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Pre-operative Pulmonary Evaluation

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  • 1. Pre-operative Pulmonary Evaluation Ri 傅莉芬 /VS 郭順文
  • 2. Pulmonary Complications
    • Infection (Pneumonia or bronchitis)
    • Atelectasis
    • Respiratory failure and prolonged mechanical ventilation
    • Bronchospasm
    • Exacebation of underlying chronic lung disease
    • ->↑ hospital day, ↑ morbidity & mortality
  • 3.
    • Benefits from surgery ←-> Risk of complications
  • 4. Outline
    • Patient related risk factors
    • Procedure related risk factors
    • Preoperative risk assessment
    • Risk reduction strategies
  • 5. Patient related risk factors
    • Age
    • Obesity
    • Smoking
    • General health status
    • Chronic obstructive pulmonary disease (COPD)
    • Asthma
  • 6. Age
    • Minor risk factor
    • independent predictor (?)
    • ASA risk class 3 or 4 , and advanced age (>50yr) independent risk factors
    • Surgery should not be declined in elderly patients who are otherwise acceptable surgical candidates.
  • 7.  
  • 8. Obesity
    • Morbid obesity -> restrictive lung disease,↓ thoracic compliance, alveolar hypoventilation
    • Not consistent
      • 169 patients treated for acetabular fracture,
        • obese subjects (BMI ≥ 30) > normal weight (BMI <25)
      • 10 series of obese gastric bypass,
        • morbidly obese patients(3.9%) ≒ non-obese patients. 8
  • 9. Smoking
    • Important risk factor
    • Smoking history of 40 pack years or more ->↑ risk of pulmonary complications
    • stopped smoking < 2 months : stopped for > 2 months = 4:1 (57% : 14.5%)
    • quit smoking > 6 months : never smoked = 1:1 (11% : 11.9%)
  • 10. General health status
    • American Society of Anesthesiologists classification
    • Goldman cardiac risk index
      • include factors from history, physical examination and laboratory data
  • 11.  
  • 12. COPD
    • P’t with severe COPD
      • 6 times more likely to have major postoperative pul. Complication
    • an absolute contraindication is NOT apparent
    • A careful preoperative evaluation of patients with COPD
      • identification of high-risk patients
      • optimizing their treatment before surgery .
  • 13. Asthma
    • Inadequate control of asthma ->↑ risk of postoperative complications
    • Well controlled, peak flow measurement of >80% of predicted or personal best -> average risk
    • Asthmatic patients treated with corticosteroids before surgery have a low incidence of complications
  • 14.  
  • 15. Procedure related risk factors
    • Surgical site
    • Size of removed lung parenchyma
    • Duration and type of anesthesia
    • Type of neuromuscular blockade
  • 16. Surgical site
    • the most important predictor of pulmonary complications
    • The incidence of complications is inversely related to the distance of the surgical incision from the diaphragm
    • The complication rates for upper abdominal and thoracic surgery are the highest (range 10% to 40%)
  • 17. Surgical site (cont.)
    • Upper abdomen
      • Incisions cross the abd. muscle ,↓ diaphragmatic motility -> ↓Vital capacity
    • Lateral thoracotomy
      • Incision of the intercostal muscle , introduction of a pleural drain -> pleural effusion, post-op pain -> ↓ thoracic compliance
  • 18. Surgical site (cont.)
    • Thoractomy
      • Without pulmonary disease
        • VC ↓ to 60~70% of the pre-operative value
        • Recovering the baseline value from one to two weeks , even if the restrictive defect can last longer, if thoracic pain persists
  • 19. Surgical site (cont.)
      • With pulmonary disease
        • The effects of thoracotomy are amplified by the coexistence of a pulmonary disease
        • Thoractomy -> thoracic pain -> ↓ deep breathing , effective coughing -> at electasis, bronchial mucous retention, worsening of gas exchange
  • 20. Surgical site (cont.)
    • Video-assisted thoracoscopic surgery ( VATS)
      • reduced pain, postoperative complications, release and responses of proinflammatory cytokines, and better ventilatory function during very early postoperative period after lung resection than standard thoracotomy
      • same or better prognosis with a lesser resection by extended segmentectomy or wedge resection with VATS in patients with small lung cancer has been recently published
  • 21.
