Critical care in post op Respi Patients.pptx

Critical Care in Post Operative
Patient in respiratory medicine

Care of Critically ill patients:
• Critical care is the process of looking after patients who either suffer from life-threatening conditions
or are at risk of developing them.
• The intensive care unit (ICU) is a distinct geographical entity in which high staffing ratios, advanced
monitoring and organ support can be offered to improve patient morbidity and mortality.
• Effective intensive care demands an integrated approach that stretches beyond the boundaries of
the ICU.
• It requires prevention, early warning and response systems, a multidisciplinary approach before and
during an ICU stay, as well as comprehensive follow-up or good quality palliative care.
• Cornerstones of intensive care management: Optimization of a patient’s physiology, the provision of
advanced organ support, and the identification and treatment of underlying pathological processes.
• This is best achieved through a multidisciplinary team approach, with shared responsibility between
the admitting ‘parent’ team and a specialized critical care team coordinated by a critical care
physician
Jackson M, Cairns T. Care of the critically ill patient. Surg Oxf. 2021;39(1):29–36.

Perioperative factors associated with
postoperative respiratory complications (PRCs).
Eikermann M, Santer P, Ramachandran SK, Pandit J. Recent advances in understanding and managing postoperative respiratory problems. F1000Research. 2019;8.

Perioperative factors associated with postoperative
respiratory complications (PRCs).

Critical organ support and monitoring support.
RESPIRATORY:

Cardiovascular

RENAL & CNS

GI and Other

Effects of respiratory drive on perioperative
respiratory complication risk

Overview of the management of
post-operative pulmonary complications

Post operative Pulmonary Complications
• Pulmonary complications are a major cause of morbidity and mortality during the postoperative
period
• The reported incidence of postoperative pulmonary complications ranges from 5 - 80 %,
depending upon the patient population and the criteria used to define a complication
• Incidence also varies across hospitals, with one study reporting lower rates of complications in
hospitals with a high volume of patients than in hospitals with a lower volume following
esophagectomy, pancreatectomy, and intact abdominal aortic aneurysm repair.
• Traditional definitions of postoperative pulmonary complications include atelectasis,
bronchospasm, pneumonia, and exacerbation of chronic lung disease. However, the list can be
expanded to include acute upper airway obstruction, complications from obstructive sleep apnea,
pleural effusions, chemical pneumonitis, pulmonary edema, hypoxemia due to abdominal
compartment syndrome, and tracheal laceration or rupture
Michelle V Conde, Sandra G Adams. Overview of the management of postoperative pulmonary complications. Uptodate. Last Updated: Nov 08, 2021. Last Reviewed: Feb 2023

ATELECTASIS
• One of the most common postoperative pulmonary complications, particularly following
abdominal and thoracoabdominal procedures
• Postoperative atelectasis can be asymptomatic or it may manifest asincreased work of
breathing and hypoxemia.
Clinical Presentation :
• The onset of hypoxemia due to postoperative atelectasis tends to occur after the patient
has left the post-anesthesia care unit.
• It typically becomes most severe during the second postoperative night and continues
through the fourth or fifth postoperative night.
• Hypoxemia that develops earlier (ie, in the post-anesthesia care unit) should prompt the
consideration of postoperative complications other than atelectasis, such as
hypoventilation due to residual anesthetic effects and upper airway obstruction due to
airway tissue edema.

ATELECTASIS
• Pathogenesis: Postoperative atelectasis is usually caused by decreased compliance
of lung tissue, impaired regional ventilation, retained airway secretions, and/or
postoperative pain that interferes with spontaneous deep breathing and coughing.
Management
• For patients without abundant secretions, continuous positive airway pressure
may be beneficial.
• For patients with abundant secretions, chest physiotherapy and suctioning are
appropriate.
• Some patients with abundant secretions may also benefit from bronchoscopy; the
absence of air bronchograms may help identify patients who are more likely to
benefit from bronchoscopy

BRONCHOSPASM
• Bronchospasm: Common during the postoperative period.
• Clinical manifestations : dyspnea, wheezing, chest tightness, tachypnea, small tidal
volumes, a prolonged expiratory time, and hypercapnia.
• Postoperative bronchospasm can be caused by aspiration, histamine release
incited by medications (eg, opiates, tubocurarine, or atracurium), an allergic
response to medications, or an exacerbation of a chronic pulmonary condition,
such as asthma or COPD
• Can also be caused by reflex constriction of bronchial smooth muscles due to
tracheal stimulation by secretions, suctioning, endotracheal intubation, or other
surgical stimulation. Reflex bronchoconstriction is particularly common when the
bronchodilatory effects of inhalational anesthetics wane

