Patients With Chronic Obstructive Pulmonary Disease/Respiratory Insufficiency: Recommendations Class IIa 1. Preoperative intensive inspiratory muscle training is reasonable to reduce the incidence of pulmonary complications in patients at high risk for respiratory complications after CABG.1199 (Level of Evidence: B) Class IIb 1. After CABG, noninvasive positive pressure ventila- tion may be reasonable to improve pulmonary me- chanics and to reduce the need for reintuba- tion.1200,1201 (Level of Evidence: B) 2. High thoracic epidural analgesia may be considered to improve lung function after CABG.37,1202 (Level of Evidence: B) See Online Data Supplement 43 for additional data on patients with chronic obstructive pulmonary disease/respira- tory insufficiency. In the STS Adult Cardiac Database predictive algorithms, the presence of chronic obstructive pulmonary disease pre- operatively was an independent predictor of mortality, the need for prolonged postoperative ventilator support, and renal failure.1203 Furthermore, most rehospitalizations following CABG are related to pulmonary dysfunction and/or infection or volume overload. The incidence of complications increases with patient age and the severity of chronic obstructive pulmonary disease, as measured with pulmonary function testing.1204,1205 None of these studies, however, address the relative risks and benefits of CABG in subjects with chronic obstructive pulmonary disease, thereby precluding a specific recommendation regarding the performance of CABG in these patients. In preparation for CABG, optimizing pulmo- nary function is imperative.1206 An RCT of 279 patients1199 showed that preoperative respiratory muscle training reduced postoperative pulmonary complications (including pneumo- nia) and length of stay in patients at high risk for such complications after CABG. Such muscle training is indicated in all patients before CABG, especially those with impaired baseline pulmonary function. 