Dr. S. Parthasarathy
MD., DA., DNB, MD (Acu),
Dip. Diab.DCA, Dip. Software statistics Ph D
physiology.
Mahatma gandhi medical college
and research institute, puducherry, India
• Global Initiative for Chronic Obstructive Lung
Disease
• as a disease state characterized by airflow limitation
that is not fully reversible
• COPD includes emphysema, an anatomically defined
condition
characterized
by
destruction
and
enlargement of the lung alveoli;
• chronic bronchitis, a clinically defined condition with
chronic cough and phlegm; and small airways
disease, a condition in which small bronchioles are
narrowed.
• COPD is present only if chronic airflow obstruction
occurs; chronic bronchitis without chronic airflow
obstruction is not included within COPD.
• Dutch hypothesis
• British hypothesis
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4 – 10 %
Cigarette smoking
Age
20 pack years + age more than 60
Repeated respiratory infections
general exposure to dust at work
Less fruits and antioxidants in diet
Genetic (alpha 1 antitrypsin deficiency)
Low birth weight
• Pulmonary hypertension
• Pulmonary thrombosis may develop sec. to
airway inflammation.
• Skeletal muscle changes – myopathy,
defective muscle protein synthesis
• Weight loss
• Osteopenia – excess osteoclastic activity
• CAD and increased CRP ,fibrinogen
• COPD is a systemic inflammatory illness
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Chronic bronchitis
Decreased airway lumen
Dyspnea moderate
FEV 1 decrease
PaO2 severe
Dif. Capa. N
Cor pulmonale more
Prog. bad
Emphysema
Loss – elastic recoil
• Severe
• FEV 1 decrease
• Moderate
• less
• better
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Smoking cessation
Bronchodilators – theo and beta 2 agonists
Steroids – oral and inhaled
Inhaled – tiotropium
PDE 4 inhibitors – noflumilast
Cromolyn ,Mucokinetics ,retinoids
Antibiotics ,rehabilitation , home oxygen
Alpha 1 antitrysin
Vaccines
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Age < 30
Atopy yes
Reversibility – yes
Chest wheezy
Cough – nonproductive ,
episodic
Nocturnal – yes
Smoking – no
Steroids yes
BAL - eosinophil
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Age > 50
Atopy no
Irreversible
Chest silent
Cough productive
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No nocturnal
Smoking yes
Steroids – poor response
BAL – neutrophil
• Optimize preop
• Bounding pulse and hand flap – hypercarbia
• History – smoking , CCF, cough , dyspnea
exercise tolerance
• Diuretics, digoxin, heparin
• Other routine history
• Premed = humidified oxygen
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RS
Breath sounds
Added sounds
Steth in trachea
Breathing pattern
Cylindrical chest
P2 in CVS
Dynamic hyperinflation
Specific --- Don’t miss others
• Radiographic abnormalities may be minimal,
• Hyperlucency due to arterial vascular deficiency in
the lung periphery and hyperinflation (flattening
of the diaphragm with loss of its normal domed
appearance and a very vertical cardiac silhouette)
suggest the diagnosis of emphysema.
• If bullae are present, the diagnosis of emphysema
is certain.
• smoking cessation,
• 12 hours – CO and tachycardia
• 6-8 weeks all benefits
• treatment of bronchospasm,
• eradication of bacterial infection.
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ECG ,Urinalysis ,CBC
Electrolytes
Drugs
Cardiac evaluation
• Preop PFT ???
• Major thoraco abdominal surgeries , lung resections
• Preop PFT should not be used to make patients unfit.
Dyspnea at rest
Cyanosis ( PaO2 less than 60 )
PaCO2 more than 45
Persistent heavy smoking
Poor response to broncho dilators and
steroids
• Pulmonary hypertension
• PFT FEV1 < 50 % and FEV1/FVC < 70%
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• 1.
Smoking is a risk factor for development of
cardiovascular disease
• 2.
Carbon monoxide decreases oxygen delivery
and increases myocardial work
• 3.
Smoking releases catecholamines and causes
coronary vasoconstriction
• 4. Smoking decreases exercise capacity
nonsmokers
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Smoking is the major risk factor for development of
chronic pulmonary disease
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Smoking decreases muco ciliary activity
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Smoking results in hyper reactive airways
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Smoking decreases pulmonary immune function
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Other Organ System Effects 1.
healing
Smoking impairs wound
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Inhaled and systemic steroids
Antibiotics
Antisialogogues ??, ranitidine ?
Narcotics, sedatives < beware
Droperidol and diphenhydramine are safe
Lung expansion education- deep breathing or
CPAP
• Lower limb / lower abdominal surgeries – spinal • Sedatives - aware of side effects .
