2OUTLINE Why do we care? At risk population Tools for assessment Prevention of Post-op complicationsRisk IndicesClinical scenariosThoracic Surgery and Lung cancerBariatric SurgeryCardiac Surgery
3WHY DO WE CARE? 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 complicationsMorbidityLength of stayMortalityPrevalence 6.8% across all surgeriesPneumonia, Atelectasis, Respiratory failure, exacerbation of underlying chronic lung disease, Infection, BronchospasmOne broad definition of postoperative pulmonary complications includes all patients with fever and either pulmonary signs, symptoms (eg, productive cough, rhonchi, or diminished breath sounds), or changes on chest x-ray (eg, atelectasis, consolidation, or incomplete expansion) [3,4]. However, many such liberally defined postoperative complications are of no clinical relevance.Another proposed definition is a pulmonary abnormality that produces identifiable disease or dysfunction that is clinically significant and adversely affects the clinical course . This would include several major categories of clinically significant complications, including [6,7]:■Atelectasis■Infection, including bronchitis and pneumonia■Prolonged mechanical ventilation and respiratory failure■Exacerbation of underlying chronic lung disease■BronchospasmThe rate of postoperative pulmonary complications across all types of surgery was 6.8 percent in a systematic review of studies that provided explicit outcome definitions .PERIOPERATIVE PULMONARY PHYSIOLOGY — Postoperative pulmonary complications follow logically as an extension of normal perioperative pulmonary physiology. Reduced lung volume after surgery is a major factor contributing to the development of postoperative pulmonary complications.Thoracic and upper-abdominal surgery are associated with a reduction in lung volumes in a restrictive pattern as follows [9,10]:■Vital capacity (VC) is reduced by 50 to 60 percent and may remain decreased for up to one week.■Functional residual capacity (FRC) is reduced by about 30 percent.Diaphragmatic dysfunction appears to play the most important role in these changes; postoperative pain and splinting are also factors . Reduction of the FRC below closing volumes contributes to the risk of atelectasis, pneumonia, and ventilation/perfusion (V/Q) mismatching. Microatelectasis results in areas of the lung that are perfused but not ventilated, leading to impaired gas exchange with consequent postoperative hypoxemia .A decrease in tidal volume, loss of sighing breaths, and increase in respiratory rate occur after abdominal and thoracic surgery and contribute to the risk of complications. In addition, residual effects of anesthesia itself and postoperative opioids both depress the respiratory drive. Inhibition of cough and impairment of mucociliary clearance of respiratory secretions are factors that contribute to the risk of postoperative infection
4Why Do We Care?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 functionAn 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 complicationsResection in patients with insufficient pulmonary reserves can result in permanent respiratory disabilityThe 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 riskClin Chest Med 32 (2011) 773–782
5SHOW OF HANDS….Which of the following is not a significant risk factor for PPC in non-cardiothoracic surgery?Age>60ASA class II or greaterCOPDFunctionally dependantMild to moderate AsthmaCHFObesity
6SHOW OF HANDS….Which of the following is not a significant risk factor for PPC in non-cardiothoracic surgery?Age>60 OR 2.0ASA class II or greater OR 4.87COPD OR 1.79Functionally dependant OR 2.51Mild to moderate AsthmaCHF OR 2.93Obesity
8AT RISK POPULATIONMalnutrition (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 riskRenal impairment (blood urea >30 mg/dl) carries an OR of 2.3 for PPCObstructive 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):581–95Association 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):1128Well-controlled asthma is not associated with postoperative complications, and neither is a short course of oral corticosteroids
9AT RISK POPULATION 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 IIMalnutrition (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 riskSmetana 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):581–95Well-controlled asthma is not associated with postoperative complications, and neither is a short course of oral corticosteroids
10SMOKING- To stop or not to stop (And when to stop…) Cigarette smoking increases the risk of PPC irrespective of the presence of COPDA significant reduction of this risk is only noted after 8 weeks of cessationRecent meta-analyses confirm that smoking cessation before surgery does not increase the risk for PPCThe data indicate that stopping smoking before surgery might lower the risk of complications, with a growing effect with longer duration of smoking cessationMills 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.Smokers: Longer hospital stays, higher risk of readmission, are more likely to be admitted to an intensive care unit, and have an increased risk of in-hospital mortalityRationale for 8 weeks: losing the cough-promoting effect of cigarettes before any improvement in sputum clearance might predispose to retention of secretions andpostoperative pulmonary complications.
