PREOPERATIVE PULMONARY ASSESSMENT - The...

PREOPERATIVE PREOPERATIVE PULMONARY PULMONARY ASSESSMENTASSESSMENT

Definition Definition -- Postoperative pulmonary Postoperative pulmonary complication complication

Postoperative pulmonary complication is Postoperative pulmonary complication is defined as an abnormalitydefined as an abnormalitythat produces identifiable disease or that produces identifiable disease or dysfunction of the lungsdysfunction of the lungsis clinically significantis clinically significantadversely affects the clinical courseadversely affects the clinical course

MechanismsMechanisms

Complications may arise from:Complications may arise from:AtelectasisAtelectasisInfection (Infection (egeg, bronchitis, pneumonia), bronchitis, pneumonia)Prolonged mechanical ventilation and Prolonged mechanical ventilation and respiratory failurerespiratory failureExacerbation of an underlying chronic Exacerbation of an underlying chronic lung diseaselung diseaseBronchospasmBronchospasm

Importance of Postoperative Pulmonary Importance of Postoperative Pulmonary Complications Complications

Increase Increase perioperativeperioperative morbidity and morbidity and mortalitymortalityMore common than cardiac complications in More common than cardiac complications in patients undergoing elective surgery to the patients undergoing elective surgery to the thorax and upper abdomenthorax and upper abdomenFrequency rate varies from 5Frequency rate varies from 5--70%70%Prolong the hospital stay by an average of Prolong the hospital stay by an average of one to two weeks one to two weeks

PERIOPERATIVE PULMONARY PERIOPERATIVE PULMONARY PHYSIOLOGYPHYSIOLOGY

Respiratory effects of general anesthesia Respiratory effects of general anesthesia Decreased respiratory drive causing a Decreased respiratory drive causing a diminished response to both diminished response to both hypercapniahypercapnia and hypoxemiaand hypoxemiaDrugs (neuromuscular blockers, anesthetic Drugs (neuromuscular blockers, anesthetic agents) cause diaphragm and chest wall agents) cause diaphragm and chest wall relaxationrelaxationThis results in a marked reduction in the This results in a marked reduction in the functional reserve capacity (FRC) and functional reserve capacity (FRC) and thereby decreased thoracic volume thereby decreased thoracic volume

Respiratory effects of general anesthesiaRespiratory effects of general anesthesia

The decrease in lung volume promotes The decrease in lung volume promotes atelectasisatelectasis in the dependent lung regions in the dependent lung regions and persists for more than 24 hours in and persists for more than 24 hours in 50% of patients50% of patients

Consequently, Consequently, arterial hypoxemiaarterial hypoxemia occurs occurs from from ventilation perfusion mismatchventilation perfusion mismatch and and increased shunt fractionincreased shunt fraction

Postoperative respiratory physiology in Postoperative respiratory physiology in upper abdominal and thoracic surgery upper abdominal and thoracic surgery

Diaphragmatic dysfunction, postoperative Diaphragmatic dysfunction, postoperative pain, and splinting reduce VC by 50% and pain, and splinting reduce VC by 50% and FRC by 30% FRC by 30%

Following upper abdominal surgery, ribcage Following upper abdominal surgery, ribcage excursions and abdominal expiratory muscle excursions and abdominal expiratory muscle activities decrease due to decreased central activities decrease due to decreased central nervous system output to the nervous system output to the phrenicphrenic nervesnerves


Tidal volume is smaller and the respiratory Tidal volume is smaller and the respiratory rate increases (rate increases (ieie, rapid shallow breathing), rapid shallow breathing)Inhibition of cough and impaired Inhibition of cough and impaired mucociliarymucociliary clearance because of:clearance because of:rapid shallow breathingrapid shallow breathingresidual effects of anesthesia and residual effects of anesthesia and postoperative narcoticspostoperative narcoticsRisk of postoperative pneumonia increased Risk of postoperative pneumonia increased


Other factors that may contribute to increased Other factors that may contribute to increased respiratory complications:respiratory complications:Electrolyte imbalance (Electrolyte imbalance (egeg, , hypokalemiahypokalemia, , hypophosphatemiahypophosphatemia, , hypocalcemiahypocalcemia))General debilitationGeneral debilitationUnderlying lung disease (Underlying lung disease (egeg, chronic , chronic obstructive lung disease [COPD])obstructive lung disease [COPD])

