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Preoperative Pulmonary Evaluation in Thoracic Surgeries

Preoperative Pulmonary Evaluation in Thoracic Surgeries. Prof. Dr. Metin ÖZKAN. No Conflict of interest. Post operative pulmonary complications (POPC): Importance. More common and serious than cardiac complications Longer hospital stay (1-2 weeks) Increased morbidity and mortality

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Preoperative Pulmonary Evaluation in Thoracic Surgeries

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  1. Preoperative Pulmonary Evaluation in Thoracic Surgeries Prof. Dr. Metin ÖZKAN

  2. No Conflict of interest

  3. Post operative pulmonary complications (POPC): Importance • More common and serious than cardiac complications • Longer hospital stay (1-2 weeks) • Increased morbidity and mortality • Frequency 2-70%; • patient selection, • risk factors due to operation, • defination of complication Toraks 2012

  4. Pulmonary pathophysiology during surgery under general anesthesia Up to 1 week Toraks 2012

  5. Postoperative pulmonary complications Toraks 2012

  6. Factors associated with the development of postoperative pulmonary complications + +,strong determinant; +, moderate; + / - weak evidence of increased risk Toraks 2012

  7. Preoperative (patient related) • Chronic lung disease + +Smoking+ + •  General health status + + (ASA> class 2) • Age + / - •  Obesity + / - •  Nutritional / metabolic status + (albumin <30 g / L and urea> 30 mg / dL) •  Concomitant infection of the respiratory system Factors associated with the development of postoperative pulmonary complications • The presence of COPD is a significant risk POPC (2.7-6.0) • Complication rates of 25-100% • POPC rate and severity correlates with Preop. PFT(FEV1 <65%: POPK> 50%) • Intensive bronchodilator therapy • smoking cessation • Short-term corticosteroid therapy • In the case of an acute attack elective surgery must be postponed • Although COPD is a serious risk,there is not a lower limit of PFTwhere the surgery is absolute contraindicated (other than resection) Toraks 2012

  8. COPD Complications after lung cancer surgery in patients with NSCLC This slide is taken from Prof. Dr. Ertürk Erdinç’s speech in Winter School of Turkish Thoracic Society. Toraks 2012 Sekine Y.Lung Cancer 37:95-101,2002

  9. 89 severe COPD (FEV1 <50%), 107 surgical procedures RESULTS: POPC 29% Significantly associated with the Type and duration of surgery and ASA classification Coronary artery bypass grafting (60%)Major abdominal surgery (56%)Other general surgical procedures (27%)Spinal anesthesia was applied (16%) Duration of the Operations; < 1h (4%), 1-2 h (23%), 2-4 h (38%) > 4h (73%) ASA; class II (10%), Class III (28%), Class IV (46%) 6 deaths and 2 non-fatal respiratory failure. 5 of 10 bypass (50%) and 1 of 97 non-coronary bypass operations (1%) died. CONCLUSION: Severe COPD is an acceptable risk factor for non-cardiac surgery. Kroenke K et al. Operative risk in patients with severe obstructive pulmonary disease. Arch Intern Med. 1992;152(5):967-71. Toraks 2012

  10. Toraks 2012

  11. Preoperative (patient related) • Chronic lung disease + +Smoking+ + •  General health status + + (ASA> class 2) • Age + / - •  Obesity + / - •  Nutritional / metabolic status + (albumin <30 g / L and urea> 30 mg / dL) •  Concomitant infection of the respiratory system Presence of asthma • Even high probability of POPC expected,there is no data on this subject. 706 patients with asthma, various general surgical procedures; pulmonary complications: • Bronchospasm 1.7% • Respiratory failure, 0.1% • 0.3% of laryngospasm. • No Death Warner DO, et al. Perioperative respiratory complications in patients with asthma. Anesthesiology 1996; 85:460–467. • In patients under control • wheezing, (-) • PEF> 80% do not have an additional risk • In the perioperative period Short-term Corticosteroid Toraks 2012