14PROCEDURE RELATED RISK FOR PPC Surgical Site- thoracic, AA, abdominal, neurosurgery, head and neck and vascularDuration of surgery- >3-4 hoursAnesthetic technique- GAEmergency surgery
15TOOLS FOR ASSESSMENT History Physical Stair Climbing 6 minute walk ABG PFTsCPETQuantitative V/Q scan
16HISTORY AND PHYSICAL EXAM Prior surgeries/anesthesiaSigns of cor pulmonaleLaryngeal height in COPD <4cm has OR 2.0 for PPC**McAlister FA, et al. Am J Resp Crit Care Med 2003; 167:741Upper border of thyroid cartilage to sternal notch.
17FUNCTIONAL ASSESSMENT 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- >400mABG ?? PaCO2 >45mmHgBrunelli A, Pompili C, Salati M. Low-technology exercise test in the preoperative evaluation of lung resection candidates. Monaldi Arch Chest Dis 2010; 73:72–78Brunelli 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;93:1796–801Kasymjanova 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.A total of 296 consecutive patients undergoing pulmonary lobectomy and systematic lymph node dissection  for pathologic stage I (pT1or pT2-N0 only) NSCLC and with complete follow-up were analyzed (2000 to 2008). Patients who received induction chemotherapy were excluded. No patients in this series underwent adjuvant chemotherapy or radiotherapyThe stair-climbing test was usually performed within 1 week of the operation. Our hospital has 16 flights of stairs, each consisting of 11 steps. Each step is meters high. Patients were asked to climb, at a pace of their own choice, the maximum number of steps and to stop only for exhaustion, limitingdyspnea, leg fatigue, or chest pain. All patients were accompanied by a physician, and the patient’s pulse rate and capillary oxygen saturation were monitored bymeans of a portable pulse oximeter with a finger probe. All tests were performed on room air.
18PFTs and CXRNo 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”
19PFTS in thoracic surgery Role of ppoFEV1 and ppoDLCOpreoperative 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 minFound 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.Varela et al.  demonstrated that ppoFEV1 was rather imprecise in predicting the FEV1 immediately after surgery. In fact, ppoFEV1 was muchhigher than the actual FEV1 measured on the first postoperative days, a period when most of the complications occurBrunelli et al.  showed that the ppoFEV1 is unable to predict postsurgical cardiopulmonary complications in lung cancer patients withmoderate to severe chronic obstructive pulmonary disease (COPD), representing a large portion of patients undergoing pulmonary resection. Moreoverthe same authors demonstrated that, 3 months following lobectomy, the actual to predicted postoperative ratios of FEV1 and DLCO in COPD patientswere 115 and 122%, respectively
21CPET For thoracic surgery VO2max >75% or >20ml/kg/min for pneumonectomyVO2 max >15ml/kg/min for lobectomyNo surgery if <35% or <10ml/kg/min
22QUANTITATIVE V/Q SCAN or ct scan Total and (-500 to -910) Regional functional lung volumeSegments generated byhounsfield units.ppo-FEV1 = preoperativeFEV1 X (1-(RFLV/TFLV)).
