Tyler Hartley, M4
Upon completion of the module, the learner will be able to;
- Risk stratify the elderly for pulmonary complications.
- List some of the major pulmonary risk factors in the elderly.
- List pulmonary tests are necessary preoperatively.
- Describe OSA in the elderly and its various complications.
- Describe current modalities used to maximize lung function in the elderly.
- A complete history and physical examination are the most important elements of preoperative risk assessment.
- Any history suggesting unrecognized chronic lung disease or heart failure, such as exercise intolerance, unexplained dyspnea, or cough, requires further consideration.
Assessing The Risk of Postoperative Pulmonary Complications Algorithm
Overview of Pulmonary Evaluation and Risk Stratification
STEP 1: Careful history and physical examination seeking known risk factors pulmonary complications.
Positive risk factors:
- Chronic obstructive lung disease
- Unexplained dyspnea or exercise intolerance
- Smoking history within past eight weeks
- Poor general health defined by ASA class >2
- Heart Failure
- Obstructive Sleep Apnea
- Pulmonary HTN
- Abnormal chest exam
- Upper abdominal, AAA, or thoracic surgery
- Surgery expected to last greater than three hours
- Emergency surgery
- Age >50
- Metabolic Factors
- 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.
- 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
Reconsider indications for surgery, Perioperative treatment to reduce risk
Consider shorter procedure
Consider epidural or spinal anesthesia or regional block
For Normal Test
Perioperative treatment to reduce risk
- Infection, including bronchitis and pneumonia
- Aspiration pneumonia
- Prolonged mechanical ventilation and respiratory failure
- Exacerbation of underlying chronic lung disease
Kozlow JH. Epidemiology and impact of aspiration pneumonia in patients undergoing surgery in Maryland, Critical care medicine. 2007;31:1930-1937.
- Chronic lung disease
- General health status
- Obstructive sleep apnea
- Pulmonary hypertension
- Heart failure
- Upper-respiratory infection
- Metabolic factors
GOAL for pre-operative pulmonary management is to maximize lung function.
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
- Preoperative antibiotics are not useful for prevention of pneumonia in patients with stable COPD or asthma, unless other disorders such as acute bronchitis, bronchiectasis, or immunodeficiency are present.
- They should be administered prior to surgery only in patients with a clinically apparent respiratory infection, manifest by purulent sputum or a change in the character of sputum
- Elective surgery should be cancelled until such treatment is completed and patient’s sputum production has returned to baseline
- Lung expansion maneuvers such as coughing, incentive spirometry, and voluntary deep breaths are best taught prior to surgery.
- It is more difficult to emphasize the importance of these strategies to a postoperative patient who may be in pain and sedated from analgesic medication.
- 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.
- 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.