Treatment of Post Op Bronchospasm:
• Treatment consists of treating the underlying cause, removing potential
contributors (eg, medications), and pharmacotherapy.
• SABA(e.g.albuterol) are bronchodilators that are considered first-line
pharmacotherapy.
• Short-acting inhaled anticholinergic agent, ipratropium bromide, is also a
bronchodilator that may have an additive effect.
• Patients who do not improve after one or two doses of the inhaled
bronchodilators may benefit from the addition of systemic glucocorticoids.

PNEUMONIA
• Postoperative pneumonia has clinical manifestations and a diagnostic approach
that is nearly identical to other types of hospital-acquired pneumonia (HAP) and
ventilator-associated pneumonia (VAP).
• Postoperative pneumonia tends to occur within five postoperative days
• May present with fever, leukocytosis, increased secretions, and pulmonary
infiltrates on chest radiographs.
• Hypoxemia may develop, or the patient may require more supplemental oxygen to
maintain the same oxyhemoglobin saturation.
• Respiratory distress, dyspnea, tachypnea, small tidal volumes, and hypercapnia
may also occur.
• The minute ventilation often increases prior to the development of any blood gas
abnormalities, a consequence of the patient becoming more catabolic due to the
developing infection

PNEUMONIA-Diagnosis
• Postoperative pneumonia should be suspected in any patient who has clinical signs
of infection (eg, fever, purulent sputum, leukocytosis or leukopenia, and worsening
oxygenation) and a new radiographic infiltrate
• Diagnosis can be difficult because there are many other postoperative causes of
fever and/or pulmonary infiltrates, such as atelectasis, pulmonary edema,
pulmonary embolism, and acute lung injury.
• Persistent PCT elevation on postoperative day 2 and beyond following abdominal
surgery is more common in individuals developing hospital-acquired pneumonia
versus those who do not develop hospital-acquired pneumonia (however more
data needed)

Pneumonia- Pathogens
Postoperative pneumonia is frequently caused by resistant organisms. This was
demonstrated by a series of 837 patients with suspected postoperative pneumonia,
occurring within the first 14 days following surgery.
Microbiologic sampling was performed in 718 of the patients (86 %), including bronchoscopic
sampling in 367 of the patients (44 %)
• Most cases of pneumonia occur within five postoperative days (61 %).
• Organisms were cultured from the respiratory samples of almost half of the patients (46
%).
• More than one organism was cultured from some patients (29 %).
• Most of the positive cultures were obtained from patients in whom pneumonia was
diagnosed before the fifth postoperative day.
• Gram-negative bacteria and Staphylococcus aureus: Most commonly cultured
microorganisms.
• Most frequent bacterial combinations: Enterobacteriaceae plus either Staphylococcus
aureus or streptococci.
• Haemophilus influenzae and Streptococcus pneumoniae accounted for 19 percent and 10
percent, respectively, of the microorganisms isolated from respiratory and blood cultures.

Rrisk factors for postoperative pneumonia caused by particular
microorganisms
 Haemophilus influenzae or Streptococcus pneumoniae – Traumatically injured patients appear to be
at increased risk.
 Staphylococcus aureus – Neurosurgical patients (particularly those who are mechanically
ventilated), victims of blunt trauma and coma, and patients who have sustained closed head injuries
seem to be at increased risk.
 Additional risk factors for Staphylococcus pneumonia : chronic kidney disease, diabetes
mellitus, a history of injection drug use, and recent influenza
 Risk Factors for MRSA: Previous antibiotic use, a positive nasal screen for (MRSA), long
operations (>300 minutes), and emergency surgery
 Pseudomonas aeruginosa – No particular type of surgery has convincingly shown to increase
likelihood of postoperative Pseudomonas pneumonia. However, risk factors include: intubation >8
days, structural lung disease ,corticosteroid therapy, malnutrition, prolonged exposure to antibiotics
 Acinetobacter species : Well-recognized cause of postoperative pneumonia, although no particular
type of surgery has shown to predispose patients to postoperative Acinetobacter pneumonia. Most
important risk factor: mechanical ventilation
 Anaerobic species – Uncertain role. Abdominal surgery is generally considered a risk factor

