Reoperative Care of Pulmonary Patients: An evaluation for postoperative pulmonary complications...
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Transcript of Reoperative Care of Pulmonary Patients: An evaluation for postoperative pulmonary complications...
reoperative Care of Pulmonary Patients: An evaluation for postoperative pulmonary
complications
Anakapong Phunmanee MD.Associated Professor
Department of Medicine, Faculty of Medicine, Khon Kaen University
Topics
• The concepts for performing effective consultation
• Factors related to PPCs
• Preoperative pulmonary evaluations
• Risk indices for preoperative assessment
• Risk reduction strategies
• Preoperative care of pulmonary patients: An example
The concepts for performing effective consultation
• Prompt response (within 24 hours)• Focus on central issue• Identified critical recommendations• Make specific and limit number of
recommendations(<5)• Use definitive language• Direct verbal contact• Specific drug dosage, route, frequency• Frequent F/U and progress note
Cohn SL. UptoDate 2002
The ideal medical consultation
• Informs without patronizing
• Educated without lecturing
• Directs without ordering
• Solves the problem without making referring physician appear to be “stupid”
Bates RC, et al. Med Econ 1997
“ Referring physician and the consultant both have
responsibilities to fulfill in order to maximize the effectiveness of the
consultation in improving the patient care”
Cohn SL. UptoDate 2002
The role of preoperative medical consultation
• Identifying and evaluation the medical status
• Provide a clinical risk profile
• To optimize the medical condition in attempt to reduce risk of PPCs
Postoperative pulmonary complications (PPCs)
• Common complications, ¼ of death related to PPCs
• Incidence and prevalence vary – Population– Type of surgery– Definition of complications
Brooks-brunn JA .Heart Lung 1995
Factors related to PPCs
• Patients-related risk factors
• Operation-related risk factors
• Anesthetic-related risk factors
• Risk factors related to postoperative care
Patient-related risk factors: Aging
Arozullah AM,et al. Ann Intern Med 2001 Ann Surg 2000
50-59 YRs
< 50 YRs
60-69 YRs
70-79 YRs
> 80 YRs
10 2 3 4 5 6 7
Postoperative pneumonia (OR)
Patient-related risk factors: General health
Arozullah AM,et al. Ann Intern Med 2001 Ann Surg 2000
CVA
Obesity
ASA >,=2
Partial depend
Total depend
10 2 3 4 5 6 7
Postoperative pneumonia (OR)
Patient-related risk factors: Immune status
Arozullah AM,et al. Ann Intern Med 2001 Ann Surg 2000
Alcoholic > 2 drink/day
Within 2 wks
IDDM
Steroid use
10 2 3 4 5 6 7
Postoperative pneumonia
Postoperative pneumonia and respiratory failure
Postoperative pneumonia
Operation-related risk factors
Arozullah AM,et al. Ann Intern Med 2001 Ann Surg 2000
Neurosurgery
Vascular
Neck
Upper abdomen
AAA-repair
10 2 4 6 8 10 12
Postoperative respiratory failure (OR)
14 16
Thoracic
Influence of surgical site on rate of PPCS
Study Upper Abdomen
Lower abdomen
Laparoscopic Thoracic
Tarhan 1973 13 7 10
Garcey 1979 25 0 19
Garribaldi 1981
17 5 40
SSA club 1994
0.3
Phillips 1994 0.4
Brooks 1997 28 15
Smetana GW, et al New Engl J Med 1999
Mortality for lung resection
0
2
4
6
8
10
12
wedge resection segmental resection lobectomy pneumonectomy
Mitsudomi T, et al. J Surg Oncol 1996; 61:218-22
Multicenter study 12,00 patients , thoracotomies usually CA
% Mortality
Anesthetic-related risk factors
General anesthesia(thoracic, Ab, Vascular)
Operation time >3 hrs
10 2 3 4 5 6 7
Smetana GW, et al New Engl J Med 1999
