ASTHMA AND COPDDR NARENDRA JAVADEKAR DR BHASKAR SHENOLIKAR

PERIOPERATIVE MANAGEMENT OF HIGH RISK PATIENTS

• O R EVALUATION

• PREMEDICATION

• ANASTHESIA TECHNIQUES

• INDUCTION

• AIRWAY MANAGEMENT

• INTRAOP MONITORING

• INTRAOP COMPLICATIONS

• RECOVERY ROOM

• POSTOP COMPLICATIONS

• DEFINITIONS

• DIAGNOSIS

• SAFETY OF SURGERY

• PREOPERATIVE EVALUATION

• CLINICAL EXAMINATION

• INVESTIGATIONS

• RISK ASSESSMENT

• OPTIMISATION

ASTHMA AND COPDPERIOPERATIVE MANAGEMENT

DR NARENDRA JAVADEKAR DR BHASKAR SHENOLIKAR

PERIOPERATIVE PULMONARY COMPLICATIONS

PULMONARY COMPLICATIONS

MORE COMMON THAN CARDIAC COMPLICATIONS

CAUSE SIGNIFICANTLY LONGER HOSPITAL STAYS

LAWRENCE, VA, HILSENBECK, SG, ET AL. J GEN INTERN MED 1995; 10:671

MOST COSTLY COMPLICATIONS

DIMICK, JB, CHEN, SL, ET AL. J AM COLL SURG 2004; 199:531

PULMONARY COMPLICATIONS 6.8% ACROSS ALL TYPES SURGERIES

ATELECTASIS, PULMONARY INFECTION,

PROLONGED MECHANICAL VENTILATION, RESPIRATORY FAILURE,

CHRONIC LUNG DISEASE EXACERBATION, BRONCHOSPASMSMETANA, GW, LAWRENCE, GA, ET AL, ANN INTERN MED 2006; 144:581

• 6% PREVALENCE

• PROGRESSIVE DYSPNEA

• SPUTUM PRODUCTION

• EXPOSURE TO RISK FACTORS

• OLDER AGE GROUP

• FAMILY HISTORY +/-

• NOT FULLY REVERSIBLE

• FEV1/FVC< 70% AFTER BRONCHODILATOR THERAPY

• 7% PREVALENCE

• INTERMITTANT DYSPNEA

• EXACERBATIONS AND REMISSIONS

• RESPONSE TO SPECIFIC ALLERGENS

• YOUNGER AGE GROUP

• FAMILY HISTORY

• RAISED IGE/EOSINOPHILLIA

• COMPLETELY REVERSIBLE

DIFFERENTIAL DIAGNOSIS

ASTHMA COPD

DIAGNOSTIC ASSESSMENT

• SPIROMETRY-AIRWAY RESISTANCE

• BODY PLETHYSMOGRAPHY(LUNG VOLUMES)-COMPLIANCE OF CHEST WALL AND LUNGS

• DLCO-PULMONARY GAS EXCHANGE

Totallung

capacity

Tidal volume

Inspiratory reservevolume

Expiratory reservevolume

Residual volume

Inspiratory capacity

Vital capacity

Lung Volume Terminology

ASTHMA MANAGEMENT• PATIENT EDUCATION

• IDENTIFICATION OF RISK FACTORS –REDUCE EXPOSURE

• STEPWISE TREATMENT

• MANAGE ACUTE EXACERBATIONS

ASTHMA MANAGEMENT• BETA 2 AGONIST

• SABA-SALBUTAMOL/TERBUTALINE• LABA-FORMOTEROL/SALMETEROL• METHYLXANTHINES

• THEOPHYLLINE/AMINOPHYLLINE• DOXOPHYLLIN

• ANTICHOLINERGICS

• IPRATROPIUM• CORTICOSTEROIDS

• PREDNISOLONE/DEXAMETHASONE HYDROCORTISONE/ METHYLPREDNISOLONE

• BECLOMETHASONE/BUDESONIDE

• FLUTICASONE/CICLESONIDE

• MAST CELL STABILISERS

• SODIUM CHROMOGLYCATE,KETOTIFEN

• ANTI IGE ANTIBODY

• OMALIZUMAB

• LEUKOTRIENE MODIFIERS

• MONTELUKAST• ZIFERLUKAST• ZILEUTON

ASTHMA COMORBIDITIES

• COPD MAY COEXIST

