high
as 20%. However, the level of evidence for imple-
menting preventive measures is relatively low.
Patient- and surgery-related factorshave been iden-
tified, but many of them cannot be modified. The
most important step is to identify high-risk
patients. Few specific measures can be managed
perioperatively. Election of anesthetic technique,
postoperative analgesia and physical therapy seem
to be the measures that are best supported by evi-
dence at this time. Aggressive treatment of PPCs
is mandatory if mortality is to be reduced.
References
1. Smetana GW. Preoperative pulmonary evaluation. N Engl J
Med 1999;340:937-44.
2. Rock P, Rich PB. Postoperative pulmonary complications.
Curr Op Anaesthesiol 2003;16:123-32.
3. Warner DO. Preventing postoperative pulmonary complica-
tions. Anesthesiology 2000;92:1467-72.
4. Duggan M, Kavanagh BP. Pulmonary atelectasis. A patho-
genic perioperativeentity. Anesthesiology 2005;102:838-54.
5. Kavanagh BP. Perioperative atelectasis. Minerva Anestesiol
2008;74.285-7.
6. Ahlers O, Nachtigall I, Lenze J, Goldmann A, Schulte E,
MINERVA MEDICA COPYRIGHT

Hhne C et al. Intraoperative thoracic epidural anaesthesia

attenuates stress-induced immunosuppression in patients
undergoing major abdominal surgery. Br J Anaesth.
2008;101:781-7.
7. Koch CG, Li L, Duncan AI, Mihaljevic T, CosgroveDM, Loop
FD et al. Morbidity and mortality risk associated with red blood
cell and blood-component transfusion in isolated coronary
artery bypassgrafting. Crit CareMed. 2006;34:1608-16.
8. Sharma RR, Axelsson H, Oberg A, Jansson E, Clergue F,
Johansson G et al. Diaphragmatic activity after laparoscopic
cholecystectomy. Anesthesiology 1999;91:406-13.
9. McAlister FA, Bertsch K, Man J, Bradley J, JackaM. Incidence
of and risk factorsfor pulmonary complicationsafter non-
cardiothoracic surgery. Am J Respir Crit Care Med
2005;171:514-7.
10. Archer C, Levy AR, McGregor M. Value of routine preop-
erative chest x-rays: a meta-analysis. Can J Anaesth
1993;40:1022-7.
11. Smetana GW, Lawrence VA, Cornell JE. Preoperative pul-
monary risk stratification for noncardiothoracic surgery: sys-
tematic review for the American College of Physicians. Ann
Intern Med 2006;144:581-95.
12. Arozullah AM, Khuri SF, Henderson WG, Daley J.
Development and validation of a multifactorial risk index for
predicting postoperative pneumonia after major noncardiac
surgery. Ann Intern Med 2001;135:847-57.
13. Arozullah AM, Daley J, Henderson WG, Khuri SF.
Multifactorial risk index for predicting postoperative respi-
ratory failure in men after major noncardiac surgery. Ann
Surg 2000;232:242-53.
14. Mller AM, Villebro N, Pedersen T, Tnnesen H. Effect of
preoperative smoking intervention on postoperative compli-
cations: a randomised clinical trial. Lancet 2002;359:114-7.
15. Warner DO. Perioperative abstinence from cigarettes.
Anesthesiology 2006;104:356-67.
16. BMA Tobacco Control ResourceCentre2006. Smoking and
surgery: a review for surgeonsand anaesthesiologists. [cited
2009 October 27]. Available at: http://www.doctorsandto-
bacco.org
17. Warner DO. Helping surgical patientsquit smoking: why,
when, and how. Anesth Analg 2005;101:481-7.
18. Warner DO, Patten CA, AmesSC, Offord K, Schroeder D.
Smoking behavior and perceived stressin cigarette smokers
undergoing electivesurgery. Anesthesiology 2004;100:1125-37.
19. Warner DO, Warner MA, BarnesRD, Offord KP, Schroeder
DR, Gray DT et al. Perioperative respiratory complications
in patientswith asthma. Anesthesiology 1996;85:460-7.
20. GibbsJ, Cull W, Henderson W, Daley J, Hur K, Khuri SF.
Preoperative serum albumina level asa predictor of operative
mortality and morbidity: resultsfrom theNational VA Surgical
Risk Study. Arch Surg 1999;134:34-62.
21. Lawrence VA, Cornell JE, Smetana GW. Strategiesto reduce
postoperative pulmonary complicationsafter noncardiotho-
racic surgery: systematic review for the American College of
Physicians. Ann Intern Med 2006;144:596-608.
22. Berg H, Roed J, Viby-Mogensen J, Mortensen CR, Engbaek
J, Skovgaard LT et al. Residual neuromuscular block isa risk
factor for postoperativepulmonary complications. A prospec-
tive, randomised, and blinded study of postoperative pul-
monary complications after atracurium, vecuronium and
pancuronium. Acta Anaesthesiol Scand 1997;41:1095-103.
