Development and Validation of a Nomogram for Predicting Postoperative Pulmonary Infection in Patients Undergoing Lung Surgery

Published:August 19, 2022DOI:


      To develop and validate a nomogram for predicting postoperative pulmonary infection (PPI) in patients undergoing lung surgery.


      Single-center retrospective cohort analysis.


      A university-affiliated cancer hospital


      A total of 1,501 adult patients who underwent lung surgery from January 2018 to December 2020.


      Observation for PPI within 7 days after lung surgery.

      Measurements and Main Results

      A complete set of demographics, preoperative variables, and postoperative follow-up data was recorded. The primary outcome was PPI; a total of 125 (8.3%) out of 1,501 patients developed PPI. The variables with p < 0.1 in univariate logistic regression were included in the multivariate regression, and multivariate logistic regression analysis showed that surgical procedure, surgical duration, the inspired fraction of oxygen in one-lung ventilation, and postoperative pain were independent risk factors for PPI. A nomogram based on these factors was constructed in the development cohort (area under the curve: 0.794, 95% CI 0.744-0.845) and validated in the validation cohort (area under the curve: 0.849, 95% CI 0.786-0.912). The calibration slope was 1 in the development and validation cohorts. Decision curve analysis indicated that when the threshold probability was within a range of 0.02-to-0.58 and 0.02-to-0.42 for the development and validation cohorts, respectively, the nomogram model could provide a clinical net benefit.


      The authors developed and validated a nomogram for predicting PPI in patients undergoing lung surgery. The prediction model can predict the development of PPI and identify high-risk groups.

