A Common consultation example

1. A Common consultation example To the consultant physician of the Respiratory Disease Service Could you please consult our patient in the preoperation period who has a medical history about Chronic Obstructive Pulmonary Disease. Dr. ……….. …….. Surgery Service

2. Preoperative evaluation and postoperative follow-up in COPD patients Mehmet Polatlı,MD,Assoc.Prof. Adnan Menderes University School of Medicine Chest Disease Dept. AYDIN

3. The anesthetic consultation is aimed to answer: • Is the patient fit for surgery? • Is it possible to improve the patient’s condition? • Are there alternate therapeutic modalitities? • What are the spesific risk and benefit related to surgical treatment? • Are there preventive measures? • How will be the patient’s life after operation?

4. Incidence of COPD in operated patients • General Surgery % 5-10 • Cardiac Surgery % 10-12 • Thoracic surgery % 40 • McAlister et al.2003;Halbert et al.2006 Co-morbidities in COPD patients • Hypertension % 34 • Oclusive and anevrismatic arterial disease % 12 • Heart failure % 5 • CArdiac arythmia and conduction disorders % 12 • İschemic heart disease % 11 • Sin et al.2005

5. Postoperative morbidity and mortality Heart failure % 1-2 • MI % 0-6 • Respiratory failure % 1-3 • Bronchopneumonia % 1-5 • Mortality from anesthesia 1/250.000 • Mortality from operation % 0.5-1 • Previous history of ischemic heart disease, COPD, renal failure increase in risk • Kaafarani et al. 2004; Fleischmann et al. 2003

6. Postoperative morbidity and mortality • Advances in surgery and anesthesia technics in 20 years • Bonnet and Marret 2005 • Lung resection • Mortality rates in Aortic abdominal reconstruction surgery Lowered to 3 % from 10 %

7. Mortality risk in noncardiac surgeryAS % 10-28HF % 11.7CAD % 6.6 In patients with > aged 65 • Aort stenosis rates 2-9 % • Congestive heart failure 8-12 % • These patients are also common in COPD patients after modern treatment effects on survival Christ et al. 2005

8. Postoperative complications • Both cardiac and pulmonary complications may develop in the same patient • For instance myocardial ischemia/infarct, VAP, sepsis and ALI related with transfusion risk increase in severe intraoperative hemorrage.

9. Postoperative pulmonary complications are common among the most common morbidities in patients undergoing mojor surgery. Despite the frequency and potential seriousness of these complications, preoperative patient evaluations often tend to focus more on cardiac, rather than pulmonary, risks.

10. Postoperative pulmonary complications • Atelectasis • Infections including acute tracheabronchitis and pneumonia • The exacerbation of underlying chronic lung disease • Prolonged mechanical ventilation and respiratory failure • Thromboembolic disease

11. Postoperative pulmonary complications • PPC rates in studies % 3-80 ?? • The type of surgery • Heterogeneous study groups in researches • The level of previous respiratory disorder • The differences of the criterias for the complications • Fisher et al. 2002 Transient changes in spirometric values, respiratory muscle strength and gas exchange are natural postoperative course which should not be always considered as a complication.

12. Postoperative pulmonary complications • Preoperative • Chronic lung disease • Smoking • General health status • Age • Obesity • Nutrition status • Airway infection before the operation

13. Postoperative pulmonary complications • Intraoperative • Type of anesthasia • Duration of anesthesia • The type of surgery • The type of incision • Postoperative • Immobilisation • İnsufficient pain control

14. Goldman Cardiac Risk İndex Skor 1:0-5; Skor 2:6-12; Skor 3:13-25; Skor 4:>26

15. Pulmonary Risk İndex (1-4)+(1-6)=Cardiopulmonary risk index >4 : Cardiopulmonary risk index %73.4, <4: risk%11 Ebstein SK et al. Chest 1993

16. Arozullah AM et al.2000, Arozullah et al.2001,Boersma E.et al.2005, Lee TH et al.1999

17. * BUN>30mg/dL (SY veya pnm), kreatinin >2 mg/dL (kardiyak komplikasyon) Arozullah AM et al.2000, Arozullah et al.2001,Boersma E.et al.2005, Lee TH et al.1999