• ADVERSE EFFECTS OF STEROIDS –APD,OSTEOPOROSIS,DIABETES,IMMUNOSUPRESSION,ORAL THRUSH,SUPRESSION OF ADRENOCORTICAL AXIS

• BRONCHODILATORS-

• HYPOKALEMIA/TACHYARRHYTHMIAS/TREMORS

COPD SEVERITY BY GOLD STAGES• STAGE 0-FEV1 N FEV1/FVC N

• STAGE 1-FEV1>= 80% FEV1/FVC<0.7

• STAGE 2-FEV1< 80% FEV1/FVC<0.7

• STAGE 3-FEV1< 50% FEV1/FVC<0.7

• STAGE 4-FEV1<30% FEV1/FVC<0.7

COPD MANAGEMENT• SMOKING CESSATION

• OXYGEN THERAPY

• LUNG VOLUME REDUCTION SURGERY

• INHALED CORTICOSTEROIDS

• SABA /ANTICHOLINERGICS/THEOPHYLLINE

• PULMONARY REHABILITATION

• NON INVASIVE VENTILLATION

• VACCINES –PNEUMOCOCCAL/INFLUENZA

• LUNG TRANSPLANTATION

COPD COMORBIDITIES• HYPERTENSION

• ATHEROSCLEROTIC VASCULAR DISEASE

• ISCHEMIC HEART DISEASE

• ARRHYTHMIAS –ATRIAL FIBRILLATION

• HEART FAILURE

• DIABETES

• MUSCULOSKELETAL WEAKNESS/OSTEOPOROSIS

• ANXIETY/DEPRESSION

COPD AND ASTHMA-IS SURGERY SAFE?• NUMBER OF COPD/ASTHMA CASES COMING FOR SURGERY IS ON RISE DUE TO

• ADVANCING AGE

• INCREASE IN LIFE EXPECTANCY

• INCREASED PREVALENCE OF COPD/ASTHMA

• INCREASED FREQUENCY OF DIAGNOSTIC AND THERAPEUTIC PROCEDURES

COPD/ASTHMA AND ANASTHESIA• SURGERY IS SAFE

• COMPLICATION RATE IS EQUAL TO CARDIAC EVENT RATE (1-3%)

• MODERN ANASTHESIA TECHNIQUES AND PERIOPERATIVE MANAGEMENT IMPROVES OUTCOMES

• RESPIRATORY DEPRESSION

• REDUCED RESPONSE TO HYPERCAPNIA AND HYPOXIA

• REDUCED FRC

• REDUCED LUNG VOLUME

• ATELECTASIS IN DEPENDANT LUNG

• V/Q MISMATCH-HYPOXIA

• REDUCE SYMPATHETIC TONE

• SYSTEMIC VASODILATION

• MYOCARDIAL DEPRESSION

• DECREASED CARDIAC OUTPUT

• DECREASE BLOOD PRESSURE

• VARIABLE EFFECT ON HEART RATE

EFFECTS OF ANASTHETIC AGENTS

CARDIVASCULAR SYSTEM RESPIRATORY SYSTEM

TYPE OF ANASTHESIA

• NEUROAXIAL SAFER THAN GENERAL FOR PREVENTION OF PULMONARY COMPLICATIONS THOUGH CARDIAC EVENTS ARE SAME.

• COMBINATION OF BOTH TO REDUCE GA REQUIREMENTS IS USEFUL.

• EPIDURAL ANALGESIA FOR PAIN RELIEF REDUCES POSTOP COMPLICATION RATE.

• (INTERSCALENE BRACHIAL PLEXUS BLOCK CAUSES IPSILATERAL PHRENIC NERVE PALSY)

GRADES OF COMMON NON-CARDIAC SURGICAL PROCEDURES• HIGHER-

• EMERGENCY SURGERY,ESP ELDERLY

• AORTIC AND NONCAROTID MAJOR VASCULAR SURGERY

• PROLONGED SURGERY/LARGE FLUID SHIFT/BLOOD LOSS

• INTERMEDIATE-

• MAJOR THORACIC SURGERY

• MAJOR ABDOMINAL SURGERY

• CAROTID ENDARTERECTOMY

• HEAD /NECK SURGERY

• ORTHOPEDIC SURGERY

• PROSTATE SURGERY

• LOWER—

• EYE,SKIN,SUPERFICIAL SURGERY

• ENDOSCOPIC PROCEDURES

PRE-OPERATIVE ASSESSMENT GOALS• NEED FOR SURGERY—IS IT URGENT?

