Relationship between cigarette smoking and the carbon monoxide concentration in the exhaled breath with perioperative respiratory complications

Ozgunay, Seyda Efsun; Karasu, Derya; Dulger, Seyhan; Yilmaz, Canan; Tabur, Zeynep

doi:10.1016/j.bjane.2018.02.003

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Scientific Articles • Rev. Bras. Anestesiol. 68 (5) • Sep-Oct 2018 • https://doi.org/10.1016/j.bjane.2018.02.003 copy

Relationship between cigarette smoking and the carbon monoxide concentration in the exhaled breath with perioperative respiratory complications

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Background

The purpose of the current study was to determine the effects of preoperative cigarette smoking and the carbon monoxide level in the exhaled breath on perioperative respiratory complications in patients undergoing elective laparoscopic cholecystectomies.

Methods

One hundred and fifty two patients (smokers, Group S and non-smokers, Group NS), who underwent laparoscopic cholecystectomies under general anesthesia, were studied. Patients completed the Fagerstrom Test for Nicotine Dependence. The preoperative carbon monoxide level in the exhaled breath levels were determined using the piCO+ Smokerlyzer 12 h before surgery. Respiratory complications were recorded during induction of anesthesia, intraoperatively, during extubation, and in the recovery room.

Results

Statistically significant increases were noted in group S with respect to the incidence of hypoxia during induction of anesthesia, intraoperative bronchospasm, bronchodilator treatment intraoperatively, and bronchospasm during extubation. The carbon monoxide level in the exhaled breath and the Fagerstrom Test for Nicotine Dependence, and number of cigarettes smoked 12 h preoperatively were designated as covariates in the regression model. Logistic regression analysis of anesthetic induction showed that a 1 unit increase in the carbon monoxide level in the exhaled breath level was associated with a 1.16 fold increase in the risk of hypoxia (OR = 1.16; 95% CI 1.01–1.34; p = 0.038). Logistic regression analysis of the intraoperative course showed that a 1 unit increase in the number of cigarettes smoked 12 h preoperatively was associated with a 1.16 fold increase in the risk of bronchospasm (OR = 1.16; 95% CI 1.04–1.30; p = 0.007). While in the recovery room, a 1 unit increase in the Fagerstrom Test for Nicotine Dependence score resulted in a 1.73 fold increase in the risk of bronchospasm (OR = 1.73; 95% CI 1.04–2.88; p = 0.036).

Conclusions

Cigarette smoking was shown to increase the incidence of intraoperative respiratory complications while under general anesthesia. Moreover, the estimated preoperative carbon monoxide level in the exhaled breath level may serve as an indicator of the potential risk of perioperative respiratory complications.

KEYWORDS
Smoking; CO exhaled; Peri-operative; Respiratory complications; Laparoscopic cholecystectomy

Variable	Group S (n = 75)	Group NS (n = 77)	p-Value
Age (years)	43 ± 11.45	48.49 ± 12.15	0.059^a a Independent samples t-test.
Height (cm)	167.12 ± 8.29	164.30 ± 9.49	0.610^a a Independent samples t-test.
Body weight (kg)	77.76 ± 14.63	77.51 ± 12.96	0.910^a a Independent samples t-test.
Female/male (%)	44 (58.70%)/31 (41.30%)	55 (71.40%)/22 (28.60%)	0.099^b b Pearson chi-square test.
Employed/unemployed/retired (%)	44.60%/40.50%/14.90%	27%/56.80%/16.20%	0.073^b b Pearson chi-square test.

Baseline characteristics	Group S (n = 75)
Starting age of smoking (years)	19.80 ± 7.46
Cigarettes smoked per day	14.61 ± 8.94
Duration of smoking (years)	20.89 ± 11.93
Number of cigarettes smoked 12 h preoperative	5.45 ± 6.36
FTND	3.76 ± 2.07

Stages of the surgery	Recorded complications	Group S (n = 75)	Group NS (n = 77)	p-Value
Preoperative	Hypoxia	9 (12%)	5 (6.50%)	0.241^a a Pearson chi-square test.
Induction	Hypoxia	14 (18.70%)	4 (5.20%)	0.010^a a Pearson chi-square test.
Intraoperative	Hypoxia	4 (5.30%)	2 (2.60%)	0.439^b b Fisher's exact test.
	Bronchospasm	6 (80%)	0	0.013^b b Fisher's exact test.
	Bronchodilator treatment	7 (9.30%)	1 (1.30%)	0.033^b b Fisher's exact test.
Extubation	Bronchospasm	4 (5.30%)	0	0.057^b b Fisher's exact test.
Extubation	Bronchodilator treatment	1 (1.30%)	0	0.493^b b Fisher's exact test.
Recovery room	Hypoxia	27 (36%)	6 (7.80%)	<0.001^a a Pearson chi-square test.
	Apnea	5 (6.70%)	0	0.027^b b Fisher's exact test.
	Sore throat	16 (21.30%)	9 (11.70%)	0.109^a a Pearson chi-square test.
	Headache	10 (13.30%)	4 (5.20%)	0.083^a a Pearson chi-square test.
	Coughing	31 (41.30%)	5 (6.50%)	<0.001^a a Pearson chi-square test.
	Bronchospasm	1 (1.30%)	0	0.493^b b Fisher's exact test.

