Preoperative Assessment and Perioperative Care: Pulmonary
PREOPERATIVE ASSESSMENT & PERIOPERATIVE CARE: Pulmonary
Developed by UNMC Anesthesia and Geriatric Departments
 Tyler Hartley, M4

Objectives
Upon completion of the module, the learner will be able to;

Pulmonary Preoperative Risk Assessment

Assessing The Risk of Postoperative Pulmonary Complications Algorithm
Overview of Pulmonary Evaluation and Risk Stratification

overview



STEP 1: Careful history and physical examination seeking known risk factors pulmonary complications.
If Negative for risk factors  - - - Low Risk: Proceed to surgery with further evaluation. 
  
Positive risk factors:

Testing

  • Chest x-ray
  • PFTs if uncharacterized dyspnea or if uncertain of airflow obstruction with COPD or asthma
    • PFTs have demonstrated good predictive value for post op course and success in LUNG RESECTIONS ONLY. Its use in other surgical procedures is less clear.
    • PFT’s may be used in patients with COPD or Reactive Airway Disease (RAD).
    • Here it can be used to evaluate if the patient is at optimal bronchodilatation or needs more medical management with bronchodilators.
    • One definition of optimal bronchodilatation is: Patient is free of wheezing and peak flow > 80% of predicted or their personal best.
  • ABG
    • Performed pre-operatively have demonstrated little predictive values nor do they help with management.
    • The exception is in the case of severe lung disease for which a PCO2 of 45 or more predicts a high rate of post operative complications.

For Abnormal Test  or Multiple Risk Factors
High risk:
Reconsider indications for surgery, Perioperative treatment to reduce risk
Consider shorter procedure
Consider epidural or spinal anesthesia or regional block

For Normal Test 
Moderate Risk:
Perioperative treatment to reduce risk  


Pulmonary Complications
  • Atelectasis
  • Infection, including bronchitis and pneumonia
  • Aspiration pneumonia
  • Prolonged mechanical ventilation and respiratory failure
  • Exacerbation of underlying chronic lung disease
  • Bronchospasm

Kozlow JH. Epidemiology and impact of aspiration pneumonia in patients undergoing surgery in Maryland, Critical care medicine. 2007;31:1930-1937.


Patient Related Risk Factors

GOAL for pre-operative pulmonary management is to maximize lung function.

Modalities

Bronchodilators, steroids, beta agonists,  ipratropium, tiatropium

Weight loss - obesity is no longer an independent risk factor for pulmonary complications, however, OSA is.

Stop smoking eight weeks prior to surgery

Warn patient to call in if developing URI in immediate pre-op period

Chest physiotherapy in thoracic and abdominal  surgery  (i.e. Deep breathing, mobilization.  CPAP or NPPV for pt’s unable to do lung expansion exercises

Urge avoidance of NG’S as much as possible


Antibiotics


Patient Education


IPPB

  •  Intermittent positive pressure breathing (IPPB) was used commonly in the 1960s and 1970s, but it is associated with more complications than other methods of lung expansion such as abdominal distension.
  • In addition IPPB is more costly than other methods of lung expansion. Thus, it should not be used for routine prophylaxis.

Summary

  • History and physical exam are the most important ways to risk stratify for pulmonary complications.
  • Age IS an independent risk factor for pulmonary complications.
  • Pulmonary labs/imaging rarely helps in management or patient outcomes.
  • OSA is more prevalent in the elderly and can cause serious post operative complications.
  • There are many modalities to maximize lung function perioperatively.