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Preoperative considerations for patients with chronic obstructive pulmonary

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Article  in  Acta chirurgica iugoslavica · January 2011

DOI: 10.2298/ACI1102071M · Source: PubMed

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/STRU^NI RAD
Preoperative considerations for patients with chronic
obstructive pulmonary disease
........
.................................
Ana Mandraš1, Dušica Simi}2,3, Vesna Stevanovi}1, Djordje Ugrinovi}4,
Vesna Škodri}2,5, Nevena Kalezi}2,6
1
Institute for Mother and Child health care "Dr Vukan ^upi}", Belgrade,
Serbia
2
School of Medicine, University of Belgrade, Belgrade, Serbia
3
University Children’s Hospital, Belgrade, Serbia
4
School of Medicine, University of Kragujevac, Clinical Center Kragujevac,
5
Clinic for Lung Diseases, Clinical Center of Serbia, Belgrade, Serbia
rezime
Chronic obstructive pulmonary disease is a risk
factor for development of intraoperative and pos-
toperative pulmonary complications. Regarding
the type and the extent of surgical procedure, pa-
tients with COPD are at risk of aggravation of
pulmonary function which leads to complicated
perioperative course. In order to reduce periope-
rative complications, preoperative evaluation and pre-
operative patient preparation are of great importance.
Goals of preoperative preparation and anesthesia in
patients with COPD are maintaining ventilation-per-
fusion ratio, preventing development of hipoxemia, in-
traoperative brochospasm, pneumothorax and distur-
bances of cardivascular system.
Key words: Chronic Obstructive Pulmonary Disease,
preoperative preparation, perioperative
complications, mechanical ventilation
INTRODUCTION
T he Global Initiative for Chronic Obstructive Pulmo-
nary Disease guideline (GOLD) defines COPD as fol-
lows: "COPD is a preventable and treatable disease
with some significant extrapulmonary effects that may
contribute to the severity in individual patients. Its pul-
monary component is characterized by airway limitation
that is not fully reversible. The airway limitation is usu-
ally progressive and associated with an abnormal inflam-
matory response of the lung to noxious particles or
gases."1
COPD includes emphysema and chronic bronchitis whi-
ch are irreversible diseases.2 Chronic bronchitis is char-
acterized by presence of productive cough in duration of
three years particulary in cold winter days. Emphysema is
characterized by histological changes such as dilatation
and destruction of airway distal of terminal bronchiolis.
Global Initiative for Asthma (GINA) defines asthma as
follows: "Asthma is a chronic inflammatory disorder of
UDK 616.24-005-089
DOI:10.2298/ACI1102071M
the airways in which many cells and cellular elements
play a role. The chronic inflammation is associated with
airway hyperresponsiveness that leads to recurrent episo-
des of wheezing, breathlessness, chest tightness, and cou-
ghing, particularly at night or in the early morning. These
episodes are usually associated with widespread, but vari-
able, airflow obstruction within the lung that is often re-
versible either spontaneously or with treatment."3
Majority of COPD patients are long-term smokers. Pro-
fessional exposeur to different gases and particles, air po-
llution, poverty and low life standard, repeated viral in-
fections and a1 ATT deficiency are known risk factors for
COPD development. GOLD predicts that in 2020. COBP
will be the third cause of mortality in world.1
COPD is important risk factor for postoperative pulmo-
nary complications with relative risk 2,7-4,7 depending on
the evaluation criteria.4 According to study which was
conducted in order to detect correlation between existing
preoperative pulmonary diseases and intraoperative and
postoperative complications in upper abdominal surgery
using logistic regression model it’s been shown signifi-
cant correlation between COPD and intraoperative as well
as postoperative pulmonary complications (OR 1,87,95%;
CI 1,11-3,15; p = 0,019)5. Bronchospasm and hypoxemia
were the most frequently detected complications. Data
analysis from retrospective study in 412 subjects has sho-
wn that COPD was the only preoperative variable related
with increased risk of post-lobectomy atelectasis.6 Risk of
postoperative pulmonary complications is grater in thora-
cic, abdominal, head and neck surgery than in orthopedic
and peripheral surgical procedures.7
THE GAOLS OF PREOPERATIVE PREPARATION IN
PATIENTS WITH COPD
The goal of preoperative preparation is prevention of
pulmonary complications- pneumonia, bronchospasm,
respiratory failure with prolonged mechanical ventilation,
72 A. Mandra{ et al. ACI Vol. LVIII

atelectasis and COPD exacerbation. The worst postopera- Coexisting coronary diseases are common in COPD pa-
tive outcome have patients with pulmonary hypertension tients. Several studies showed that reduced FEV1 (for
and chronic fatigue of respiratory muscles due to possi- 10%) increases cardiovascular mortality (28%) with rela-
bility of right heart failure, cardiovascular insufficiency tive risk of 1,1-2,2.13,14 In order to better describe cardio-
and prolonged mechanical ventilation.8 vascular risk in these patients, pharmacological stress test
During anamnesis special attention should be taken to can help detect possible coronary ischemia.