PATIENT AND PROCEDURE RELATED RISK PATIENT AND PROCEDURE RELATED RISK FACTORSFACTORS

PatientPatient--related risk factorsrelated risk factorsAgeAge

Advanced age is not an independent risk Advanced age is not an independent risk factor for pulmonary complications factor for pulmonary complications In a study of patients over 80 years of age, In a study of patients over 80 years of age, overall 30overall 30--day mortality was 6.2%, patients day mortality was 6.2%, patients who belonged to ASA class II had less who belonged to ASA class II had less than 1% mortalitythan 1% mortalityTherefore, surgery should not be declined Therefore, surgery should not be declined on the basis of advanced age aloneon the basis of advanced age alone

PatientPatient--related risk factorsrelated risk factors

Obesity (BMI > 27 kg/mObesity (BMI > 27 kg/m22))Obesity decreasesObesity decreases

Expiratory reserve volumeExpiratory reserve volumeFunctional residual capacityFunctional residual capacity

Morbid obesity causesMorbid obesity causesRestrictive lung diseaseRestrictive lung diseaseDecreases thoracic complianceDecreases thoracic complianceLeads to alveolar hypoventilationLeads to alveolar hypoventilation


Severe obesity is associated with pulmonary Severe obesity is associated with pulmonary hypertension, hypertension, corcor--pulmonalepulmonale and and hypercapnichypercapnic respiratory failure (respiratory failure (PickwickianPickwickian syndrome)syndrome)


General health statusGeneral health statusPatients who have poor exercise capacity are Patients who have poor exercise capacity are at increased risk of developing postoperative at increased risk of developing postoperative pulmonary complicationspulmonary complicationsInability to raise heart rate by a simple Inability to raise heart rate by a simple exercise predicts 79% of pulmonary exercise predicts 79% of pulmonary complicationscomplications


SmokingSmokingCurrent smokers: 2Current smokers: 2--fold increased risk of fold increased risk of postoperative complicationspostoperative complications

The risk is highest in patients who The risk is highest in patients who smoked within the last 2 monthssmoked within the last 2 monthsPatients who quit smoking for more than 6 Patients who quit smoking for more than 6 months have a risk similar to the months have a risk similar to the nonsmokersnonsmokersPostoperative morbidity is not decreased Postoperative morbidity is not decreased in patients who quit smoking for less than in patients who quit smoking for less than 8 weeks 8 weeks


Beneficial effects of smoking cessationBeneficial effects of smoking cessationImprovement in Improvement in ciliaryciliary and small airway and small airway functionfunctionDecrease in sputum productionDecrease in sputum production


Chronic obstructive pulmonary disease Chronic obstructive pulmonary disease (COPD)(COPD)One of the most important risk factorsOne of the most important risk factorsPatients with severe COPD (FEVPatients with severe COPD (FEV11 less than less than 40% predicted) are 6 times more likely to 40% predicted) are 6 times more likely to have a major postoperative complicationhave a major postoperative complicationHowever, there is no prohibitive level of However, there is no prohibitive level of pulmonary function for an absolute pulmonary function for an absolute contraindicationcontraindicationThe benefits of surgery must be weighed The benefits of surgery must be weighed against these complicationsagainst these complications


Chronic obstructive pulmonary disease Chronic obstructive pulmonary disease (COPD)(COPD)A careful preoperative evaluation of patients A careful preoperative evaluation of patients with COPD should include identification of with COPD should include identification of highhigh--risk patients and aggressive treatmentrisk patients and aggressive treatmentElective surgery should be deferred in Elective surgery should be deferred in patients who are symptomatic, have poor patients who are symptomatic, have poor exercise capacity or if acute exacerbation is exercise capacity or if acute exacerbation is present present


AsthmaAsthmaInadequate control of asthma preoperatively Inadequate control of asthma preoperatively may increase risk of postoperative may increase risk of postoperative complicationscomplicationsOptimal asthma control is defined as Optimal asthma control is defined as absence of symptoms and forced expiratory absence of symptoms and forced expiratory flow (FEVflow (FEV11 ) more than 80% predicted or ) more than 80% predicted or personal best should be achievedpersonal best should be achieved


Sleep apneaSleep apneaIncreased risk of developing in the Increased risk of developing in the postoperative periodpostoperative period

Deterioration of sleep disordered Deterioration of sleep disordered breathingbreathingSevere hypoxemiaSevere hypoxemiaHypercapniaHypercapnia

