Perioperative Respiratory Risk and Pulmonary Protection in Upper Abdominal Surgery: From Early Prediction to Stepwise Ventilatory Support

Abstract

Pleuropulmonary complications remain a frequent cause of morbidity after upper abdominal surgery and are associated with prolonged hospitalization, greater need for respiratory support, and delayed postoperative recovery. This study analyzed current evidence regarding the prediction, prevention, and stepwise management of postoperative pulmonary complications in adult patients undergoing major upper abdominal procedures. A structured integrative review was conducted using the Scientific Method, incorporating randomized clinical trials, observational studies, systematic reviews, meta-analyses, and relevant multicenter investigations. The evidence was organized into three main domains: perioperative risk prediction, preventive respiratory strategies, and escalation of postoperative respiratory support. The results showed that variables such as low preoperative oxygen saturation, advanced age, recent respiratory infection, anemia, prolonged surgery, emergency procedures, and upper abdominal incisions contribute to increased pulmonary risk. Preoperative physiotherapy and inspiratory muscle training were associated with reductions in postoperative respiratory complications in selected populations. Intraoperatively, lung-protective ventilation based on lower tidal volumes and individualized assessment of PEEP, respiratory compliance, and driving pressure was associated with improved pulmonary outcomes, whereas routine use of high PEEP did not consistently reduce complications. Postoperatively, prophylactic CPAP did not demonstrate universal benefit, while noninvasive ventilation reduced re-intubation and healthcare-associated infections in patients with established hypoxemic respiratory failure. Overall, the findings support a multimodal, risk-adapted, and stepwise perioperative strategy integrating early risk identification, pulmonary protection, postoperative surveillance, and timely escalation of respiratory support.