Anesthetic Consideration in COPD

Rizki Anwar Utamy

Pembimbing: dr Kulsum SpAn-KNA
 What is chronic obstructive pulmonary
disease
• persistent airflow limitation that is usually
progressive and associated with an enhanced
chronic inflammatory response in the airways
and the lung to noxious particles or gases
• Chronic bronchitis and emphysema are the
two main diseases incorporated under COPD
mechanisms underlying airflow limitation in
COPD
 How COPD is diagnosed
• Dispneu
• Chronich cough/ sputum production
• History of exposure to risk factor
• the presence of a post-bronchodilator
FEV1/FVC < 0.70
 What concurrent medications the patient can
be on and anaesthetic importance of the same?

• Bronchodilators
– beta 2 agonists, xanthine derivatives, mast cell
inhibitors ( used for prevention of an attack of
bronchospasm)
• Steroid
Anything important in personal history?

• Duration and number of cigarates per day

– PACK YEARS : number of packs of cigarettes/day ×
number of years of smoking
• One pack = 20 cigarettes. > 40 pack years is high risk
for post operative pulmonary complications
– SMOKING INDEX : number of cigarettes /day ×
total duration in years
• – SI 300 heavy smoker, SI 100-300 moderate smoker, SI
>300 heavy smoker
Anaesthetic importance of smoking
• Smoking increases the carboxy haemoglobin
levels due to increased carbon monoxide
inhalation. Increase in carboxy haemoglobin
levels
• produces hypertrophy and hyperplasia of mucus
secreting glands
• Induces coronary vasoconstriction
• Impairs muco ciliary transport mechanism
leading to infection, atelectasis and collapse.
What are the main points to be considered in
general physical examination ?
• obesity (BMI >30kg/m2 )
• Signs of respiratory distress
• Pallor
• Cyanosis
• Pedal oedema and raised JVP
CXR Finding
 What induction agents are used and their
advantages and disadvantages
• Propofol
Advantages Disadvantages
• Rapid onset  Pain on injection
• Airway reflexes obtunded  Hypotension
• Direct bronchodilator  Bradycardia
• Reduces PONV
• Antiarrhythmic
• Suppression of intubation responses
• Ketamin
Advantages
 Profound analgesia
 Good bronchodilator
 Maintains HR ,BP
 Decreases post op shivering
Disadvantages
 Increased secretions
 Airway reflexes exaggerated
 Emergence delirium
 Hypertension, tachycardia.
 Increased systemic and
pulmonary vascular resistance
 Dysrhythmias
 Inhalational induction
• Potent inhalational anaesthetics may prevent
development of bronchospasm by
– Blocking airway reflexes
– Direct relaxation of smooth muscles of airway
– Inhibition of mediator release
• Halothane and sevoflurane are preferred
How do you ventilate this patient?
• Ventilatory Strategy:
Aim: Minismise dynamic hyperinflation, iPEEP
• Settings:
Decrease minute vent Low frequency
Adequate Exp time,
Reduce exp flow resistance
Recruitment maneuvers
Acceptance of mild hypercapnia & acidemia
•  Humidification of gases
•  Pressure Controlled mode
 Mangement of patients under GA
• tracheal intubation should be avoided by using
the laryngeal mask airway or similar device
where possible
• barbiturates may sometimes provoke
bronchospasm
• Adjuvants to increase the depth of anaesthesia
and blunt airway reflexes before intubation
• Volatile anaesthetics are useful due to their
excellent bronchodilating properties
 Intraoperative problems
• Bronchospasm
• Auto-positive end expiratory pressure
• Haemodynamic instability in chronic
obstructive pulmonary disease patients
• Atelectasis
Post operative problems