Due to associated obesityDue to associated obesityDifficulties with Difficulties with endotrachealendotracheal

intubationintubationEarly postoperative upper airway Early postoperative upper airway

obstruction requiring obstruction requiring reintubationreintubation or or other therapiesother therapies

ProcedureProcedure--related risk factors related risk factors

Surgical siteSurgical siteThe incidence of complications is inversely The incidence of complications is inversely related to the distance of the surgical related to the distance of the surgical incision from the diaphragmincision from the diaphragmComplication rates:Complication rates:

Upper abdominal surgery 17Upper abdominal surgery 17--76%76%Lower abdominal surgery 0Lower abdominal surgery 0--5%5%Thoracic surgery 19Thoracic surgery 19--59%59%


Duration of surgeryDuration of surgery

Patients undergoing procedures lasting for Patients undergoing procedures lasting for

more than 3more than 3--4 hours have a higher incidence 4 hours have a higher incidence

of pulmonary complication than for surgeries of pulmonary complication than for surgeries

less than 2 hours (40% versus 8%)less than 2 hours (40% versus 8%)


Key hole surgeryKey hole surgeryLaparoscopic abdominal surgery, Laparoscopic abdominal surgery, particularly particularly cholecystectomycholecystectomy, is associated , is associated with fewer postoperative pulmonary with fewer postoperative pulmonary abnormalities and a shorter hospital stayabnormalities and a shorter hospital stayLaparoscopic surgery causes a 23% Laparoscopic surgery causes a 23% decrease in FVC and 16% decrease in FEVdecrease in FVC and 16% decrease in FEV11 making it possible for patients with severe making it possible for patients with severe COPD to tolerate surgeryCOPD to tolerate surgery


VideoVideo--assisted assisted thoracoscopicthoracoscopic surgery surgery utilizes much smaller incisionsutilizes much smaller incisionsHospitalization time is substantially reducedHospitalization time is substantially reducedSmaller incisions, performed without Smaller incisions, performed without separation of ribs and less postoperative separation of ribs and less postoperative pain leads to early ambulation and reduced pain leads to early ambulation and reduced pulmonary complicationspulmonary complications


Type of anesthesiaType of anesthesiaData are inconsistent about whether the Data are inconsistent about whether the complication rate is lower with spinal or complication rate is lower with spinal or epidural anesthesia compared to general epidural anesthesia compared to general anesthesiaanesthesiaThe spinal or epidural anesthesia is safe and The spinal or epidural anesthesia is safe and should be considered in highshould be considered in high--risk patientsrisk patientsRegional nerve block is associated with a Regional nerve block is associated with a lowlow--risk and should be considered whenever risk and should be considered whenever possible for highpossible for high--risk patientsrisk patients

PREOPERATIVE RISK ASSESSMENTPREOPERATIVE RISK ASSESSMENT

History History Perform a complete history and physical Perform a complete history and physical

examination to identify risk factorsexamination to identify risk factorsFocus onFocus on

History of smokingHistory of smokingExercise intoleranceExercise intoleranceUnexplained Unexplained dyspneadyspneaCoughCough

Note evidence of COPDNote evidence of COPD


Pulmonary function tests (PFT)Pulmonary function tests (PFT)1.1. Patients undergoing cardiac or upper Patients undergoing cardiac or upper

abdominal surgery with a history of abdominal surgery with a history of smoking or smoking or dyspneadyspnea

2.2. Patients undergoing lower abdominal Patients undergoing lower abdominal surgery if surgery if dyspneadyspnea or history of smoking or history of smoking anticipating prolonged surgery anticipating prolonged surgery

3.3. Patients undergoing orthopedic surgery Patients undergoing orthopedic surgery with uncharacterized lung disease with uncharacterized lung disease

4.4. All patients undergoing lung resectionAll patients undergoing lung resection


SpirometrySpirometry

An extremely useful tool for objectively An extremely useful tool for objectively evaluating the respiratory status of evaluating the respiratory status of patients preoperativelypatients preoperativelyUsed to predict postoperative Used to predict postoperative complications and to guide optimization of complications and to guide optimization of airflow obstruction in preparation for airflow obstruction in preparation for surgerysurgeryHigh postoperative risk:High postoperative risk:

