Anti-cholinergic agents and beta2-agonists are equally effective in reducing symptoms and airflow obstruction. The combination of these agents may provide further symptomatic relief [52]. Long-acting bronchodilators are more effective in reducing symptoms and airflow obstruction than their short-acting counterparts, partially due to their anti-inflammatory effects [53, 54]. The use of systemic corticosteroid should be reserved for patients experiencing an acute see more exacerbation or those with persistent symptoms after maximal bronchodilators treatment [55]. Asthma Well-controlled asthma is not a risk factor for PPCs. A study involving 706 asthmatic patients demonstrated

that the rate of bronchospasm was just 1.7%, while one respiratory failure and two Selleck Ganetespib additional laryngospasms occurred during the perioperative period. There were no other clinically significant PPCs or deaths in the entire group [29]. However, some clinical Selleck SHP099 factors, including recent asthma symptoms, use of rescue inhalers, and medical consultation for asthmatic attack, were associated with an increased risk for PPCs [29]. Treatment with inhalers for asthma should be optimized prior to hip fracture surgery. Ideally, patients should be symptoms-free

with a peak expiratory flow greater than 80% of the predicted or personal best value before surgery [56]. A short course of systemic corticosteroid (e.g., oral prednisone 0.5–1 mg/kg or equivalent), starting from 1 to 2 days before surgery, should be given to patients at risk for PPCs [57].

The perioperative use of systemic corticosteroid has not been found to increase respiratory infection or delay wound healing among asthmatic patients [58, 59]. Obstructive sleep apnea OSA is a syndrome characterized by periodic, partial, or complete obstruction of the upper airway Lepirudin during sleep. A case-control study showed that there is a trend towards a higher rate of PPCs among patients with OSA undergoing major orthopedic surgery compared with those without [60]. The possible explanations of the increased risk of PPCs are: (1) OSA patients may have coexisting difficult airway and CHF, which may in turn increase the risk of PPCs [32], and (2) the use of anesthetics and analgesics that decrease pharyngeal tone and blunt the ventilatory response to hypoxia, together with supine positioning, may aggravate the severity of OSA during the perioperative period [61]. Patients should be screened for OSA before hip fracture surgery. Physicians should judge the probability of OSA based on the presence of risk factors and validated questionnaires. Major risk factors for OSA include male gender, obesity (body mass index >35 kg/m2), wide neck (neck circumference > 40 cm), crowded oropharynx, and craniofacial abnormalities affecting the upper airway [62].