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Preventing postoperative pulmonary complications

By: Cindy Paradiso, MA, RN-BC, CNE

Using ERAS and I COUGH to improve outcomes.


  • Postoperative pulmonary complications are costly and responsible for extended hospital stays and mortalities.
  • Enhanced recovery after surgery (ERAS) are multimodal evidence-based guidelines aimed at reducing stress, decreasing recovery time, enhancing patient satisfaction, and optimizing functionality.
  • I COUGH was designed to mitigate postoperative pneumonia and emphasize incentive spirometry, coughing and deep breathing, oral care, patient and family understanding, getting out of bed, and head of bed elevation.

Editor’s note: This is web exclusive is an early release article for an upcoming issue of the American Nurse Journal. 

Alan Steely* is a 70-year-old man who weighs 205 pounds (93 kg) and has a body mass index (BMI) of 31. Mr. Steely, who has a history of smoking cigarettes (one pack a week for 40 years) and obstructive sleep apnea (OSA), has returned to the medical/surgical unit for postoperative care after a colon resection for colon cancer. In addition to assessing his surgical wound, managing his pain, and monitoring his nasogastric drainage output, you’re especially concerned about his respiratory status because of his BMI, smoking, and OSA history. His care plan calls for managing his postoperative care in accordance with enhanced recovery after surgery (ERAS) and I COUGH protocols, which your institution recently implemented.

Postoperative pulmonary complications

Postoperative pulmonary complications (PPCs) can increase hospital costs, 30-day mortality, and length of stay. PPCs (such as atelectasis, acute respiratory distress syndrome, and postoperative pneumonia) have an occurrence rate of 6% to 80%. Fernandez-Bustamante and colleagues, in a study of a high-risk surgical population, found that the presence of at least one mild or severe PPC was significantly associated with increased early postoperative mortality, intensive care unit admission, and prolonged stays. PPCs occur in one-third of noncardiothoracic surgical patients with severe systemic disease. According to the National Surgical Quality Improvement Program, PPCs include pneumonia, reintubation, and failure to wean from mechanical ventilation after 48 hours; they can cost up to $52,466 per patient.

Because Mr. Steely has all of the risk factors for postoperative pneumonia, you suspect he might develop a PPC. (See Postoperative pulmonary complications risk factors.)

Postoperative pulmonary complications risk factors

Risk factors for postoperative pulmonary complications include smoking, general anesthesia, obesity, advanced age, and obstructive sleep apnea (OSA).

  • Prolonged exposure to cigarette toxins triggers bronchoconstriction, inhibiting the ability of cilia to expel mucus.
  • Anesthesia affects lung wall elasticity pressures by reducing lung volume and compliance, potentially resulting in atelectasis, ventilation-perfusion mismatch, impaired gas exchange, and hypoxia.
  • Patients who are obese are at higher risk of developing atelectasis and decreased expiratory flow and may have difficulty clearing secretions because lung reserve capacity and lung volume decrease as body mass index increases.
  • Age-related changes weaken respiratory musculature strength, diminish thoracic compliance, and decrease the cough reflex. In addition to postoperative pneumonia, older patients may experience pulmonary emboli, pneumothorax, and aspiration pneumonia.
  • OSA reduces airway muscle tone and has been linked to postoperative hypoxia, intensive care unit transfers, and increased lengths of stay. Between 9% and 24% of all surgical patients are at high risk for OSA, underscoring the importance of preoperative screening.

You can use ERAS and I COUGH bundles to optimize his respiratory status.

What is ERAS?

Surgery is a major stressor to the system, resulting in a catabolic physiologic response when stress hormone production triggers inflammation and insulin resistance. ERAS protocol—which is used in colorectal, gynecologic, and general surgery specialties—offers perioperative multimodal evidence-based guidelines for reducing stress, decreasing recovery time, enhancing patient satisfaction, and optimizing functionality. You can use it to follow the patient throughout the perioperative experience until discharge. Highlights of the ERAS protocol include avoiding bowel preparation to prevent dehydration and having the patient consume a clear carbohydrate-rich beverage before midnight and 2 to 3 hours before surgery to prevent thirst, hunger, anxiety, and postoperative insulin resistance. This article focuses on the protocol’s respiratory aspects. (See ERAS protocol highlights.)

