1. 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

2. Topics The concepts for performing effective consultationThe 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 examplePreoperative care of pulmonary patients: An example

3. 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

4. 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

5. “ 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

6. 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

7. 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

8. Factors related to PPCs Patients-related risk factors Operation-related risk factors Anesthetic-related risk factors Risk factors related to postoperative care

9. 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 10234567 Postoperative pneumonia (OR)

10. 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 10234567 Postoperative pneumonia (OR)

11. 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 10234567 Postoperative pneumonia Postoperative pneumonia and respiratory failure Postoperative pneumonia

12. Operation-related risk factors Arozullah AM,et al. Ann Intern Med 2001 Ann Surg 2000 Neurosurgery Vascular Neck Upper abdomen AAA-repair 1024681012 Postoperative respiratory failure (OR) 1416 Thoracic

13. Influence of surgical site on rate of PPCS Study Upper Abdomen Lower abdomen Laparoscopic Thoracic Tarhan 1973 13710 Garcey 1979 25019 Garribaldi 1981 17540 SSA club 1994 0.3 Phillips 1994 0.4 Brooks 1997 2815 Smetana GW, et al New Engl J Med 1999

14. Mortality for lung resection Mitsudomi T, et al. J Surg Oncol 1996; 61:218-22 Multicenter study 12,00 patients, thoracotomies usually CA % Mortality

15. Anesthetic-related risk factors General anesthesia (thoracic, Ab, Vascular) Operation time >3 hrs 10234567 Smetana GW, et al New Engl J Med 1999

16. Neuromuscular block and PPCs: Long acting VS shorter acting Berg H, et al Acta Anaesthesiol Scand 1997 Incidence of residual NMB 26*, VS 5.3** Incidence of Complication

17. 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

18. Preoperative pulmonary evaluations History and physical examination Chest radiography Arterial blood gas analysis Pulmonary function test Quantitative lung scan Exercise test

19. Chest radiography Two potential indication 1. To identified abnormalities  correcting, modification cancellation surgery 2. Serve as a base line finding

20. The value of an abnormal CXR before surgery Smetana GW, et al Med Clin N Am 2003

21. The abnormal CXR and aging Silvestri L, et al Eur J Anaesthesiol 1999

22. 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

23. 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 1975 Stein M, et al. JAMA 1962

24. Spirometry

25. 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

26. Adapt from Smetana GW,et al. New Engl J Med 1999;340:937-944. Stein 1970 Collin 1968 Appleberg 1974 Fogh 1987 Kispert 1992 10246810121416 Swensson 1991 Use of preoperative spirometry to predicted PPCs Kroenke 1993 Kocabas 1996 Bando 1997 Jacob 1997

27. 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.

28. PFT Diagram in Preoperative Evaluation PFT (FEV1,MVV, DLCO) Cleared for any resection High risk consider exercise test Perfusion 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, <1.3 PPO-FEV1 <0.8

29. 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

30. uantitative lung scan

31. Interpretation of quantitative lung scan

32. Exercise testing Assessing the risk in pts undergoing thoracotomy is controversial Acceptable value; maximum oxygen consumption > 15 ml/kg/min

33. Risk indices for preoperative assessment Risk class Pneumonia Risk (total point) Predicted Prob. pneumonia (%) Respiratory Failure (total point) Predicted Prob. Res. failure (%) 1 0-150.20-100.5 2 16-251.211-192.2 3 26-404.020-275.0 4 41-559.428-4011.6 5 >5515.4>4030.5 Arozullah AM,et al. Med Clin N Am 2003

34. ตัวอย่างการประเมินโดยใช้ Risk indicies ผู้ป่วยชายอายุ 60 ปี (9) ต้องเข้ารับการผ่าตัดมะเร็งปอดระยะ IIa (14) มีประวัติสูบบุหรี่ 30 pack/year จนหยุดสูบมา 4 สัปดาห์ (3) ได้รับการวินิจฉัยเป็น COPD (5) รวมได้คะแนน 31 จากตาราง risk class 3 ซึ่ง predicted prob. pneumonia 4%, respiratory failure 11.6 %

35. 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

36. 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)

37. Preoperative smoking cessation and PPCs Warner MA,et al. Mayo Clin Proc 1989 Prospective study 200 patients, CABG % Complication

38. Preoperative smoking cessation and PPCs Nakagawa M, et al Chest 2001;120:705-10 Retrospective study 288 patients, pulmonary surgery % Complication

39. 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 1998 Warner MA, et al. Mayo Clin Proc 1989

40. Short term smoking cessation Decrease carboxyhemoglobin and nicotine level Improved mucocilliary function and upper airway hypersensitivity Buist AS, et al. Am Rev Respir Dis 1976 Camner P, et al. Chest 1973 Kamban JR,et al. Anesth Analg 1986

41. 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)

42. 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.

43. 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

44. 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.

45. 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.

46. 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

47. 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

48. Pre- RX (%) Post – RX (%) % CHG FEV1/FVC (%) 5560 FEV1 (L) 1.31(48)1.39(53)5 FVC (L) 2.40(66)2.50(69)4 FEF 25- 75% (L/min) 0.43(15)0.6(22)22 Spirometry of the patient

49. Further evaluation PPO-FEV1 RUL : RLL= 0.55: 0.45 RUL = 24.7% RLL= 20.3% LL = 55%

50. 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

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