Others:
• ACUTE UPPER AIRWAY OBSTRUCTION
• EXACERBATION OF OBSTRUCTIVE SLEEP APNEA
• PLEURAL EFFUSION
• CHEMICAL PNEUMONITIS
• PULMONARY EDEMA
• PULMONARY EMBOLISM
• ABDOMINAL COMPARTMENT SYNDROME
• TRACHEAL LACERATION OR RUPTURE

POST-OPERATIVE RESPIRATORY FAILURE
• Accounts for > 20 % of all patients receiving ventilatory support
• Respiratory failure requiring unplanned reintubation in the postoperative
period is associated with high morbidity, leading to a longer hospital stay,
and increase in 30-day mortality
• Incidence of unanticipated reintubation in the first 72 hours is, in general,
low (<1 %) but higher in older patients (up to 3 %)
• Other than low-flow oxygen, there is no single intervention in this
population that is routinely used to prevent or treat postoperative acute
respiratory failure.
• Other options: noninvasive ventilation (NIV) and oxygen delivered high
flow nasal cannula (HFNC)

NIV
• NIV has been studied in the postoperative population.
• Not routinely applied as a primary prevention strategy
• Typically used as a secondary intervention for the treatment of hypoxemic respiratory failure that is
refractory to or not suitable for low-flow or high-flow oxygen

HFNC
• High-flow nasal oxygen, which can oxygenate patients as well as provide a small amount of positive
airway pressure and reduce dead space.
• Randomized trials evaluating the efficacy of HFNC are lacking such that HFNC is not routinely used as
first line therapy for the treatment or prevention of postoperative respiratory failure.
• However, it may be an alternative to NIV, particularly in those in whom NIV is not tolerated.
• HFNC has been studied in the treatment and prevention of respiratory failure in the postoperative
setting.
• Most of these trials compared HFNC with conventional low-flow oxygenation strategies and were
performed in patients following thoracic surgery. Studies were flawed by low event rates,
heterogeneity, imprecision, and indirectness.
• A meta-analysis of seven randomized trials involving 2781 patients: HFNC had a similar reintubation rate
compared with either conventional oxygen therapy or NIV. However, in a subgroup analysis, critically-ill patients
treated with HFNC had a lower reintubation rate compared with the COT group.
• In another meta-analysis of 14 studies, HFNC resulted in a reduction in intubation rate that was not significant
and a reduction in the hospital length of stay.
• A subsequent meta-analysis of nine trials, compared with COT, use of HFNC post-operatively lowered
reintubation rates and decreased the need to escalate respiratory support. HFNC had no effect on mortality, ICU
and hospital length of stay, or rate of postoperative hypoxia

Critical Care Management
Following Lung Transplantation

Need of Multidisciplinary team
• After successful transplant surgery  Patients routinely transferred to ICU immediately
• Recipients are still intubated and some might require postop ECMO support.
• Regular ICU rounds by the transplant team are very important (over and above intensivist care) in
order to monitor the patient’s clinical status and obtain a comprehensive update on the patient’s
progress, including graft and other organ function, early immunosuppressive therapy, wound and
drain monitoring, nursing information, and physical therapy
• Ideally, at least 1 daily round by a thoracic surgeon, a transplant physician, and the intensivist as a
team is suggested.
• An infectious disease specialist should be part of daily transplant team rounds, since infections are
the most frequent complications in the early postoperative period.
• A clinical pharmacist should also be involved in the multidisciplinary team due to the complexity of
immunosuppressive therapy, which has a narrow therapeutic index, leading to potential severe
adverse drug events and drug–drug interactions in critically ill patients.
Jeon K. Critical Care Management Following Lung Transplantation. Journal of Chest Surgery. 2022 Aug 8;55(4):325.

Postoperative monitoring in the intensive care unit
• Patients typically arrive in the ICU with a pulmonary artery catheter (PAC) in addition to venous and
arterial lines in place, chest tubes to drain pleural spaces, and an indwelling bladder catheter
• Patients should undergo a full physical examination, evaluation of hemodynamic parameters, and
assessment of peripheral circulation and perfusion upon arrival in the ICU.
• Post Op patients are generally hypothermic  Increased pulmonary vascular resistance and the
likelihood of bleeding and infection . Hence patients should be warmed using a forced air warming
device.
• ICU monitoring is similar to intraoperative monitoring.
• Monitoring is essential because it provides information on the patient’s clinical status, diagnostic
assessment of complications, and future management plans, while monitoring in the operating room
is designed to assess acute changes in vital functions resulting from the patient’s response to
medication and surgical manipulation.