FEVFEV11 < 70% predicted< 70% predictedFVC < 70 percent predictedFVC < 70 percent predictedFEVFEV11/FVC ratio <65%/FVC ratio <65%


ABGABGA PaCOA PaCO22 of more than 45 mmHg indicates a of more than 45 mmHg indicates a high risk, although it is not necessarily high risk, although it is not necessarily prohibitiveprohibitiveHypoxemia is not a significant predictor of Hypoxemia is not a significant predictor of complicationscomplicationsPatients undergoing cardiac or abdominal Patients undergoing cardiac or abdominal surgery who have surgery who have dyspneadyspnea or are smokers or are smokers and thoracic surgery patients should have and thoracic surgery patients should have arterial blood gas analysis arterial blood gas analysis


Chest radiographChest radiographChest xChest x--rays add little to the clinical rays add little to the clinical evaluation in healthy patientsevaluation in healthy patientsAll patients older than 60 years, or with All patients older than 60 years, or with clinical findings of cardiac or pulmonary clinical findings of cardiac or pulmonary disease should have a preoperative chest xdisease should have a preoperative chest x-- ray unless one was done in the last 6 monthsray unless one was done in the last 6 months

Pulmonary Risk Index Pulmonary Risk Index

1.1. Obesity (Obesity (ieie, body mass index more than 27 , body mass index more than 27 kg/m2) kg/m2)

2.2. Cigarette smoking within 8 weeks of Cigarette smoking within 8 weeks of surgerysurgery

3.3. Productive cough within 5 days of surgeryProductive cough within 5 days of surgery

4.4. Diffuse wheezing within 5 days of surgeryDiffuse wheezing within 5 days of surgery

5.5. FEVFEV11 /FVC ratio less than 70% and PaCO/FVC ratio less than 70% and PaCO22 within 45 mmHg within 45 mmHg

RISK INDICES RISK INDICES

American Society of Anesthesiology (ASA) American Society of Anesthesiology (ASA) ClassificationClassificationThis score is based on simple clinical criteria This score is based on simple clinical criteria and is easy to quantifyand is easy to quantifyAlthough subjective, the scores of 2Although subjective, the scores of 2--5 5 indicate increasing level of severity, and indicate increasing level of severity, and increased postoperative morbidityincreased postoperative morbidity

ASA ClassificationASA Classification

ASA Class I:ASA Class I: A normal, healthy patient A normal, healthy patient without organic, physiologic or psychiatric without organic, physiologic or psychiatric disturbance; e.g., healthy with good exercise disturbance; e.g., healthy with good exercise tolerance tolerance ASA Class II:ASA Class II: A patient with controlled A patient with controlled medical conditions without significant medical conditions without significant systemic effects; e.g. controlled systemic effects; e.g. controlled hypertension or controlled diabetes without hypertension or controlled diabetes without systemic effects, cigarette smoking without systemic effects, cigarette smoking without COPD, anemia, mild obesity, age less than 1 COPD, anemia, mild obesity, age less than 1 or greater than 70 year, pregnancy or greater than 70 year, pregnancy


ASA Class IIIASA Class IIIA patient having medical conditions with A patient having medical conditions with significant systemic effects, intermittently significant systemic effects, intermittently associated with significant functional associated with significant functional compromise; e.g., controlled CHF, stable compromise; e.g., controlled CHF, stable angina, old MI, poorly controlled angina, old MI, poorly controlled hypertension, morbid obesity, hypertension, morbid obesity, bronchoscopasticbronchoscopastic disease with disease with intermittent symptoms, chronic renal intermittent symptoms, chronic renal failure failure


ASA Class IVASA Class IV

A patient with a medical condition that is A patient with a medical condition that is poorly controlled, associated with poorly controlled, associated with significant dysfunction and is a potential significant dysfunction and is a potential threat to life; e.g., unstable angina, threat to life; e.g., unstable angina, symptomatic COPD, symptomatic CHF, symptomatic COPD, symptomatic CHF, hepatorenalhepatorenal failurefailure


ASA Class V:ASA Class V: A patient with a critical medical A patient with a critical medical condition that is associated with little change condition that is associated with little change of survival with or without the surgical of survival with or without the surgical procedure; e.g., procedure; e.g., multiorganmultiorgan failure, sepsis failure, sepsis syndrome with syndrome with hemodynamichemodynamic instability, instability, hypothermia, poorly controlled hypothermia, poorly controlled coagulopathycoagulopathy

