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reoperative Care of Pulmonary Patients: An evaluation for postoperative pulmonary complications

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Title: reoperative Care of Pulmonary Patients: An evaluation for postoperative pulmonary complications


1
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

2
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

3
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(lt5)
  • Use definitive language
  • Direct verbal contact
  • Specific drug dosage, route, frequency
  • Frequent F/U and progress note

Cohn SL. UptoDate 2002
4
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
5
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

6
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

7
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
8
Factors related to PPCs
  • Patients-related risk factors
  • Operation-related risk factors
  • Anesthetic-related risk factors
  • Risk factors related to postoperative care

9
Patient-related risk factors Aging
Postoperative pneumonia (OR)
gt 80 YRs
70-79 YRs
60-69 YRs
50-59 YRs
lt 50 YRs
1
0
2
3
4
5
6
7
Arozullah AM,et al. Ann Intern Med 2001
Ann Surg 2000
10
Patient-related risk factors General health
Postoperative pneumonia (OR)
Total depend
Partial depend
ASA gt,2
CVA
Obesity
1
0
2
3
4
5
6
7
Arozullah AM,et al. Ann Intern Med 2001
Ann Surg 2000
11
Patient-related risk factors Immune status
Postoperative pneumonia
Steroid use
Postoperative pneumonia and respiratory failure
Alcoholic gt 2 drink/day Within 2 wks
Postoperative pneumonia
IDDM
1
0
2
3
4
5
6
7
Arozullah AM,et al. Ann Intern Med 2001
Ann Surg 2000
12
Operation-related risk factors
Postoperative respiratory failure (OR)
AAA-repair
Thoracic
Upper abdomen
Neck
Neurosurgery
Vascular
1
0
2
4
6
8
10
12
14
16
Arozullah AM,et al. Ann Intern Med 2001
Ann Surg 2000
13
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
14
Mortality for lung resection
Mortality
Multicenter study 12,00 patients , thoracotomies
usually CA
Mitsudomi T, et al. J Surg Oncol 1996 61218-22
15
Anesthetic-related risk factors
General anesthesia (thoracic, Ab, Vascular)
Operation time gt3 hrs
1
0
2
3
4
5
6
7
Smetana GW, et al New Engl J Med 1999
16
Neuromuscular block and PPCs Long acting VS
shorter acting
Incidence of Complication
Incidence of residual NMB 26, VS 5.3
Berg H, et al Acta Anaesthesiol Scand 1997
17
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

18
Preoperative pulmonary evaluations
  • History and physical examination
  • Chest radiography
  • Arterial blood gas analysis
  • Pulmonary function test
  • Quantitative lung scan
  • Exercise test

19
Chest radiography
  • Two potential indication
  • 1. To identified abnormalities ?
  • correcting, modification
    cancellation surgery
  • 2. Serve as a base line finding

20
The value of an abnormal CXR before surgery
Smetana GW, et al Med Clin N Am 2003
21
The abnormal CXR and aging
ASA gt 2 comorbid
ASA lt,2 no comorbid
Silvestri L, et al Eur J Anaesthesiol 1999
22
Recommendation for preoperative CXR
  • Age gt 50 years
  • Known pre-existing cardiopulmonary diseases
  • S/S like hoods of cardiopulmonary disease

Smetana GW, et al Med Clin N Am 2003
23
Arterial blood gas
  • Small study series identified Hypercarbia(PaCO2gt45
    ) ? 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 1975 Stein M, et al. JAMA
1962
24
Spirometry
25
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

40 PFTs do not meet guideline Improving
adherence ordering PFTs saving 29-100 million
Dollar/Yr
Anonymous. Ann Intern Med 1990 112793-4.
26
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
1
0
2
4
6
8
10
12
14
16
Adapt from Smetana GW,et al. New Engl J Med
1999340937-944.
27
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 1996110744-50.
28
PFT Diagram in Preoperative Evaluation
PFT(FEV1,MVV,DLCO)
FEV1 gt2 L MVV gt50 DLCO gt60
FEV1 gt 2 L MVVlt50 DLCO lt60
High risk consider exercise test
FEV1 lt2 L
Cleared for any resection
Perfusion Scanning PPO-FEV1
PPO-FEV1 gt1.3
PPO-FEV1 gt0.8, lt1.3
PPO-FEV1 lt0.8
High risk consider exercise test
Cleared for any resection
Consider Lesser resection Non surgical therapy
29
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
30
uantitative lung scan
31
Interpretation of quantitative lung scan
32
Exercise testing
  • Assessing the risk in pts undergoing thoracotomy
    is controversial
  • Acceptable value maximum oxygen consumption gt
    15 ml/kg/min

33
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 gt55 15.4 gt40 30.5
Arozullah AM,et al. Med Clin N Am 2003
34
???????????????????????? Risk indicies
  • ?????????????? 60 ?? (9)
  • ?????????????????????????????????IIa (14)
  • ?????????????????? 30 pack/year ??????????? 4
    ??????? (3)
  • ????????????????????? COPD (5)
  • ??????????? 31 ???????? risk class 3
    ???? predicted prob. pneumonia 4,
    respiratory failure 11.6

35
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
36
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)

37
Preoperative smoking cessation and PPCs
Complication
Prospective study 200 patients, CABG
Warner MA,et al. Mayo Clin Proc 1989
38
Preoperative smoking cessation and PPCs
Complication
Retrospective study 288 patients, pulmonary
surgery
Nakagawa M, et al Chest 2001120705-10
39
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
40
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
41
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)

42
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 743-10.
43
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
44
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.
45
Risk-reduction strategies Intraoperatively
  • Limit duration of surgery to lt3 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.
46
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
47
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

48
Spirometry of the patient
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
Irreversible airway obstruction
49
Further evaluation
  • PPO-FEV1

Lt0.55(55)
Rt0.45(45)
RUL 24.7
LL 55
RLL 20.3
RUL RLL 0.55 0.45
Acceptable, See Mx
PPO-FEV11.04(39)
50
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

51
Thank you
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