reoperative Care of Pulmonary Patients: An evaluation for postoperative pulmonary

complications

Anakapong Phunmanee MD.Associated Professor

Department of Medicine, Faculty of Medicine, Khon Kaen University

Topics

• The concepts for performing effective consultation

• Factors related to PPCs

• Preoperative pulmonary evaluations

• Risk indices for preoperative assessment

• Risk reduction strategies

• Preoperative care of pulmonary patients: An example

The concepts for performing effective consultation

• Prompt response (within 24 hours)• Focus on central issue• Identified critical recommendations• Make specific and limit number of

recommendations(<5)• Use definitive language• Direct verbal contact• Specific drug dosage, route, frequency• Frequent F/U and progress note

Cohn SL. UptoDate 2002

The ideal medical consultation

• Informs without patronizing

• Educated without lecturing

• Directs without ordering

• Solves the problem without making referring physician appear to be “stupid”

Bates RC, et al. Med Econ 1997

“ Referring physician and the consultant both have

responsibilities to fulfill in order to maximize the effectiveness of the

consultation in improving the patient care”

Cohn SL. UptoDate 2002

The role of preoperative medical consultation

• Identifying and evaluation the medical status

• Provide a clinical risk profile

• To optimize the medical condition in attempt to reduce risk of PPCs

Postoperative pulmonary complications (PPCs)

• Common complications, ¼ of death related to PPCs

• Incidence and prevalence vary – Population– Type of surgery– Definition of complications

Brooks-brunn JA .Heart Lung 1995

Factors related to PPCs

• Patients-related risk factors

• Operation-related risk factors

• Anesthetic-related risk factors

• Risk factors related to postoperative care

Patient-related risk factors: Aging

Arozullah AM,et al. Ann Intern Med 2001 Ann Surg 2000

50-59 YRs

< 50 YRs

60-69 YRs

70-79 YRs

> 80 YRs

10 2 3 4 5 6 7

Postoperative pneumonia (OR)

Patient-related risk factors: General health

Arozullah AM,et al. Ann Intern Med 2001 Ann Surg 2000

CVA

Obesity

ASA >,=2

Partial depend

Total depend

10 2 3 4 5 6 7

Postoperative pneumonia (OR)

Patient-related risk factors: Immune status

Arozullah AM,et al. Ann Intern Med 2001 Ann Surg 2000

Alcoholic > 2 drink/day

Within 2 wks

IDDM

Steroid use

10 2 3 4 5 6 7

Postoperative pneumonia

Postoperative pneumonia and respiratory failure

Postoperative pneumonia

Operation-related risk factors

Arozullah AM,et al. Ann Intern Med 2001 Ann Surg 2000

Neurosurgery

Vascular

Neck

Upper abdomen

AAA-repair

10 2 4 6 8 10 12

Postoperative respiratory failure (OR)

14 16

Thoracic

Influence of surgical site on rate of PPCS

Study Upper Abdomen

Lower abdomen

Laparoscopic Thoracic

Tarhan 1973 13 7 10

Garcey 1979 25 0 19

Garribaldi 1981

17 5 40

SSA club 1994

0.3

Phillips 1994 0.4

Brooks 1997 28 15

Smetana GW, et al New Engl J Med 1999

Mortality for lung resection

0

2

4

6

8

10

12

wedge resection segmental resection lobectomy pneumonectomy

Mitsudomi T, et al. J Surg Oncol 1996; 61:218-22

Multicenter study 12,00 patients , thoracotomies usually CA

% Mortality

Anesthetic-related risk factors

General anesthesia(thoracic, Ab, Vascular)

Operation time >3 hrs

10 2 3 4 5 6 7

Smetana GW, et al New Engl J Med 1999

Neuromuscular block and PPCs: Long acting VS shorter acting

0

2

4

6

8

10

12

14

16

18

long acting* Shorter acting**

Berg H, et al Acta Anaesthesiol Scand 1997

Incidence of residual NMB 26*, VS 5.3**

Incidence of Complication

Risk factors related to postoperative care

• NG tube– Postoperative NG tube not significant

associated with PPCs– Empty GI tract may decrease aspiration

outweigh risk of ineffective coughing and oropharygeal aspiration

• Pain control– Adequate pain control improving outcomes– Epidural analgesia seem to be better

