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
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•
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•
•
•
•
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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
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•
•
•
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
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•
•
•
Patients-related risk factors
Operation-related risk factors
Anesthetic-related risk factors
Risk factors related to postoperative care
Patient-related risk factors: Aging
Postoperative pneumonia (OR)
> 80 YRs
70-79 YRs
60-69 YRs
50-59 YRs
< 50 YRs
0
1
2
3
4
5
6
7
Arozullah AM,et al. Ann Intern Med 2001
Ann Surg 2000
Patient-related risk factors: General health
Postoperative pneumonia (OR)
Total depend
Partial depend
ASA >,=2
CVA
Obesity
0
1
2
3
4
5
6
7
Arozullah AM,et al. Ann Intern Med 2001
Ann Surg 2000
Patient-related risk factors: Immune status
Postoperative pneumonia
Steroid use
Postoperative pneumonia and respiratory failure
Alcoholic > 2
drink/day
Within 2 wks
Postoperative pneumonia
IDDM
0
1
2
3
4
5
6
7
Arozullah AM,et al. Ann Intern Med 2001
Ann Surg 2000
Operation-related risk factors
Postoperative respiratory failure (OR)
AAA-repair
Thoracic
Upper abdomen
Neck
Neurosurgery
Vascular
0
1
2
4
6
8
10
12
14
16
Arozullah AM,et al. Ann Intern Med 2001
Ann Surg 2000
Influence of surgical site on rate of PPCS
Laparoscopic
Upper
Abdomen
Lower
abdomen
Tarhan 1973
13
7
10
Garcey 1979
25
0
19
Garribaldi
1981
17
5
40
Study
SSA club
1994
0.3
Phillips 1994
0.4
Brooks 1997
28
Thoracic
15
Smetana GW, et al New Engl J Med 1999
Mortality for lung resection
12
% Mortality
10
8
6
4
2
0
wedge resection
segmental resection
lobectomy
pneumonectomy
Multicenter study 12,00 patients , thoracotomies usually CA
Mitsudomi T, et al. J Surg Oncol 1996; 61:218-22
Anesthetic-related risk factors
General anesthesia
(thoracic, Ab, Vascular)
Operation
time >3 hrs
0
1
2
3
4
5
6
7
Smetana GW, et al New Engl J Med 1999
Neuromuscular block and PPCs:
Long acting VS shorter acting
Incidence of
Complication
18
16
14
12
10
8
6
4
2
0
long acting*
Shorter acting**
Incidence of residual NMB 26*, VS 5.3**
Berg H, et al Acta Anaesthesiol Scand 1997
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
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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
60
Abnormal
Normal
50
40
30
20
10
0
Makee 1987
Wiencek
1987
Charpak
1988
Tape 1988
Bouillot
1996
Silvestri
1999
Smetana GW, et al Med Clin N Am 2003
The abnormal CXR and aging
50
45
40
35
30
25
20
15
10
5
0
< 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
Milledge JR, et al. BMJ 1975
Stein M, et al. JAMA 1962
• Recent systematic review by Fisher BW, et
al 2002 dose not find hypercarbia useful
predictor for PPCs
Spirometry
Pulmonary function testing
(PFTs) and PPCs
• ACP guideline 1990
– Lung resection
40% PFTs do not meet
– Coronary artery bypass surgery
guideline
– Upper abdominal
surgery with smoking or
dyspnea
Improving adherence
– Lower abdominal surgery if unexplained
ordering
PFTs
saving
pulmonary
diseases
with prolong
extensive
surgery
29-100 million Dollar/Yr
– Head, neck, orthopedic surgery with
unexplained pulmonary diseases
Anonymous. Ann Intern Med 1990; 112:793-4.
Use of preoperative spirometry to predicted PPCs
Jacob 1997
Bando 1997
Kocabas 1996
Kroenke 1993
Kispert 1992
Swensson 1991
Fogh 1987
Appleberg 1974
Stein 1970
Collin 1968
0
1
2
4
6
8
10
12
14
16
Adapt from Smetana GW,et al. New Engl J Med 1999;340:937-944.
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
FEV1 >2 L
MVV >50%
DLCO >60%
PFT(FEV1,MVV,DLCO)
Cleared for any resection
PPO-FEV1 >1.3
Cleared for any resection
FEV1 > 2 L
MVV<50%
DLCO <60%
FEV1 <2 L
High risk consider exercise test
Perfusion Scanning PPO-FEV1
PPO-FEV1 <0.8
Consider “Lesser” resection
Non surgical therapy
PPO-FEV1
>0.8, <1.3
High risk consider exercise test
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
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
Risk
class
Arozullah AM,et al. Med Clin N Am 2003
ตัวอย่ างการประเมินโดยใช้ Risk indicies
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ผูป้ ่ วยชายอายุ 60 ปี (9)
ต้องเข้ารับการผ่าตัดมะเร็ งปอดระยะIIa (14)
มีประวัติสูบบุหรี่ 30 pack/year จนหยุดสู บมา 4 สัปดาห์ (3)
ได้รับการวินิจฉัยเป็ น COPD (5)
รวมได้คะแนน 31 จากตาราง risk class 3
ซึ่ง 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
% Complication
60
50
40
30
20
10
0
Stop >2 mth
Stop<2 mth
Stop>6 mth
Never smoke
Prospective study 200 patients, CABG
Warner MA,et al. Mayo Clin Proc 1989
Preoperative smoking cessation and
PPCs
% Complication
60
50
40
30
20
10
0
Current <2wks Recent2-4wks
Exsmoke
Never smoke
Retrospective study 288 patients, pulmonary surgery
Nakagawa M, et al Chest 2001;120:705-10
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 1998
Warner 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 1976
Camner 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
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•
•
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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
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•
•
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Adequate pain control
Early ambulation
Use lung expansion maneuver
Maximized pulmonary function
(medication)
To The last
Smetana GW, et al. New Engl J Med 1999; 346: 937-944.
Preoperative Care of Pulmonary
Patients: Example(1)
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Male 60 yrs.
Dx: NSCLC stage Ib , RUL
Underlying COPD
Assessment
– Not urgent surgery, high benefit
– Risk ; elderly, COPD
– History / Physical examination
– Laboratory
Spirometry of the patient
PreRX(%)
Post –
RX(%)
55
60
FEV1 (L)
1.31(48)
1.39(53)
5
FVC (L)
2.40(66)
2.50(69)
4
FEF25- 75%
0.43(15)
0.6(22)
22
FEV1/FVC
%CHG
(%)
(L/min)
Further evaluation
• PPO-FEV1
RUL = 24.7%
LL = 55%
RLL= 20.3%
RUL : RLL= 0.55: 0.45
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
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