URVASHI VAID MD,MSAUG 2012

Why do we care? At risk population Tools for assessment Prevention of Post-op complications Risk Indices Clinical scenarios

Thoracic Surgery and Lung cancer Bariatric Surgery Cardiac Surgery

What are PPC? VC reduced by 50-60% after thoracic/upper

abdominal Sx- remains or a week, FRC reduced by 30%

As prevalent as cardiac complications Morbidity Length of stay Mortality Prevalence 6.8% across all surgeries

In most cases of operable lung cancer, a substantial part of functional lung tissue has to be resected which leads to a permanent loss of pulmonary function

An estimated 90% of all patients with lung cancer have underlying COPD and cardiovascular disorders in varying degrees caused by the shared risk factor from tobacco smoking thus at higher risk of intraoperative and postoperative complications

Resection in patients with insufficient pulmonary reserves can result in permanent respiratory disability

The assumption that there is a level of respiratory impairment beyond which resection bears a high risk and is prohibitive drives the ongoing search for the ideal test to predict postoperative lung function and identify the patients at high risk

Clin Chest Med 32 (2011) 773–782

Which of the following is not a significant risk factor for PPC in non-cardiothoracic surgery? Age>60 ASA class II or greater COPD Functionally dependant Mild to moderate Asthma CHF Obesity

Which of the following is not a significant risk factor for PPC in non-cardiothoracic surgery? Age>60 OR 2.0 ASA class II or greater OR 4.87 COPD OR 1.79 Functionally dependant OR 2.51 Mild to moderate Asthma CHF OR 2.93 Obesity

Malnutrition (albumin <3g/dL) reduces ventilatory drive to hypoxia and hypercapnia, contributes to respiratory muscle dysfunction, alters lung elasticity, and impairs immunity but nutritional intervention before surgery has not been shown to attenuate the risk

Renal impairment (blood urea >30 mg/dl) carries an OR of 2.3 for PPC

Obstructive sleep apnea –early hypoxemia and unplanned reintubation. 9/172 patients had PPC esp if ODI4% >15. Screening-

Pulmonary HTN- ??? Smetana GW. Preoperative pulmonary evaluation. N Engl J Med 1999;340(12):937–44. Smetana GW, Lawrence VA, Cornell JE. Preoperative pulmonary risk stratification for noncardiothoracic

surgery: systematic review for the American College of Physicians. Ann Intern Med 2006;144(8):581–95 Association of sleep-disordered breathing with postoperative complications.AUHwang D, Shakir N, Limann

B, Sison C, Kalra S, Shulman L, Souza Ade C, Greenberg HSOChest. 2008;133(5):1128

Age (more comorbidities) COPD- RR of 4.7 The OR for in patients ASA class III or higher is 2.6

compared with patients with ASA class I and II Malnutrition (albumin <3g/dL) reduces ventilatory drive

to hypoxia and hypercapnia, contributes to respiratory muscle dysfunction, alters lung elasticity, and impairs immunity but nutritional intervention before surgery has not been shown to attenuate the risk

Smetana GW. Preoperative pulmonary evaluation. N Engl J Med 1999;340(12):937–44. Smetana GW, Lawrence VA, Cornell JE. Preoperative pulmonary risk stratification for noncardiothoracic

surgery: systematic review for the American College of Physicians. Ann Intern Med 2006;144(8):581–95

Cigarette smoking increases the risk of PPC irrespective of the presence of COPD

A significant reduction of this risk is only noted after 8 weeks of cessation

Recent meta-analyses confirm that smoking cessation before surgery does not increase the risk for PPC

The data indicate that stopping smoking before surgery might lower the risk of complications, with a growing effect with longer duration of smoking cessation

Mills E, Eyawo O, Lockhart I, et al. Smoking cessation reduces postoperative complications: a systematic review and meta-analysis. Am J Med 2011;124(2):144.e8–54.e8.

Myers K, Hajek P, Hinds C, et al. Stopping smoking shortly before surgery and postoperative complications: a systematic review and meta-analysis. Arch Intern Med 2011;171(11):983–9.

Surgical Site- thoracic, AA, abdominal, neurosurgery, head and neck and vascular

Duration of surgery- >3-4 hours

Anesthetic technique- GA

Emergency surgery

History Physical Stair Climbing 6 minute walk ABG PFTs CPET Quantitative V/Q scan

Prior surgeries/anesthesia Signs of cor pulmonale Laryngeal height in COPD <4cm has

OR 2.0 for PPC*

*McAlister FA, et al. Am J Resp Crit Care Med 2003; 167:741

Stair Climbing- height of 20 meters or rate of ascent 15m/min (=VO2 max of 20ml/kg/min) and 12m/min (= VO2 max of 15ml/kg/min)

Brunelli study-5 year survival (97 vs 74; 77% vs 54%, p < 0.001)

Stair climb > 44 steps (Holden, Chest, 1992)

6 minute walk- >400m

ABG ?? PaCO2 >45mmHg

Brunelli A, Pompili C, Salati M. Low-technology exercise test in the preoperative evaluation of lung resection candidates. Monaldi Arch Chest Dis 2010; 73:72–78

Brunelli et al. Performance at Preoperative Stair-Climbing Test Is Associated With Prognosis After Pulmonary Resection in Stage I Non-Small Cell Lung Cancer Ann Thorac Surg 2012;93:1796–801

Kasymjanova G, Correa JA, Kreisman H, et al. Prognostic value of the six-minute walk in advanced non-small cell lung cancer. J Thorac Oncol 2009;4:602–7.