  12. Preoperative (patient related) •  Chronic lung disease + +Smoking+ + •  General health status + + (ASA> class 2) • Age + / - •  Obesity + / - •  Nutritional / metabolic status + (albumin <30 g / L and urea> 30 mg / dL) •  Concomitant infection of the respiratory system Smoking • A prospective study of 200 patients underwent coronary by-pass surgery. Eight weeks ago for those who quit smoking POPC, significantly lower than those who continue to smoke (14.5% vs. 57.1%). • In those who quit smoking before 6 months the complication rates were determined at the same level of never smokers (11.9% to 11.1%) Warner MA et al. Mayo Clin Proc. 1989 Jun;64(6):609-16. Although most of the smokers have normal PFT;increased secretion,mucociliary dysfunction,increased pain,opiates,impaired cough,retained secretionsdue to atelectasis,infection andhypoxemia. Toraks 2012

  13. “American Society of Anesthesiologists” (ASA) classification Toraks 2012

  14. Pulmonary Risk Index Cardiopulmonary risk index score: ( 1 - 4 ) + ( 0 - 6 ) KPRIS >4; 22 times more higher complication <2 low complication Toraks 2012

  15. Preoperative (patient related) •  Chronic lung disease + +Smoking+ + •  General health status + + (ASA> class 2) • Age + / - •  Obesity + / - •  Nutritional / metabolic status + (albumin <30 g / L and urea> 30 mg / dL) •  Concomitant infection of the respiratory system AGE Stolz A. Ind CardVasc 2;623-630,2003 This slide is taken from Prof. Dr. Ertürk Erdinç’s speech in Winter School of Turkish Thoracic Society. Toraks 2012

  16. Obesity • Preoperative (patient related) •  Chronic lung disease + +Smoking+ + •  General health status + + (ASA> class 2) • Age + / - • Obesity + / - •  Nutritional / metabolic status + (albumin <30 g / L and urea> 30 mg / dL) •  Concomitant infection of the respiratory system • Chest wall, diaphragm and abdominal fat accumulation reduces total respiratory compliance in 60%. • This change will increase in the supine position . • Decreased compliance: • increased work of breathing; • Increase in minute ventilation, • An increase in oxygen consumption • Increased production of CO2 Toraks 2012

  17. Obesity • A prospective study of 272 non-thoracic surgery • hypercapnia (45 mm Hg or more) (odds ratio, 61.0), • FVC <1.5 L / min (odds ratio, 11.1), • maximal laryngeal height: 4 cm or less (odds ratio, 6.9), • Forced expiratory time> 9 seconds (odds ratio, 5.7), • More than 40 pack-years or more smoking (odds ratio, 5.7), • Body mass index: 30 or higher (odds ratio, 4.1). McAlister FA, et al. Accuracy of the preoperative assessment in predicting pulmonary risk after nonthoracic surgery.J Respir Crit Care Med. 2003;167(5):741-4. Toraks 2012

  18. OSA Hwang D, Shakir N, Limann B, Sison C, Kalra S, Shulman L, Souza Ade C, Greenberg H Association of sleep-disordered breathing with postoperative complications. Chest. 2008;133(5):1128-34. 172 patients with evidence of OSA (snoring, daytime sleepiness, witnessed apnea) undergone elective surgery Patients were followed up with oximetry and for at least 4% desaturation index (ODI4%) had been established. Cardiac complications (4% - 1%) and POPC (8%-1%) were determined higher in patients with ODI4%> 5. Pulmonary complications; pneumonia, atelectasis, and hypoxemia Toraks 2012

  19. OSA (postoperative follow-up ) Pain control: Systemic opioids should be avoided; regional aneljezi or nonsteroidal antiinflammatory drugs . O2 support: postoperative oxygen supplementation should be provided for all patients with OSA. CPAP: Should be continued postoperatively.  CPAP training should be given preoperatively to the patients with untreated OSA. SaO2 monitoring: Monitoring with Pulse oximetry should be continuously, not intermittent, done after leaving intensive care unit Body Position: Turn the person on the lateral position or upright position Toraks 2012

  20. Preoperative (patient related) •  Chronic lung disease + +Smoking+ + •  General health status + + (ASA> class 2) • Age + / - •  Obesity + / - • Nutritional / metabolic status + (albumin <30 g / L and urea> 30 mg / dL) •  Concomitant infection of the respiratory system Metabolic disorder • Malnutrition (albumin <30g / l, odds ratio =2.5) • By reducing the work of breathing  causes of hypoxia and hypercapnia. • Contribute to respiratory muscle dysfunction and reduces lung elasticity. • Elevated urea (BUN>30mg/dl) odds ratio=2.3. Toraks 2012