ERAS protocol highlights

The goal of the enhanced recovery after surgery (ERAS) protocol is to reduce the risk of postoperative complications. The protocol follows patients from pre-admission through discharge.

Preoperative Intraoperative Postoperative
Preadmission counseling Venous thromboembolism prophylaxis
Early discharge teaching Antibiotic prophylaxis and skin preparation Early ambulation
Reduced fasting Strategies to prevent postop nausea and vomiting Use chewing gum to accelerate GI motility
Carbohydrate loading Prevent hypothermia Breathing and coughing exercises
No selective bowel prep Anesthetic protocol Defined discharge criteria (ambulation, oral solids)
Smoking cessation Minimize opioid use for pain and

prevent nausea and vomiting

Pulmonary rehabilitation and prehabilitation Remove urinary catheters/ drains within 24 hours

Preoperative respiratory management

Systematic reviews (conducted by Batchelor and colleagues and Gustafsson and colleagues) examined studies assessing smoking cessation interventions and preoperative pulmonary rehabilitation to reduce PPC risk.

Smoking cessation. Pulmonary complications related to smoking decrease by 20% to 30% if patients stop smoking 4 weeks before surgery. Behavioral support, nicotine replacement, and pharmacotherapy result in short-term smoking cessation and long-term abstinence. The evidence demonstrating that such interventions actively decrease postoperative morbidity is weak. However, patients should be encouraged to stop smoking at least 4 weeks before surgery to improve airway function and decrease the risk of developing a PPC.

Pulmonary rehabilitation and prehabilitation. The preoperative period is a good opportunity to strengthen the patient’s reserves to withstand surgery. Prehabilitation is defined as preoperatively enhancing functional, nutritional, physiologic, and psychological status and is associated with successful outcomes. It includes aerobic and resistance exercises as well as protein supplementation and relaxation strategies.

Respiratory exercises included within the prehabilitation regimen have been shown to enhance lung function and notably reduce PPCs. However, the exact duration, intensity, structure, and patient selection for prehabilitation are unknown. Although more research is needed, prehabilitation is strongly recommended for patients who can tolerate it and for those with borderline lung function or exercise capacity.

Intraoperative and postoperative respiratory management

Anesthesia management and early patient mobilization are critical to recovery and complication reduction.

Anesthesia and analgesia. Preanesthetic long-acting benzodiazepines are associated with prolonged intubation. Therapeutic communication during preadmission counseling can mitigate patient anxiety, potentially reducing the need for benzodiazepines. Short-acting anesthetic agents, if permissible, should be chosen to allow for early extubation. The combination of regional and general anesthetic management is strongly recommended.

A multimodal postoperative analgesic regimen—including acetaminophen, nonsteroidal anti-inflammatories, gabapentin, and glucocorticoids—is recommended to avoid opioids’ respiratory suppressing effects. If opioids are used, providers must balance their benefits and the adverse effects of suppressing ventilation and coughing.

 Early mobilization. Immobilization is correlated with atelectasis, pneumonia, and venous thromboembolisms (which may progress to pulmonary embolism). Drains, tubes, and catheters are barriers to mobilization. The American College of Obstetricians and Gynecologists recommends removing tubes and drains as soon as possible and getting patients out of bed on postoperative day 0, if not contraindicated.

Fortunately for Mr. Steely, because you’ve been trained on the ERAS protocols, you advocate for his mobility and the use of multimodal pain management (the provider orders acetaminophen for the first 24 hours and gabapentin 300 mg I.V. every 8 hours) rather than opioids to avoid respiratory compromise.

I COUGH. Cassidy and colleagues detail an intervention—I COUGH—developed to reduce PPC.

Incentive spirometry. Incentive spirometry (IS) is recommended 10 times every hour (or, to help patients remember, during television commercial breaks). Instruct patients to inhale slowly, without stopping to exhale, to the prescribed level (based on gender, age, and height) on the IS device. Ensure the device is within easy reach of the patient, and document the patient’s IS volume every 4 hours while he or she is awake.