• ABGs should be performed regularly.
• Venous blood samples to monitor CBC, coagulation- renal- hepatic profile, and
lactate levels.
• Bedside ECG and portable chest radiography should be routinely performed.
• A PAC is routinely used starting in the operating room even though there is a paucity
of data on its use in the Post Op lung transplantation period.
• Most common indications for PAC use: severe pulmonary hypertension
• The PAC can also be used to evaluate right ventricular (RV) function, which
might be associated with the prognosis of lung transplantation

• However, several studies have suggested that RV function normalizes in adult
patients after lung transplantation, even in patients with severe preoperative RV
dysfunction.
• Therefore, there is no need to monitor pulmonary hypertension or RV function
postoperatively unless there are other problems that affect the pulmonary artery
pressure.
• Cardiac function could be evaluated with bedside echocardiography, including RV
function.
• Therefore, the PAC itself can only be beneficial after lung transplantation if its use
guides therapies that improve patient outcomes

Management of mechanical ventilation
• Goals of MV following lung transplantation:
• promote graft function,
• maintain adequate gas exchange,
• prevent ventilator-induced lung injury
• No large, multicenter trials are done to guide MV management after lung transplantation
despite the critical role of MV in lung transplantation
• Currently applied lung protective MV strategies in lung transplantation have been extrapolated
from the practice guideline for MV patients with ARDS, since experimental data suggest that all
lung transplantation recipients are at risk of ventilator-induced lung injury
• The benefits of lung-protective ventilation also extend to surgical patients at risk for ARDS.
• However, a recent survey addressing MV practices after lung transplantation showed that
many of the reported practices did not conform to the consensus guidelines on ARDS
management.

• Low tidal ventilation (usually 6 mL/kg of predicted body weight) has been the preferred
strategy even in lung transplantation
• However, a survey on MV following lung transplantation indicated that recipient
characteristics most commonly determine tidal volume.
• Titrating the tidal volume to the donor-predicted body weight rather than the recipient-
predicted body weight reduces the risk of delivering insufficient or excessive tidal volume
in size-mismatched allografts.
• However, undersized allografts might receive higher tidal volumes than oversized
allografts based on the donor-predicted body weight.
• Therefore, adjustments of the adequate tidal volume should be made based on gas
exchange over the next several hours following initial low-tidal volume ventilation.

• A driving pressure higher than 15 cmH2O has recently been shown to be strongly
associated with mortality in patients with ARDS; this corresponds to the pressure
required for alveolar opening (tidal volume/respiratory system compliance) and is
calculated as the plateau pressure minus positive end-expiratory pressure (PEEP).
• This pressure can be used as an indicator of ventilator-induced lung injury risk.
Therefore, driving pressure-guided ventilation has been proposed as another
technique to reduce postoperative pulmonary complications and improve
recovery in thoracic surgery patients.
• However, use of a high PEEP to reduce driving pressure is generally avoided due
to its potential negative effects on the healing of bronchial anastomosis and
alveolar overdistension in grafts.

• Weaning from MV is usually completed within 72 hours, and extubation is
performed in the ICU in non-complicated patients after lung transplantation.
• Median MV duration after lung transplantation: 2 to 3 days.
• MV weaning is usually intentionally performed slowly in patients with a high risk
of severe graft dysfunction or inadequate gas exchange.
• Lung allografts involve a disruption of the nerve supply as a consequence of
harvesting from the donor.
• A weak cough, poor respiratory mechanics caused by deconditioning, and
inadequate pain control lead to an inability to clear airway secretions.
• Early tracheostomy should be considered when more than 1 week elapses before
weaning from MV

• Routine use of inhaled Nitric Oxide (NO) in lung transplantation is not
recommended, but its selective use is recommended for patients with severe graft
dysfunction showing severe hypoxemia and elevated pulmonary artery pressure.
• Inhaled epoprostenol was recently reported to be equivalent to inhaled NO for
preventing severe graft dysfunction.
• However, it remains unclear whether either inhaled NO or epoprostenol conferred
any benefit and whether their routine use to prevent graft dysfunction should be
supported

• In patients with severe graft dysfunction, MV may be insufficient to provide
adequate gas exchange, and high ventilator settings may be harmful to the
allograft. ECMO support is rescue therapy for this critical presentation.
• Data supports the use of ECMO to manage severe graft dysfunction, particularly
to correct refractory hypoxemia and to reduce additional damage from MV to the
already injured graft. The high incidence of complications, such as bleeding,
vascular injury, and neurologic deficits, has been a major concern when using
ECMO in the postoperative period after lung transplantation, although the
incidence of such complications has dramatically decreased in recent years.
• Veno-venous ECMO is recommended to support most patients with severe graft
dysfunction, even in the setting of hemodynamic compromise

