POSTOPERATIVE PULMONARY COMPLICATIONS

POSTOPERATIVE PULMONARY COMPLICATION

Despite advances in anaesthesia practice and surgical care, peri-operative pulmonary complications remain a significant cause of morbidity, mortality, and prolonged hospital stay. Pulmonary complications are most commonly seen postoperatively.
Patients with pre-existing pulmonary pathology are at increased risk. It is thus important to identify these patients pre-operatively and implement appropriate measures to optimise their pulmonary function, with the aim of preventing or reducing peri-operative morbidity.

Peri-operative pulmonary complications include pneumonia, respiratory failure bronchospasm, atelectasis, hypoxaemia and exacerbation of underlying chronic lung diseases. Adverse Effects of Anaesthesia and Surgery Anaesthesia : 1- Anaesthetic drugs may result in an impairment of central respiratory regulation and tone of respiratory muscles 2-Mechanical ventilation can produces atelectasis due to inactivation of respiratory muscles. 3- Reflex stimulation during airway manipulation and release of inflammatory mediators by some anaesthetic agents can produce bronchospasm, resulting in hypoxia

4-. Dry anaesthetic gases and prolonged mechanical ventilation may impair normal mucociliary mechanism. This causes retention of secretions which can lead to atelectasis from mucus-plugs and pneumonia from superimposed infection 5-Risk of aspiration pneumonitis with general anaesthesia when airway reflexes are obtunded.

Surgery:Surgical incisions cause physical disruption of respiratory muscles, such as intercostals

and abdominal muscles, and impair their mechanical efficiency.

Post-operative pain, especially from thoracic and upper abdominal incisions, causes voluntary limitation of respiratory effort

Stimulation of viscera intra-operatively, such as esophageal dilatation and traction on gallbladder, markedly decreases phrenic neuronal output and reduces the force of diaphragmatic contraction during inspiration

Patient Factors

General health status:-1- ASA class 3

2- Poor exercise tolerance reflected as symptom-limited stair climbing

Smoking :-mentioned
previously

Chronic Pulmonary Disorders

The common disorders include chronic obstructive pulmonary disease and asthma. Chronic Obstructive Pulmonary Disease Complications arise from airflow obstruction, mucus hypersecretion and repeated infections. Incidence of pulmonary complications varies according to the severity of lung disease, with Asthma Asthma is a result of hypersensitive airways with inflammation and narrowing due to smooth muscle spasm, which is characteristically reversible. Fortunately, bronchospasm which can occur during anaesthesia, is rarely associated with serious morbidity. Obstructive Sleep Apnoea (OSA) Patients with sleep apnoea are at increased risk of severe hypoxaemia, hypercapnia and deterioration of sleep disordered breathing in the post-operative period. These patients are usually obese males who invariable have a history of snoring. OSA is also associated with hypertension, arrhythmias, congestive heart failure, coronary heart disease and stroke. This group of patients may have excessive pharyngeal tissues which pose a challenge during tracheal intubation and extubation. Regional anaesthesia for post-operative analgesia is preferred as the use of post-operative opioids for analgesia may be associated with increased risk of pharyngeal collapse

Obesty / result in :1- Difficult intubation 2- Aspiration during anaesth. due to :-a /Delayed gastric emptying + b/ gastroesophageal reflux. 3-Risk of basal atelectasis & hypoxia due to decreased FRC,ERV 4-Hypoventilation due to decreased thoracic wall compliance 5- Obstructive sleep apnoea

Age :- patients > 65 years Pulm.function tests :-mentioned previously

Procedure-related Factors Surgical Site This is the single most important predictor for peri-operative pulmonary complications. The risk increases as the incision approaches the diaphragm: upper abdominal and thoracic surgery carries the greatest risk, ranging from 10 to 40%. Degree of Surgical Trauma (Laparoscopic vs Open Surgery) The risk is lower in laparoscopic cholecystectomy (0.3 to 0.4%) compared to open cholecystectomy (13 to 33%). Anaesthetic Techniques and Post-operative Analgesia lower risk of pulmonary complications with regional anaesthesia compared to general anaesthesia. Regional anaesthesia avoids the associated risks of anaesthetic agents, airway manipulation and mechanical or assisted ventilation which disturbs lung mechanics. Duration of Surgery Surgery lasting more than 3 hours is associated with a higher risk of perioperative pulmonary complications. Emergency Surgery Patients with respiratory conditions for emergency surgery tend to be more sick, and have significantly less time for optimisation of their coexisting disorders. Also, they may not be adequately fasted, predisposing them to aspiration.

Atelectasis & pneumonia :

Aelecasis is a collapsed of an area of lung secondary to retained mucus in the bronchial tree. Atelectasis & pneumonia represent 90% of postoperative pulmonary complication.

pathophysiology

: due to 1-increase bronchial and salivary secreation. 2-decrease ciliary reaction

TREATMENT
1-Adequate reversal of muscle relaxants. 2-postoperative analgesia : enhances coughing and increases expectoration. 3-warm humidified oxygen. 4-proper antibiotics. 5-bronchodilators. 6- steroid . 7-physiotherapy.

ASPIRATION
Occur at : 1- induction & termination of anaesthesia. 2- early postoperative period. The incidence for the development of severe pneumonitis (mendelson syndrom ) is very high if the gastric content is highly acidic (PH less than 2.5) or the volume of inhaled gastric contents more than 25 ml.

POSTOPERATIVE HYPOXIA CAUSES: 1-Reduced cardiac out put : this will result to reduction in oxygen flux (the volume of oxygen supplied to tissue per minute ) ,which may be insufficient to meet the patients oxygen demand especially if he is shivering. 2-increased V/Q mismatch : due to decrease functional residual capacity during anaesthesia especially in the elderly , obese patient , smokers. 3 - Diffusion hypoxia or fink effect. 4-Hypoventilation : due to A Drugs : most anaesthetic agents depress ventilation , also incompelete reversal of muscle relaxation effect. B-Obstruction : partial respiratory obstruction in the postoperative period is often not recognized immediately. C- Pain : in some patients like those who have had upper abdominal surgery , pain may preventing them from breathing more deeply. Elevation of diaphragm due to abdominal distension will also contribute to hypoventilation. D-Intraoperative hyperventilation : many patient are hyperventilation during operation.When spontaneous ventilation is restored , there may be a considerable total body deficit of CO2 .Reduction of CO2 excretion by hypoventilation during the early postoperative period allows this deficit to be made up.

Causes of prolonged unconsciousness (delay recovery ) after anaesthesia :

1-pharmacological: benzodiazepine , opioids , nenromuscular block , I.V. anaesthetic agents , volatile anaesthetics. 2-Metabolic causes : hypoglycaemia , hyperglyceamia , hyponatraemia , hypernatraemia , uraemia . 3-Hypothermia. 4-Respiratory failure. 5-Neurological causes : head injury , cereberal oedema , stroke. 6- Acid base imbalance & electrolyte disturbances.