Neuromuscular block and PPCs: Long acting VS shorter acting
0
2
4
6
8
10
12
14
16
18
long acting* Shorter acting**
Berg H, et al Acta Anaesthesiol Scand 1997
Incidence of residual NMB 26*, VS 5.3**
Incidence of Complication
Risk factors related to postoperative care
• NG tube– Postoperative NG tube not significant
associated with PPCs– Empty GI tract may decrease aspiration
outweigh risk of ineffective coughing and oropharygeal aspiration
• Pain control– Adequate pain control improving outcomes– Epidural analgesia seem to be better
outcomes than standard opioid analgesia
Preoperative pulmonary evaluations
• History and physical examination
• Chest radiography
• Arterial blood gas analysis
• Pulmonary function test
• Quantitative lung scan
• Exercise test
Chest radiography
Two potential indication
1. To identified abnormalities correcting, modification cancellation surgery
2. Serve as a base line finding
The value of an abnormal CXR before surgery
0
10
20
30
40
50
60
Makee 1987 Wiencek1987
Charpak1988
Tape 1988 Bouillot1996
Silvestri1999
Abnormal
Normal
Smetana GW, et al Med Clin N Am 2003
The abnormal CXR and aging
0
5
10
15
20
25
30
35
40
45
50
< 60 >60
Silvestri L, et al Eur J Anaesthesiol 1999
Recommendation for preoperative CXR
• Age > 50 years
• Known pre-existing cardiopulmonary diseases
• S/S like hoods of cardiopulmonary disease
Smetana GW, et al Med Clin N Am 2003
Arterial blood gas
• Small study series identified Hypercarbia(PaCO2>45) risk for PPCs
• Recent systematic review by Fisher BW, et al 2002 dose not find hypercarbia useful predictor for PPCs
Milledge JR, et al. BMJ 1975Stein M, et al. JAMA 1962
Spirometry
Pulmonary function testing (PFTs) and PPCs
• ACP guideline 1990– Lung resection– Coronary artery bypass surgery– Upper abdominal surgery with smoking or
dyspnea– Lower abdominal surgery if unexplained
pulmonary diseases with prolong extensive surgery
– Head, neck, orthopedic surgery with unexplained pulmonary diseases
Anonymous. Ann Intern Med 1990; 112:793-4.
40% PFTs do not meet guideline
Improving adherence ordering PFTs saving
29-100 million Dollar/Yr
Adapt from Smetana GW,et al. New Engl J Med 1999;340:937-944.
Stein 1970
Collin 1968
Appleberg 1974
Fogh 1987
Kispert 1992
10 2 4 6 8 10 12 14 16
Swensson 1991
Use of preoperative spirometry to predicted PPCs
Kroenke 1993
Kocabas 1996
Bando 1997
Jacob 1997
PFTs and PPCs
• Case-control study, elective abdominal surgery:– CXR highly associated with PPCs (OR 5.8)– Abnormal PE associated with PPCs– Whereas PFTs were not predictive
Lawrence VA, et al. Chest 1996;110:744-50.
PFT Diagram in Preoperative Evaluation
PFT(FEV1,MVV,DLCO)
Cleared for any resection
High risk consider exercise
testPerfusion
Scanning PPO-FEV1
Consider “Lesser” resection
Non surgical therapy
Cleared for any resection
High risk consider exercise
test
FEV1 >2 L
MVV >50%DLCO >60%
FEV1 > 2 L
MVV<50%
DLCO <60%
FEV1 <2 L
PPO-FEV1 >1.3
PPO-FEV1 >0.8, <1.3PPO-
FEV1 <0.8
Preoperative PFTs : Summary
• Thoracic surgery
• Upper abdominal surgery with respiratory symptoms remain unexplained after careful evaluation
• Routine PFTs should not ordered solely without clinical assessment
Arozullah AM. Med Clin N Am 2003; 87: 153-173
uantitative lung scan
Interpretation of quantitative lung scan
Exercise testing
• Assessing the risk in pts undergoing thoracotomy is controversial
• Acceptable value; maximum oxygen consumption > 15 ml/kg/min
Risk indices for preoperative assessment
Risk class
Pneumonia Risk
(total point)
Predicted
Prob. pneumonia
(%)
Respiratory
Failure
(total point)
Predicted
Prob.