Management of hemodynamics
• The initial hemodynamic management goal following lung transplantation: To maintain
adequate organ perfusion, which is monitored by measuring lactate, urine output, and
mixed venous oxygen saturation, if available
• However, transplanted lungs have varying degrees of pulmonary edema.
• In addition, increasing cardiac output with inotropes, with or without vasopressors, may
also contribute to pulmonary edema by increasing the amount of flow through the lung
allograft.
• Individualized management is required to maintain adequate perfusion pressure balance
with the lowest possible cardiac output to reduce the exacerbation of pulmonary edema
risk
• The implementation of a dedicated protocol that maintains specific hemodynamic
targets has been shown to be associated with reduced graft dysfunction severity
• More aggressive diuresis and fluid restrictions in the early postoperative period after
lung transplantation have potential benefits.

• Hypotension is common in the immediate postoperative setting
• Patients with low systemic vascular resistance may need additional vasopressor
treatment, with norepinephrine and vasopressin being the preferred agents
• Vasopressin does not increase pulmonary vascular resistance since V1 receptors
are not present in the pulmonary arteries.
• Choice of inotropes and vasopressors in postoperative lung transplantation care
should be made with consideration of their effects on systemic and pulmonary
vascular resistance and should be individualized based on patient response.

• Risk of pulmonary edema is higher with transient diastolic dysfunction of the left ventricle (LV),
which becomes incapable of handling a normal preload in the early postoperative period in
patients with significant pulmonary hypertension before lung transplantation.
• The small and “deconditioned” LV of patients with severe pulmonary hypertension is prone to
developing diastolic dysfunction when exposed to a normal or high preload after transplantation,
resulting in elevated left-sided filling pressures and pulmonary edema.
• Bridging this period with veno-arterial ECMO has been described for the postoperative
management of recipients with severe pulmonary hypertension as a way to specifically address
these issues and allow time for recovery of the “deconditioned” LV, which can take several days

Physiological effects of inotropes and vasopressors for critical care
management in lung transplantation recipients
CO, cardiac output; SVR, systemic vascular resistance; PVR, pulmonary vascular resistance.
a)Based on a recent systematic review and meta-analysis of 23 trials that included 3,088 patients with distributive shock, the addition of vasopressin
to catecholamine vasopressors compared with catecholamine vasopressors alone was significantly associated with a lower atrial fibrillation risk

Critical Care of Patients After Pulmonary
Thromboendarterectomy
Kratzert WB, Boyd EK, Saggar R, Channick R. Critical care of patients after pulmonary thromboendarterectomy. Journal of Cardiothoracic and Vascular Anesthesia. 2019 Nov 1;33(11):3110-26.

• CHRONIC THROMBOEMBOLIC PULMONARY HYPERTENSION (CTEPH) is a pulmonary vascular disease
caused by chronic obstruction of pulmonary arteries and represents group 4 of the World Health
Organization classification of pulmonary hypertension.
• Defined as precapillary pulmonary hypertension with mean pulmonary artery pressure (PAPm) ≥ 25
mmHg and pulmonary arterial occlusion pressure ≤15 mmHg by right heart catheterization in the
presence of organized flow-limiting thrombi or emboli in the pulmonary arteries after at least 3
months of therapeutic anticoagulation.
• The prevalence of CTEPH is estimated at 3 to 30 individuals per million per year, with an incidence
after pulmonary embolus of up to 3%.
• When untreated, mortality is high with only 30% - 80% of patients surviving 3 years.
• Medical therapy remains unsatisfactory, and surgical pulmonary thromboendarterectomy (PTE) offers
the only curative intervention.
• With evolving expertise, mortality rates are now less than 5% in highly specialized centers
• The immediate postoperative course after PTE presents with several unique considerations for the
intensivist. Preexisting pathophysiology and its sequelae, as well as intraoperative techniques,
predispose these patients to specific postoperative complications and require expertise in their
management.

