From Clinic to Recovery · First Edition
Chapter 19 — Lung Disease, Sleep Apnea, and Surgery
Dr. Tamer Rushdy Elalfy · 12 min read
In this chapter
Lung complications, such as pneumonia, collapse of parts of the lung, and breathing failure, are among the most common serious problems after surgery, and they lengthen hospital stays more than many surgical complications. Patients with asthma, chronic obstructive pulmonary disease (COPD), or obstructive sleep apnea, and those who smoke, are at higher risk. Much of this risk can be reduced by preparation before surgery and by simple actions afterward that patients and families can learn. In the Gulf, the rising prevalence of obesity means that undiagnosed sleep apnea is common among surgical patients, and the widespread use of shisha and vaping adds to the risk.
Learning objectives After reading this chapter you should be able to:
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Table 19.1. Lung disease and surgery at a glance.
| At a glance | |
|---|---|
| Highest-risk patients | Older age, low oxygen levels, recent chest infection, anemia, smoking, COPD, poorly controlled asthma, and sleep apnea |
| Highest-risk operations | Upper abdominal and chest operations, operations longer than 2 hours, and emergencies |
| Before surgery | Stop smoking; optimize inhalers; bring CPAP; delay elective surgery after a recent chest infection |
| After surgery | Good pain relief, sitting up, walking early, deep breathing, coughing, and oral care |
| The key counseling message | “Your lungs need preparing for surgery, just as your body does. After the operation, sitting up, walking, and deep breathing are part of your treatment.” |
STEP 1 Explaining the risk and making the plan
19.1 Who is at risk
The ARISCAT score identifies the main predictors of postoperative pulmonary complications: older age, low preoperative oxygen saturation, a respiratory infection in the previous month, anemia, an upper abdominal or chest incision, an operation lasting more than 2 hours, and emergency surgery [1]. Smoking, COPD, asthma, and sleep apnea add to the risk. Figure 19.1 links each risk factor to an action that patients and teams can take.
[Figure — diagram omitted in this text edition; see the figure caption below and the Word chapter file for the image]
Figure 19.1. Risk factors for lung complications after surgery, and what helps.
Script: explaining lung risk “Your lungs are more likely to have problems after this operation because of [your COPD / your smoking / the type of operation]. The most common problem is that small parts of the lung do not fully open, which can lead to a chest infection.” “There is a lot we can do together. Before the operation, we will make sure your inhalers are working well and help you stop smoking. Afterward, we will control your pain so you can breathe deeply, and get you sitting up and walking early.” |
19.2 Asthma
Patients with well-controlled asthma rarely have serious problems. Ask about recent attacks, hospital admissions, and courses of oral steroids. Patients should continue their usual inhalers, including on the morning of surgery, and bring their reliever inhaler to hospital [2]. Elective surgery is best delayed if asthma is poorly controlled or after a recent attack. Patients who have taken oral steroids recently may need steroid cover (Chapter 21). Some patients with asthma react to anti-inflammatory medicines such as ibuprofen; ask before prescribing them for pain.
19.3 COPD
For patients with COPD, check symptoms, recent exacerbations, oxygen saturation, and inhaler technique. Continue regular inhalers, review whether pulmonary rehabilitation is possible before major elective surgery, and delay elective surgery until an exacerbation has fully resolved [3]. Patients on home oxygen need a plan for oxygen in hospital and at discharge. Discuss the higher risk of chest infection, prolonged oxygen need, and possible intensive care admission honestly, in natural frequencies where unit data are available. Preoperative inspiratory muscle training reduced lung complications in trials of major surgery and may be offered where available [4].
19.4 Obstructive sleep apnea
Obstructive sleep apnea is common in surgical patients, especially those with obesity, and is often undiagnosed. It increases the risk of airway difficulty during anesthesia and of breathing problems after surgery, particularly with opioids and sedatives. Screen all adults with the STOP-Bang questionnaire (Table 19.2); a score of 5 or more, or 3 or more with certain features, indicates a high likelihood of moderate to severe sleep apnea [5]. Patients with known sleep apnea should bring their CPAP machine and use it in hospital. Patients with suspected but undiagnosed sleep apnea can usually proceed with surgery, with precautions, unless they have uncontrolled related conditions such as heart failure or very low oxygen levels [6].