• CONFIRM THE DIAGNOSIS

• ASSESS SEVERITY OF THE DISEASE

• ASSESS ONGOING TREATMENT-IS IT EFFECTIVE

• PREOPERATIVE OPTIMISATION

• PLAN ANASTHESIA MANAGEMENT

TOOLS FOR ASSESSMENT• HISTORY

• SMOKING HISTORY, DURATION ,NO OF CIGARETTES/DAY

• EXERCISE TOLERANCE.

UNRELIABLE WHEN SELF-REPORTED

• ENQUIRE ABOUT THE MAXIMAL LEVEL OF EXERTION.

• THE FREQUENCY OF EXACERBATIONS.

• TIMING OF THE MOST RECENT COURSE OF ANTIBIOTICS OR STEROIDS.

• HOSPITAL ADMISSIONS.

• PREVIOUS REQUIREMENTS FOR INVASIVE AND NON-INVASIVE VENTILATION.

• ANY CO-MORBID CONDITIONS IDENTIFIED. SIGNS OF CHF, COR PULMONALE.

PRE-OP EVALUATION (CONTD)

• ROUTINE PRE-OPERATIVE BLOOD TESTS.

• ECG (LOOK FOR ANY EVIDENCE OF RIGHT-SIDED HEART DISEASE OR CONCOMITANT ISCHEMIC HEART DISEASE).

• XRC IS NOT MANDATORY AND MAY ADD LITTLE VALUE

• ( CONSIDERED IF THERE IS CURRENT INFECTION OR RECENT DETERIORATION IN SYMPTOMS.)

• SPIROMETRY IS USEFUL TO CONFIRM THE DIAGNOSIS AND TO ASSESS THE SEVERITY OF COPD .

• ASSESS THE FUNCTIONAL STATUS OF PATIENTS, SIMPLE AND SAFE TESTS SUCH AS STAIR CLIMBING AND THE 6-MIN WALK TEST CORRELATING WELL WITH MORE FORMAL EXERCISE TESTING.

• ABG- MEASUREMENT MAY BE USEFUL IN PREDICTING HIGH-RISK PATIENTS.

• 2DECHO-IF SUSPECTED COR PULMONALE OR CHF.

WHAT IS SPIROMETRY?

SPIROMETRY IS A METHOD OF ASSESSING LUNG FUNCTION BY MEASURING THE VOLUME OF AIR THE PATIENT CAN EXPEL FROM THE LUNGS AFTER A MAXIMAL EXPIRATION.

WHY PERFORM SPIROMETRY?

• Measure airflow obstruction to help make a definitive diagnosis of COPD

• Confirm presence of airway obstruction

• Assess severity of airflow obstruction in COPD

• Detect airflow obstruction in smokers who may have few or no symptoms

• Monitor disease progression in COPD

• Assess one aspect of response to therapy

• Assess prognosis (FEV1) in COPD

• Perform pre-operative assessment

FLOW MEASURING SPIROMETER

SMALL HAND-HELD SPIROMETERS

Totallung

capacity

Tidal volume

Inspiratory reservevolume

Expiratory reservevolume

Residual volume

Inspiratory capacity

Vital capacity

Lung Volume Terminology

STANDARD SPIROMETRIC INDICES

• FEV1 - FORCED EXPIRATORY VOLUME IN ONE SECOND:

THE VOLUME OF AIR EXPIRED IN THE FIRST SECOND OF THE BLOW

• FVC - FORCED VITAL CAPACITY:

THE TOTAL VOLUME OF AIR THAT CAN BE FORCIBLY EXHALED IN ONE BREATH

• FEV1/FVC RATIO:

THE FRACTION OF AIR EXHALED IN THE FIRST SECOND RELATIVE TO THE TOTAL VOLUME EXHALED

• VC - VITAL CAPACITY:

