Preventing Postoperative Pneumonia

摘要

While pneumonia is a common postoperative complication, there is a paucity of literature on pneumonia prevention outside of the intensive care unit.Wren and colleagues designed and implemented a wardbased pneumonia prevention program at the Veterans Affairs Palo Alto Health Care System in 2007. They previously reported an initial 81% decrease in the incidenceofward-acquiredpneumonia1 andnow report a significant long-term decrease when compared both with preintervention rates and the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP).2 Although encouraging, these findings should be interpreted with caution. The preintervention rate of pneumonia was 0.78% in the Veterans Affairs Palo Alto Health Care System and 2.56% in ACS-NSQIP—a difference of 328% that is already of statistical significance. This remarkably low rateof pneumonia calls into question the adequacyof detection and reportingof pneumonia on their ward and alsomakes their finding of a significant differencebetween theirpostinterventionandACS-NSQIP rate of somewhat less consequence. A second concern is that the authors’ previous article reported that the overall rate of postoperative non– ventilator-associated pneumonia did not change with implementation of their program. Although the number of ward cases decreased from 13 to 3, the number of non– ventilator-associated pneumonia intensive care unit cases increased from 4 to 17, and therefore, the reported decrease could be due to redistribution in the location of patients. A third concern is that the authors did not evaluate changes in patient care or surgical technique that could have altered the incidence of postoperative pneumonia. A systematic review of strategies to reduce postoperative pulmonary complications3 found that choice of neuraxial blockade over general anesthesia led to a significant reduction in the rate of postoperative pneumonia (odds ratio = 0.61; 95% CI, 0.48-0.76), as did selective nasogastric decompression (odds ratio = 0.49; P < .001). Moreover, the authors’ program was implemented and evaluated over a period in which there was an ongoing shift from open to laparoscopic or robotic surgical techniques, which has been shown to significantly decrease the rates of postoperative pneumonia, particularly in colorectal and prostate operations.4,5 Without collecting and analyzing such data, it is impossible to know if any of them contributed to their findings. Despite these concerns, the authors should be commended for the development and implementation of a quality improvementmeasureaimedatdecreasing the rateofpostoperative pneumonia in a Veterans Affairs population. The 8 interventionsused in their programarenot particularly costly or time-consuming and serve to increase awareness and education of all health care professionals caring for postoperative patients.