Cough and deep breathe every 2 hours. During the early postanesthesia period, encourage patients to take a slow deep breath, hold it for 2 seconds, then cough a number of times (splinting the incision from beginning to end of expiration if necessary) to adequately clear airway secretions and re-expand the alveolar surface area.

Oral care. Patients should brush their teeth at least twice a day, floss, and use an oral rinse to reduce the oral bacteria. If a patient can’t perform these tasks, use a specialized kit with a suction toothbrush and antiseptic cleanser.

Understanding why. Provide postoperative education to patients and families via discussions, brochures, videos, and posters. See the Boston University School of Medicine Surgery website for more information.

Get out of bed and ambulate at least three times a day. Accompany patients the first time they get out of bed and ensure they sit in a chair for meals. Emphasize that inactivity puts patients at risk for pulmonary complications.

Head of bed elevation. Elevate the head of the bed higher than 30 degrees to prevent aspiration.

ERAS nursing implications

ERAS protocols can be difficult to implement because they challenge the perioperative dogma nurses and surgeons have used for centuries. For example, preoperative fasting after midnight (no matter when the surgery is scheduled) has been proven to be harmful.

Ideally, ERAS education should begin in nursing school. Buy-in from administrators, nursing staff, surgical staff, and interprofessional teams is paramount for effective implementation. For more information, visit

Essential knowledge

Mr. Steely is discharged in a week thanks, in part, to your postoperative management. You ensured that his nasogastric tube and urinary catheter were promptly removed so he could ambulate, he used his IS 10 times per hour, you administered heparin 5,000 units subcutaneously three times daily as ordered to prevent venous and pulmonary embolism, and you ensured he was out of bed for all meals and walking the unit at least three times each day beginning the second postoperative day. His diet progressed from clear liquids to a low-fiber diet in a timely fashion, and you provided smoking cessation education. Your knowledge of ERAS and I COUGH protocols were essential to his successful surgical outcome.

Cindy Paradiso is a clinical quality analyst at White Plains Hospital in White Plains, New York, and a clinical adjunct instructor at Pace University in Pleasantville, New York.


American College of Obstetricians and Gynecologists. Perioperative pathways: Enhanced recovery after surgery. September 2018.

American College of Surgeons. Quit smoking before surgery program.

Batchelor TJP, Rasburn NJ, Abdelnour-Berchtold E, et al. Guidelines for enhanced recovery after lung surgery: Recommendations of the Enhanced Recovery After Surgery (ERAS®) Society and the European Society of Thoracic Surgeons (ESTS). Eur J Cardiothorac Surg. 2019;55(1):91-115.

Cassidy MR, Rosenkranz P, Macht RD, Talutis S, McAneny D. The I COUGH multidisciplinary perioperative pulmonary care program: One decade of experience. Jt Comm J Qual Patient Saf. 2020;46(5):241-9.

Cassidy MR, Rosenkranz P, McCabe K, Rosen JE, McAneny D. I COUGH: Reducing postoperative pulmonary complications with a multidisciplinary patient care program. JAMA Surg. 2013;148(8):740-5.

Fernandez-Bustamante A, Frendl G, Sprung J, et al. Postoperative pulmonary complications, early mortality, and hospital stay following noncardiothoracic surgery: A multicenter study by the perioperative research network investigators. JAMA Surg. 2017;152(2):157-66.

Gustafsson UO, Scott MJ, Hubner M, et al. Guidelines for perioperative care in elective colorectal surgery: Enhanced Recovery After Surgery (ERAS®) Society recommendations: 2018. World J Surg. 2019;43(3):659-95.

Lemus LP, McMullin B, Balinowski H. Don’t ignore my snore: Reducing perioperative complications of obstructive sleep apnea. J PeriAnesth Nurs. 2018;33(3):338-45.

Pędziwiatr M, Mavrikis J, Witowski J, et al. Current status of enhanced recovery after surgery (ERAS) protocol in gastrointestinal surgery. Med Oncol. 2018;35(6):95.

Porhomayon J, Pourafkari L, El-Solh A, Nader ND. Novel therapies for perioperative respiratory complications. J Cardiovasc Thorac Res. 2017;9(3):121-6.

Pusey-Reid E. Preventing postoperative pneumonia. Nursing2014CriticalCare. 2014;9(4):42-7.

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