      Key Words

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Journal of Cardiothoracic and Vascular Anesthesia
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Schussler O
        • Alifano M
        • Dermine H
        • et al.
        Postoperative pneumonia after major lung resection.
        Am J Respir Crit Care Med. 2006; 173: 1161-1169
        • Chughtai M
        • Gwam CU
        • Mohamed N
        • et al.
        The epidemiology and risk factors for postoperative pneumonia.
        J Clin Med Res. 2017; 9: 466-475
        • Agostini PJ
        • Lugg ST
        • Adams K
        • et al.
        Risk factors and short-term outcomes of postoperative pulmonary complications after VATS lobectomy.
        J Cardiothorac Surg. 2018; 13: 28
        • Zou X
        • Jia M
        • Wang X
        • et al.
        Changing epidemic of lung cancer & tobacco and situation of tobacco control in China.
        Zhongguo Fei Ai Za Zhi. 2017; 20: 505-510
        • Dela Cruz CS
        • Tanoue LT
        • Matthay RA
        Lung cancer: Epidemiology, etiology, and prevention.
        Clin Chest Med. 2011; 32: 605-644
        • Stephan F
        • Boucheseiche S
        • Hollande J
        • et al.
        Pulmonary complications following lung resection: A comprehensive analysis of incidence and possible risk factors.
        Chest. 2000; 118: 1263-1270
        • Shiono S
        • Yoshida J
        • Nishimura M
        • et al.
        Risk factors of postoperative respiratory infections in lung cancer surgery.
        J Thorac Oncol. 2007; 2: 34-38
        • Simonsen DF
        • Sogaard M
        • Bozi I
        • et al.
        Risk factors for postoperative pneumonia after lung cancer surgery and impact of pneumonia on survival.
        Respir Med. 2015; 109: 1340-1346
        • Neto AS
        • da Costa LGV
        • Hemmes SNT
        • et al.
        The LAS VEGAS risk score for prediction of postoperative pulmonary complications: An observational study.
        Eur J Anaesthesiol. 2018; 35: 691-701
        • Li S
        • Su J
        • Sui Q
        • et al.
        A nomogram for predicting postoperative pulmonary infection in esophageal cancer patients.
        BMC Pulm Med. 2021; 21: 283
        • Xiao H
        • Zhou H
        • Liu K
        • et al.
        Development and validation of a prognostic nomogram for predicting post-operative pulmonary infection in gastric cancer patients following radical gastrectomy.
        Sci Rep. 2019; 9: 14587
        • Zhang D
        • Zhuo H
        • Yang G
        • et al.
        Postoperative pneumonia after craniotomy: Incidence, risk factors and prediction with a nomogram.
        J Hosp Infect. 2020; : 105167-105175
        • Abbott TEF
        • Fowler AJ
        • Pelosi P
        • et al.
        A systematic review and consensus definitions for standardised end-points in perioperative medicine: pulmonary complications.
        Br J Anaesth. 2018; 120: 1066-1079
        • Jammer I
        • Wickboldt N
        • Sander M
        • et al.
        Standards for definitions and use of outcome measures for clinical effectiveness research in perioperative medicine: European Perioperative Clinical Outcome (EPCO) definitions: A statement from the ESA-ESICM joint taskforce on perioperative outcome measures.
        Eur J Anaesthesiol. 2015; 32: 88-105
        • Horan TC
        • Andrus M
        • Dudeck MA.
        CDC/NHSN surveillance definition of health care-associated infection and criteria for specific types of infections in the acute care setting.
        Am J Infect Control. 2008; 36: 309-332
        • Purwar A
        • Singh SK.
        Hybrid prediction model with missing value imputation for medical data.
        Expert Syst Appl. 2015; 42: 5621-5631
        • Vickers AJ
        • Holland F.
        Decision curve analysis to evaluate the clinical benefit of prediction models.
        Spine J. 2021; 21: 1643-1648
        • Bevilacqua Filho CT
        • Schmidt AP
        • Felix EA
        • et al.
        Risk factors for postoperative pulmonary complications and prolonged hospital stay in pulmonaryresection patients: A retrospective study.
        Braz J Anesthesiol. 2021; 71: 333-338
        • Agostini P
        • Cieslik H
        • Rathinam S
        • et al.
        Postoperative pulmonary complications following thoracic surgery: Are there any modifiable risk factors?.
        Thorax. 2010; 65: 815-818
        • Foster CA
        • Charles EJ
        • Turrentine FE
        • et al.
        Development and validation of procedure-specific risk score for predicting postoperative pulmonary complication: ANSQIP analysis.
        J Am Coll Surg. 2019; 229 (.e3): 355-365
        • Howington JA
        • Blum MG
        • Chang AC
        • et al.
        Treatment of stage I and II non-small cell lung cancer: Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines.
        Chest. 2013; 143: e278S-e313S
        • Agostini P
        • Lugg ST
        • Adams K
        • et al.
        Postoperative pulmonary complications and rehabilitation requirements following lobectomy: A propensity score matched study of patients undergoing video-assisted thoracoscopic surgery versus thoracotomy.
        Interact Cardiovasc Thorac Surg. 2017; 24: 931-937
        • Mei J
        • Guo C
        • Xia L
        • et al.
        Long-term survival outcomes of video-assisted thoracic surgery lobectomy for stage I-II non-small cell lung cancer are more favorable than thoracotomy: A propensity score-matched analysis from a high-volume center in China.
        Transl Lung Cancer Res. 2019; 8: 155-166
        • Bendixen M
        • Jørgensen OD
        • Kronborg C
        • et al.
        Postoperative pain and quality of life after lobectomy via video-assisted thoracoscopic surgery or anterolateral thoracotomy for early stage lung cancer: A randomised controlled trial.
        Lancet Oncol. 2016; 17: 836-844
        • Loop T.
        Fast track in thoracic surgery and anaesthesia: Update of concepts.
        Curr Opin Anaesthesiol. 2016; 29: 20-25
        • Batchelor TJP
        • Rasburn NJ
        • Abdelnour-Berchtold E
        • et al.
        Guidelines for enhanced recovery after lung surgery: Recommendations of the Enhanced Recovery After Surgery (ERAS) Society and the European Society of Thoracic Surgeons (ESTS).
        Eur J Cardiothorac Surg. 2019; 55: 91-115
        • Marshall K
        • McLaughlin K.
        Pain management in thoracic surgery.
        Thorac Surg Clin. 2020; 30: 339-346
        • Staehr-Rye AK
        • Meyhoff CS
        • Scheffenbichler FT
        • et al.
        High intraoperative inspiratory oxygen fraction and risk of major respiratory complications.
        Br J Anaesth. 2017; 119: 140-149
        • Okahara S
        • Shimizu K
        • Suzuki S
        • et al.
        Associations between intraoperative ventilator settings during one-lung ventilation and postoperative pulmonary complications: A prospective observational study.
        BMC Anesthesiol. 2018; 18: 13
        • Li XF
        • Jiang D
        • Jiang YL
        • et al.
        PROtective Ventilation with a low versus high Inspiratory Oxygen fraction (PROVIO) and its effects on postoperative pulmonary complications: Protocol for a randomized controlled trial.
        Trials. 2019; 20: 619
        • Six S
        • Jaffal K
        • Ledoux G
        • et al.
        Hyperoxemia as a risk factor for ventilator-associated pneumonia.
        Crit Care. 2016; 20: 195
        • Hirota K
        • Yamakage M
        • Hashimoto S
        • et al.
        Perioperative respiratory complications: Current evidence and strategy discussed in 2017 JA symposium.
        J Anesth. 2018; 32: 132-136
        • Nightingale CE
        • Margarson MP
        • et al.
        • Members of the Working Party
        Peri-operative management of the obese surgical patient 2015: Association of Anaesthetists of Great Britain and Ireland Society for Obesity and Bariatric Anaesthesia.
        Anaesthesia. 2015; 70: 859-876
        • Cheng H
        • Chen BP
        • Soleas IM
        • et al.
        Prolonged operative duration increases risk of surgical site infections: A systematic review.
        Surg Infect (Larchmt). 2017; 18: 722-735
        • Willis-Owen CA
        • Konyves A
        • Martin DK.
        Factors affecting the incidence of infection in hip and knee replacement: An analysis of 5277 cases.
        J Bone Joint Surg Br. 2010; 92: 1128-1133