COMMENTS AND RESPONSES Risk Assessment for and Strategies to Reduce Perioperative Pulmonary Complications TO THE EDITOR: In their clinical guidelines for risk assessment for

and strategies to reduce perioperative pulmonary complications in patients undergoing noncardiothoracic surgery, Qaseem and col-leagues (1) have overlooked an important factor in preventing post-operative pneumonia related to acid aspiration. Pulmonary aspira-tion of gastric contents during the perioperative period may be associated with postoperative death or pulmonary morbidity (2). Al-though acid aspiration during induction of anesthesia is rare, with an incidence of 3 in 10 000, this complication causes high morbidity and mortality. Aspiration-related complications, such as pneumoni-tis, adult respiratory distress syndrome, and laryngeal complications, remain important causes of perioperative morbidity and mortality. In a study by Rosenstock and colleagues (3), 7 of 60 patients with adverse respiratory events during anesthesia had pulmonary aspira-tion of gastric contents, and of these 7, 6 died. It has also been reported that patients who undergo outpatient procedures are mor