A VOLUME OF A FULL BREATH EXHALED IN THE PATIENT’S OWN TIME AND NOT FORCED. OFTEN SLIGHTLY GREATER THAN THE FVC, PARTICULARLY IN COPD

SPIROMETRIC CRITERIA

FEV1< 1L ,NORMAL PaO2 AND PaCO2—

LOW RISK

FEV1< 1L ,LOW PaO2 AND NORMAL PaCO2---

WILL NEED O2

FEV1<1L,LOW PaO2 AND HIGH PaCO2---

MAY NEED MECHANICAL VENTILLATION

SPIROMETRYFEV1 LESS THAN 50% OF PREDICTED WAS A CONTRAINDICATION

TO SURGERY.

1992 STUDY BY KROENKE ET AL, THAT EVALUATED 107 GENERAL SURGICAL PROCEDURES (SOME HIGH-RISK)

IN 89 PATIENTS WITH SEVERE COPD (IE, FEV1 < 50% OF PREDICTED). MORTALITY WAS 6% OVERALL AND WAS CLUSTERED IN THE SUBSET

OF PATIENTS UNDERGOING CORONARY ARTERY BYPASS GRAFT

(CABG) SURGERY (5 OF 10 PATIENTS; 50%);

MORTALITY WAS 1% FOLLOWING THE 92 NON CARDIAC OPERATIONS.

PULMONARY COMPLICATIONS OCCURRED FOLLOWING 29% OF OPERATIONS;

MAJOR PULMONARY COMPLICATIONS OCCURRED AFTER 7%.

HOWEVER FOR CABG SURGERY FEV1<60% IS INDICATIVE OF HIGH RISK

SPIROMETRY

• FOR CABG FEV1 <60% IS PREDICTIVE OF HIGH RISK

• SPIROMETRY IS MUST FOR PREOPERATIVE EVALUATION OF LUNG RESECTION PATIENTS

BEDSIDE PFTS

• THE COUGH TEST-• ASKING THE PATIENT TO TAKE A DEEP INSPIRATION AND COUGH ONCE. TEST IS POSITIVE IF FIRST COUGH LEADS TO RECURRENT BOUTS OF COUGHING

• THE WHEEZE TEST-

• FIVE DEEP INSPIRATIONS AND EXPIRATIONS, AUSCULTATE BETWEEN THE SHOULDER BLADES POSTERIORLY WHEEZE? INDICATES POSITIVE TEST.

• MAXIMUM LARYNGEAL HEIGHT-

• DISTANCE BETWEEN THE TOP OF THYROID CARTILAGE AND SUPRASTERNAL NOTCH -- <4 CMS IS ABNORMAL.

BEDSIDE PFTS• FORCED EXPIRATORY TIME-BELL OF STETHOSCOPE ON TRACHEA IN

SUPRASTERNAL NOTCH, STOPWATCH TO ZERO. DEEP INSPIRATION AND BLOW IT OUT AS FAST AS POSSIBLE, TIME TO NO AUDIBLE EXPIRATION IS MEASURED. FET >6 SEC INDICATES SEVERE EXP AIRFLOW OBSTRUCTION.FEV1<50%

• AVERAGE WITH THREE RESULTS

• SABRASEZ BHT-DEEP BREATH HOLDING FOR AS LONG AS POSSIBLE PLACE STETHOSCOPE ON TRACHEA TO KNOW EARLY EXPIRATION

• >40 SEC- NORMAL ,20-30 SEC CPMPROMISED CP RESERVE, <20 SEC VERY POOR CP RESERVE

• PEAK EXPIRATORY FLOW RATE – IN ASTHMA

OPTIMISATION PREOPERATIVELY

OPTIMISE THE PATIENT1) CESSATION OF SMOKING

>8 WEEKS BEST RESULTS( IMPROVEMENT IN MUCOCILIARY

FUNCTION INCREASED SPUTUM CLEARANCE, REDUCED AIRWAY

HYPER REACTIVITY AND DECREASED SPUTUM PRODUCTION)