ASA VI:ASA VI: A patient who is brain dead and A patient who is brain dead and undergoing anesthesia care for the purposes undergoing anesthesia care for the purposes of organ donationof organ donation

PREOPERATIVE EVALUATION: THORACIC PREOPERATIVE EVALUATION: THORACIC SURGERY SURGERY Lung ResectionLung Resection

Preoperative assessment identifies patients at Preoperative assessment identifies patients at greatest risk for postoperative complications greatest risk for postoperative complications and those patients with severe impairment, and those patients with severe impairment, where risk of surgery is prohibitivewhere risk of surgery is prohibitiveinin--hospital patient mortality rates:hospital patient mortality rates:

3.8% after wedge resection3.8% after wedge resection3.7% after segmental resection3.7% after segmental resection4.2% after 4.2% after lobectomylobectomy11.6 % after 11.6 % after pneumonectomypneumonectomy

PREOPERATIVE EVALUATION: THORACIC PREOPERATIVE EVALUATION: THORACIC SURGERY SURGERY

Significant predictors of mortality are:Significant predictors of mortality are:Age > than 60 yearsAge > than 60 yearsExtended resectionExtended resectionChronic heart or lung diseaseChronic heart or lung diseaselow FEVlow FEV11

The following are recommended:The following are recommended:Preoperative pulmonary functionPreoperative pulmonary functionCalculation of predicted postoperative Calculation of predicted postoperative

pulmonary functionpulmonary functionGas exchangeGas exchangeExercise testingExercise testing

Preoperative pulmonary function Preoperative pulmonary function

Forced expiratory volume in 1 second Forced expiratory volume in 1 second (FEV(FEV11 ) is the primary value used for ) is the primary value used for resectabilityresectabilityFEVFEV11 predicts pulmonary reserve and is a predicts pulmonary reserve and is a strong predictor of postoperative strong predictor of postoperative complicationscomplicationsPneumonectomyPneumonectomy: preoperative FEV: preoperative FEV11 of of greater than 2 L/sec is requiredgreater than 2 L/sec is requiredLobectomyLobectomy: 1 L/sec: 1 L/sec


Diffusion capacity Diffusion capacity A good predictor of morbidity and mortality A good predictor of morbidity and mortality after lung resectionafter lung resectionA diffusion capacity of below 60% predicted A diffusion capacity of below 60% predicted was found to have a patient mortality rate of was found to have a patient mortality rate of 24%24%A diffusion capacity of < 40% with borderline A diffusion capacity of < 40% with borderline FEVFEV11 criteria is associated with high criteria is associated with high mortality and morbidity and may be mortality and morbidity and may be prohibitive prohibitive


Predicting postoperative pulmonary Predicting postoperative pulmonary functionfunction

Predicted postoperative function = (Preoperative Predicted postoperative function = (Preoperative function) X (% of function contributed by the lung function) X (% of function contributed by the lung that will remain postoperatively)that will remain postoperatively)This measurement improves the predictive value This measurement improves the predictive value of preoperative testingof preoperative testingBased upon a combination of Based upon a combination of spirometryspirometry and and quantitative perfusion lung scan, a predicted quantitative perfusion lung scan, a predicted postpneumonectomypostpneumonectomy FEVFEV11 more than 0.8 L/sec. is more than 0.8 L/sec. is suggested as the lower limitsuggested as the lower limit


The percentage of predicted value is a better The percentage of predicted value is a better measure as it reflects differences in size, measure as it reflects differences in size, age, gender, and raceage, gender, and raceThe predicted postoperative FEVThe predicted postoperative FEV11 of 40% of 40% more is associated with the least mortalitymore is associated with the least mortalityA predicted FEVA predicted FEV11 of 40% predicted is of 40% predicted is required for performance of minimal required for performance of minimal activities of daily living without activities of daily living without dyspneadyspnea


FEVFEV11 of less than 30% is associated with of less than 30% is associated with 20 to 30% 520 to 30% 5--year survival ratesyear survival ratesPostoperative FEVPostoperative FEV11 less than 30% will less than 30% will cause immediate postoperative morbidity cause immediate postoperative morbidity and mortality and also excessive longer and mortality and also excessive longer term mortalityterm mortalityUse of radionuclide lung scanning to Use of radionuclide lung scanning to calculate this value is requiredcalculate this value is requiredIf the predicted postoperative FEVIf the predicted postoperative FEV11 is less is less than 0.8 L/sec or less than 40% predicted, than 0.8 L/sec or less than 40% predicted, the patient is the patient is unresectableunresectable