establish the level of physical tolerance (stairs climbing) Moderate dehydration due to hyperpnoea and diuretic
since it correlates well with pulmonary function tests. therapy and low potassium level due to diuretic and ß2
Patients with domination of emphysema are usually agonist therapy can be present in CODP patients. Malnu-
thin, tachypnoic with breathlessness even in steady state. trition is present in 25%-33% of these patients.15 One
They are hypoxic and CO2 retention is developed late or should manage fluid, electrolyte and nutrition status in
is a sign of terminal phase of illness. these patients before surgery.
Patients with dominant obstructive bronchitis are usua- Preoperative preparation should optimize respiratory
lly obese with peripheral edema , weak respiratory muscle function and minimize possibility for development of pe-
activity and CO2 retention. In clinical practice "blue blo- rioperative complications.
aters" and "pink puffers" are rarely seen separate, commo-
nly there’s a combination of both features of disease. SPECIAL CONSIDERATIONS IN PREOPERATIVE
The basic problem in COPD patients are hypersecretion PREPARATION
and airway obstruction which worsens in presence of in-
COPD symptoms develop usually after 55 years of age.
fection. Presence of weakened breathing sounds, prolon-
GOLD recommends to continue established treatment
ged expirium, wheezing and murmurs correlates whit in-
plan with all hygiene - dietetic, pharmacological and reha-
creased postoperative pulmonary complications.9 One
bilitation methods.1
should check if reversible obstruction (asthma) is well
Bronchodilatatory therapy with addition of one more
managed. Incidence of pulmonary complications is grater
bronchodilatating agent should continue to surgery since
with positive findings on physical exam and pulmonary
this treatment showed reduction of respiratory postopera-
function tests showing FEV1 less than 50% of predicted
tive complications.16,17,18. Bronchodilatators rarely im-
and if there is hypoxemia which requires oxygen thera-
prove FEV1 more than 10%.15 Nebulized bronchodilata-
py.10
tors should be applied before, as well as 24-48 hours after
Pulmonary function tests and blood gas analysis can
surgery.
predict lung function after lung resection surgery but are
Preoperative use of corticosteroids does not increase
not reliable predictors of postoperative pulmonary com-
risk of pneumonia or compromise wound healing.19,20
plications in non-thoracic surgery.
Prophylactic use of antibiotics without bacteriological
Study of 2000 patients showed that FEV1 and FVC had
conformation of infection is not recommended but every
no significant predictive value regarding development of
lung infection should be properly treated before surgery.
postoperative pulmonary complications in contrast to phy-
Knowing that smoking cigarettes is a risk factor for
sical exam, chest radiography, Goldman’s and Carlson’s
COPD2, cessation of smoking is advised minimally 2
index.9 Non the less, in lung resection surgery, FEV1 and
months before elective surgery. Prospective blinded study
DLCO are important predictors of postoperative course.11
that was conducted in Mayo clinic on 200 subjects sub-
FEV1 less than 20% and DLCO less than 20% are associ-
mitted to coronary bypass showed increased postoperative
ated with high risk of postoperative mortality. Patients at
pulmonary complications in those who quit smoking 1-8
risk, that have FEV1 <70%, FEV1/FVC <65% or PaCO2
weeks before surgery - 58%, in contrast to those who quit
>45mmHg can submit to surgery, even lung resection
smoking 8 and more weeks before surgery-12%. Those
with acceptable risk of postoperative pulmonary compli-
that didn’t quit smoking at all had 33% of postoperative
cations.12
respiratory complications.21 Besides positive respiratory
Blood gas analysis, chest radiography and CT enable
effect, cessation of smoking 6 weeks before surgery al-
more detailed evaluation of respiratory system but their
lows liver enzymes and immune system to restore their
routine conduction is unnecessary for uncomplicated in-
functions.12
terventions. In these situations detailed anamnesis and
Acute deterioration of COPD is often treated with non
physical exam can be sufficient to identify patients at risk.
invasive ventilation (NIV) through full face or nasal
Blood gas analysis should be preformed if patient have di-
mask, depending on the severity of clinical manifestation.
fficulties climbing up the stairs (first floor), is cyanotic,
Multicentric randomized trial gave conclusion that early
SaO2 is 95% in room air or has peripheral edema.
use of NIV decrease mortality rate and need for endotra-
Chest radiography should exclude active infection or
cheal intubation.22 Noninvasive ventilation decreases
other conditions such as bronchial carcinoma.
work of breathe, decrease respiratory muscle strength and
ECG can show right heart problems - hypertrophy of ri-
overall patient breathing effort.22,23,24 Measurements of
ght ventricle. In this case, ultrasound of heart is recom-
diaphragmatic action potential (EMG) showed that nonin-
mended.
vasive ventilation reduced activity of diaphragm in COPD
patients.23
Br. 2 Preoperative considerations for patients with chronic
obstructive pulmonary disease
This type of respiratory support is useful postopera-
tively in sever COPD cases or after major surgery.