<8 WEEKS MAX 57 % COMPLICATIONS

WITHIN 12 HRS OF CESSATION OF SMOKING THE CARBOXY HB LEVELS DROP

RISK OF PATIENTS WHO QUIT FOR MORE THAN 6 MONTHS IS SAME AS THOSE WHO NEVER SMOKED

OPTIMISATION

2)INFECTION-

TREAT INFECTION WITH APPROPRIATE ANTIBIOTICS

IN CASE OF URI IDEALLY WAIT FOR 2-3 WEEKS

3)BRONCHODILATORS-

BENEFITS THOSE WITH AND WITHOUT BRONCHOSPASM. USE OF INHALED STEROIDS + SALBUTAMOL 3 DAYS PRE-OP REDUCED THE INCIDENCE OF POST-OP BRONCHOSPASM FROM 93% TO 6.3%

4)CARDIAC STABILISATION- CHF/COR PULMONALE SHOULD BE TREATED WITH DIURETICS OR /AND DIGITALIS .CARDIOSELECTIVE BETA BLOCKERS ARE SAFE.STATINS REDUCE RISK.ACE INHIBITORS SHOULD BE STOPPED 24 HRS PRIOR.

OPTIMISATION

5)HYDRATION +MUCOLYTIC THERAPY,

-LOOSENS SECRETIONS AND CHEST PHYSIOTHERAPY CLEARS THE CHEST OF SECRETIONS

6)INCENTIVE SPIROMETRY-AND DEEP BREATHING EXERCISES HAVE BEEN SHOWN TO REDUCE POSTOPERATIVE PULMONARY COMPLICATION RATE.

7)EXPLANATION TO PATIENT ABOUT POSTOPERATIVE O2/ NIV / IPPV THERAPIES HELPS IN GETTING COOPERATION FOR SUCH THERAPIES WITH POSITIVE RESULTS.

8)NIL BY MOUTH ORDER

PERIOPERATIVE LUNG EXPANSION MANEUVERS• A META-ANALYSIS EVALUATING: UPPER ABDOMINAL SURGERY

• INCENTIVE SPIROMETRY (IS)

• DEEP BREATHING EXERCISE (DB)

• INTERMITTENT POSITIVE PRESSURE BREATHING (IPPB)

• SIMILAR IN EFFICACY

• BETTER THAN NO RESPIRATORY THERAPY

• PREOPERATIVE- BETTER RESULTS

Thomas JA, et al. Physical Therapy 1994; 74:3-10.

OPTIMISATION

ORAL STEROIDS- METHYLPREDNISOLONE 40 MG/DAY FOR 5 DAYS PREOPERATIVELY

-ONGOING WHEEZE

-NEWLY DIAGNOSED PATIENT

-POORLY COMPLIANT PATIENT

- FOR MODERATE TO SEVERE

ASTHMA/COPD

MAST CELL STABILIZERS LIKE CROMOLYN AND MONTELUKAST PREVENT REFLEX BRONCHOSPASM

PATIENTS ON PRE-OP STEROID THERAPY

• WHO HAVE BEEN TREATED WITH STEROIDS FOR MORE THAN 2 WEEKS IN LAST 6 MONTHS

• ASSUMED TO HAVE ADRENO-CORTICAL AXIS SUPPRESSION

• TREAT FULLY WITH STEROIDS FOR MAJOR SURGERY

• 100 MG TDS I.-V.

• FOR 48 HRS

• ( STUDY-NO INCREASE IN THE INCIDENCE OF WOUND INFECTIONS)

DRUGS PRECIPITATING ASTHMA• ASPIRIN

NASOGASTRIC TUBE INSERTION

• PROPHYLACTIC NASOGASTRIC TUBE INSERTION IN COPD /ASTHMA CASES HAS BEEN SHOWN TO INCREASE THE RISK OF POST-OPERATIVE PULMONARY COMPLICATIONS,

• HENCE SELECTIVE NASOGASTRIC TUBE INSERTION ONLY WHEN THERE IS POSTOPERATIVE NAUSEA ,VOMITTING OR SYMPTOMATIC ABDOMINAL DISTENSION IS ADVOCATED