Radionuclide quantitative lung scanningRadionuclide quantitative lung scanning

Radionuclide scanning is used to Radionuclide scanning is used to quantitatequantitate the function of a lung or a lobe, which will be the function of a lung or a lobe, which will be resectedresectedTherefore, the function of the remaining lung Therefore, the function of the remaining lung can be calculatedcan be calculatedPostpneumonectomyPostpneumonectomy FEVFEV11 < 0.8 L/sec is < 0.8 L/sec is associated with prohibitive riskassociated with prohibitive risk

Measurement of gas exchange Measurement of gas exchange

Gas exchange : diffusing capacity and ABGGas exchange : diffusing capacity and ABGPostoperative Diffusion of less than 40% Postoperative Diffusion of less than 40% predicted: high morbidity and mortality predicted: high morbidity and mortality A low resting arterial PaOA low resting arterial PaO22 is not a strong is not a strong predictor, but predictor, but hypercapniahypercapnia (PaCO(PaCO22 > 45 > 45 mmHg) has been considered a significant mmHg) has been considered a significant risk factor, though not provenrisk factor, though not proven

Exercise testing Exercise testing

This may be done as:This may be done as:Stair climbingStair climbingComplete cardiopulmonary exercise Complete cardiopulmonary exercise testing testing

Stair climbing has been shown to identify Stair climbing has been shown to identify patients at increased risk for lung resectionpatients at increased risk for lung resection

Patients capable of climbing 3 or more flights Patients capable of climbing 3 or more flights of stairs have lower complication ratesof stairs have lower complication rates

Exercise testing Exercise testing

VOVO22 max of less than 1 L/min have excess max of less than 1 L/min have excess mortalitymortalityA VOA VO22 max of more than 20 ml/kg/min is max of more than 20 ml/kg/min is associated with least postoperative associated with least postoperative complicationscomplicationsValue of less than 10 ml/kg/min may be Value of less than 10 ml/kg/min may be prohibitive because of the high morbidity prohibitive because of the high morbidity and mortalityand mortalityA VOA VO22 max of between 10max of between 10--20 ml/kg/min 20 ml/kg/min may have increased but an acceptable riskmay have increased but an acceptable risk

PREPARATION FOR SURGERY PREPARATION FOR SURGERY

Smoking cessationSmoking cessationInstruct patients undergoing elective surgery Instruct patients undergoing elective surgery to abstain from smoking for to abstain from smoking for 8 weeks8 weeks before before surgery surgery

Use of counselingUse of counselingNicotine replacement therapiesNicotine replacement therapiesBupropionBupropion


Chronic obstructive pulmonary diseaseChronic obstructive pulmonary diseaseAggressively treat patients with COPD to Aggressively treat patients with COPD to achieve the best possible baseline achieve the best possible baseline function function Use of Use of bronchodilatorsbronchodilators, , smoking smoking cessationcessation, , antibioticsantibiotics, and , and chest physical chest physical therapytherapy may reduce significantly may reduce significantly pulmonary complications pulmonary complications Treat patients who have a persistent Treat patients who have a persistent wheeze, functional limitation, or severe air wheeze, functional limitation, or severe air flow obstruction with flow obstruction with perioperativeperioperative steroidssteroids


Asthma Asthma Optimize asthma control prior to surgeryOptimize asthma control prior to surgeryPerioperativePerioperative systemic corticosteroids are systemic corticosteroids are recommended for persistent symptoms if recommended for persistent symptoms if the peak flow rate and FEVthe peak flow rate and FEV11 are less than are less than 80% predicted or previous best80% predicted or previous bestThe The safety of safety of perioperativeperioperative corticosteroid corticosteroid use is well establisheduse is well establishedRisk of death, serious infections, or Risk of death, serious infections, or adrenal suppression is not increasedadrenal suppression is not increased


AsthmaAsthmaHypothalamicHypothalamic--pituitarypituitary--adrenal axis adrenal axis suppression should be assumed to be suppression should be assumed to be present in patients who receive systemic present in patients who receive systemic steroids for more than 3 weeks in the past 6 steroids for more than 3 weeks in the past 6 monthsmonthsCover Cover perioperativelyperioperatively (Hydrocortisone 100 (Hydrocortisone 100 mg IV Q8H) mg IV Q8H)