18. Risk ratios for pneumonia and respiratory failure Arozullah AM et al.2000, Arozullah et al.2001,Boersma E.et al.2005, Lee TH et al.1999

19. Patient related risk factors for PPC • COPD • Asthma • OSA • Age • Obesity • General health status (ASA classification) • Smoking • Alcohol • Malnutrition Christ et al. 2005 * PPC rates. Qaseem A et al.2006

20. General Health Status • Medical history and physical examination • Inability to go the stairs for 2 floors • Functional dependency • Physiological evaluation criteria • VO2 max • 6MWT VO2max<15mL/kg/dak 6MWT < 300m Unable to go to the stairs for 4 floors SPİROMETRİDEN DEĞERLİ Licker M, 2007

21. COPD ?? CVD Muscle-skeletal diseases Mental disorders Cancer Sleep disorders Malnutrition • Abnormal inflammatory response in the lung against noxious gases and particles • Not fully reversible • Characterized by progressive airflow limitation • Severe systemic consequences • Preventable and treatable

22. Can PFT predict accurately postoperative risks? • Abnormal physical examination OR=5.8 • Abnormal chest X-ray, OR=3.2 • GCRI, OR=2.0 • Charlson co-morbidity index, OR=1.6 • FEV1,FVC,FEV1/FVC does not differ in patients with pulmonary complication (+) from (-) patients • Lawrence et al.Chest 1996 • Wong et al. Anest Analg 1995 • Kocabaş A et al. Respir Med 1996

23. Follow-up ciriteria in COPD • It seems unable to predict the disease prognosis and assess the treatment outcomes, so to measure all aspects of the disease using only one parameter because of the many seperate pathological mechanisms.

24. Exacerbation in COPD bronchial inflammation • Instrumentation to the airways • Preoperative airway colonization • Immunsupression induced by surgery • İncreased muscle load for ventilation

25. In addition to the severity of COPD • Decrease in lung sounds • Wheezing • Roncus • Prolonged expiration and/or • Marked alterations in gas exchange and hypoxemia increase the risk. PAH and chronic respiratory muscle fatigue (+) • hemodynamic collaps and • RVF and ventilator-dependency  Jaber et al. 2005

26. Which limit of PFT value does not permit to go to surgery? • Preoperative FEV1<% 50  PPC % 29, mortality % 6; but with the exception of heart surgery these rate was found as 1 among the others. • Although these incidences are important, surgical procedure should be done in anyway if it is necessary. • Kroenke et al. 1992 • Spirometry should be performed in lung resection and cardiovascular surgery.

27. Risk increase according to PFT in lung resection

29. Predicted Postoperative Lung Volum Juhl ve Frost formula Ppo FEV1 (veya ppo FVC) =po FEV1 x (1-[S x 5.26 /100]) =po FEV1 x (1-[S x 0.0562]) (S): Segment numbers Kristersen /Olsen formula Ppo FEV1 (or ppo FVC)= po FEV1 x (1-segments’ functional contribution that will be resected)

30. AVAC NICE Guideline

31. LUNG TRANSPLANTATION • FEV1< %25 (no reversibility) and/or • CO2≤55mmHg and/or • Progresively deterioration in high PAP (cor pulmonale) • preference should be given to those patients with elevated PaCO2 with progressive deterioration who require long-term oxygen therapy, as they have the poorest prognosis Age • Single lung aged 65, double lung aged 60 limited

32. Results of Lung transplantation • FEV1, Exercise capacity, increase in QoL • Trulock EP, III. Lung Transplantation for COPD. Chest 1998;113(4):269S-276S. • Hospital mortality % 3.9 • 5 years survay % 58.64.4 • Bilateral lung % 66.74.0 • Single lung % 44.96.0 • Cassivi SD, Meyers BF, Battafarano RJ, Guthrie TJ, Trulock EP, Lynch JP et al. Thirteen-year experience in lung transplantation for emphysema. Ann Thorac Surg 2002;74:1663-9.

