This document discusses preoperative optimization for patients undergoing thoracic surgery. It covers evaluating patients' pulmonary and cardiovascular systems through history, exams, tests like pulmonary function tests and CT scans. Key aspects of preoperative optimization include smoking cessation, using bronchodilators and medications to clear airways, chest physiotherapy, and exercise training. The goal is to reduce postoperative risks by improving lung function and maximizing patient strength and endurance prior to surgery.

1. PREOPERATIVE OPTIMIZATION
IN THORACIC SURGERY
-Dr Santosh Dhakal
Moderator: Dr Shyam Krishna Maharjan

2. INTRODUCTION
NON-CARDIAC SURGERY
• Infection
• Malignancies (lungs and oesophagus)
• Chest trauma
• Oesophageal disease
• Mediastinal tumors
• Diagnostic procedures (bronchoscopy, mediastinoscopy, and
open-lung biopsies)
• Tracheal resection
• Lung and heart transplantation
• Thoracic aortic aneurysm
• Lung volume reduction
• VATS ( Video assisted thoracoscopic surgery )
CARDIAC SURGERY

3. PREOPERATIVE EVALUATION
• Focusing on the extent and severity of pulmonary
disease and cardiovascular involvement
• To determine whether the patient will be able to
tolerate the planned lung resection
• Optimal pulmonary preparation

4. HISTORY
• Dyspnea
• Cough
• Cigarette smoking
• Exercise tolerance
• Risk factors for acute lung injury
(preoperative alcohol abuse, patients
undergoing pneumonectomy)

5. • Physical examination
- Respiratory pattern: cyanosis, clubbing,
breathing pattern, type of breath sounds
• Tracheal deviation, Potentially difficult intubation
of the trachea, airway obstruction on induction of
anaesthesia

6. EVALUATION OF
CARDIOVASCULAR SYSTEM
• Presence of increased pulmonary vascular resistance
secondary to fixed reduction in cross-sectional area of
pulmonary vascular bed
• Auscultatory signs of increased PAP and PVR:
a. narrowly split second heart sound,
b. increased intensity of the pulmonary component of
second heart sound,
c. fourth heart sound,
d. high pitched early systolic ejection click

7. H/o angina or ECG suggestive of ischemia
Non-invasive exercise ECG testing
(limited by low ventilatory or cardiac reserve)
If normal, if indicates ischemia
proceed to surgery
If negative
Thallium exercise test plan for surgery
If positive for ischemia
Coronary angiography

8. • If significant coronary artery disease, coronary artery
bypass grafting before or at the time of pulmonary
resection
• For lesser degree of CAD, preoperative appropriate
medical therapy and then plan for surgery
• In cases that require large resections in compromised
patients, CABG should be done first and pulmonary
resection should be delayed until the patient has gained
weight and muscle mass (usually 4 to 6 weeks).

9. INVESTIGATIONS
• Blood investigations: Hct, Hb, TC, DC, RFT, Na+, K+, RBS
• ECG
- low voltage QRS complex
- poor progression of R wave across the precordial leads
- features of RVH
• Chest x-ray: location of lung lesion assessed by PA and
lateral view
- Tracheal or carinal shift
- Hyperinflated lung field
- increased vascular markings
- Bullae
- Mediastinal mass

10. • Arterial blood gas analysis
• Pulmonary function tests
• Echocardiography
• CT scan chest
• Splint-lung function test
• Diffusing capacity for carbon monoxide

11. PULMONARY FUNCTION
TESTING
• To identify the patient at risk of increased
postoperative morbidity and mortality
• To identify the patient who will need short-term or
long-term postoperative ventilatory support
• To evaluate the beneficial effect and reversibility
of airway obstruction with the use of
brochodilators

12. SPIROMETRY
• An abnormal vital capacity: 33% likelihood of complications
and 10% risk of postoperative mortality
• FEV1: a more direct indication of airway obstruction
• Ratio FEV1/FVC
• Maximum voluntary ventilation (MVV): < 50% of predicted
value – high risk
• Ratio of RV/TLC: > 50% of predicted value – usually
indicative for high risk patient for pulmonary resection

