Pulmonary

PULMONARY RISK ASSESSMENT AND MANAGEMENT

Preoperative evaluation
Assessment: 1 Risk factors: COPD Age >60 ASA class II+ Functionally dependent CHF Obstructive Sleep Apnea Consider: Serum albumin if suspected 1 hypoalbuminemia. Note that obesity and mild-moderate asthma were not found to be risk factors for postoperative pulmonary 1 complications.

See Obstructive Sleep Apnea Albumin (<3.6 g/dl) predicts postoperative complications However, this finding may not change management with regard purely to pulmonary complications. Surgeons are usually highly attentive to nutritional status for other reasons (overall morbidity, mortality, wound healing, etc.) and will delay surgery for those reasons. Smoking cessation was previously thought to have benefit if done 6-8 weeks or greater prior to surgery, with concern for harm if cessation occurred too close to surgery. However, a systematic review concluded that existing evidence does not support an increased risk of 2 complications due to stopping smoking prior to surgery.

Advise smoking cessation

Diagnostic tests: Chest x-ray

Pulmonary function tests (PFTs)

Arterial Blood Gas (ABG)

Routine preop chest x-rays are NOT indicated. No consensusguidelines differ. ACP guidelines: may be helpful in patients >50 year of age who are undergoing upper abdominal, thoracic, AAA surgery, or in 1 patients with cardiac or pulmonary disease. Rarely changes management dramatically, but may be very useful in these select populations. Routine PFTs NOT indicated except for certain surgeries (e.g. thoracic surgeryusually defer this testing to the surgeon) Known COPD: assess by symptoms and exam Consider for patient with suspected but previously undiagnosed obstructive lung disease. Consider for patients with elevated serum HCO3, O2 dependence, moderate to severe COPD, or suspected obesity-hypoventilation syndrome.

The Medicine Consult Handbook 2011

Pulmonary Postoperative management

Lung expansion maneuvers (e.g. incentive spirometry) Nasogastric (NG) tube Recommended in ACP guidelines Cochrane Review found no evidence of incentive spirometry reducing pulmonary complications in upper abdominal surgery, but was limited by few quality 3 studies. ACP guidelines recommend Selective use of NG tubes for decompression for nausea, vomiting, abdominal 1 distension. In practice, we defer this to the surgery team. For many patients, a new anastomosis (e.g. esophageal surgery) makes NG tube placement potentially dangerousalways discuss with the surgical team. Recovery room pulse oximetry is routine and managed by anesthesia. Consider for patients with sleep apnea or high risk of hypoxemia. (see Obstructive Sleep Apnea)
1

Pulse oximetry

Discussion

Risk stratification: Despite attention paid to cardiovascular risk stratification and complications, pulmonary complications likely exceed those of cardiovascular complications. Cardiovascular risk stratification, however, has benefited from easy to use, well validated risk tools such as the Revised Cardiac Risk Index (see Cardiovascular Risk Stratification). Risk models for postoperative pulmonary complications have identified age, preoperative O2 sat, recent respiratory infection, preoperative anemia, upper abdominal or thoracic surgical site, duration of surgery, and emergent procedures as risk factorshowever the scoring system requires adding up weight scores for each 4 risk factor. Other pulmonary conditions: Other conditions have had increasing evidence for risks of postoperative complications, including obstructive sleep apnea and pulmonary hypertension. These are discussed separatelysee Obstructive Sleep Apnea, Asthma and COPD, Pulmonary Hypertension Venous Thromboembolic Disease. References
1. Qaseem A, Snow V, Fitterman N, et al. Risk Assessment for and Strategies to Reduce Perioperative Pulmonary Complications for Patients Undergoing Noncardiothoracic Surgery: A Guideline from the American College of Physicians. Annals of Internal Medicine.2006;144:575-580. 2. Myers K, Hajek P, Hinds C, et al. Stopping Smoking Shortly Before Surgery and Postoperative Complications. Arch Intern Med. Published online March 14, 2011. 3. Guimaraes MMF, El Dib RP, Smith AF, et al. Incentive Spirometry for Prevention of Postoperative Pulmonary Complications in Upper Abdominal Surgery. Cochrane Database of Systematic Reviews. 2009;3: CD006058. (updated 2011). 4. Canet J, Gallart L, Gomar C, et al. Prediction of Postoperative Pulmonary Complications in a Population-based Surgical Cohort. Anesthesiology 2010; 113: 1338-1350.

Updated May 2011

The Medicine Consult Handbook 2011