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Pulmonary

The Medicine Consult Handbook 2011

PULMONARYRISKASSESSMENTANDMANAGEMENT

Preoperativeevaluation

Assessment:

Riskfactors:

1

COPD

Age>60

ASAclassII+

Functionally

dependent

CHF

Notethatobesityandmild-moderateasthmawerenotfoundtoberiskfactorsforpostoperativepulmonary

complications.1

ObstructiveSleep

Apnea

SeeObstructiveSleepApneaConsider:

Serumalbuminifsuspected

hypoalbuminemia.1

Albumin(50yearofagewhoare

undergoingupperabdominal,thoracic,AAAsurgery,orin

patientswithcardiacorpulmonarydisease.1

Rarelychangesmanagementdramatically,butmaybeveryusefulintheseselectpopulations.Pulmonaryfunction

tests(PFTs)

RoutinePFTsNOTindicatedexceptforcertainsurgeries(e.g.thoracicsurgeryusuallydeferthistestingtothe

surgeon)

KnownCOPD:assessbysymptomsandexam Considerforpatientwithsuspectedbutpreviously

undiagnosedobstructivelungdisease.

ArterialBloodGas

(ABG)

ConsiderforpatientswithelevatedserumHCO3,O2dependence,moderatetosevereCOPD,orsuspected

obesity-hypoventilationsyndrome.

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The Medicine Consult Handbook 2011

Postoperativemanagement

Lungexpansion

maneuvers

(e.g.incentive

spirometry)

RecommendedinACPguidelines 1 CochraneReviewfoundnoevidenceofincentive

spirometryreducingpulmonarycomplicationsinupper

abdominalsurgery,butwaslimitedbyfewquality

studies.3

Nasogastric(NG)

tube

ACPguidelinesrecommendSelectiveuseofNGtubesfordecompressionfornausea,vomiting,abdominal

distension.1

Inpractice,wedeferthistothesurgeryteam.Formanypatients,anewanastomosis(e.g.esophagealsurgery)

makesNGtubeplacementpotentiallydangerousalways

discusswiththesurgicalteam.

Pulseoximetry Recoveryroompulseoximetryisroutineandmanagedbyanesthesia.

Considerforpatientswithsleepapneaorhighriskofhypoxemia.(seeObstructiveSleepApnea)

DiscussionRiskstratification:Despiteattentionpaidtocardiovascularriskstratificationandcomplications,

pulmonarycomplicationslikelyexceedthoseofcardiovascularcomplications.Cardiovascularrisk

stratification,however,hasbenefitedfromeasytouse,wellvalidatedrisktoolssuchastheRevised

CardiacRiskIndex(seeCardiovascularRiskStratification).Riskmodelsforpostoperative

pulmonarycomplicationshaveidentifiedage,preoperativeO2sat,recentrespiratoryinfection,

preoperativeanemia,upperabdominalorthoracicsurgicalsite,durationofsurgery,andemergent

proceduresasriskfactorshoweverthescoringsystemrequiresaddingupweightscoresforeach

riskfactor.4

Otherpulmonaryconditions :Otherconditionshavehadincreasingevidenceforrisksof

postoperativecomplications,includingobstructivesleepapneaandpulmonaryhypertension.

ThesearediscussedseparatelyseeObstructiveSleepApnea,AsthmaandCOPD,Pulmonary

HypertensionVenousThromboembolicDisease.

References

1.QaseemA,SnowV,FittermanN,etal.RiskAssessmentforandStrategiestoReducePerioperativePulmonary

ComplicationsforPatientsUndergoingNoncardiothoracicSurgery:AGuidelinefromtheAmericanCollegeof

Physicians.AnnalsofInternalMedicine.2006;144:575-580.

2.MyersK,HajekP,HindsC,etal.StoppingSmokingShortlyBeforeSurgeryandPostoperativeComplications.

ArchInternMed.PublishedonlineMarch14,2011.

3.GuimaraesMMF,ElDibRP,SmithAF,etal.IncentiveSpirometryforPreventionofPostoperativePulmonary

ComplicationsinUpperAbdominalSurgery.CochraneDatabaseofSystematicReviews.2009;3:CD006058.

(updated2011).

4. CanetJ,GallartL,GomarC,etal.PredictionofPostoperativePulmonaryComplicationsinaPopulation-based

SurgicalCohort.Anesthesiology2010;113:1338-1350.

UpdatedMay2011