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Prediction tools

Prediction tools. CXR Low yield in in patient without risk factors In a systematic review of 14 studies abnormal CXR lead to Rx change in 10% of cases without changing PPC rate. ABG Cardiac, thoracic, abdominal surgeries Pts who have SOB or smokers Pt with abnormal pulse oximetry.

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Prediction tools

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  1. Prediction tools • CXR Low yield in in patient without risk factors In a systematic review of 14 studies abnormal CXR lead to Rx change in 10% of cases without changing PPC rate. • ABG Cardiac, thoracic, abdominal surgeries Pts who have SOB or smokers Pt with abnormal pulse oximetry

  2. Prediction tools • Cardiopulmonary Exercise Testing Purely lung resection surgery MVO2 maximum oxygen consumption MVO2 > 20ml/kg low risk MVO2 < 10 ml/kg very high risk • Stair climbing Prospective study in 110 pts who underwent high risk procedures  thoracotomy , sternotomy or upper abd sx 7 Flights of stairs each flight consists of 18 steps Cardioplumonary complications & mortality Girisch et al Chest 2001

  3. Girisch et al Chest 2001

  4. Girisch et al Chest 2001

  5. Lung Resection The risks associated with thoracotomy can be divided into 2 categories: I- short-term riskperioperative morbidity and mortality II- long-term riskactivity limitation resulting from loss of lung reserve. Low Risk FEV1 (Forced Expiratory Volume in one second ) 1.2 L Predicted postoperative FEV1.8 L or 40% predicted MVV ( Maximum Voluntary Ventilation) 50% predicted High Risk PCO2 45 or PO2 50 Predicted Postoperative FEV1 0.7 L 40% predicted Poor exercise performance Rilley Chest 1999

  6. American College Of Chest Physician Guidelines 2007

  7. Preventive Measures • Incentive spirometry & deep breathing exercises Meta-analysis of 14 studies of incentive spirometry & deep-breathing exercises Vs no intervention odds ratios of 0.44 and 0.43 for PPC Preoperative education reduces PPC to a greater degree than instruction that begins after surgery Arch Phys Med Rehab 1985 & AmRev Respir Dis 1984

  8. Preventive Measures Non invasive positive pressure ventilation • Prospective study of 72 post abdominal Sx pts with acute hypoxic failure were treated with escalating PSV /PEEP to achieve target tidal volume of 8-10 ml/kg . • 48/72 (67%) avoided intubation • LOS was shorter 17 days Vs 34 days • Mortality was less 6% Vs 29% • 10/72 had esophageal & gastric surgery no leak Jaber Chest oct 2005

  9. To put everything together Sematana NEJM 2007

  10. Take Home Message • Conducting detailed history taking & physical examination should be the first screening tool • Investigations selection had to tailored to detected abnormalities • Risk factors for PPC are either patient or procedure related. It could be modifiable or non modifiable • The variation in definition of PPC & patient population lead to different reported rate of PPC • All prediction tools of PPC have not been validated after being derived further studies is needed

  11. Thanks The more you know the more you realize how much you don’t know

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