Table 19.2. The STOP-Bang screening questionnaire for obstructive sleep apnea.
| Letter | Question | Score 1 point if yes |
|---|---|---|
| S | Snoring: do you snore loudly? | Yes |
| T | Tired: do you often feel tired or sleepy during the day? | Yes |
| O | Observed: has anyone seen you stop breathing during sleep? | Yes |
| P | Pressure: do you have high blood pressure? | Yes |
| B | BMI above 35 | Yes |
| A | Age over 50 | Yes |
| N | Neck circumference above 40 cm | Yes |
| G | Gender: male | Yes |
Caution: sleep apnea and opioids
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19.5 Smoking, shisha, and vaping
Smoking increases wound and lung complications, and stopping before surgery reduces them; at least 4 weeks is ideal, but stopping at any time is worthwhile (Chapter 2) [7, 8]. Ask specifically about shisha (waterpipe) and vaping, which many patients do not regard as smoking. Offer support and nicotine replacement (Chapter 27).
STEP 2 Preparation and recovery
19.6 Before the operation
- Stop smoking, including shisha and vaping, as early as possible.
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Inhalers. Continue them, check technique, and bring them to hospital.
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CPAP. Bring the machine, mask, and tubing, labeled with the patient’s name.
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Chest infection. Treat it and delay elective surgery until recovered.
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Activity. Walk daily; offer inspiratory muscle training or pulmonary rehabilitation before major surgery where available.
19.7 After the operation: I COUGH
A simple bundle called I COUGH (incentive breathing, coughing, oral care, understanding, getting out of bed, and head of bed elevation) reduced postoperative pneumonia when introduced as a hospital-wide program [9] (Figure 19.2). Incentive spirometry used alone has not been shown to prevent lung complications after abdominal surgery [10], so it should be part of the bundle, not a replacement for walking and good pain control.
[Figure — diagram omitted in this text edition; see the figure caption below and the Word chapter file for the image]
Figure 19.2. The I COUGH steps for protecting the lungs after surgery, for use with patients.
STEP 3 Questions patients ask
“Should I take my inhalers on the morning of the operation?”
Yes. Take your usual inhalers and bring your reliever with you.
“Why do you ask about my snoring?”
Loud snoring and stopping breathing during sleep can be signs of sleep apnea, which affects how we give anesthesia and pain medicines [5].
“Do I need to bring my CPAP machine?”
Yes, please. You will use it after the operation and every night in hospital.
“I only smoke shisha. Does that count?”
Yes. Shisha and vaping also affect your lungs and healing. Stopping before surgery helps.
“Why do you want me out of bed so soon?”
Sitting up and walking open your lungs and prevent chest infections and clots. It is part of your treatment.
“It hurts to cough. Should I avoid it?”
No. Hold a pillow over your wound and cough gently. Tell us if pain stops you from coughing or breathing deeply, and we will adjust your pain relief.
“I had a chest infection last week. Can I still have my operation?”
For a planned operation, it is usually safer to wait until you have fully recovered.
STEP 4 Risks, warning signs, and consent
19.8 Additional risks
Table 19.3. Additional risks for patients with lung disease or sleep apnea. Square brackets mark figures to replace with unit data.
| Band | Risk | Typical frequency | Example wording |
|---|---|---|---|
| Common | Shortness of breath or low oxygen needing extra oxygen for a few days | [unit data] | “You may need oxygen for a few days.” |
| Less common | Chest infection after surgery | Higher with COPD, smoking, and upper abdominal surgery [unit data] | “A chest infection is more likely because of your lungs.” |
| Less common | Asthma or COPD flare | [unit data] | “Your breathing may get worse for a while; we will treat it.” |
| Rare but serious | Breathing failure needing a breathing machine or intensive care | [unit data] | “Rarely, people need help from a breathing machine.” |
| Rare but serious | Breathing problems related to sleep apnea and pain medicines | [unit data] | “Using your CPAP and careful pain medicines keep you safe.” |
19.9 Checklist
Before surgery ☐ Smoking, shisha, and vaping asked about; cessation support offered. ☐ Asthma and COPD control reviewed; inhaler technique checked; recent infection excluded. ☐ STOP-Bang screening done; CPAP plan confirmed for known sleep apnea. ☐ Oral steroid use in the last months asked about (Chapter 21). ☐ Anti-inflammatory sensitivity in asthma asked about. ☐ I COUGH steps taught with teach-back; pain plan supports deep breathing. |
19.10 Warning signs
Table 19.4. Green, amber, and red warning signs for lung problems after surgery.