No role in non-thoracic surgery unless you suspect COPD or asthma

“Recommendation 5: Preoperative spirometry and chest radiography should not be used routinely for predicting risk for postoperative pulmonary complications”

Role of ppoFEV1 and ppoDLCO preoperative FEV1 X [19 - patent segments to be removed/19]

Group A, patients with ppoFEV1 and ppoDLCO > 40% predicted, and group B, patients with either ppoFEV1 or ppoDLCO < 40% predicted or both between 30 and 40% predicted and ppoVO2 peak > 10 ml/kg per min

Found a similar complication rate among the two groups, but a higher 30-day mortality (1.9 vs. 13.5%) in group B.

Puente-Maestu´ L, Villar F, Gonza´ lez-Casurra´n G, et al. Early and long-term validation of an algorithm assessing fitness for surgery in patients with postoperative FEV1 and diffusing capacity of the lung for carbon monoxide <40%. Chest 2011; 139:1430–1438.

For thoracic surgery VO2max >75% or >20ml/kg/min for

pneumonectomy VO2 max >15ml/kg/min for lobectomy No surgery if <35% or <10ml/kg/min

Segments generated by hounsfield units.ppo-FEV1 = preoperativeFEV1 X (1-(RFLV/TFLV)).

ERS/ESTS 2009 guidelines BTS/SCTS 2012 guidelines

Salati M and Brunelli A. Preoperative assessment of patients for lung cancer surgery. Curr Opin Pulm Med 2012, 18:289–294

Bolliger et al. Functional Evaluation before Lung Resection. Clin Chest Med 32 (2011) 773–782

Operability (Physiologic) Resectability (Anatomic)

Preoperative Evaluation of Patients with Lung Cancer Undergoing Thoracic Surgery Batra, Vikas MD; Kane, Gregory C. MD; Weibel, Sandra MD . Clin Pulm Med 2002;9(1):46–52

Assessment of cardiopulmonary reserve before lung resection ERS/ESTS

Risk assessment of post-treatment dyspnea- BTS/SCTS

(1) limited role of traditional spirometry and predicted postoperative FEV1

(2) importance of a systematic measurement of carbon monoxide lung diffusion capacity

(3) global approach in fitness evaluation, by assessing the entire oxygen transport system with CPET

Arozullah AM, Daley J, Henderson WG, Khuri SF. Multifactorial risk index for predicting postoperative respiratory failure in men after major noncardiac surgery. The National Veterans Administration Surgical Quality Improvement Program. Ann Surg. 2000;232:242-53.

>32,000 patients 2006-2008 0.6% developed PRF and 0.6% PP 30 day mortality greater if developed either (4.3%

versus 0.16% and 13.7% versus 0.10%, P < .0001)

CHF OR 5.3 (1.2-23) Stroke OR 4.1 (1.4-11) Dyspnea at rest OR 2.64 (1.1-6) Age, COPD, smoking, diabetes, anesthesia time,

increasing weight, type of surgery Gupta et al. Predictors of pulmonary complications after bariatric surgery. Surg Obes

Relat Dis. 2011 May 13.

1997-2010 >11,000 patients 3 groups- normal or mild (<70%, FEV1 >80%),

moderate 50-80%, Severe <50% Early mortality: 1.4% vs 2.9% vs 5.7% (p<0.001) Similar trend for post-op complications Saleh et al. Impact of chronic obstructive pulmonary disease severity on surgical

outcomes in patients undergoing non-emergent coronary artery bypass grafting. Eur J Cardiothorac Surg. 2012 Jul;42(1):108-13.

OTHERS: h/o CABG, emergent surgery, infiltrate on CXR, BUN>30, acute MI on admission

Lung Specific Strategies Anesthetic techniques Surgical techniques Peri-operative care

Lung Specific Strategies Smoking Cessation Lung Expansion

Optimize bronchodilators

Anesthetic techniques Surgical techniques Peri-operative care

172 patients- Celli, B and Snider GL. ARRD 1984

Prospective, RCT in Abdominal surgery

Cochrane review 2009: “We found no evidence regarding the effectiveness of the use of incentive spirometry for prevention of postoperative pulmonary complications in upper abdominal surgery. This review underlines the urgent need to conduct well-designed trials in this field”

For IS: Same applies to CABG (IPPB may work) and esophagectomies too! (Cochrane)

Control=44

IPPB=45

IS=42 DBE=41

PPC 48% 22% 21% 22%

LOS 13 +- 5 8.6+-3 9.6+-3 9.9+-6

Lung Specific Strategies Anesthetic techniquesNM blockade (longer acting

worse) Intraoperative PEEP (No effect)

Surgical techniques Peri-operative care

Cochrane Database Syst Rev. 2010 Sep 8;(9):CD007922

Lung Specific Strategies Anesthetic techniques Surgical techniques Peri-operative care

Lung Specific Strategies Anesthetic techniques Surgical techniques Peri-operative care Selective NOT routine

use of nasogastric tubes after elective lap lower rates of pneumonia/atelectasis

Don’t forget- early ambulation and DVT prophylaxis

THANK YOU!