Stages of the anesthesia	Factor	Wald	OR (95% CI)	p-Value
Preoperative	Tabagism	0.22	0.97 (0.84-1.12)	0.643
	E(BCO)	0.19	0.96 (0.79-1.17)	0.664
	FTND	0.57	1.15 (0.81-1.62)	0.450
Induction	Tabagism	0.73	0.95 (0.85-1.07)	0.393
	E(BCO)	4.32	1.16 (1.01-1.34)	0.038
	FTND	0.35	0.90 (0.65-1.26)	0.553
Intraoperative	Tabagism	0.07	1.02 (0.88-1.18)	0.798
	E(BCO)	0.26	1.06 (0.86-1.31)	0.609
	FTND	0.47	0.82 (0.45-1.47)	0.495
Recovery room	Tabagism.	4.38	0.88 (0.77-0.99)	0.036
	E(BCO)	0.01	1.09 (0.84-1.40)	0.943
	FTND	0.38	1.09 (0.85-1.39)	0.537

Stages of the anesthesia	Factor	Wald	OR (95% CI)	p-Value
Extubation	Tabagism	3.43	1.12 (0.99-1.25)	0.067
	E(BCO)	0.18	0.94 (0.71-1.25)	0.663
	FTND	0.01	1.02 (0.60-1.76)	0.937
Intraoperative	Tabagism	7.39	1.16 (1.04-1.30)	0.007
	E(BCO)	0.25	1.05 (0.87-1.27)	0.616
	FTND	0.47	0.84 (0.50-1.40)	0.492
Recovery room	Tabagism	0.13	0.69 (0.42-1.14)	0.151
	E(BCO)	0.64	1.05 (0.86-1.29)	0.642
	FTND	4.40	1.73 (1.04-2.88)	0.036

	Group S (n = 75)	Group NS (n = 77)	p-Value
Duration of anesthesia (min)	77.50 (30-190)	70 (40-170)	0.048^b b Mann-Whitney U test.
Duration of surgery (min)	60 (20-180)	55 (30-160)	0.213^b b Mann-Whitney U test.
Time required for recovery (min)	20 (16-60)	15 (10-45)	0.031^b b Mann-Whitney U test.
MAS (5th minute)	7 (1-10)	9 (6-10)	<0.001^b b Mann-Whitney U test.
MAS (10-5th minute)	2 (0-5)	1 (0-3)	<0.001^b b Mann-Whitney U test.
MAS (15-5th minute)	2 (0-7)	1 (0-4)	<0.001^b b Mann-Whitney U test.
eBCO	7.50 ± 4.66	2.53 ± 1.22	<0.001^a a Independent samples t-test.

Source	Study design	Period	Respiratuvar complications	Validation	Nicotine dependency	Type of surgery
Graybill et al.¹1 Graybill WS, Frumovitz M, Nick AM, et al. Impact of smoking on perioperative pulmonary and upper respiratory complications after laparascopic gynecologic surgery. Gynecol Oncol. 2012;125:556-60.	Retrospective	30 day postsurgey	Hypoxia	None	FTND	Laparoscopic gynecology
			Coughing
			Respiratory failure-infection
Moller et al.³3 Møller AM, Villebro N, Pedersen T, et al. Effect of preoperative smoking intervention on postoperative complications: a randomised clinical trial. Lancet. 2002;359:114-7.	Randomized controled trial	During hospital stay	Respiratuar complications	CO reading	FTND	Orthopedic
Myles et al.⁴4 Myles PS, Iacono GA, Hunt JO, et al. Risk of respiratory complications and wound infection in patients undergoing ambulatory surgery: smokers versus nonsmokers. Anesthesiology. 2002;97:842-7.	Cohort prospective	İntraope Uyanma 7 day postsurgey	Hypoxia Bronchospasm	CO reading	None	Ambulatory surgery
			Laringospasm
			Coughing
			Apne
Sakai et al.⁵5 Sakai RL, Abrao GM, Avres JF, et al. Prognostic factors for perioperative pulmonary events among patients undergoing upper abdominal surgery. Sao Paulo Med J. 2007;125:315-21.	Retrospective	Intraoperative	Hypoxia Bronchospasm	None	None	Abdominal surgery
		Recovery
		Postoperative
Schwilk et al.¹³13 Schwilk B, Bothner U, Schraag S, et al. Perioperative respiratory events in smokers and nonsmokers undergoing general anaesthesia. Acta Anaesthesiol Scand. 1997;41:348-55.	Retrospective	Perioperative	Bronchospasm	CO reading	FTND	Orthopedic
Lee et al.¹⁸18 Lee A, Chui PT, Chui CH, et al. Risk of perioperative respiratory complications and postoperative morbidity in a cohort of adults exposed to passive smoking. Ann Surg. 2015;261:297-303.	Prospective	Intraoperative Recovery Pacu Postoperative	Hypoxia Bronchospasm Coughing	Uriner cotinin	FTND	Urological
						Orthopedic
						Cardiac
						General
Lindström et al.¹⁵15 Lindström D, Azodi OS, Aladis A, et al. Effects of a perioperative smoking cessation intervention on postoperative complications. Ann Surg. 2008;248:739-45.	Randomized controled trial	30 day postsurgery	Hypoxia Bronchospasm Bronchodilator need	CO reading	FTND	General
	Randomized controled trial	30 day postsurgery	Hypoxia Bronchospasm Bronchodilator need	CO reading	FTND	Orthopedic
Warner et al.²²22 Warner DO, Warner MA, Offord KP, et al. Airway obstruction and perioperative complications in smokers undergoing abdominal surgery. Anesthesiology. 1999;90:372-9.	Retrospective	Perioperative 30 day postsurgery	Bronchospasm Bronchodilator need	None	None	General
						Urology
						Cardiology
						Gynecology

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[1] Conflicts of interest

The authors declare no conflicts of interest.