| Level | Signs | What to do |
|---|---|---|
| Green | Mild cough and slight breathlessness that improve each day | Expected. Keep doing I COUGH. |
| Amber | Cough with yellow or green phlegm Temperature of 38 °C or more Needing your reliever inhaler more than usual | Call the clinic or your doctor the same day. |
| Red | Breathlessness at rest or getting worse Chest pain, or coughing blood Lips turning blue, or confusion Severe asthma attack not relieved by your inhaler | Call an ambulance or go to the emergency department now. |
Key points
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STEP 5 Patient education guide
The following pages may be photocopied and given to patients. Add your unit’s name, phone numbers, and review date before use.
PATIENT GUIDE Your Lungs and Your Operation For people with asthma, COPD, sleep apnea, or who smoke, and their families. |
Before your operation
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Stop smoking now, including shisha and vaping. Ask us for help.
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Keep taking your inhalers, including on the morning of the operation. Bring them with you.
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If you have sleep apnea, bring your CPAP machine, mask, and tubing.
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If you get a chest infection before your operation, tell us. We may need to wait.
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Walk every day to keep your lungs strong.
After your operation: I COUGH
[Figure — diagram omitted in this text edition; see the figure caption below and the Word chapter file for the image]
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Take 10 slow, deep breaths every hour while you are awake.
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Cough while holding a pillow over your wound.
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Brush your teeth and rinse your mouth twice a day.
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Sit up in a chair for meals and walk several times a day.
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Rest with your head raised.
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Use your CPAP every time you sleep, including naps.
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Tell us if pain stops you from breathing deeply or coughing.
At home
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Keep walking every day and doing your deep breaths.
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Keep using your inhalers and CPAP.
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Stay smoke-free. Your lungs keep healing.
Warning signs: when to get help
| Level | What you notice | What to do |
|---|---|---|
| GREEN | Mild cough and slight breathlessness that improve each day | This is normal. Keep doing I COUGH. |
| AMBER | Yellow or green phlegm; temperature of 38 °C or more; needing your reliever more than usual | Call us or your doctor today. |
| RED | Breathless at rest or getting worse; chest pain; coughing blood; blue lips; confusion; an asthma attack your inhaler does not help | Call an ambulance or go to the emergency department now. |
My contacts Clinic phone: ______________________ Hours: ______________ Out of hours: ______________________ [Unit name] [Guide version and review date] |
References
1. Canet J, Gallart L, Gomar C, et al. Prediction of postoperative pulmonary complications in a population-based surgical cohort. Anesthesiology. 2010;113(6):1338-1350.
2. Global Initiative for Asthma. Global Strategy for Asthma Management and Prevention. 2025 update. Available from ginasthma.org.
3. Global Initiative for Chronic Obstructive Lung Disease. Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease: 2025 report. Available from goldcopd.org.
4. Katsura M, Kuriyama A, Takeshima T, Fukuhara S, Furukawa TA. Preoperative inspiratory muscle training for postoperative pulmonary complications in adults undergoing cardiac and major abdominal surgery. Cochrane Database Syst Rev. 2015;(10):CD010356.
5. Chung F, Abdullah HR, Liao P. STOP-Bang Questionnaire: a practical approach to screen for obstructive sleep apnea. Chest. 2016;149(3):631-638.
6. Chung F, Memtsoudis SG, Ramachandran SK, et al. Society of Anesthesia and Sleep Medicine guidelines on preoperative screening and assessment of adult patients with obstructive sleep apnea. Anesth Analg. 2016;123(2):452-473.
7. Thomsen T, Villebro N, Møller AM. Interventions for preoperative smoking cessation. Cochrane Database Syst Rev. 2014;(3):CD002294.
8. Myers K, Hajek P, Hinds C, McRobbie H. Stopping smoking shortly before surgery and postoperative complications: a systematic review and meta-analysis. Arch Intern Med. 2011;171(11):983-989.
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):740-745.
10. do Nascimento Junior P, Módolo NSP, Andrade S, et al. Incentive spirometry for prevention of postoperative pulmonary complications in upper abdominal surgery. Cochrane Database Syst Rev. 2014;(2):CD006058.
Note: references are numbered within this chapter for the pilot. Items marked in square brackets are collected in the Author Fill-in and Verification Log.