33. Chest X-rays In surgery patients • Pathological x-ray %10, ancak % 1.3’ünde unexpected pathology. • Preoperative chest x-ray abnormality % 23.1 % 3 changed in treatment. In patients with known cardiopulmonary disease aged >50 yaş and upper abdominal, thoracic, abdominal aort anevrizma surgery should be performed. • Qaseem A,et al. 2006

34. Laboratuary tests • BUN ≥21mg/dL  risk faktor • Serum albumin < ~ 35g/L the most important risk faktor related with the patient. Qaseem A et al. 2006 • National VA Surgery Risk Study Group: Low serum albumin level is the most important morbidity and mortality factor in perioperative 30 days. • Gibbs et al.Arch Surg 1999 • Low Serum Albumin importance >High serum BUN

35. Grading of postoperative cardiopulmonary complications • In cardiothoracic and abdominal surgeries • Low hypoxemia, diffuse microatelectasis minimally effect clinical prognosis. • Lobar atelektasis • Refractery hypoxemia to oxygen treatment Bronchopleural fistul, bronchopneumonia, ALI, RF

36. Grading of postoperative cardiopulmonary complications • The new scoring system ranks the severity of postoperative complications by assessing • Organ dysfunction • İncremental need for pharmacological treatment • Supportive/corrective interventions • Physiotherapy • Endoscopy • Drainage • Re-interventions • Dindo et al. 2004

39. Respiratory changes due to anesthesia • Lung volume • Atelektasis • FRC , CV, compliance  • In COPD FRC ve dead space  • Airways • bronchodilation (volatil anesthesics) • Tonic activity  in upper airway muscles • Mucociliary clerance  • Airway resistance  • Control of ventilation • Hipercapnia, hypoxia, ventilatory response to asidosis  • Pulmonary circulation • Hypoxic vazoconstrictor response  (Volatil anesthesics) • Blood gas changes • PA-aO2 gradient  due to regional V/Q changes • İmmun function • Bactericidal activity of macrophages , pro-inflamatuary cytokine release 

40. Effect of general anesthesia Supine position in healthy subjects FRC 0.8-1.0 L decrease Anesthesia additional 0.4-0.5 L decrease. • FRC 3.5 L2 L (near to residual volum)  atelectasis ve V/Q areas  compliance 95 60 mL/cmH2O • Atelectasis areas are associated with decrease in FRC and SaO2 • Licker et al. 2007 • Stiffness lungs increase the ventilation work in postoperative period • Hedenstierna and Edmark 2005

41. The effects of major surgery on pulmonary function • Thoracic and upper abdominal surgery  pulmonary restrictive sendrom • Preoperatif VC value in upper abdominal surgery 7-10 days; • Severe in thoracic surgery 6-17 wk • PPC is higher in verticaly insicion than horizontal insicion. Bastin R. Chest 1997;111:559-63

42. Pulmonary complications with thoracic surgery

43. Laparoscopic surgeries • The avantages of laparoscopic surgery are small incision, lower postoperative pain, small effect on diaphragmatic and abdominal muscles and short hospitalization period.

44. Preoperative strategies for reducing complication risks • Smoking cessation before at least 8 wk • Treatment of airway obstruction • If there is airway infection, treat it before surgery • Patient education about lung expansion maneureas • DVT and PTE are important in all major surgeries. VTE incidence % 50-60 is in hip and knee surgeries  Heparin prophylaxis • Beta blockers are important in reducing mortality in cardiac patients • Beta agonists should be carefully ordered in patients with arythmia and coronary ischemia

45. Protection from cardiac risks • RCRI (+) • Limited exercise capacity • Major surgery operation The patients who benefit from cardiac protection strategies and revascularization (beta blokers, antithrombotic, statin) are determined • Thalium sintigraphy • Echocardiography • Stress test Fleisher et al. 2006

46. Abdominal Surgery

48. Özetle • PPC are common risk factors for morbidity and mortality in COPD patients • Procedure related risk factors are more important than patient related risk factors bu clinicians should assess both types of factors • Only PFT has limited value but should be performed in COPD patients for grading the severity. • Preoperative optimum management of the patients, lung expansion maneures, pain control, nasogastric tube in selected patients, cardioprotective measures, VTE prophylaxis, analgesic for nosiseptive pains, balance of fluid-elektrolites, management of co-morbidities should taken be account.

49. Thank you