23. Schultz MJ, Haitsma JJ, Slutsky AS, Gajic O. What tidal vol-
umesshould be used in patientswithout acute lung injury?.
Anesthesiology 2007;106:1226-31.
24. HansGA, Sottiaux TM, Lamy ML, JorisJL. Ventilatory man-
agement during routinegeneral anaesthesia. Eur JAnaesthesiol
2009;26:1-8.
25. Henzler D, Dembinski R, Kuhlen R, Rossaint R. Anesthetic
considerationsin patientswith chronic pulmonary diseases.
Minerva Anestesiol 2004;70:279-84.
26. Pelosi P, Ravagnan I, Giurati G, Panigada M, Bottino N,
Tredici S et al. Positive end-expiratory pressure improves
respiratory function in obese but non in normal subjects
during anesthesia and paralysis. Anesthesiology 1999;91:
1221-31.
27. Rusca M, Proietti S, Schnyder P, Frascarolo P, Suter M, Spahn
DR et al. Prevention of atelectasisformation during theinduc-
tion of general anesthesia. Anesth Analg 2003;97:1835-9.
28. Magnusson L, Spahn DR. New conceptsof atelectasisduring
general anesthesia. Br J Anaesth 2003;91:61-72.
29. Fernandez-Perez ER, Keegan MT, Brown DR, Hubmayr RD,
Gajic O. Intraoperative tidal volume asa risk factor for res-
piratory failure after pneumonectomy. Anesthesiology
2006;105:14-8.
30. Grocott MP, Mythen MG, Gan TJ. Perioperative fluid man-
agement and clinical outcomes in adults. Anesth Analg
2005;100:1093-106.
31. Walder B, Schafer M, Henzi I, Tramer MR. Efficacy and safe-
ty of patient-controlled opioid analgesia for acute postoper-
ativepain. A quantitativesystematic review. Acta Anaesthesiol
Scand 2001;45:795-804.
32. Liu SS, Block BM, Wu CL. Effectsof perioperative central
neuraxial analgesia on outcome after coronary artery bypass
surgery: a meta-analysis. Anesthesiology 2004;101:153-61.
33. Fagevik Olsen M, Hahn I, Nordgren S, Lnroth H, Lundholm
K. Randomized controlled trial of prophylactic chest physio-
therapy in major abdominal surgery. Br J Surg 1997;84:
1535-8.
34. ThomasJA, McIntosh JM. Areincentivespirometry, intermit-
tent positive pressure breathing, and deep breathing exercis-
es effective in the prevention of postoperative pulmonary
complicationsafter upper abdominal surgery?. A systematic
overview and meta-analysis. PhysTher 1994;74:3-10.
35. Overend TJ, Anderson CM, Lucy SD, Bhatia C, Jonsson BI,
TimmermansC. The effect of incentive spirometry on post-
operativepulmonary complications: asystematic review. Chest
2001;120:971-8.
36. Nelson R, EdwardsS, TseB. prophylactic nasogastric decom-
pression after abdominal surgery. Cochrane Database Syst
Rev 2007;18:CD004929.
37. Canet J, RicsM, Vidal F. Early postoperativearterial oxygen
desaturation. Determinig factorsand responseto oxygen ther-
apy. Anesth Analg 1989;69:207-12
38. McBrien ME, SellersWFS. A comparison of threevariableper-
formancedevicesfor postoperativeoxygen therapy. Anaesthesia
1995;50:136-8.
39. Squadrone V, Coha M, Cerutti E, Schellino MM, Biolino P,
OccellaP et al. Continuouspositive airway pressure for treat-
ment of postoperative hypoxemia: A randomized controlled
trial. JAMA 2005;293:589-95.
40. Jaber S, Delay JM, Chanques G, Sebbane M, Jacquet E,
Souche B et al. Outcomesof patientswith acute respiratory
failureafter abdominal surgery treated with noninvasivepos-
itive pressure ventilation. Chest 2005;128:2688-95.
Fundings.Supported by Fundaci La Marat de TV3 grant 041610 (2003).
Conflictsof interest.None.
Acknowledgments.M. E. Keransedited the English language in a version of the manuscript.
Received on April 14, 2009 - Accepted for publication on October 13, 2009.
Corresponding author: J. Canet, Department of Anesthesiology, Hospital Universitari GermansTriasi Pujol, Badalona, Barcelona, Spain.
E-mail: jcanet.germanstrias@gencat.cat
POSTOPERATIVE PULMONARY COMPLICATIONS CANET
Vol. 76 - No. 2 MINERVA ANESTESIOLOGICA 143
MINERVA MEDICA COPYRIGHT