outcomes than standard opioid analgesia

Preoperative pulmonary evaluations

• History and physical examination

• Chest radiography

• Arterial blood gas analysis

• Pulmonary function test

• Quantitative lung scan

• Exercise test

Chest radiography

Two potential indication

1. To identified abnormalities correcting, modification cancellation surgery

2. Serve as a base line finding

The value of an abnormal CXR before surgery

0

10

20

30

40

50

60

Makee 1987 Wiencek1987

Charpak1988

Tape 1988 Bouillot1996

Silvestri1999

Abnormal

Normal

Smetana GW, et al Med Clin N Am 2003

The abnormal CXR and aging

0

5

10

15

20

25

30

35

40

45

50

< 60 >60

Silvestri L, et al Eur J Anaesthesiol 1999

Recommendation for preoperative CXR

• Age > 50 years

• Known pre-existing cardiopulmonary diseases

• S/S like hoods of cardiopulmonary disease

Smetana GW, et al Med Clin N Am 2003

Arterial blood gas

• Small study series identified Hypercarbia(PaCO2>45) risk for PPCs

• Recent systematic review by Fisher BW, et al 2002 dose not find hypercarbia useful predictor for PPCs

Milledge JR, et al. BMJ 1975Stein M, et al. JAMA 1962

Spirometry

Pulmonary function testing (PFTs) and PPCs

• ACP guideline 1990– Lung resection– Coronary artery bypass surgery– Upper abdominal surgery with smoking or

dyspnea– Lower abdominal surgery if unexplained

pulmonary diseases with prolong extensive surgery

– Head, neck, orthopedic surgery with unexplained pulmonary diseases

Anonymous. Ann Intern Med 1990; 112:793-4.

40% PFTs do not meet guideline

Improving adherence ordering PFTs saving

29-100 million Dollar/Yr

Adapt from Smetana GW,et al. New Engl J Med 1999;340:937-944.

Stein 1970

Collin 1968

Appleberg 1974

Fogh 1987

Kispert 1992

10 2 4 6 8 10 12 14 16

Swensson 1991

Use of preoperative spirometry to predicted PPCs

Kroenke 1993

Kocabas 1996

Bando 1997

Jacob 1997

PFTs and PPCs

• Case-control study, elective abdominal surgery:– CXR highly associated with PPCs (OR 5.8)– Abnormal PE associated with PPCs– Whereas PFTs were not predictive

Lawrence VA, et al. Chest 1996;110:744-50.

PFT Diagram in Preoperative Evaluation

PFT(FEV1,MVV,DLCO)

Cleared for any resection

High risk consider exercise

testPerfusion

Scanning PPO-FEV1

Consider “Lesser” resection

Non surgical therapy

Cleared for any resection

High risk consider exercise

test

FEV1 >2 L

MVV >50%DLCO >60%

FEV1 > 2 L

MVV<50%

DLCO <60%

FEV1 <2 L

PPO-FEV1 >1.3

PPO-FEV1 >0.8, <1.3PPO-

FEV1 <0.8

Preoperative PFTs : Summary

• Thoracic surgery

• Upper abdominal surgery with respiratory symptoms remain unexplained after careful evaluation

• Routine PFTs should not ordered solely without clinical assessment

Arozullah AM. Med Clin N Am 2003; 87: 153-173

uantitative lung scan

Interpretation of quantitative lung scan

Exercise testing

• Assessing the risk in pts undergoing thoracotomy is controversial

• Acceptable value; maximum oxygen consumption > 15 ml/kg/min

Risk indices for preoperative assessment

Risk class

Pneumonia Risk

(total point)

Predicted

Prob. pneumonia

(%)

Respiratory

Failure

(total point)

Predicted

Prob.

Res. failure

(%)

1 0-15 0.2 0-10 0.5

2 16-25 1.2 11-19 2.2

3 26-40 4.0 20-27 5.0

4 41-55 9.4 28-40 11.6

5 >55 15.4 >40 30.5

Arozullah AM,et al. Med Clin N Am 2003

ตั�วอย่�างการประเมิ�นโดย่ใช้� Risk indicies

• ผู้��ป่�วยชายอาย� 60 ป่ (9)

• ต้�องเข้�ารั�บการัผู้�าต้�ดมะเรั�งป่อดรัะยะIIa (14)

• ม�ป่รัะว�ต้�สู�บบ�หรั�� 30 pack/year จนหย�ดสู�บมา 4 สู�ป่ดาห" (3)