23THORACIC SURGERY ESP LUNG CANCER ERS/ESTS 2009 guidelinesBTS/SCTS 2012 guidelinesSalati M and Brunelli A. Preoperative assessment of patients for lung cancer surgery. Curr Opin Pulm Med 2012, 18:289–294Bolliger et al. Functional Evaluation before Lung Resection. Clin Chest Med 32 (2011) 773–782European Respiratory Society (ERS) and the European Society of Thoracic Surgeons (ESTS), the second was published in 2010 on behalf ofthe British Thoracic Society (BTS) and the Society for Cardiothoracic Surgeons (SCTS) of Great Britain and Ireland
24tenets 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):46–52lung cancer is one of the main indications for lung resection, despite only 15% to 25% of all lung cancers being operable at the time of presentation.
25Assessment of cardiopulmonary reserve before lung resection ERS/ESTS They affirmed that all patients should undergo a detailed cardiac history, physical and electrocardiographic examination in order to be risk stratified according to the Revised Cardiac Risk Index (RCRI)  proposed by the American College of Cardiology (ACC) Foundation and the American Heart Association (AHA) .Those patients with an RCRI of 3 or greater should be carefully evaluated with specific cardiac tests in order to identify pathological conditions that can betreated
26Risk assessment of post-treatment dyspnea- BTS/SCTS
27Take home for lung surgery candidates (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
28Risk indicesArozullah 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:The first model was developed using data from 81,719 noncardiac surgeries at 44 medical centers between 1991 and 1993; it was validated using data from 99,390 noncardiac surgeries at 132 medical centers between 1994 and Minor procedures and major transplantations were excluded. Women were also excluded because they were much younger and healthier than the average male patient.1 Patients were followed for 30 days. The model was designed to predict respiratory failure, defined as mechanical ventilation required for at least 48 hours after surgery or as reintubation after having been extubated postoperatively.
30BARIATRIC SURGERY CHF OR 5.3 (1.2-23) Stroke OR 4.1 (1.4-11) >32,000 patients0.6% developed PRF and 0.6% PP30 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 surgeryGupta et al. Predictors of pulmonary complications after bariatric surgery. Surg Obes Relat Dis May 13.
31CARDIAC SURGERY>11,000 patients3 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 complicationsSaleh 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 Jul;42(1):OTHERS: h/o CABG, emergent surgery, infiltrate on CXR, BUN>30, acute MI on admission
32PREVENTION OF POST-OP COMPLICATIONS Lung Specific StrategiesAnesthetic techniquesSurgical techniquesPeri-operative care
33PREVENTION OF POST-OP COMPLICATIONS Lung Specific Strategies Smoking Cessation Lung Expansion Optimize bronchodilatorsAnesthetic techniquesSurgical techniquesPeri-operative careLung expansion techniques include incentive spirometry; chest physical therapy, including deep breathing exercises; cough; postural drainage; percussion and vibration; suctioning and ambulation; intermittent positive-pressure breathing; and continuous positive-airway pressure.The available evidence suggests that for patients undergoing abdominal surgery, any type of lung expansion intervention is better than no prophylaxis at all.
34Lung expansion 172 patients- Celli, B and Snider GL. ARRD 1984 Prospective, RCT in Abdominal surgeryCochrane 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=44IPPB=45IS=42DBE=41PPC48%22%21%LOS8.6+-39.6+-39.9+-6
35PREVENTION OF POST-OP COMPLICATIONS Lung Specific StrategiesAnesthetic techniques NM blockade (longer acting worse) Intraoperative PEEP (No effect)Surgical techniquesPeri-operative careCochrane Database Syst Rev Sep 8;(9):CD007922
36PREVENTION OF POST-OP COMPLICATIONS Lung Specific StrategiesAnesthetic techniquesSurgical techniquesPeri-operative careNot enough evidence
37PREVENTION OF POST-OP COMPLICATIONS Lung Specific StrategiesAnesthetic techniquesSurgical techniquesPeri-operative care Selective NOT routine use of nasogastric tubes after elective lap lower rates of pneumonia/atelectasisDon’t forget- early ambulation and DVT prophylaxis