Postoperative Complications After
PEA - Neurological

PEA - Pulmonary

PEA -Haemodynamic

PEA -
Hematologic

Conclusion
• Postoperative management of patients after PTE confronts intensivists with
significant challenges specific to CTEPH disease and PTE surgery.
• Knowledge of underlying physiology, intraoperative management, and
postoperative complications is imperative to optimize outcomes.
• Intensive care unit management by a multidisciplinary team can provide
contemporary care in an evolving field of highly specialized patients.
• Key attention is paid to avoidance and management of neurologic insults,
residual pulmonary hypertension, RLI, RV failure, and postoperative recurrent
thromboembolic events.
• Advancement of expert centers and collaboration among them may offer more
evidence-based research in the future and is warranted to optimize
postoperative ICU care for this population

The Society for Translational Medicine:
Clinical practice guidelines for mechanical ventilation
management for patients undergoing lobectomy
Gao S, Zhang Z, Brunelli A, Chen C, Chen C, Chen G, Chen H, Chen JS, Cassivi S, Chai Y, Downs JB. The Society for Translational Medicine: clinical practice guidelines for mechanical ventilation management for patients undergoing lobectomy.
Journal of Thoracic Disease. 2017 Sep;9(9):3246.

Background
• Anesthesia for lobectomy in thoracic surgery is a great challenge as it requires single
contralateral lung ventilation with collapse of the ipsilateral lung.
• Collapse of the operated lung and ventilation of the other lung may induce an inflammatory
response.
• The ventilated lung is hyperperfused, receiving most of the cardiac output and may be damaged
by mechanical ventilation.
• The collapsed lung is exposed to ischemia, reperfusion injury and shear stress on re-expansion
and postresection ventilation.
• Consequently, patients who undergo lobectomy postoperatively may develop compromised
lung function.
• Acute lung injury, reduced lung compliance and hypoxemia and an increase in pro-
inflammatory cytokines, all are reported.
• Aim of mechanical ventilation during one-lung ventilation:
(I) To facilitate carbon dioxide elimination;
(II) To maintain oxygenation
(III) To minimize postoperative lung dysfunction
• Systematic literature search was performed to determine appropriate methods for mechanical
ventilation
Gao S, Zhang Z, Brunelli A, Chen C, Chen C, Chen G, Chen H, Chen JS, Cassivi S, Chai Y, Downs JB. The Society for Translational Medicine: clinical practice guidelines for mechanical ventilation management for patients
undergoing lobectomy. Journal of Thoracic Disease. 2017 Sep;9(9):3246.

Therapeutic hypercapnia
• Hypercapnia, secondary to reduced alveolar ventilation has been noted as a
component of protective lung ventilation in clinical practice
• In patients undergoing lobectomy with one-lung ventilation, hypercapnia
facilitates inhibition of local and systemic inflammatory responses.
• Postoperative respiratory function, assessed by peak plateau pressure and
dynamic compliance, was improved by hypercapnia induced by inhaled CO2
• Hypercapnia reduces systemic vascular resistance, increases cardiac index and
pulmonary vascular resistance, as per evidence from small, pilot RCTs.
• hypercarbia is not harmful, except in the face of pulmonary hypertension,
possibly cardiac arrhythmia and high intracranial pressure.

Recommendation for hypercapnia
Permissive/therapeutic hypercapnia,
to maintain a partial pressure of carbon dioxide of 50-70
mmHg potentially may be beneficial in patients
undergoing single lung ventilation during pulmonary
lobectomy operations
(class IIa, level B).

Protective mechanical ventilation
• Although low mechanical ventilation rate, higher levels of PEEP and low inspired
oxygen levels are considered to be “protective”, the primary components of
protective ventilation (PV) include low tidal volume (LTV, tidal volume 6–8 mL/kg)
and limited peak airway pressure, with or without PEEP.
• Landmark study by Amato and coworkers: Low tidal volume ventilation can
effectively reduce mortality in patients with acute respiratory distress syndrome
(ARDS)
• During operative lobectomy with one-lung ventilation, results of PV in improving
patients’ outcomes are confusing

Studies investigating protective ventilation

Recommendation for Protective Ventilation
PV with tidal volume of 6–8 mL/kg and a PEEP of 5
cmH2O is reasonable based on current evidence

Recommendation for Alveolar recruitment
Alveolar recruitment (open lung ventilation) may be
potentially beneficial in patients undergoing lobectomy
with one-lung ventilation
(class IIb, level C).
Low FIO2 may
prevent absorption atelectasis

Recommendation for mode of mechanical ventilation
PC or PCV-PG is recommended over VCV
and can be used in patients undergoing lung
resection with single-lung ventilation
(class IIa, level B)

Recommendation for
Pre-and post-operative noninvasive ventilation
CPAP can be used in patients undergoing lobectomy and one lung
ventilation, and is beneficial in improving short term oxygenation
(class IIa, level A).