Prolonged endotracheal intubation decrease mucocilliar
transport preventing adequate evacuation of sputum from
airways and ventilation over 18 hours causes atrophy of
diaphragmatic muscle bundles.25 Possibility for bacterial
colonization of lungs and development of pneumonia as-
sociated with high mortality rate is increased especially
after thoracic surgical interventions.26
It is necessary preoperatively to carefully plan anesthe-
siological technique and to make adequate choice of
agents (hypnotics, analgetics, muscle relaxants) which are
suitable for COPD patients.
ANESTHESIA IN COPD PATIENTS
The formation of atelectasis is less than expected in an-
esthezied patients with COPD due to presence of intrinsic
PEEP, maintainense of FRC due to abdominal muscle
activity in expirium27 and caracteirstics of ventilation-per-
fusion mismatch.28
When ever is possible, tracheal intubation should be
avoided. Obese patients as well as patients preparing for
major surgical procedures are not candidatets for anesthe-
sia techniques that maintain spontaneous breathing. Also,
presence of hypersecretion demands evacuation of spu-
tum through endotracheal tube.
If the patient has severe form of COPD, admition in
ICU after major thoracic or abdominal surgery may be
necessary because of respiratory failure.
POSTOPERATIVE TRETAMENT
Extubation of these patients should be preformed in sit-
ting position. Mobilisation should start as early as possi-
ble. Respiratory physical therapy (deep breathing, dia-
phragmatic breathing, drainage positioning of patient)
prevents sputum retention, postoperative respiratory fail-
ure and development of pneumonia. If necessary, oxygen
therapy can be applied.
If the patient becomes febrile with purulent sputum,
bacteriological analyses must be conducted and start anti-
biotic treatment.
Inhalation of bronchodilatators should be continued un-
till patient is fully mobilized.
Optimal analgesia without unnecessary sedation and
early mobilization contribute to rapid and uncomplicated
recovery. Many studies pointed out the benefit of
neuroaxial analgesia in postoperative pain management in
COPD patients.29,30,31 Epidural analgesia improves mobi-
lization of respiratory muscles enabeling early respiratory
system rehabilitation in these patients. Retrospective
study in COPD patients underwent lung transplantation
showed that limited use of intravenous analgetic agents
and perioperative epidural analgesia create optimal condi-
tions for early extubation COPD patients.32,33,34,35 One
should keep in mind that opioid analgetics can cause ven-
tilatory depression regardless the way of administration,
even 12 hours after administration.15
73
Restrictive fluid administration decreases risk of pulmo-
nary edema,it has been accepted in thoracic surgery10 and
showed good outcomes after major abdominal interven-
tions.36
CONCLUSION
COPD as comorbidity, specially when it comes to major
surgery (thoracic, abdominal), is important risk factor for
postoperative pulmonary complications. Number of high
risk patients is increasing and doctors are facing with
great number of those who need surgery. Progress of di-
agnostic procedures, pharmacotherapy, development of
minimal invasive cardiosurgical procedures and modern
techniques of anesthesia enables these patients to face sur-
gery with decreased risk of unwanted outcome. Good pre-
operative disease control and adequate choice of anesthe-
sia in accordance with recommended protocols, provide
uncomplicated postoperative course. Good surgical tech-
niques and sufficient level of postoperative analgesia con-
tribute to successful outcome of surgical treatment.
SUMMARY
PREOPERATIVVNA PRIPREMA BOLENIKA SA
HRONI^NIM OPSTRUKTIVNIM BOLESTIMA PLU]A
Hroni~na opstruktivna bolest plu}a (HOBP) predstavlja
faktor rizika za nastanak intraoperativnih i postoperativnih
plu}nih komplikacija. U zavisnosti od vrste i obima hirur-
škog zahvata bolesnici sa HOBP su u riziku od pogoršanja
osnovne bolesti i razvoja komplikovanog perioperativnog
toka. Preoperativnom evaluacijom i pripremom za inter-
venciju smanjuje se mogu}nost nastanka komplikacija ve-
zanih za perioperativni period. Ciljevi anestezije kod obo-
lelih od HOBP su usmereni ka odr‘avanju ventilaciono-
perfuzionog odnosa, spre~avanju nastanka hipoksemije,
intraoperativnog bronhospazma, pnumotoraksa i poreme-
}aja kardiovaskularnog sistema.
Klju~ne re~i: hroni~ne opstruktivne bolesti plu}a,
preoperativnae priprema, perioperativne
komplikacije, mehani~ka ventilacija
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