  21. İntraoperative risk factors Aortic aneursym Thoracic SurgeryUpper abdominal surgeryBrain surgeryProlonged surgeryHead and neck surgery Emergency surgeryVascular surgery Toraks 2012

  22. Anesthesia-Analgesia Pancuronium does the residual NM blockade. The incidence of POPC increases 3-fold. Postoperative epidural analgesia prevents respiratory muscle dysfunction and pain induced hypoventilation FRK  Tidal volume V / Q imbalance  • Deterioration in oxygenation and CO2 excretion • An epidural anesthesia at T4 level does not cause a significant change in FRC, VC, FEV1, alveolar-arterial oxygen gradient, shunt ratio or in cardiac output. • duration of anesthesia • 3-4 hours anesthesia may cause serious complications. • Risk of pneumonia is 5 times greater in a-4 hours operation when compared with a-2 hours one. Toraks 2012

  23. Surgical Site • Complication rates (except for thromboembolism) : • non-thoracoabdominal surgery  <1% • Lower abdominal surgery <5% • Upper abdominal surgery > 5% (there are reports of 7-76%) • Some factors influencing the complication rates of lung resectional surgery • (1) the presence of underlying disease • (2)  the amount of resection of the functional lung Toraks 2012

  24. Type of surgical incision • In abdominal surgeries vertical incision is more risky than horizontal incision. • Laparoscopic and thoracoscopic surgery are more reliable: • Short hospital stay, • Quick return to everyday life • Less incisional pain • Laparoscopic cholecystectomy • lung volumes are preserved, • Less PO pain, • use of less anelgesic • Higher SaO2 Toraks 2012

  25. POSTOPERATIVE RISK FACTORS  • Inappropriate Postoperative Analgesia During PO period effective pain control is very important. • Pain; blocks cough, deep breathe and early mobilization. Barriers to better PO pain control: • Hiding the pain by the patient • Not to use narcotic analgesics when needed • Immobilization Prolonged bed rest and inactivity increases POPC‘s: • FRC, 500-1000 ml reduced in the supine position • Atelectasis • Short duration of hospitalization increases the mobilization and excretion of secretions. • PO inactivity is a high risk for deep venous thrombosis and pulmonary thromboembolism Toraks 2012

  26. Pulmonary evaluationAnamnesis • Deatiled history and physical exam • Undiagnosed chronic lung disease • Decreased exercise tolerance • unexplained dyspnea • Sputum, cough • Symptoms of sleep apnea • Pre-existing lung diseases • Existing respiratory infections or exacerbations • Smoking • signs of COPD • Decreased breath sounds • prolongation of expirium • wheezing • Signs of deep vein thrombosis Toraks 2012

  27. Pulmonary function testing: To which patient • All candidates for lung • Patients with asthma or COPD • Others: • Patients undergoing coronary bypass or upper abdominal surgery with a history of smoking or dyspnea. • Patients undergoing head and neck, orthopedic, or lower abdominal surgery with unexplained dyspnea or pulmonary symptoms

  28. PFTs (cont.) • PFTs should not be used as the primary factor to deny surgery • the results from PFT should be interpreted in context of clinical situation and should not be the sole reason to withhold necessary surgery • Two reasonable goals to use of preoperative PFTs • Identification of a group of patients for whom the risk of the proposed surgery is not justified by the benefit • Identification of a subset of patients at higher risk for whom aggressive perioperative management is warranted

  29. PFTs (cont.) • Spirometry • performed when the patient is clinically stable and receiving maximal bronchodilator therapy • Risky for Pneumonectomy • FEV1< 60% of the predicted value or < 2 liters • DLCO< 60% of the predicted value • MVV< 50% of the predicted value • Safe lower limit for Pneumonectomy • FEV1> 80% of the predicted value or > 2 liters • Safe lower limit for Lobectomy • FEV1 > 60% of the predicted value or >1.5 litres

