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Preoperative Pulmonary Evaluation

Michael Lin MD NCB Ambulatory Lecture Series Summer/Fall 2005

 Identify important postoperative pulmonary complications  Preoperative risk assessment  Use of ancillary tests  Identify strategies to reduce postoperative pulmonary complications

Postoperative Complications
 Contribute significantly to overall perioperative morbidity and mortality  More common than cardiac complications resulting in longer hospital stays  Generally rare in healthy patients  Common in selected patient groups and high-risk procedures

Postoperative Complications
 Atelectasis  Infection bronchitis/pneumonia (mortality 20%!)  Respiratory failure (prolonged vent)  COPD exacerbation  Bronchospasm  Pulmonary embolism (discussed elsewhere)

Perioperative Pulmonary Physiology

 Primarily with thoracic and upper abdominal surgeries, lesser with lower abdominal
Reduction in lung volumes
 Vital capacity reduced 50-60 percent
Can remain reduced for one week

 FRC reduced by 30%  Diaphragmatic dysfunction

General anesthesia and neuromuscular blockers

 Postoperative pain and splinting

Reduced FRC atelectasis, pneumonia, V/Q mismatch

 Anesthesia/opioid analgesia
Reduce respiratory drive

 Inhibition of cough and mucociliary clearance

Postoperative Decline in Vital Capacity

 Upper abdominal surgery
VC decrease sharply
Post op Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7 42% 42% 47% 53% 58% 65% 72%

Preoperative Risk Factors

 Patient related
History of chronic lung disease
 Most important risk factor (OR 2.7-6.0)  Some studies COPD up to 25% complications

 No additional risk with controlled asthma  >80 percent of best peak flow avg risk

 Independent risk factor  Smoking <2 months (OR 1.55-2.3)  Stop smoking >6 months = never smoked

Preoperative Risk Factors

 Patient related
General health status ASA (American Society of Anesthesiology Score 1 Well  2 mild/mod systemic disease  3 severe systemic disease  4 sev. Dz threatening to life  5 moribund ASA Score >2 (OR 1.5-3.2)

Preoperative Risk Factors

 Patient related
Physiologic problems
Reduction lung volumes V/Q mismatch Relative hypoxemia

Conflicting data
Gastric bypass surgeries: pneumonia and atelectasis rates equal Other studies: BMI >27 independent risk for pulmonary complications

Preoperative Risk Factors

 Patient related
>60 minor risk factor (OR 1.51-1.91) Conflicting data corrected for comorbidities

Limited data prudent to delay elective procedures

Metabolic factors
Multifactorial risk index for respiratory failure Albumin <3 g/dL (OR 2.53), BUN >30 (OR 2.29)

Preoperative Risk Factors

 Procedure Related
Surgical site
 Most important factor  Related to proximity of diaphragm
Upper abdominal/lower thoracic most problematic Thoracic surgery ( 19% - 59%) Upper abdominal (17%-76%) Lower abdominal (0% - 5%)

 Effect upon respiratory muscles and diaphragmatic function  High risk with AAA repair  Laparoscopy vs. open repair (quicker recovery of FVC)  Vertical laparotomy > transverse

Preoperative Risk Factors

 Procedure Related
Duration of surgery
> 3-4 hours increased pulmonary complications
Post op pneumonia: 520 patients <2 hours 8% >4 hours 40%

Higher risk patients opt for briefer procedure

Preoperative Risk Factors

 Procedure Related
Type of anesthesia
Spinal/epidural vs. general Conflicting data Large literature review
141 trials 9559 patients Epidural/spinal 39% risk reduction for pneumonia Epidural/spinal 59 % risk reduction of resp. depression

Neuromuscular blocker
Pancuronium long-acting higher complication rates


Predictors of Postop Pulmonary Risk

 272 patients for nonthoracic surgery 22 (8%) with post op pulm complications (respiratory failure, pneumonia, bronch)          Hypercapnea pCO2 >45 Hypoxemia pO2<75 FVC <1.5 L FEV1 <1 L BMI >30 Positive cough test Wheezing Age >65 >40 pack year tobacco OR 66 OR 13.4 OR 11.1 OR 7.9 OR 4.1 OR 4.3 OR 3.1 OR 1.8 OR 1.9

Slide 14 M1
Michael, 7/12/2005

Postoperative Pneumonia Risk Index

 VA study 155,600 noncardiac cases  2466 patients with pneumonia (1.5%)
21% mortality

 Point system risk index

Type of surgery (AAA, thoracic, abd) Age, functional status, recent wt loss Chronic lung disease General anesthesia, impaired sensorium, CVA. BUN <8, emergent surgery, smoking, ETOH Low risk - .2%, mod 9.4%, high 15.3%

Preoperative Risk Assessment

 History and Physical
Identify risk factors Assess stability/control of diseases Detect undiagnosed chronic lung disease
History of exercise intolerance Unexplained dyspnea or cough Chest exam for breath sounds, wheezing, rhonchi

Preop for Lung Resection

 PFTs  ABGs  CXR  Exercise testing

Preoperative Ancillary Tests

Debatable uses adds little to estimation of risk, overused Identify subset of patients at higher risk
Selection of procedure, anesthesia More aggressive perioperative management

Who should get preop PFTs

 Known pulmonary disease  Planned lung resection  Heavy smokers  Tests:
Peak flow Match test: FEV1 1.8 L Bedside spirometry (FVC, FEV1)

Chest X-Rays
 Adds little to clinical evaluation  One meta-analysis >14,000 preop xrays
14 cases abnormal and influenced managment

 Reasonable >60 years or clinical findings, change in cardiopulmonary status

Strategies to Reduce Complications

 Reserved for higher risk patients/procedures  Atelectasis  Infection  Respiratory failure/prolonged venting  COPD exacerbation  Bronchospasm

Strategies to Reduce Complications

 Smoking cessation
D/C at least 8 weeks prior 200 patient CABG study
d/c <2 months 57% d/c >2 months 11.9%

Strategies to Reduce Complications

Treat aggressively to reach maximal baseline Group that would benefit from PFTs/ABGs Daily atrovent Perioperative beta agonists Antibiotics with productive sputum Systemic steroids if responsive

Strategies to Reduce Complications

Well controlled asthmatics confer little additional risk Perioperative beta agonists Systemic corticosteroids
Recommendations by National Asthma Education Program consensus statement
Wheezing, productive cough, chest tightness, SOB Peak flow/FEV1 <80% Prednisone 40 mg/day 3 days preop and post op

Strategies to Reduce Complications

 Intraoperative strategies
Type of anesthesia
Spinal/epidural vs general for higher risk patients

Type of neuromuscular blockade

Pancuronium long acting Vecuronium/atracurium intermediate acting

Type of Surgery
> 3-4 hours more complications Laparoscopic vs open laparotomy Incision type

Strategies to Reduce Complications

 Postoperative strategies
Lung expansion maneuvers
Chest PT Deep breathing exercises Incentive spirometry Intermittent CPAP/BiPAP

Adequate pain control Early NG tube removal

 64 male h/o hypertension, controlled with HCTZ , no known pulmonary diseases, presents for preoperative evaluation prior to elective abdominal aorta repair (6 cm).  50 pack year history of smoking, discontinued one month ago.  Reports no chest pain, but limited exertional capacity, 2 blocks, due to dyspnea.  Physical exam is unremarkable.  EKG shows LVH  Chest Xray with mild hyperinflation.  What are the preoperative pulmonary concerns?