SMOKING AND POSTOPERATIVE PULMONARY COMPLICATIONS: An Evidence-Based Review of the Recent Literature

doi:10.1016/S0272-5231(05)70013-7

Clinics in Chest Medicine

Volume 21, Issue 1, 1 March 2000, Pages 139-146

https://doi.org/10.1016/S0272-5231(05)70013-7 Get rights and content

Surgical procedures, both thoracic and nonthoracic, can adversely affect pulmonary function and result in postoperative pulmonary complications (PPC) that significantly affect morbidity and mortality. The incidence of PPCs in the literature varies widely, related mainly to differences in study design, population, and definition of pulmonary complications. Several risk factors for the development of a PPC have been identified, including the site of operation, the type and duration of anesthesia, and the existence of comorbid conditions, especially underlying chronic lung disease. Smoking, through its effects on the cardiovascular and respiratory systems, is believed to increase this risk.

Section snippets

SMOKING AS A RISK FACTOR FOR POSTOPERATIVE PULMONARY COMPLICATIONS

The relationship between smoking and PPCs was first noted by Morton¹⁶ in 1944, who found a sixfold increase in the postoperative morbidity in patients who smoked more than 10 cigarettes per day. Wightman²² subsequently demonstrated that smokers had more frequent postoperative fever, increased sputum production, and new abnormal chest physical findings than did nonsmokers. The data concerning the relationship between smoking and PPCs are difficult to apply clinically. Often, the sample size is

SMOKING CESSATION

If we are to accept the fact that smoking increases the risk of developing a PPC, it would be logical to assume that smoking cessation or reduction might lessen this risk. The benefits of smoking cessation on cardiovascular morbidity have been reviewed extensively1, 7, 17 and are:

Decreased heart rate
Decreased systolic and diastolic blood pressure
Increased oxygen content
Increased tissue oxygen delivery and utilization.

Specific outcome studies on the usefulness of short-term smoking

CONCLUSION

Active smoking may be an independent risk factor for the development of PPC, likely through the mechanisms of decreased mucociliary clearance and abnormal small airway function. The exact role of smoking in the development of PPC is difficult to tease out given the confounding by the presence of smoking-related lung disease. The optimal time for smoking cessation among patients who have not previously quit is likely at least 6 to 8 weeks prior to surgery. It is unclear whether smoking cessation