Res. failure
(%)
1 0-15 0.2 0-10 0.5
2 16-25 1.2 11-19 2.2
3 26-40 4.0 20-27 5.0
4 41-55 9.4 28-40 11.6
5 >55 15.4 >40 30.5
Arozullah AM,et al. Med Clin N Am 2003
ตั�วอย่�างการประเมิ�นโดย่ใช้� Risk indicies
• ผู้��ป่�วยชายอาย� 60 ป่ (9)
• ต้�องเข้�ารั�บการัผู้�าต้�ดมะเรั�งป่อดรัะยะIIa (14)
• ม�ป่รัะว�ต้�สู�บบ�หรั�� 30 pack/year จนหย�ดสู�บมา 4 สู�ป่ดาห" (3)
• ได�รั�บการัว�น�จฉั�ยเป่%น COPD (5)
• รัวมได�คะแนน 31 จากต้ารัาง risk class 3 ซึ่)�ง predicted prob. pneumonia 4%,
respiratory failure 11.6 %
Limitation of risk indicies
• Developed from male, high co morbid level may not generalized to healthy population
• Hospital based study from Veterans Hospital
Arozullah AM,et al. Ann Intern Med 2001 Ann Surg 2000
Risk reduction strategies(1)
• Smoking cessation at least 8 weeks
• Perioperative lung expansion maneuver– Incentive spirometry– Chest physical therapy– Intermittent positive pressure breathing (IPPB)– Continuous positive airway pressure (CPAP)
Preoperative smoking cessation and PPCs
0
10
20
30
40
50
60
Stop >2 mth Stop<2 mth Stop>6 mth Never smoke
Warner MA,et al. Mayo Clin Proc 1989
Prospective study 200 patients, CABG
% Complication
Preoperative smoking cessation and PPCs
0
10
20
30
40
50
60
Current <2wks Recent2-4wks Exsmoke Never smoke
Nakagawa M, et al Chest 2001;120:705-10
Retrospective study 288 patients, pulmonary surgery
% Complication
Paradoxical increase PPCs after short-term abstinence
• Sicker pts tend to quit smoking closer to surgery
• Stop smoking decrease irritation
decrease stimulus for cough
Still have bronchial hypersecretion
increase sputum retention
Bluman LG, et al. chest 1998Warner MA, et al. Mayo Clin Proc 1989
Short term smoking cessation
• Decrease carboxyhemoglobin and nicotine level
Improved mucocilliary function and upper airway hypersensitivity
Buist AS, et al. Am Rev Respir Dis 1976Camner P, et al. Chest 1973
Kamban JR,et al. Anesth Analg 1986
Risk reduction strategies(2)
• Smoking cessation at least 8 weeks
• Perioperative lung expansion maneuver– Incentive spirometry– Chest physical therapy– Intermittent positive pressure breathing (IPPB)– Continuous positive airway pressure (CPAP)
Perioperative lung expansion maneuvers
• A meta-analysis evaluating: upper abdominal surgery– Incentive spirometry (IS)– Deep breathing exercise (DB)– Intermittent positive pressure breathing (IPPB)
• Similar in efficacy
• Better than no respiratory therapy
Thomas JA, et al. Physical Therapy 1994; 74:3-10.
Perioperative lung expansion maneuvers: Summary
• No specific lung expansion maneuver is clearly superior
• CPAP may be benefit in patients unable to perform DB or IS
• Initiative lung expansion maneuver preoperatively is more effective in reducing PPCs than postoperatively
Arozullah AM. Med Clin N Am 2003; 87: 153-173
Risk-reduction strategies: preoperatively
• Encourage smoking cessation at least 8 weeks• Delay operation if respiratory infection is
present, productive cough (several weeks)• Education lung expansion maneuvers • Maximize pulmonary function
– Bronchodilator– Inhaled corticosteroid– Theophylline– Antibiotic
Smetana GW, et al. New Engl J Med 1999; 346: 937-944.
Risk-reduction strategies: Intraoperatively
• Limit duration of surgery to <3 hours
• Use spinal or epidural anesthesia
• Avoid pancuronium
• Use laparoscopic procedure when possible
Smetana GW, et al. New Engl J Med 1999; 346: 937-944.
Risk-reduction strategies: postoperatively
• Adequate pain control
• Early ambulation
• Use lung expansion maneuver
• Maximized pulmonary function (medication)
Smetana GW, et al. New Engl J Med 1999; 346: 937-944.To The last
Preoperative Care of Pulmonary Patients: Example(1)
• Male 60 yrs.
• Dx: NSCLC stage Ib , RUL
• Underlying COPD
• Assessment– Not urgent surgery, high benefit– Risk ; elderly, COPD– History / Physical examination– Laboratory
Pre-RX(%)
Post –RX(%)
%CHG
FEV1/FVC (%)
55 60
FEV1 (L) 1.31(48) 1.39(53) 5
FVC (L) 2.40(66) 2.50(69) 4
FEF25- 75%
(L/min)
0.43(15) 0.6(22) 22
Spirometry of the patient
Further evaluation• PPO-FEV1
RUL : RLL= 0.55: 0.45
RUL = 24.7%
RLL= 20.3%
LL = 55%
Preoperative Care of Pulmonary Patients: Conclusion
• Many factors related to PPCs
• Working as a team plays major roles
• Assessment of the risks ,do appropriated testing and modifying are the keys of preoperative caring
Thank you
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