• Brachial plexus blocks – satisfactory
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High spinals are associated with desaturation
Neuraxial opioids – post op pain relief
Nasogastric drainage – useful in selected cases
IV morphine - no
• Spinal epidural below thoracic – no effect on
respiratory function except in obese 20 % reduction in
FEV1
• TEA – 10 % decrease in inspiratory capacity
• but no effect on bronchial smooth muscle, HPV
ventilatory response to hypoxia and hypercarbia
• It also confers cardio protection
• Propofol induction
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Thio – may increase bronchospasm
Etomidate is not all useful
IV – not spray of lignocaine
If active wheezing, ketamine is an induction
agent of choice
• Sure - it is noncardiac acute wheezing
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Vecuronium
Rocuronium
Cisatracurium
Atra , doxa, pancuronium – no
DTC – worst
Neostigmine – danger of wheezing
Residual neuro muscular block – predictor of
PPC
• Halo – yes – no airway irritation
• But – sensitivity to catecholamines
• Sevo and des – ok
• Iso better but think of airway spasm
• Nitrous – increase bulla size – CT bulla –
beware
• Introduction of LMA proseal
• airway manipulation is less – but active wheezing
patients – may not be ideal
• Tube is replaced by LMA proseal in COPD ??
• (Nasogastric tube)
• ET has definite indications
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Humidification of inspired gas
PCV with decelerating flow
High tidal volumes with less rate.
Adequate depth
Head lift and open eyes may not be of use
To add TEA or paravertebral block
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Kinked ET tube
Pulmonary edema
Wheezing
secretions thick
Pneumo – bulla rupture
Endobronchial
• Treatment
• Check, deepen, relaxants, salb, steroids, FiO2
• Diaphragmatic
function
is
well
preserved
during
anesthesia in patients with COPD due to ‘length
adaptation’ phenomenon and they experience little
decrement in gas exchange.
• Therefore general anesthesia with controlled ventilation
need not be considered an evil that has to be avoided at all
costs. However, one should pay attention to the pattern of
ventilation in these patients.
• consisting of sustained (8 to 15 seconds) application of high
airway pressures (30 to 40 cm H2O),
• followed by positive end-expiratory pressure [PEEP] and
limited
inspired
dependent
oxygenation
lung
oxygen
atelectasis
concentration,
and
improve
may
minimize
intraoperative
• Hemodynamic goal directed
• Liberal
• Restricted
• Institute lung volume expansion maneuvers
(voluntary deep breathing, incentive
spirometry, continuous positive airway
pressure)
Maximize analgesia (neuraxial opioids,
intercostal nerve blocks, patient-controlled
analgesia)
No NSAIDs
• atelectasis or pneumonia and death
• PPCs have been reported to occur in 5%-10% and
• in 4%-22% of patients undergoing abdominal surgery
• In COPD patients [with FEV1 ≤ 1.2 L and FEV1/FVC <
75%] undergoing non-cardiothoracic surgery, an incidence
of 37% [excluding atelectasis] and a 2-year mortality rate
of 47%
• death, pneumonia, prolonged intubation, refractory
bronchospasm, and prolonged intensive care unit
(ICU) stay.
• ASA physical status ≥ IV, FEV1 < 1 Liter were
significant preoperative risk factors and emergency
operation, abdominal incision, anesthesia duration
• [> 3h] and general anesthesia, were the intraoperative
risk factors.
• Pao2 of around 60
• PaCO2 of 45
• Care for prevention and cure of PPCs
• Analgesia by blocks, paracetomol, opioids
• IV fluids tuned to that patient.
• Early ambulation
• Neuraxial opioids
• Continued mechanical ventilation in the
postoperative period may be necessary in patients
with severe COPD who have undergone major
abdominal or intrathoracic surgery.
• Patients with preoperative FEV1/FVC ratios less
than 0.5 or with a preoperative PaCO2 of more
than 50 mm Hg are likely.
• If the PaCO2 has been chronically increased, it is
important not to correct the hypercarbia too
quickly
• Lead on arrythmias or seizures may result
• A combination of chest physiotherapy and postural
drainage plus deep-breathing exercises taught during the
preoperative period may decrease the incidence of
postoperative pulmonary complications.
• vibrations produced on the chest wall by physiotherapy
result in dislodgment of mucus plugs from peripheral
airways. Appropriate positioning facilitates elimination of
loosened mucus
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Definition of COPD
Types
Clinical features – systemic
Treatment
Preop – smoking, infections, B’dilations, other
systems
• Intraop – FiO2, nitrous, SEVO, tube/LMA, rocu, vec.
neo/sugammadex
• PPCs – avoid and treat PPC, use blocks, neuraxial
opioids
• Minimal invasion
• Or
• maximal support