Recommendation for Non-intubated thoracoscopic lobectomy
Thoracoscopic lobectomy without tracheal intubation may be an
alternative to conventional one-lung ventilation, in selected patients
(class II, level C).

Recommendation for Inspiratory to expiratory ratio (I:E)
Controlled mechanical ventilation with I:E ratio of
1:1, or greater, is reasonable in patients undergoing
one-lung ventilation

Recommendation for Low inspired oxygen concentration
Application of the lowest FIO2 necessary to
maintain satisfactory arterial oxygen saturation is
reasonable

Recommendation for Adjuvant drug use
Adjuvant drugs such as nebulized budesonide,
intravenous sivelestat and ulinastatin may have
beneficial effect in attenuating inflammatory
response following one-lung ventilation

Post-Operative Care for Lung Decortication

Background:
• Lung decortication is a simple yet formidable procedure.
• It involves the excision of the thick fibrinous peel from the pleural surface, thereby
permitting the expansion of the underlying lung parenchyma.
• Patients with long-standing empyema, pleural thickening, hemothorax, and pleural
tumors are candidates for decortication.
• Postoperative Care
• Includes adequate analgesia, antibiotic therapy, hydration, and nutritional support.
• Sick patients often require mechanical ventilation. Therefore, intensive monitoring must be ensured
during the initial postoperative period in these patients.
• Adequate care of the chest tubes must also be ensured.
• Apart from serial chest radiographs, periodic arterial blood gas analysis might be required in these
patients.
• Nurses play a vital role in the postoperative lung expansion by ensuring periodic chest
physiotherapy and incentive spirometry.
• The pharmacist might ensure that the patient is on appropriate formulation and doses of
anticholinergic medications
• Detailed planning and discussion with the interprofessional team are highly recommended to
decrease morbidity and to improve outcomes
Kumar, Akshay, and Sachit Anand. "Lung Decortication." (2020).

Lung Decortication Complication and Management:
• Hemorrhage:
• Blood loss from the raw lung surfaces can result in a significant hemorrhage.
• A postoperative blood profile should be done to ascertain the need for blood transfusion.
• Persistent air-leak and bronchopleural fistula:
• Minor air-leaks can occur during decortication. However, these leaks resolve
spontaneously after a few days.
• Large leaks must be closed with formal suturing to avoid the development of a
bronchopleural fistula.
• Persistent lung collapse:
• Collapse, and non-expansion of the lung parenchyma is frequently noticed in post op
period after decortication.
• Incentive spirometry and chest physiotherapy play a crucial role in the re-expansion of
underlying parenchyma.
• However, a subset of patients may not show adequate lung expansion due to
diseased/destroyed lung.

Lung Decortication Complication and Management:
• Injury to vital structures:
• Decortication must be performed carefully by experienced surgeons.
• Injury to vital structures, including subclavian vessels, diaphragm, esophagus, and
pericardium, is common if the limits of peel removal are not followed.
s
• Retained infective focus and sepsis:
• Removal of the pus and pleural toileting must be thoroughly performed during decortication.
• Retained pus is a nidus of infection and may lead to sepsis in the postoperative period.
• Severe postoperative pain:
• Any thoracotomy, especially those with rib resection, may lead to significant pain in the postoperative
period.
• Adequate postoperative analgesia is a must and may require a combination of intravenous and epidural
analgesia.
• Chest wall deformity and scoliosis

Enhancing Healthcare Team Outcomes
• Role of an experienced thoracic surgeon is important and also crucial it is to
consult with an interdisciplinary team of specialists.
• An experienced pulmonologist and radiologist must be engaged in preoperative
and postoperative management.
• Patients undergoing decortication for chronic empyema might also require
intensive monitoring in the intensive care unit (ICU) during the initial
postoperative period. Therefore, the involvement of an intensivist is always
beneficial.
• Nurses also play a vital role in the postoperative lung expansion by ensuring
periodic chest physiotherapy and incentive spirometry. The pharmacist might
ensure that the patient is on appropriate formulation and doses of
anticholinergic medications. Thus, detailed planning and discussion with the
interprofessional team are highly recommended to decrease morbidity and to
improve outcomes