      • VATS lobectomy in NSCLC at clinical stage I could well be acceptable
        • VATS lobectomy for Stage I lung cancer, with 97.2% 8-year survival rate for Stage IA lung cancer, better than outcomes by thoracotomy
        • VATS lobectomy for lung cancer has the benefits of less pain, shorter hospital stay, less inflammatory response and better long term functional level (extremity movement)
      • It suggests that these procedures would be applied for patients with poor pulmonary reserve who have not been considered as candidates for pulmonary resection.
  • 22. Surgical site (cont.)
    • Lung biopsy through small thoracotomy
      • Minimal incision, very small resected lung parenchyma
      • Rare respiratory effects
      • Few contraindications (eg. Hemodynamic instability, serious haemocoagulative alterations)
  • 23. Surgical site (cont.)
    • Heart-surgery
      • usually require median sternotomy
      • functionally better tolerated than lateral thoracotomy (due to preserves the pleural space)
      • respiratory function is generally well preserved, except for a transitory reduction in pulmonary volumes.
  • 24. Size of removed lung parenchyma
    • Removal of non-functional lung
      • Bulla
        • may cause an improvement or at least no deterioration in lung function
      • Bronchiectasis
        • ↓ secretions and purulent exudates
      • Benign tumor (ex. thickened pleura decortication)
        • may allow the remaining lung to re-expand
  • 25. Size of removed lung parenchyma (cont.)
    • However, in most patients, thoracic surgery results in some function impairment
    • Lobectomy shows less functional consequences than pneumonectomy
  • 26. Size of removed lung parenchyma (cont.)
    • Lobectomy
      • the remaining lobes on that side rapidly expand to fill the vacant space
      • only a modest reduction in VC, in Maximal Voluntary Ventilation (MVV) and in the DLCO occur
      • After surgery, the adaptation of the remaining lobe may take up to three months
  • 27. Size of removed lung parenchyma (cont.)
      • The entity of the functional reduction depends on the removed lobe
        • lobectomy of the right middle lobe (2 segments) has a smaller functional impact than the lobectomy of the right inferior lobe (5 segments)
  • 28. Size of removal of removed lung parenchyma (cont.)
    • Pneumonectomy
      • Space remains is partly filled by mediastinal displacement and ascent of the diaphragm
      • Pleural fluid usually collects and replaces the pneumothorax
  • 29. Size of removed lung parenchyma (cont.)
      • Inspite of this, ventilatory capacity after pneumonectomy may be surprisingly good
      • If the parenchyma of the remaining lung is normal, blood gases remain in the normal range both at rest and during exertion
      • Only pulmonary arterial pressure , which is normal at rest, may increase during exertion
  • 30. Duration and type of anaesthesia
    • Anesthesia time of > 3.5 hours ->↑ incidence of pulmonary complications
    • in a very high risk patient -> a less ambitious, briefer procedure
  • 31. Duration and type of anaesthesia (cont.)
    • a review of high risk p’t
      • rate of respiratory failure
        • general anesthesia > epidural analgesia and light anesthesia
  • 32. Duration and type of anaesthesia (cont.)
    • The review evaluated the results of 141 trials that included 9559 p’t
      • a reduction in risk of pulmonary complications among patients receiving neuraxial blockade (either epidural or spinal anesthesia) with or without general anesthesia , when compared to those receiving general anesthesia alone
      • neuraxial blockade
        • ↓ 39 % risk of pneumonia, ↓ 59 % risk of respiratory depression
  • 33. Duration and type of anaesthesia (cont.)
