P er operative Pulmonary Evaluation in Non -T horacic Surger ies

1. Peroperative Pulmonary Evaluation in Non-ThoracicSurgeries Assoc. Prof.Ömer Özbudak AKDENIZ UNIVERSITY SCHOOL OF MEDICINE DEPARTMENT OF PULMONARY MEDICINE

2. I have no conflict of interest

3. Presentation Outlines • Non-thoracic surgeries and pulmonary complications • The importance of preoperative pulmonaryevaluation • Postoperative physiological changes and clinical results • Preoperative evaluation of patients • Which tests?, When?, How to interpret?

4. Major surgeryleads to measurable physiological changes in the patient Complications occur according to the physiological changes and features of the process In thorax and upper abdominal surgeries, pulmonary changescontinue two weeks or more

5. Surgeries Causing to Pulmonary Complications • Major surgeries may result in postoperative complications • Well-known surgeries Thoracic Abdominal Thoraco-abdominal Cardiovascular

6. The Importance of Pulmonary Complications • Adversely affects mortalityandmorbidity • Increases the duration of hospitalization • Increases the need for intensive care • Increases the cost Sweitzer BJ, Anesthesiology Clin 27 (2009); 673 – 86

7. Pulmonary Complications Incidence: • Non- thoracicSurgery 2 – 29% • CardiothoracicSurgery 8 – 39% Bapoje SR et al. Chest 2007; 132:1637–45

8. Pulmonary Complications Major Complications • Atelectasis • Infection • Exacerbation of underlying chronic lung disease • Hypoxia • Respiratory failure • Difficulties in Weaning • Bronchospasm • But also • Upperairwayobstruction • Pleuraleffusion • Aspirationpneumonitis • Noncardiogenicpulmonaryedema • Tracheallaceration / rupture • Pulmonaryembolism

9. Non-thoracic Surgeries • Upper Abdominal Surgery • Lower Abdominal Surgery • Head and Neck Surgery • Orthopedic Surgery

10. Upper Abdominal Surgery • The most important risk factor of the postoperative pulmonary complications is the surgery area. • The risk of postoperative pulmonary complicationsincreases in the surgeries closer to the diaphragm.

13. Upper Abdominal Surgery • The negative effect on diaphragmatic function and respiratory muscle • Pulmonary complications after upper abdominal surgery 33% Pedersen T, Acta Anaesthsiol Scand 1990

14. Lower Abdominal Surgery • Compared to the upper abdominal surgery, the incidence of postoperative pulmonary complications is less. • Lower abdomen 7.7% • Lower abdomen 6% Smetana GW, et al. Ann Intern Med. 2006;144 Pedersen T, Acta Anaesthsiol Scand 1990

15. Surgical Method • Laparoscopic surgery? Open surgery? • Laparoscopic abdominal surgery should have less risk of PPC • Less pain / more comfortable breathing / better improvement in lung volumespostoperatively • Sepsis, cardiovascular side effects andrisk of reoperation are significantly higher in open surgical procedures Smetana GW. Cleveland clınıc journal of medıcıne 2009

16. Nasogastric Tube Application • The routine use of nasogastric tube increases the risk of postoperative pulmonarycomplications. • Aspiration The risk of pneumonia • 148 patients (Elective non- thoracic surgery) PPC risk rate 11% 81% Nasogastric Tube (+) Mitchell CK, Arch Surg 1998;133

17. Head & Neck Surgery • The risk of developing respiratory failure is high in orofacial surgery • It can cause severe airway obstruction • Aspiration • Hypersecretion in patientswithlaryngectomy • PPC occurrence risk 10.3% Smetana GW, et al. Ann Intern Med. 2006;144

18. Orthopedic surgery • PPC risk 5.1% • Deep vein thrombosis • Pulmonary Embolism

19. Smetana GW. Ann Intern Med. 2006;144

20. Preoperative Pulmonary Evaluation • Determination of Risks • Prevention of Risks • Rescheduling/ Cancel of the operation?

21. Preoperative Pulmonary Evaluation • Postoperative physiological changes and clinical results • Preoperative evaluation of patients • Which tests?, When?, How to interpret?

22. Preoperative Pulmonary Evaluation • Postoperative physiological changes and clinical results • Preoperative evaluation of patients • Which tests?, When?, How to interpret?

23. Respiratory pathophysiology during/after surgery Changes in lung volumes Postoperative pain& Muscle splinting Restrictive lung function Diaphragmatic dysfunction due to CNS output to phrenic nerves Hypoxia FRC Airway closure Atelectasis

24. Respiratory pathophysiology during/after surgery Changes in control of breathing Residual effects of anesthetics Respiratory depression Narcotics for analgesics Deep breaths Hypoxia ± Hypercapnia Difficulty weaning Atelectasis

25. Respiratory pathophysiology during/after surgery Impaired lung defence Pain Cough Excessive use of analgesics Damage to cilia Mucociliary clearance Presence of ETT Anesthetic gases Secretions Atelectasis Colonisation Infections

26. Respiratorypathophysiology during/after surgery Bronchoconstriction Aspiration of gastric contents Exacerbation of underlying asthma or COPD Bronchospasm Endotracheal intubation or surgical stimulation Histamine release secondary medication

27. Preoperative Pulmonary Evaluation • Postoperative physiological changes and clinical results • Preoperative evaluation of patients ; Which tests?, Which patients? • How to interpret?