13. • Predicted postoperative FEV1 value:
Preoperative FEV1 x (1- % functional lung tissue removed/100)
if < 30%: increased risk for postoperative pulmonary
complications, more likely to need postoperative ventilation
• Significance of bronchodilator therapy: for assessment of the
degree of airways obstruction and the patient’s effort ability
- A 15% improvement in PFTs may be considered a positive
response to bronchodilator therapy

14. Preoperative FEV1 = 70% of predicted
Postoperative FEV1 = 70 x (1 – 29/100)
= 50%

15. FLOW-VOLUME LOOPS

16. SPLINT-LUNG FUNCTION TEST
• To predict the function of the lung tissue that would
remain after lung resection
• Regional perfusion test
• Regional ventilation test
CT scan chest
• Provide anatomic sections through the chest
• Can delineate the size of the airway
• Reveals if there is airway or cardiovascular compression

17. Diffusing capacity for Carbon monoxide
• Reflects ability of the lung to perform gas
exchange
• A predicted postoperative diffusing capacity for
carbon monoxide <40% is associated increased
risk
• Predicted postoperative diffusing capacity percent
is the strongest single predictor of risk of
complications and mortality after lung resection

18. MAXIMAL OXYGEN CONSUMPTION
• A predictor of postoperative complications
• Patients with a VO2 max > 15 to 20 ml/kg/min are at
reduced risk
• A VO2 max < 10 ml/kg/min indicates very high risk for
lung resection
• Exercise oximetry: a decrease of 4 % during exercise is
associated with increased risk
• A 6 minute walk test

20. IMPORTANCE OF PREOPERATIVE
OPTIMIZATION
• High risk for postoperative pulmonary
complications –
- positively correlate with the degree of
preoperative respiratory dysfunction
- impairment of lung function due to performance
of surgery
- resistance to deep breathing and coughing
secondary to painful incision

21. • Preoperative preparation efforts for managing any
preexisting pulmonary disease.
• Elements of the preoperative regimen:
1) Stopping smoking,
2) Dilating the airways,
3) Loosening secretions
4) Removing secretions
5) Adjunct medication
6) Increased education, motivation, and
facilitation of postoperative care

22. 1) Stop smoking, avoid industrial pollutants
(if able to)
- cessation of smoking for more than 4 to
8 weeks associated with a decrease in the
incidence of postoperative respiratory
complications

23. Beneficial effects of smoking
cessation and time course
Time course Beneficial effects
12 – 24 hrs Decreased CO and nicotine levels
48 – 72 hrs COHb levels normalized, ciliary function improves
1 – 2 wk Decreased sputum production
4 – 6 wk PFTs improve
6 – 8 wk Immune function and metabolism normalizes
8 – 12 wk Decreased overall postoperative morbidity and
mortality

24. 2) Dilate airways
a. Beta2 – agonists
b. Ipratropium bromide- especially if severe
COPD
c. Methylxanthines
d. Inhaled steroids (systemic steroids – when
bronchospasm is severe)

25. 3) Loosen secretions
a. Airway hydration (humidifier/nebulizer)
b. Systemic hydration
c. Mucolytic and expectorant drugs
4) Remove secretions
a. Postural drainage
b. Coughing
c. Chest physiotherapy (percussion and vibration)

26. • Relative contraindications of chest
physiotherapy:
a) lung abscesses
b) metastases to the ribs
c) a history of significant hemoptysis
d) inability to tolerate the postural drainage
positions

27. 5) Adjunct medication
a. Antibodies – if purulent sputum/bronchitis
b. Antacids, H2 blockers, or PPIs – if symptomatic reflux
6) Increased education, motivation, and facilitation of
postoperative care
a. Psychological preparation
b. Preoperative pulmonary care training
1. Incentive spirometry
2. Secretion removal maneuvers
c. Preoperative exercise
d. Weight loss/gain
e. Stabilize other medical problems

28. • Lung expansion maneuver:
- deep breathing exercise and use of incentive
spirometry
- critical for limiting postoperative morbidity
related to atelectasis and pneumonia
- preoperative preparation better than delaying
until after the surgery

29. • Preoperative prophylaxis against atrial flutter/fibrillation
- approx. 25% of patients
- etiology: poorly understood, may be due to manipulation
of heart, reduction in available vascular bed for perfusion
after resection of pulmonary tissue
- 60 years or older : most consistent independent
preoperative risk factor
- Digoxin, calcium channel blocker

30. THANK YOU