    • it appears likely that general anesthesia leads to a higher risk of clinically important pulmonary complications than do epidural or spinal anesthesia, although further studies are required to confirm this
  • 34. Type of neuromuscular blockade
    • Pancuronium , a long-acting neuromuscular blocker
      • a higher incidence of postoperative residual neuromuscular blockade
      • a higher incidence of postoperative pulmonary complications in those patients with residual neuromuscular blockade
  • 35. Preoperative risk assessment
    • Resective thoracic surgery
    • Extra-thoracic and thoracic surgery without lung resection
  • 36. Resective thoracic surgery
    • Clinical evaluation
      • History & PE
    • Pulmonary function test
      • Spirometry & Blood gas analysis
    • Split lung function studies
    • Cardopulmonary exercise test
  • 37. Clinical evaluation
    • Complete history
      • Smoking, poor exercise tolerance, unexplained dyspnea or cough
      • unrecognized chronic lung disease should be determined
    • Good physical examination
      • directed toward evidence for obstructive lung disease
      • decreased breath sounds, wheezes, rhonchi, or prolonged expiratory phase
  • 38. Pulmonary function testing
    • all candidates for lung resection should have preoperative PFT
    • PFTs should not be ordered routinely prior to abdominal surgery or other high risk surgeries
      • 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
  • 39. Pulmonary function testing(cont.)
    • These tests simply confirm the clinical impression of disease severity in most cases, adding little to the clinical estimation of risk
    • There has also been concern that preoperative PFTs are overused and a source of wasted health care dollars
  • 40. Pulmonary function testing(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
    • Most patients with abnormal spirometry would be apparent based on history and physical examination
  • 41. Pulmonary function testing(cont.)
    • 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
  • 42. Pulmonary function testing(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>1.5 litres or > 60% of the predicted value
  • 43. Pulmonary function testing(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
  • 44. Pulmonary function testing(cont.) At-risk p’t require a closer diagnostic examination to estimate the likely post-resection pulmonary reserve
  • 45. Split lung function studies
    • 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)
  • 46. Split lung function studies(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
        • Correlations between the predicted and observed post-resection FEV1 values have proved to be good , although errors tend to underestimate postoperative function
      • Quantitatve CT
  • 47. Split lung function studies(cont.)
    • FEV1ppo > 40%, DLco ppo > 40%
      • Widely accepted as a predictor of average risk for complications
    • FEV1ppo < 40%, DLco ppo < 40%
      • High risk of perioperative complications including death
      • FEV1ppo <1L -> sputum retention
      • FEV1ppo <0.8L -> preclude resection , dependent on a ventilator
    • Post-operative lung function shows borderline values -> Cardiopulmonary exercise test
  • 48. Cardiopulmonary exercise test
    • stress the entire cardiopulmonary and oxygen delivery system -> expect the functional reserve after pulmonary resection
    • Maximal oxygen uptake (VO2max)
      • V O 2max > 20mL/kg/min
        • are not at increased risk for complications or death
      • V O 2max < 15 mL/kg/min
        • an increased risk of peri-operative complications
      • V O 2max < 10 mL/kg/min
        • a very high risk for post-operative complications or death
  • 49. Assessment of p’t candidate for lung resection
  • 50. A Case of lung resection
  • 51. Admission
    • Chief Complaint
      • One mass over right paratracheal area was accidentally found by Chest X-ray
    • Diagnosis
      • Lung cancer
    • VATS lobectomy, RUL and LN dissection
  • 52.
    • Present Illness
      • 林 X 雲 , 63-year-old woman
      • Histories of COPD , angina, peptic ulcer and renal stone
      • Cigarette smoking for more than 40 yrs and got COPD since youth
      • Since 4 years ago
        • Cough with whitish sputum and dyspnea with dizziness while suddenly standing and exercise
  • 53.
      • Regular follow-up and took medicine for COPD and angina every month at 苗栗弘大 hospital
      • Follow up chest X ray in 96/08
        • Right paratracheal lesion
        • CEA: 7.5
      • Body weight loss from 38 kg to 34 kg in 2 months
      • She was admitted for further survey and managements
  • 54.
    • Past History
      • Major systemic disease
        • COPD , angina, peptic ulcer, renal stone, DM(-), HTN(-)
      • Operation
        • Appendectomy, C/S, hysterectomy for myoma, cataract
      • Drug allergy: pyrine
      • Drinking(-); Smoking(+): <1PPD for 40 yrs
  • 55.