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Correlation Between Smoking Status and Short-term Outcome of Thoracoscopic Surgery for Lung Cancer
2022, Annals of Thoracic Surgery
Citation Excerpt :
Nakagawa and colleagues22 concluded that at least 4 weeks of smoking cessation was necessary for a discernible reduction in the incidence of pulmonary complications. A review by Moores23 summarized that a preoperative smoking cessation period of 6 to 8 weeks is optimal23 because smoking cessation for 2 months reduces airway inflammation and intraoperative sputum volume. Our results showed that a shorter smoking cessation period was associated with a higher pulmonary complication rate.
Smoking has a major role in the risk of postoperative pulmonary complications. This study aimed to elucidate the correlation between smoking status and pulmonary complications after thoracoscopic surgery for lung cancer.
A total of 1751 patients who underwent thoracoscopic lobectomy or segmentectomy for lung cancer between April 2011 and March 2020 were assessed. The rate of pulmonary complications was evaluated according to smoking status and preoperative duration of smoking cessation. Univariate and multivariate logistic regression analyses were performed.
Pulmonary complications were observed in 50 patients (2.9%), whereas 3 (0.2%) died within 90 days of surgery. The rate of pulmonary complications was higher in smokers than in nonsmokers (4.6% vs 0.9%; P < .001), and smoking history was an independent risk factor for pulmonary complications (odds ratio, 3.31; P = .007). The complication rate in patients with a cessation period of more than 2 months was significantly lower than that in patients who ceased smoking within 2 months (4.0% vs 8.5%; P = .043), but it was still higher than that in nonsmokers (4.0% vs 0.9%; P < .001). In the multivariable analysis for smokers, preoperative short-term smoking cessation within 2 months, male sex, histologic type, tumor size, and cardiopulmonary comorbidities were associated with pulmonary complications instead of pack-year smoking history.
Smoking habits and preoperative smoking cessation were independently associated with pulmonary complications after thoracoscopic surgery for lung cancer. A preoperative smoking cessation period of 2 months or more is preferable for reducing the risk of such complications.
Cognitive impairment assessment and interventions to optimize surgical patient outcomes
2020, Best Practice and Research: Clinical Anaesthesiology
Citation Excerpt :
Tobacco use is linked to greater functional impairment, postoperative complication rates across surgical specialties, and mortality [143]. In a systematic review, patients who were current smokers had a 24% greater risk of developing postoperative complications [144], including respiratory infections, delayed wound healing, increased LOS in the ICU, prolonged hospital LOS, and greater chance of readmission [145–148]. The downstream negative effects of tobacco smoking are due to carbon monoxide and nicotine, which increase the heart rate, blood pressure, and the overall demand for oxygen.
For elderly patients undergoing elective surgical procedures, preoperative evaluation of cognition is often overlooked. Patients may experience postoperative delirium (POD) and postoperative cognitive decline (POCD), especially those with certain risk factors, including advanced age. Preoperative cognitive impairment is a leading risk factor for both POD and POCD, and studies have noted that identifying these deficiencies is critical during the preoperative period so that appropriate preventive strategies can be implemented. Comprehensive geriatric assessment is a useful approach which evaluates a patient's medical, psycho-social, and functional domains objectively. Various screening tools are available for preoperatively identifying patients with cognitive impairment. The Enhanced Recovery After Surgery (ERAS) protocols have been discussed in the context of prehabilitation as an effort to optimize a patient's physical status prior to surgery and decrease the risk of POD and POCD. Evidence-based protocols are warranted to standardize care in efforts to effectively meet the needs of these patients.
Current evidence on the role of smoking in plastic surgery elective procedures: A systematic review and meta-analysis
2018, Journal of Plastic, Reconstructive and Aesthetic Surgery
Citation Excerpt :
Smoking is highly associated with the development of postoperative complications after a variety of surgical procedures. Specifically, tobacco use has been reported as a major risk factor for postoperative pulmonary, cardiovascular and surgical site complications.1–6 The indirect effect of tobacco metabolism byproducts on oxygen supply to the tissues has been proposed as a possible mechanism, as it impairs the healing process and increases the risk for wound infections.7–11
Smoking is considered to be a significant risk factor for the development of postoperative complications after various surgical procedures, mainly by limiting oxygen delivery to tissues. Evidence on the collective impact of smoking in aesthetic procedure outcomes is scarce. The aim of this study is to evaluate the current evidence on the association between smoking and postoperative outcomes in patients who underwent common elective procedures in plastic surgery.
PubMed and Cochrane bibliographical databases were searched from January 1950 to October 2016 for studies reporting on patients who underwent facelift, abdominoplasty, breast reduction and breast reconstruction and for studies with included data on smoking history of treated patients.
Fifty-three studies reporting on postoperative complications in tobacco users undergoing facelift, abdominoplasty, breast reduction and reconstruction were identified. Tobacco use is found to significantly increase the total number of postoperative complications as far as abdominoplasty (OR: 5.43; 95% CI = 2.92–10.10), breast reduction (OR: 2.36; 95% CI = 1.64–3.39) and breast reconstruction (OR: 1.91; 95% CI = 1.69–2.17) are concerned. Smoking history does not significantly affect total postoperative complications after facelift procedures (OR: 3.36; 95% CI = 0.92–12.30).
