Peri-op  TOC  

PERIOPERATIVE POCKET MANUAL 2005  (Contents)  - 3^rd Edition
Maracus Magallanes, MD 2005

5. PULMONARY CONCERNS

• COPD/asthma.
• Restrictive lung disease.
• Postop PROPHYLACTIC Measures
• Postop Pulmonary Embolism  

CHRONIC OBSTRUCTIVE LUNG DISEASE

*COPD/asthma
is a major risk factor for the development of postoperative pulmonary complications. As a rule, the risk of pulmonary complications is directly related to the severity of the lung disease AND the proximity of the surgical site to the thorax and diaphragm. Pulmonary function testing has very limited utility in the inpatient pre-operative setting.

MANAGEMENT:

1. Bronchodilator therapy with albuterol HHN; add atrovent HHN if emphysematous type lung disease.
2. • a. Inhaled steroids should be continued perioperatively if patient uses chronically and respiratory status is stable.
   • b. Treatment with oral or IV steroid therapy can be given to patients who have active COPD/asthma preoperatively or who develop exacerbation postoperatively. Try to limit the duration of steroid therapy, particularly in the postop interval, due to concerns for wound/infection.
   • c. Prophylactic oral or IV steroids preoperatively should be considered in patients with stable COPD/asthma who clinically are at significant risk of post-op exacerbation, especially for those who have been responsive to steroids in the past. A brief course of preoperative steroids alone (<1 week) is not associated with increased surgical complications and, in fact, has been shown to markedly decrease the occurrence of postoperative pulmonary complications in these patients. (A simple regimen is prednisone 40mg or 60mg daily for 1 to 3 days preop.)
3. Oral theophylline therapy should be continued if patient uses this chronically. If the patient is NPO for an extended interval and is dependent on theophylline therapy, then IV aminophylline can be administered until patient is able to resume the PO medication. (For many patients, however, theophylline therapy is of question-able value and can simply be withheld while NPO.)
4. Antibiotics should only be administered if bronchitis or pneumonia is suspected; no use prophylactically for lung disease.

         PERIOPERATIVE POCKET MANUAL 2005  (Contents)

RESTRICTIVE LUNG DISEASE    
*The risk of pulmonary complications in patients with restrictive lung disease is unknown, although it appears to be much less than that associated with obstructive disease.

MANAGEMENT:

• There are no general management recommendations for patients with restrictive lung disease.
• Anesthesia should be made aware of underlying restrictive disease, particularly if general anesthesia is employed: tidal volumes should be set lower (with a higher respiratory rate) to avoid high peak pressures.

         PERIOPERATIVE POCKET MANUAL 2005  (Contents)

POSTOPERATIVE PROPHYLACTIC MEASURES IN PATIENTS WITH LUNG DISEASE:

1. Incentive spirometry
2. Sit patient up and mobilize out of bed ASAP
3. Pain control
4. Aggressive suctioning if secretions are increased
5. DVT prophylaxis

         PERIOPERATIVE POCKET MANUAL 2005  (Contents)

POSTOPERATIVE PULMONARY EMBOLISM

*Mortality in general for acute PE is up to 30% but can be reduced to 10% or less with proper management.

PRESENTATION:
Acute dyspnea, tachypnea and pleuritic pain are the most common signs/symptoms. Other findings may include tachycardia/tachyarrhythmia, cough, hemoptysis, fever, or rales. Massive PE may cause shock or sudden death.

DIAGNOSIS:

• Hypoxia is present in the majority of patients, but a normal pO2 does not rule out the diagnosis in itself.
• EKG findings are neither sensitive nor specific for PE.
• CXR is helpful mainly to rule out other possible entities, such as pulmonary edema, pneumonia, or pneumothorax.
• V/Q scan-normal study eliminates PE as possibility, high probability is 90% likelihood, low probability is 10% likelihood, indeterminant is 15-60% likelihood. Thus, only normal and high probability results are useful. (Reliability is dependent on degree of CXR abnormality)
• Chest CT (spiral)-64-93% sensitivity and 89-100% specificity (may miss smaller emboli).
• Pulmonary Angiogram-gold standard but invasive.
• D-Dimer assay-only useful to rule-out PE if "sensitive" D-Dimer assay is negative (positive test is not helpful).

Management:
Acute anticoagulation (heparin drip or enoxaparin, later coumadin)-*Must address bleeding risk with surgeon before initiating anticoagulation. IVC filter recommended if patient with PE cannot be anticoagulated.

         PERIOPERATIVE POCKET MANUAL 2005  (Contents)