Preoperative antibiotics Preoperative antibiotics Indiscriminate use of prophylactic antibiotics Indiscriminate use of prophylactic antibiotics does not lead to a reduction in pulmonary does not lead to a reduction in pulmonary complicationscomplicationsThese drugs should be used in patients with These drugs should be used in patients with a clinically apparent respiratory infectiona clinically apparent respiratory infectionCancel elective surgery if patient has active Cancel elective surgery if patient has active infectioninfection


Patient educationPatient educationLung expansionLung expansionDeep breathing and coughingDeep breathing and coughingIncentive Incentive spirometryspirometry

INTRAOPERATIVE STRATEGIES INTRAOPERATIVE STRATEGIES

Type of anesthesia Type of anesthesia

The type of anesthesia and neuromuscular The type of anesthesia and neuromuscular blockage affect the incidence of blockage affect the incidence of postoperative pulmonary complicationspostoperative pulmonary complications

Intermediate and shorter acting agents (e.g., Intermediate and shorter acting agents (e.g., vecuroniumvecuronium, , rocuroniumrocuronium) are preferred, as ) are preferred, as residual neuromuscular blockade from residual neuromuscular blockade from longer acting agents may contribute to longer acting agents may contribute to pulmonary complications pulmonary complications


Type of anesthesia Type of anesthesia Spinal anesthesia may be safer than general Spinal anesthesia may be safer than general anesthesia; considered for highanesthesia; considered for high--risk patientsrisk patients

Depending on the type and duration of Depending on the type and duration of surgery, surgery, endotrachealendotracheal intubationintubation and and mechanical ventilation may be preferable, mechanical ventilation may be preferable, because of the ability to monitor and control because of the ability to monitor and control respiratory rate and tidal volumerespiratory rate and tidal volume


Type of neuromuscular blockadeType of neuromuscular blockade

PancuroniumPancuronium, a long, a long--acting neuromuscular acting neuromuscular blocker, may lead to residual effects, cause blocker, may lead to residual effects, cause hypoventilation, and increase complications hypoventilation, and increase complications Use the intermediateUse the intermediate--acting agents (acting agents (egeg, , vecuroniumvecuronium, , atracuriumatracurium) in high) in high--risk risk pulmonary patientspulmonary patients


Duration and type of surgeryDuration and type of surgeryWhen available, a less ambitious, shorter When available, a less ambitious, shorter procedure should be considered in extremely procedure should be considered in extremely highhigh--risk patientsrisk patients

As upper abdominal and thoracic operations As upper abdominal and thoracic operations carry the greatest risk, a carry the greatest risk, a percutaneouspercutaneous (laparoscopic) procedure should be (laparoscopic) procedure should be substituted for an open procedure if possible substituted for an open procedure if possible

POSTOPERATIVE STRATEGIES POSTOPERATIVE STRATEGIES

Lung expansionLung expansion maneuversmaneuversDeep breathingDeep breathingIncentive Incentive spirometryspirometry

Regular physiotherapy visitsRegular physiotherapy visitsIntermittent positive pressure breathingIntermittent positive pressure breathing: The : The cost and potential for abdominal distension cost and potential for abdominal distension does not warrant its use. does not warrant its use. Continuous positive airway pressureContinuous positive airway pressure: Shown : Shown to be beneficial as a secondary intervention to be beneficial as a secondary intervention for refractory for refractory atelectasisatelectasis

POSTOPERATIVE STRATEGIES POSTOPERATIVE STRATEGIES

Pain controlPain controlAdequate postoperative pain control will Adequate postoperative pain control will minimize the pulmonary complications by minimize the pulmonary complications by encouraging earlier ambulation and encouraging earlier ambulation and performance of lung expansion maneuversperformance of lung expansion maneuvers

Management of postoperative pain includes Management of postoperative pain includes narcotics and narcoticsnarcotics and narcotics--like medications like medications administered peripherally, in to the epidural administered peripherally, in to the epidural or or intrathecalintrathecal spacespace

Prevention of Pulmonary Complications - A team Effort

PulmonologistPulmonologist

SurgeonSurgeon

AnesthesiologistAnesthesiologist

Respiratory PhysiotherapistRespiratory Physiotherapist

Nursing StaffNursing Staff

All the best..All the best..

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