Objective To assess whether preoperative incentive spirometer training would influence the development of postoperative pulmonary complications after lung resection. Methods Sixty-two lung resection patients were prospectively investigated; 17 were given an incentive spirometer preoperatively and 45 did not have an incentive spirometer preoperatively. Postoperatively, both arms exercised with an incentive spirometer. The number of repetitions per day, balls raised per repetition, correct technique of exercising, and postoperative pulmonary complications were compared between the 2 groups. Univariate binary logistic regression analysis of potential predictors of postoperative pulmonary complications led to multivariate analysis of independent predictors. Receiver operating characteristic analysis established the cutoff points of predictors. Results The group with no preoperative incentive spirometer developed more postoperative pulmonary complications than the preoperative incentive spirometer group (24.4% vs. 5.9%, respectively, p = 0.045). The preoperative incentive spirometer arm achieved more repetitions per day, balls per repetition, and correct incentive spirometer technique ( p = 0.002, p < 0.001, p = 0.034, respectively). Balls raised per repetition and repetitions per day postoperatively were identified as independent predictors of postoperative pulmonary complications ( p = 0.032 and p = 0.021, respectively). Less than 5 repetitions per day (sensitivity 93%, specificity 77%, p < 0.001) and less than 2 balls per repetition (sensitivity 93%, specificity 77%, p < 0.001) were predictive of postoperative pulmonary complications. Conclusion Preoperative incentive spirometer exposure ensured better compliance with postoperative treatment and a more accurate technique (balls raised per repetition, repetitions per day). These variables correlated with a lower postoperative pulmonary complication rate.

The presentation of post lung resection atelectasis can vary between simple atelectasis and total lung collapse i.e., "white -out", making its treatment demanding in many occasions. We herein present the technique of continuous suctioning of the right upper lobe (RUL) by positioning a suction catheter inside the right upper lobe bronchus (RULB) through a tracheostomy in a sedated patient. This technique was used in the case of a 70-year-old patient who underwent a complicated redo thoracotomy and right lower lobectomy for lung cancer after a previous middle lobectomy via double thoracotomy for similar pathology. He had a significant ankylosis spondylitis past medical history with bamboo spine treated with long term high doses of steroids and methotrexate. Post redo surgery he developed respiratory failure with a radiologically significant RUL collapse, i.e., a "white-out", of the operated side which was refractory to usual conservative or bronchoscopic treatment. As a last resort, and in an effort to avoid high risk pneumonectomy, the patient was sedated, and a suction catheter was left inside the RULB under direct bronchoscopic guidance. This allowed the secretions inside the airways to be cleared, giving the remaining upper lobe infection time to subside, protected the stump from infective secretions and blind suctioning and led to avoidance of a high-risk pneumonectomy. The upper lobe cleared up from its collapse and patient's discharge from high dependency unit was achieved. This described maneuver can be useful in refractory cases of atelectasis when other measures have failed, in borderline patients or in patients where further surgery is technically cumbersome.