  30. PFTs (cont.) • Blood gas analysis • Current data do not support the use of preoperative arterial blood gas analyses to stratify risk for postoperative pulmonary complications • Hypoxemia: SaO2 < 90% • Hypercapnia: PaCO2 > 45mmHg • not necessarily an absolute contraindication for surgery • lead to a reassessment of the indication for the proposed procedure and aggressive preoperative preparation

  31. Split PFT • Predicting post-resection pulmonary function • Predicted postoperative FEV1 (ppoFEV1) is the most valid single test available • ppoFEV1 = preoperative FEV1 × (1– %functional tissue removed/100) • lung function can be calculated by counting the number of segments removed • The lungs contain 19 segments (3 right upper lobes, 2 right middle lobes, 5 right lower lobes, 3 left upper lobes, 4 left lower lobes, 2 left lingula)

  32. Split PFT (cont.) • Ventilation-perfusion(V/Q) scan • allows detailed assessment of the functional capacity of the lung and accurate determination of which lobes or segments contribute proportionally to ventilation and perfusion before their resection • Allows the calculation of the functional remaining parenchyma after surgery and the predicted post-resection FEV1 value • Quantitatve CT

  33. Split PFT (cont.) • ppoFEV1 > 40%, ppo DLco > 40% • Widely accepted as a predictor of average risk for complications • ppoFEV1 < 40%, ppo DLco < 40% • High risk of perioperative complications including death • FEV1ppo <1L→ sputum retention • FEV1ppo <0.8L → preclude resection , dependent on a ventilator

  34. Cardiopulmonary exercise test • Maximal oxygen uptake (VO2max) • VO2max > 20mL/kg/min • are not at increased risk for complications or death • VO2max < 15 mL/kg/min • an increased risk of peri-operative complications • VO2max < 10 mL/kg/min • a very high risk for post-operative complications or death

  35. Chest x-ray Low contribution in healthy subjects Pathologies that affect the operation were detected in only 1-3 % patients with routine preoperative chest X-ray The possibility of an abnormal X-ray increases with age Routine application: Known cardiopulmonary disease Risky surgery > 50 years Toraks 2012

  36. Blood gases Not necessary routinely Neither hypercapnia nor hypoksemia is an independant factor However, ACP (American College of Physicians) recommends the following cases: Coronary artery bypass Upper abdominal surgery Pulmonary resection PaO2 >60 mmHg , PaCO2 < 45 mmHg Low risk PaCO2 > 45 mmHg (aggressive preoperative evaluation)(PFT, exercise testing) Toraks 2012

  37. Non pulmonary resection POPC assessment Careful physical exam, historyAny risk factor for pulmonary Complications? NO: Low risk No need for other tests • YES: • COPD • Unexplained dyspnea or dyspnea on exertionThe story of smoking in last 8 weeks • Poor general health status> ASA2 • Pathologic examination of lung • Upper abdominal, abdominal aortic aneurysm or thoracic surgery • Operation will take longer than 3 hours • Emergency surgery Chest x-ray PFT Normal Abnormal or multiple risk factors High Risk: Re-evaluation of surgical indication Perioperative treatmentChoose a short-term procedureEpidural or spinal anesthesia Medium risk: Peroperative treatment to decrease the risk Toraks 2012

  38. Preoperative evaluation for lung resection

  39. Lung resection surgery • The initial PFT assessment should include: • FEV1 • FVC • DLCO • FEV1 > 2.0 L or > %80 pneumonectomy • DLCO >%80 pneumonectomy • FEV1 > 1.5 Lobectomy • VO2max>20/ml/kg or > 75% of predicted pneumonectomy • VO2max>15ml/kg/dak lobectomy • <10ml/kg/dak or <%40: major risk for POPC Toraks 2012

  40. Estimated FEV1 after resection For Pneumonectomy: Estimated PO FEV1 = Preoperative FEV1 X The percentage of remaining lungperfusion For Lobectomy: Estimated PO FEV1 = Preoperative FEV1 X Number of segments after resection The total number of segments in both lungs • Further investigations must be planned to measure the contribution of lung to be resected: • Anatomical calculation • Quantitative CT • Split perfusion scintigraphy Toraks 2012