• ได�รั�บการัว�น�จฉั�ยเป่%น COPD (5)

• รัวมได�คะแนน 31 จากต้ารัาง risk class 3 ซึ่)�ง predicted prob. pneumonia 4%,

respiratory failure 11.6 %

Limitation of risk indicies

• Developed from male, high co morbid level may not generalized to healthy population

• Hospital based study from Veterans Hospital

Arozullah AM,et al. Ann Intern Med 2001 Ann Surg 2000

Risk reduction strategies(1)

• Smoking cessation at least 8 weeks

• Perioperative lung expansion maneuver– Incentive spirometry– Chest physical therapy– Intermittent positive pressure breathing (IPPB)– Continuous positive airway pressure (CPAP)

Preoperative smoking cessation and PPCs

0

10

20

30

40

50

60

Stop >2 mth Stop<2 mth Stop>6 mth Never smoke

Warner MA,et al. Mayo Clin Proc 1989

Prospective study 200 patients, CABG

% Complication

Preoperative smoking cessation and PPCs

0

10

20

30

40

50

60

Current <2wks Recent2-4wks Exsmoke Never smoke

Nakagawa M, et al Chest 2001;120:705-10

Retrospective study 288 patients, pulmonary surgery

% Complication

Paradoxical increase PPCs after short-term abstinence

• Sicker pts tend to quit smoking closer to surgery

• Stop smoking decrease irritation

decrease stimulus for cough

Still have bronchial hypersecretion

increase sputum retention

Bluman LG, et al. chest 1998Warner MA, et al. Mayo Clin Proc 1989

Short term smoking cessation

• Decrease carboxyhemoglobin and nicotine level

Improved mucocilliary function and upper airway hypersensitivity

Buist AS, et al. Am Rev Respir Dis 1976Camner P, et al. Chest 1973

Kamban JR,et al. Anesth Analg 1986

Risk reduction strategies(2)

• Smoking cessation at least 8 weeks

• Perioperative lung expansion maneuver– Incentive spirometry– Chest physical therapy– Intermittent positive pressure breathing (IPPB)– Continuous positive airway pressure (CPAP)

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

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

Perioperative lung expansion maneuvers: Summary

• No specific lung expansion maneuver is clearly superior

• CPAP may be benefit in patients unable to perform DB or IS

• Initiative lung expansion maneuver preoperatively is more effective in reducing PPCs than postoperatively

Arozullah AM. Med Clin N Am 2003; 87: 153-173

Risk-reduction strategies: preoperatively

• Encourage smoking cessation at least 8 weeks• Delay operation if respiratory infection is

present, productive cough (several weeks)• Education lung expansion maneuvers • Maximize pulmonary function

– Bronchodilator– Inhaled corticosteroid– Theophylline– Antibiotic

Smetana GW, et al. New Engl J Med 1999; 346: 937-944.

Risk-reduction strategies: Intraoperatively

• Limit duration of surgery to <3 hours

• Use spinal or epidural anesthesia

• Avoid pancuronium

• Use laparoscopic procedure when possible

Smetana GW, et al. New Engl J Med 1999; 346: 937-944.

Risk-reduction strategies: postoperatively

• Adequate pain control

• Early ambulation

• Use lung expansion maneuver

• Maximized pulmonary function (medication)

Smetana GW, et al. New Engl J Med 1999; 346: 937-944.To The last

Preoperative Care of Pulmonary Patients: Example(1)

• Male 60 yrs.

• Dx: NSCLC stage Ib , RUL

• Underlying COPD

• Assessment– Not urgent surgery, high benefit– Risk ; elderly, COPD– History / Physical examination– Laboratory

Pre-RX(%)

Post –RX(%)

%CHG

FEV1/FVC (%)

55 60

FEV1 (L) 1.31(48) 1.39(53) 5

FVC (L) 2.40(66) 2.50(69) 4

FEF25- 75%

(L/min)

0.43(15) 0.6(22) 22

Spirometry of the patient

Further evaluation• PPO-FEV1

RUL : RLL= 0.55: 0.45

RUL = 24.7%

RLL= 20.3%

LL = 55%

Preoperative Care of Pulmonary Patients: Conclusion

• Many factors related to PPCs

• Working as a team plays major roles

• Assessment of the risks ,do appropriated testing and modifying are the keys of preoperative caring

Thank you

Go Back