Therefore, antibiotics should be administered or hip fracture surgery should be delayed for as long as 72 h if bacterial infection is present in the lower respiratory tract. However, viral infection in the upper respiratory tract does not increase the risk of PPCs, even in asthmatic patients [29]. Prophylactic antibiotics covering Staphylococcus aureus, which are commonly given before hip fracture surgery to prevent wound infections, are also effective in reducing the risk of respiratory tract infection [42]. Chronic respiratory symptoms The presence of chronic respiratory symptoms, such as chronic cough, dyspnea, or wheeze, is common among the elderly. In

addition, diffuse rales, wheezing, or rhonchi may be identified on chest examination before surgery. Most of these symptoms and signs suggest the presence of underlying cardiopulmonary ACP-196 diseases, such as CHF, COPD, 4SC-202 ic50 or uncontrolled asthma, which will then increase the risk of PPCs [43].

Physicians should take a detailed history and perform a focused cardiopulmonary examination, together with limited investigations to identify the causes of these unexplained chronic symptoms. A chest radiograph may reveal hyperinflation, cardiomegaly, or interstitial changes, which represent airway diseases, CHF, and interstitial lung diseases, respectively. Guidelines from the American College of Physicians suggest that spirometry should be performed in patients with unexplained respiratory symptoms before undergoing orthopedic surgery [44]. While spirometry with bronchodilator NVP-LDE225 supplier test is useful in demonstrating the presence, severity, and reversibility of airflow obstruction and, thus, differentiating asthma from COPD, lung volume measurements are also essential in confirming the presence of restrictive Acyl CoA dehydrogenase ventilatory defects, which is suggestive of interstitial lung

disease, neuromuscular disease, or chest wall deformity [45]. Echocardiography may help to determine the systolic and diastolic heart function and the presence of pulmonary hypertension. Chronic obstructive pulmonary disease The presence of COPD increases the risk of PPCs by one- to twofold [20, 32, 46]. The increased risk in COPD patients attributes to the airflow obstruction and the presence of other co-morbidities commonly seen in smokers, such as CHF and weight loss. A correlation has been identified between the severity of the disease as defined by the percentage of FEV1 of predicted value and the risk of PPCs [47]. However, there is no prohibitive lower limit of FEV1 or FVC, which indicates that surgery should not be performed because operations could be safely carried out in patients with severe COPD [48]. Physicians should optimize the management of COPD before hip fracture surgery to minimize the risk of PPCs [49]. The commonly used preoperative management strategy can be remembered as A (antibiotic), B (bronchodilator), and C (corticosteroid) [50].