SMOKİNG CESSATİON FOR ≥8 WEEKS TREATMENT FOR PATİENTS WİTH UNDERLYİNG ASTHMA / COPD

(PFT) DELAY ELECTİVE SURGERY AND TREAT WİTH ANTİBİOTİCS İF

RESPİRATORY İNFECTİON İS PRESENT PATİENT EDUCATİON REGARDİNG LUNG EXPANSİON MANEUVERS STEROIDS WHEN INDICATED PREOPERATIVE AEROSOL NEBULISATION OBESE PATİENTS SHOULD BE MANAGED TO LOSE WEİGHT CHOOSE PROCEDURE LASTİNG < 4 HRS (İF POSSİBLE)/REGIONAL

ANASTHESIA PREFERED. SELECTIVE NASOGASTRIC TUBE INSERTION

SUMMARY

PREDICTORS OF PULMONARY COMPLICATIONS

• Patient Related

Age > 50, 60, 70, 80

Chronic Lung Disease

Asthma

Smoking

Heart Failure

Albumin

BUN

Functional Dependence

ASA Class >= 2

Qasam, A, et al, Ann Intern Med, 2006; 144:575

• Odds Ratio of Complications

1.5, 2.28, 3.9, 5.63

2.36

Uncontrolled 3, Controlled 1

Current 5.5, 2 mo Cessation 1.26

2.93

2.53

2.29

Total 2.51 Partial 1.65

4.87

AROZULLAH RESPIRATORY FAILURE RISK INDEX• Type of Surgery

– AAA– Thoracic

– Neurosurgery, Upper Abdominal Peripheral Vascular, Neck

• Emergency Surgery• Albumin < 3.0 g/dL• BUN > 30 mg/dL• Partial/Full Dependence• History of COPD• Age > 70• Age 60 - 69

• Point Value

27

21

14

11

9

8

7

6

6

5

AROZULLAH RESPIRATORY FAILURE INDEX SCORING

Class Point Total % Respiratory Failure

One <= 10 0.5

Two 11 – 19 1.8

Three 20 – 27 4.2

Four 28 – 40 10.1

Five > 40 26.6

Arozullah, AM, Daley, J, et al, Ann Surg 2000; 232:242

INDICATORS OF POSTOPERATIVE PULMONARY COMPLICATIONS• Age 60

• H/o smoking for 40 pack years or more . risk 6 times more.

• +cough test

• +wheeze test

• Forced expiratory time 9sec

• Wheeze, cough,dyspnoea,excessive sputum production chest pain

• Spirometry-FEV11 L/min, FVC1.5 L/min

• ABG-pCo245mm hg(61 times more risk) ,pO275 mm hg.

• Presence of CHF

• ASA grade 2 and above

Risk factors Point> 70 years old 5Myocardial infarction within the last 6 months

10

S3 gallop or jugular venous distension 11Significant aortic stenosis 3Premature atrial beats or arrhythmias 7Premature ventricular contractions> 5 min 7Intrathoracic, intraperitoneal, and aortic surgery

3

Emergency operation 4Impairment of general health status 3

Goldman cardiac risk index

Ebstein SK. Chest 1993; 104:694-700,

Variable PointBMI>27 kg/m2 1

Cigarette (last 8 weeks) 1

Productive cough (last 5 days) 1

Wheezing (last 5 days) 1

FEV1/FVC < 70% 1

Pa CO2 > 45 mmHg 1

Pulmonary risk index: Risk factors known to increase PPC

Ebstein SK. Chest 1993; 104

Goldman CRI

0 - 5 points : 1

6 -12 points : 2

13 - 25 points : 3

26 - 53 points : 4

Pulmonary risk index

Between 0 - 6

Cardiopulmonary risk index scor

( 1 ... 4 ) + ( 0... 6 ) = 10 ; total

If the CPRIS is higher than 4, prognosis is poor

Cardiopulmonary complication risk is more than 22 folds

Ebstein SK. Chest 1993; 104

STOP-BANG SCORE

• S Snoring Do you Snore Loudly? Louder than talking or loud enough to be heard through a closed door?

• T Tiredness Do you often feel Tired?Do you sleep during the daytime?

• O Observed apnea Has anyone observed you stop breathing during sleep?

• P Pressure Do you have high blood pressure?

• B BMI > 35 kg m−2

• A Age Over 50 years

• N Neck Circumference >40 cm

• G Gender Male

• High risk for OSAS: ≥3 positive responses Low risk for OSAS: <3 positive responses.

THANK YOUDR JAVADEKAR NARENDRA