Critical care post Pneumonectomy

Pneumonectomy
• An invasive procedure used as a management option for patients with advanced
malignant and non-malignant lung disease.
• Proper patient selection, appropriate preoperative testing, multidisciplinary care are
vital for optimal patient outcomes.
• Postoperative care is of great importance to decrease the incidence of complications.
• Ideally, patients should be managed in an intensive care unit.
• Extubation should be done early if deemed appropriate.
• Oxygen should be supplemented, if necessary, to maintain saturation while avoiding
positive pressure whenever possible.
• Invasive monitoring should be continued. Care should be taken not to react to
hypotension with fluid boluses as this may result in pulmonary edema and subsequent
increase in morbidity and mortality. The chest tube, if present, should be off suction.
• The multimodal analgesic strategy should be employed. Esophageal dysmotility should
be anticipated, and diet should be advanced gradually.
Beshara, Michael, and Vaibhav Bora. "Pneumonectomy." (2020). https://www.ncbi.nlm.nih.gov/books/NBK555969/

Pneumonectomy Complications and Management
• Following pneumonectomy, pulmonary functions decrease but are usually less than anticipated for
removal of 50% of lung, especially for residual volume, and this may be explained by overexpansion of
the remaining lung tissue.
• FEV1, FVC, DLCO, and lung compliance decrease.
• Airway resistance increases.
• Patients with no disease in the remaining lung usually do have normal SaO2, PO2, and PaCO2 at rest.
• A chest X-ray immediately following pneumonectomy usually show the trachea in the midline and the
postpneumonectomy space to be filled with air.
• Later, that space becomes filled gradually with fluid at a rate of 1 to 2 intercostal spaces/day. The
ipsilateral diaphragm becomes elevated, and the mediastinum is gradually shifted towards the
operative side.
• Resting heart rate typically increases, and stroke volume decreases.
• Pulmonary artery pressure, pulmonary vascular resistance, and central venous pressure usually do not
change. Cardiac function in long-term survivors is usually compromised, and the altered position of the
heart may explain this

Complications:
• Cardiac arrhythmias:
• One of the most common complications after pneumonectomy. Atrial fibrillation/flutter is
the most common and usually occurs in the first three days following surgery.
• Postpneumonectomy cardiac herniation:
• Usually occurs within the first 24 hours after surgery, but it has been reported up to 6 months
following pneumonectomy.
• The condition presents with an abrupt drop in blood pressure and hemodynamic collapse. It
requires and an immediate reoperation.
• Pulmonary complications like pneumonia, atelectasis, respiratory failure are also
common. The incidence and severity of such complications increase with
advanced age and may require reintubation and mechanical ventilation.

Complications:
• Bronchopleural fistula
• About 1.5% to 4.5% of patients undergoing pneumonectomy will end up having a
bronchopleural fistula. Associated with a mortality of 29% - 79%.
• Risk factor: Right-sided procedures, a large diameter bronchial stump, residual tumor,
concurrent radiation or chemotherapy, age > 60 years, and prolonged postoperative
mechanical ventilation.
• Symptoms: fever, cough, hemoptysis, subcutaneous emphysema.
• A persistent air leak is usually detected if a chest tube is still in place. A chest X-ray usually
demonstrates a new air-fluid level or worsening of a preexisting air-fluid level.
• If the patient is still intubated and mechanically ventilated, measures to reduce airway
pressure should be taken to limit the amount of leak.
• Some patients may require lung isolation using a double-lumen tube for proper oxygenation
and ventilation. Management includes drainage of pleural space, systemic antibiotics.
Surgical repair may be required in severe cases.

Complications:
• Injury to the diaphragm, liver, spleen, or a major vessel is also known
complications.
• Postpneumonectomy pulmonary edema.
• Occurs in 2% - 5% of cases and typically presents on postoperative days 2 to 3.
• Associated with a significant increase in mortality by up to 50%.
• Patients usually present with dyspnea and poor oxygenation with an increased alveolar-arterial gradient.
• More common after right-sided pneumonectomy. Liberal IV fluid administration has been implicated; however, it
may still occur in patients with restrictive fluid management. Proposed mechanisms include increased capillary
permeability, lymphatic damage, and ventilator-induced lung injury.
• A single intraoperative dose of methylprednisolone just before pulmonary artery ligation may decrease the risk of
pulmonary edema as well as ARDS after pneumonectomy.
• Treatment is generally supportive, with ventilatory support as required together with restrictive fluid management
and diuretics.
• Other potential complications: multiorgan dysfunction, acute lung injury, acute respiratory
distress syndrome (ARDS), postoperative acute kidney injury

Critical care in post op Respi Patients.pptx

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