  41. Interpretation of postoperative predicted (ppo) FEV1 and DLCO after resection * CPET should be done Toraks 2012

  42. FEV1 Akciğer rezeksiyonu için Preoperatif değerlendirme FEV1< 2lt veya < beklenen normalin %80’i FEV1>2lt veya > beklenen normalin %80’i PPO FEV1 Pnömonektomi yapılabilir Pnömonektomi için PPO FEV1>%40 Pnömonektomi için PPO FEV1=%30-40 Pnömonektomi için PPO FEV1<%30 Pnömonektomi yapılabilir Pnömonektomi Yüksek riskli Sınırda Pnömonektomi için PPO DLCO Lobektomi için PPO FEV ve DLCO Pnömonektomi için PPO DLCO > %40 Pnömonektomi için PPO DLCO < % 40 Beklenen post lobektomi FEV1veya DLCO < %40 Beklenen post lobektomi FEV1ve DLCO >%40 Pnömonektomi yapılabilir Pnömonektomi Yüksek riskli Toraks 2012 Lobektomi yapılabilir Lobektomi yüksek riskli

  43. Case1 A 57-year-old man is booked for right thoracotomy and lungresection. His pulmonary function tests show that his spirometryvalues are near normal, but that his TLCO is significantly reduced: The surgeon plans to perform a right upper lobectomy, but mayconsider upper and middle bi-lobectomy or pneumonectomydepending on his findings at thoracotomy Toraks 2012

  44. Which resection rate is suitable for this case ? Only right upper lobectomy Right upper + middle lobe Pneumonectomy Not suitable for operation Toraks 2012

  45. Case 1 The calculations show that his predicted postoperative DLCO after pneumonectomy mean that adequate oxygenation will not be achievable without oxygen therapy. * calculated as 16/19 x preoperative TLCO (55.5%). If his right upper lobeis accepted as non fonctional new predicted post-pneumonectomyTLCO value is 31.2%. He is athigh risk of preoperative complications, independent survival postpneumonectomyis possible. Toraks 2012

  46. Case 2 • A 65-year-old woman requires pneumonectomy for non-small cellcarcinoma of the right lung. Her preoperative pulmonary functiontests are: • Can pneumonectomy be performed? A. Yes B. No C. Ask to patient’s family Toraks 2012

  47. Case 2 • FEV1 and TLCO are borderline • However significant parts of herright lung may be non-functional. • Ventilation scan, which demonstrates that the relative contribution • On ventilation scan contribution of her right lung 36% and left lung 64% • When her FEV1 and TLCO be calculated by multiplying the preresection values by 0.64 (64%), new values are: • FEV1= 41.6% and DLCO= 45.4% Pneumonectomy can be done Toraks 2012

  48. Assessment of suitability for lung resection Post-bronchodilator FEV1 Summary of stair-climbing assessment of performance <1.5 litres for lobectomy <2 litres for pneumonectomy >1.5 litres for lobectomy >2 litres for pneumonectomy Full pulmonary function tests including DLCO with calculation of ppo values Proceed to surgery ppo FEV1 > %40 ppo DLCO > %40 ppo FEV1 < %40 ppo DLCO < %40 Interpreting the VO2 max Exercise testing VO2 max > 15ml/kg/min VO2 max < 15ml/kg/min or Shuttle walk < 250m or desaturation on >4% on stair climb Consider alternative options (palliative therapy or chemotherapy) Toraks 2012

  49. Summary: Preoperative pulmonary preparation • Respiratory function in patients with obstructive lung disease should be optimized • bronchodilators; • corticosteroids, • antibiotics, • If neded respiratory physiotherapy • Quiting smoking (ideally a minimum of 8 weeks ago) • Weight control • Patient education (deep breathing exercises, cough, and pain control, and the use of "incentive" spirometry) Preoperative pulmonary preparation reduces the complication rates 50%. Toraks 2012

  50. SUMMARY: Intraoperative risk-reducing strategies Duration of surgery < 3-4h Spinal or epidural anesthesia in high risk patients Regional anesthesia (nerve block) in high-risk patients,  Refrain from using Pancuranium Laparoscopic surgery is preferred if possible If possible less aggressive methods should be used in upper abdominal or thoracic surgery Toraks 2012

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