Smoking predisposes to surgical site infections, delayed wound healing and skin necrosis in patients undergoing the most common aesthetic procedures in plastic surgery. More rigorous and detailed reporting on the history of tobacco use and surgical outcomes following plastic surgery procedures is needed to better quantify the impact of smoking on the overall postoperative care for this patient population.
Prevention of Postoperative Pulmonary Complications
2015, Surgical Clinics of North America
Citation Excerpt :
A review of smoking cessation found an overall postoperative complication risk reduction of 41%; this risk reduction was improved with each additional week of cessation.142 A transient increase in sputum production may actually increase risk for PPCs in the first several weeks after smoking cessation.143–146 Therefore, abstinence should be recommended for a period of at least 4 weeks preoperatively to be beneficial.147–150
Smoking and plastic surgery, part I. Pathophysiological aspects: Update and proposed recommendations
2015, Annales de Chirurgie Plastique Esthetique
Citation Excerpt :
Cardiovascular events related to tobacco are largely due to the action of nicotine on the sympathetic nervous system [66]. The period of early tobacco withdrawal is said to involve a risk of pulmonary complications that are associated with a increase in mucus secretion and bronchial hyperreactivity (Fig. 3), but the affirmation remains controversial [41,67]. For most of the authors, 6 to 8 weeks of withdrawal suffice to significantly improve pulmonary function [68,69].
Smoking patients undergoing a plastic surgery intervention are exposed to increased risk of perioperative and postoperative complications. It seemed useful to us to establish an update about the negative impact of smoking, especially on wound healing, and also about the indisputable benefits of quitting. We wish to propose a minimum time lapse of withdrawal in the preoperative and postoperative period in order to reduce the risks and maximize the results of the intervention.
A literature review of documents from 1972 to 2014 was carried out by searching five different databases (Medline, PubMed Central, Cochrane library, Pascal and Web of Science).
Cigarette smoke has a diffuse and multifactorial impact in the body. Hypoxia, tissue ischemia and immune disorders induced by tobacco consumption cause alterations of the healing process. Some of these effects are reversible by quitting. Data from the literature recommend a preoperative smoking cessation period lasting between 3 and 8 weeks and up until 4 weeks postoperatively. Use of nicotine replacement therapies doubles the abstinence rate in the short term. When a patient is heavily dependent, the surgeon should be helped by a tobacco specialist.
Total smoking cessation of 4 weeks preoperatively and lasting until primary healing of the operative site (2 weeks) appears to optimize surgical conditions without heightening anesthetic risk. Tobacco withdrawal assistance, both human and drug-based, is highly recommended.
Le patient tabagique bénéficiant d’une intervention de chirurgie plastique est exposé à un risque majoré de complications péri- et postopératoires. Il nous semblait utile d’établir une mise au point sur le retentissement négatif, en particulier cicatriciel, du tabagisme et sur les bénéfices incontestables du sevrage. Nous souhaitons proposer un délai minimal de sevrage pré- et postopératoire en vue de réduire les risques et d’optimiser les résultats de l’intervention.
Une revue de la littérature a été réalisée sur la période 1972–2014 en interrogeant cinq bases de données (Medline, PubMed Central, Cochrane library, Pascal et Web of Science).
La fumée de cigarette agit de manière diffuse et multifactorielle dans l’organisme. L’hypoxie et l’ischémie tissulaire ainsi que les désordres immunitaires induits par le tabac sont responsables de l’altération du processus cicatriciel. Une partie de ces effets est réversible au sevrage. Les données de la littérature conseillent un délai d’arrêt du tabagisme préopératoire situé entre 3 et 8 semaines et allant jusqu’à 4 semaines postopératoires. L’utilisation de traitements substitutifs nicotiniques double le taux d’abstinence à court terme. Le chirurgien doit s’aider d’un tabacologue en cas de dépendance importante de son patient.
Un sevrage tabagique total de 4 semaines préopératoires et jusqu’à la cicatrisation primaire du site opératoire, soit 2 semaines postopératoires, semble optimiser les conditions chirurgicales sans majorer le risque anesthésique. Un accompagnement du sevrage aussi bien humain que médicamenteux est recommandé.
Anaesthesia in smokers
2013, Trends in Anaesthesia and Critical Care
Smoking increases the risk of postoperative complications. The potentially most serious smoking-related complications are cardiovascular and respiratory events and delayed wound healing and infection. Smokers should have these risks explained in the preoperative visit and lifetime exposure should be calculated. High exposure should signal the need to refer patients for expert management whether or not clinical manifestations of respiratory disease are found. Preoperative abstinence from smoking must be strongly recommended in all situations because it has been shown to reduce postoperative morbidity. The parents of children about to undergo surgery should be warned of the consequences of passive smoking.

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: Address reprint requests to Lisa K. Moores, MD, Pulmonary and Critical Care Medicine Service, Wd 77, Bldg 2, Walter Reed Army Medical Center, 6900 Georgia Avenue, NW, Washington, DC 20307, e-mail: [email protected]

^*: Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland; and Invasive Procedures Suite, Pulmonary and Critical Care Medicine Service, Walter Reed Army Medical Center, Washington, DC

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SMOKING AND POSTOPERATIVE PULMONARY COMPLICATIONS: An Evidence-Based Review of the Recent Literature

Section snippets

SMOKING AS A RISK FACTOR FOR POSTOPERATIVE PULMONARY COMPLICATIONS

SMOKING CESSATION

CONCLUSION

Chest

Chest

Heart Lung

Respir Med

J Clin Anesth

Am J Med

Chest

J Clin Anesth

Chest

Lancet

Am J Med Sci