    • 96/11/13
      • PFT
        • FVC: 1.92L; % of predict: 93.1%
        • FEV1: 0.78L; % of predict: 47.7%
        • FEV1/FVC: 40.6%<60%->airflow obstruction
    • 96/11/16
      • CT-guided biopsy
        • Lung cancer, Squamous cell carcinoma
    • 96/11/19
      • Bone scan: negative
  • 56.
    • 96/11/22
      • Exercise PFT
        • VO2(ml/min/Kg):61.89%
        • Discontinued due to weakness and dyspnea
      • Whole body PET
        • Solitary FDG hypermetabolic lesion at RUL
    • 96/11/26
      • VATS lobectomy,RUL and LN dissection
      • Hemodynamic calculation
        • PVR: 749 DS/cm5
  • 57. ICU Treatment Course
    • 96/11/27
      • Cardiac echo
        • Good LV contractility, LVEF: 84.6%
        • TR(+): moderate with PG 25 mmHg
        • CVP: 11~12
        • PAP:47/22(32)------ Pulmonary Hypertension!
        • ABP:87/52(66)
      • After PGE1 use
        • PVR: 491 DS/cm5
      • Try weaning gradually
      • Chest tube: -10cm H2O low pressure
  • 58.
    • 96/11/30
      • Right lung pneumonia
      • Change Cefametazon to Tazocin for pulmonary infiltration increase
      • CRP: 8.15
      • Off PGE1
      • Remove S-G( 留 sheeth)
  • 59. Risk reduction strategies
    • Pre-operative strategies
    • Intra-operative strategies
    • Post-operative strategies
  • 60. Pre-operative strategies
    • goals of preoperation pulmonary evaluation
      • identify high-risk patients in whom prophylactic measures may reduce the risk of postoperative complications
  • 61. Pre-operative strategies(cont.)
    • Smoking cessation
      • As least 8 weeks before surgery
      • Counseling accompanied with nicotine replacement or bupropion therapy improves the success rate
  • 62.
    • COPD
      • be treated aggressively to achieve their best possible baseline function
      • Bronchodilators, smoking cessation, antibiotics, and chest physical therapy
      • give preoperative course of systemic steroids to patients who continue to have symptoms despite bronchodilator therapy.
  • 63.
    • Asthma
      • an evaluation before surgery
        • a review of symptoms, medication use (particularly the use of systemic corticosteroids for longer than 2 weeks in the past 6 months ), and measurement of pulmonary function.
      • A short course of systemic corticosteroids may be necessary to optimize pulmonary function.
      • For patients who have received systemic corticosteroids during the past 6 months
        • give 100 mg hydrocortisone every 8 hours intravenously during the surgical period and reduce dose rapidly within 24 hours following surgery
  • 64.
    • Pre-operative antibiotics
      • Treat respiratory infection if present
      • Indiscriminate use of prophylactic antibiotics does not lead to a reduction in pulmonary complications and should be avoided
    • Patient education
      • Lung expansion, deep breathing and coughing
  • 65. Intra-operative strategies
    • Type of anesthesia
      • Intermediate and shorter acting agents are preferred
      • Spinal anesthesia is safer than general anesthesia for high-risk patients
  • 66.
    • Duration and type of surgery
      • a less ambitious, shorter procedure should be considered in high-risk patients.
      • Because upper abdominal and thoracic operations carry the greatest risk, a laparoscopic procedure should be preferred over an open procedure if possible.
  • 67. Post-operative strategies
    • Lung expansion maneuvers
      • Deep breathing exercises, incentive spirometry
        • ↓ postoperative pulmonary complications in high-risk patients
      • Postoperative continuous positive airway pressure (CPAP)
        • ↓ the incidence of pulmonary complications after major abdominal surgery
  • 68.
    • Pain control
      • helps minimize pulmonary complications
        • encouraging early ambulation, performance of lung expansion maneuvers.
      • opioid narcotics and related medications
        • Intrathecal: longer duration of analgesia (15-22 h) but may be associated with respiratory depression and headaches
        • Epidural: an alternative to systemic analgesia
  • 69.  
  • 70. Thanks for your listening!