28. PPC risk factors Bapoje et al. Chest 2007; 132 Delisser HM, Grippi MA. Fishman 1998

29. The evaluation of patient • Clinical Evaluation (History - Physical Examination) • Laboratory EvaluationFunctional evaluation (PFT)Arterial Blood GasesChest X-rayECG • General Condition AssessmentClassification of ASA (American Society of Anesthesiologists)Cardiopulmonary Risk Index

30. Theevaluation of patient HISTORY - PHYSICAL EXAMINATION Age Symptoms of the respiratory system Exercise tolerance, general health status Physical examination, predominance of cardiopulmonary system Smoking habits Concomitant diseases (asthma, COPD, CHF, etc.) Previously developed PPC Drugs, history of atopy Snore The type and urgency of the operation

31. Theevaluation of patient CLNICAL EVALUATION:It is the most important and the first step of preoperative pulmonary riskevaluation. Clinical Evaluation Normal Additional tests are unnecessary Doyle RL. Chest 1999; 115

32. The evaluation of patient LABORATORY EVALUATION-CHEST X-ray • In patients without risk factors, contribution to the decision to prevent the operationis minimal, but still it is recommended. Silent state of an unknown disease can be scanned. In the postoperative period, it is allowed to do comparative evaluation. • preoperative chest X-ray should be taken in patients over 60 years old, those with cardiac or pulmonary problems, who the high risk group for PPC. Doyle RL. Chest 1999; 115

33. The evaluation of patient LABORATORY EVALUATION-SPIROMETRY • Age> 60 years old • Smoking history • History of lung disease • Symptoms of the respiratory system • Smoking habits / in the presence of dyspnea + Upper / lower abdominal surgery • ACCP, Ann Inter Med 1990; 112

34. Pulmonary Function Test • PFT results do not always correlate with the complications • Normal PFT results do not indicate the low risk of postoperative complications • Abnormal PFT results do not solely prevent the non-resectional surgery

35. The evaluation of patient LABORATORY EVALUATION- ARTERIAL BLOOD GASES It particularly contributes in the patients with an underlying disease. In cardiac, thoracic or abdominalsurgeries, arterial blood gas analysis should be performed in the presence of dyspnea. The presence of hypercapnia and hypoxemia is not an absolute contraindication for the Operation PaO2 --- PaCO2 Doyle RL. Chest 1999; 115:77S–81

36. Preoperative Pulmonary Evaluation • Postoperative physiological changes and clinical results • Preoperative evaluation of patients ; Which tests?, Which patients? • How to interpret?

37. COPD • Pre-operative stability • Bronchodilator +Physiotherapy + Antibiotics +Smoking cessation + Corticosteroid • SymptomaticCOPD patients with low exercise capacity should be treated until the symptomatic improvement achieved • Elective surgery should rescheduled in acute exacerbation

38. Asthma • The patient should assessed one week before the surgery • Stable • During the operation, inhaled beta agonists could be given by endotracheal tube as before the surgery • Corticosteroids (IV / oral)

39. Recommendations for safe perioperative period in patients with suspected OSAS • Preoperative • OSAS patients should be questionedand the required physical examination should be done • Theyshould be evaluated for the possibility of difficult intubation • Particularly, theelective surgical procedures should be rescheduled, suspicioussevere OSAS patients should be evaluated for PSG • Patients with a diagnosis of OSAS and AHI> 40/hrs should be supported for the use of nCPAPat least 2 weeks before surgery Powell N, Otolaryngol Head Neck Surg 1988

40. Recommendations for safe perioperative period in patients with suspected OSAS • Operative • Patients were evaluated for fiberoptic bronchoscope intubation • Even for a short-termperiod, theloss of airwaycontrol should be avoided • Alternative methods of airway patency should be ensured that in case of failed intubation Powell N, Otolaryngol Head Neck Surg 1988

41. Recommendations for safe perioperative period in patients with suspected OSAS • Postoperative • Untilthefull alertnessachieved in patients, close monitoring with oximetry and blood pressure should be provided andanalgesic requirements should be minimized • Additional oxygenshouldbe usedin awake patientsandnCPAP especially in patients with knownOSAS shouldbe usedduring sleeping • Instead of continuous use of opiates for postoperative pain control,regional anesthesia shouldpreferredandanalgesia should be titrated carefully Powell N, Otolaryngol Head Neck Surg 1988

42. High risk of thromboembolism • Major surgery patients over 40 and with a history of previous VET, cancer or hypercoagulopathy • Hip or knee arthroplasty • Hip fracture surgery • Major trauma • Spinal injuries

45. Goldman cardiac risk index Ebstein SK. Chest 1993; 104:694-700,

46. Pulmonary risk index: Risk factors known to increase PPC Ebstein SK. Chest 1993; 104

47. Pulmonary risk index Between 0 - 6 Goldman CRI 0 - 5 points : 1 6 -12 points : 2 13 - 25 points : 3 26 - 53 points :4 Cardiopulmonary risk index scor ( 1 ... 4 ) + ( 0... 6 ) = 10 ; total If the CPRIS is higher than 4, prognosis is poor Cardiopulmonary complication risk is more than 22 folds Ebstein SK. Chest 1993; 104

48. PREOPERATIVE PULMONARY EVALUATION YES Risk Factors for PPC Elective non-thoracic, Non-resectional surgery Modification on Aggresive Risk Factors YES NO Surgery Surgery Risk Factors for PPC: Preoperative COPD, Age, Smoking,NYHA class-II Pulmonary HT,OSA, Low Albumin Value Intraoperative Surgical area, General Anesthesia,Use of Pancuronium,Duration of surgery Bapoje SR et al. Chest 2007

49. Prevention of Risks • Smoking cessation for ≥8 weeks • Treatment for patients with underlying asthma / COPD (PFT) • Delay elective surgery and treat with antibiotics if respiratory infection is present • Patient education regarding lung expansion maneuvers • Obese patients should be managed to lose weight • Choose procedure lasting < 4 hrs (if possible) • Minimize duration of anesthesia • Avoid use of long-acting neuroblockers (ie pancuronium) in high risk patients

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