Perioperative medical management of patients with COPD

Figures & data

Table 1 Grading of postoperative cardiopulmonary complications

	Diagnostic criteria	Grade I	Grade II	Grade III	Grade IV
Cardiac
– Arrythmia	ECG, treatment with electrolytes, drugs and/or electrical shock	SVE, benign VE, sinus tachycardia, AF + electrolytes adjustment	+ pharmacological treatment (anti-arrhythmic)	tachyarrhythmia + electrical shock	cardiac arrest + defibrillation and/or resuscitative maneuvers
– Conduction blockade	ECG, treatment with pacemaker	AV 1st–2nd degree block	AV 2nd degree block (Wenckeback)	AV 3rd degree block + pacemaker
– Cardiac insufficiency	Chest X-rays, drugs, echocardiography, ICU/HDU transfer, assist device	asymptomatic	+ diuretics, vasodilators	+ transfer in HDU or ICU,inotropes	low cardiac output syndrome, aortic balloon counterpulsation
– Tamponnade	echocardiography, drainage			pericardial drainage	low cardiac output and drainage
– Myocardial ischemia/infarct	ECG, troponin	Transient ECG changes: ST-segment, T wave	Troponin 0.1–1.5 ng/ml	Troponin > 1.5 ng	Troponin > 1.5 ng, unstable angina, arrhythmias, low cardiac output
Pulmonary
– Atelectasis	Chest-X rays, CT-scan, treatment	+ chest physiotherapy	+ CPAP	+ bronchial fibroscopy
– Bronchopneumonia	Temperature, WBC count,bacteriology, treatment		+ antibiotics, on the ward	+ antibiotics and supportive respiratory treatment	+ respiratory failure
– Hypoxemia	SpO2, PaO2, A-aDO2, PaO2/FIO2, chest X-rays treatment	+ oxygen therapy	+ oxygen therapy	PaO2/FIO2 < 220 + NIV ALI/ARDS	PaO2/FIO2 < 220 + intubation, mechanical ventila tion, ALI/ARDS
– Respiratory failure	Need for ventilatory support			+ NIV	intubation, mechanical ventilation
– Bronchopleural fistula	bronchoscopy, treatment		+ endoscopic treatment	+ surgical closure, empyema
– Pleural effusion	chest X-rays, drainage	mild	+ thoracic drainage

Abbreviations: SVE, supraventricular extrasystole; VE, ventricular extrasystole; AF, atrial fibrillation; AV, atrioventricular; HDU, high dependency unit; ICU, intensive care unit; ALI, acute lung injury; ARDS, adult respiratory distress syndrome.

Adapted from Dindo D, Clavien PA. 2004.

Table 2 Multivariate risk indices for postoperative pneumonia, respiratory failure and cardiac complications

Variables	Odds ratio (95% CI) for PPC	Points for pneumonia	Points for respiratory failure	Odds ratio (95% CI) for cardiac complications
Surgery type/site
AAA repair	6.9 (2.7–17.4)	15	27	2.8 (1.6–4.9)
Thoracic	4.2 (2.9–6.2)	14	21	2.8 (1.6–4.9)
Neurosurgery	2.5 (1.8–3.5)	8	14
Upper abdominal	2.9 (2.3–3.6)	10	14	2.8 (1.6–4.9)
Vascular	2.2 (1.8–2.7)	3	14	2.8 (1.6–4.9)
Head and neck	1.5 (1.3–1.7)	8	11
Emergency surgery	2.2 (1.6–3.1)	3	11
Prolonged surgery	2.3 (1.4–3.5)
General anesthesia	1.8 (1.4–2.5)	4
Transfusion > 4 units		4
Age 60–69	2.1 (1.6–2.6)
Age 70–79	3.0 (2.1–4.4)	13	6
Age > 80		17	NA
COPD	1.8 (1.4–2.2)	5	6
Coronary artery disease		na	na	2.4 (1.3–4.2)
History of cardiac failure	2.9 (1.0–8.0)	na	na	1.9 (1.1–3.5)
History of stroke/TIA		4		3.2 (1.3–6.0)
Renal insufficiency *		3	8	3.0 (1.4–6.8)
ASA ≥ 3	2.6 (1.7–3.8)
Functional dependency		10	7
Weight loss > 10%		7	na
Altered sensorium		4
Smoking (<1 yr)	1.3 (1.0–1.6)	3
Steroid treatment		3
Alcohol (≥2 drinks)		2
Albumin <3 g/dL	2.5	NA	9
Risk class (total)		Risk for pneumonia	Risk for respiratory failure
Class 1
10–15 for pneumonia		0.24%
≤10 for resp. failure			0.50%
Class 2
16–25 for pneumonia		1.19%
11–19 for resp. failure			2.10%
Class 3
26–40 for pneumonia		4.0%
20–27 for resp. failure			5.3%
Class 4
41–55 for pneumonia		9.4%
28–40 for resp. failure			11.9%
Class 5
≥55 for pneumonia		15.8%
≥40 for resp. failure			30.9%

* BUN >30 mg/dl (respiratory failure or pneumonia), creatinine >2 mg/dl (cardiac complications).

Abbreviations: AAA, aortic abdominal aneurysm; TIA, transient ischemic attack.

Adapted from Arozullah AM et al 2000, Arozullah AM et al 2001, Boersma E et al 2005, Lee TH et al 1999.

Table 3 General health status assessment

Variables	Class I	Class II	Class III	Class IV	Class V
ASA	Normal healthy, without organic physiologic, or psychiatric disorders	Controlled medical condition without systemic effects (smoking without COPD, anemia, >70 years	Medical condition with systemic effects and/or functional compromise (stable angina or heart failure, moderate BPCO)	Poorly controlled-medical condition potentially life-threatening (eg, unstable angina, severe COPD)	Moribund, expected to survive less than 24 hr postoperatively
Duke Activity Status Index	>8 MET run, swim, play tennis	5–7 MET yardwork, climb 4 flights of stairs	2–4 MET Light housework, <3 flights of stairs	<2 MET walking 1–2 blocks, climb 1–2 flights of stairs, bedbound

Abbreviation: MET, metabolic equivalent (1 MET = basal oxygen cons umption).

Figure 1 Thoracic wall and diaphragmatic motion during breathing in awake (dotted line) and in anesthetized subjects (continuous line).

Table 4 Effects of anesthesia on respiratory function

1. Lung volume

Atelectasis in dependent lung areas

↙ Functional respiratory capacity (FRC)

↗ Closing volume

↙ Lung compliance

In COPD patients: ↗ FRC and ↗ dead space (air trapping) due to incomplete expiratory emptying of the most diseased lung regions

2. Airways

Bronchodilatation (volatile anesthetic agents)

↙ Tonic activity of the muscle controlling the upper airways

↙ Bronchial mucociliary clearance

↗ = Airway resistance

3. Ventilatory control

↙ Ventilatory response to hypercarbia

↙ Ventilatory response to hypoxia

↙ Ventilatory response to acidosis

4. Pulmonary circulation

↙ Hypoxic vasoconstrictor response (volatile anesthetic agents)

5. Blood gas exchange

↗P A-aO2 gradient due to mismatch in regional VA/Q ratios

6. Immune function

↙ Bactericidal activity of alveolar and bronchial macrophages

↗ Release of pro-inflammatory cytokines

Abbreviations: P_A-aO₂ gradient, alveolar-arterial oxygen gradient; V_A/Q ratios, ventilation – perfusion ratios.

Table 5 Strategies to reduce the risk of major postoperative complications

Risk reduction strategy for postoperative cardiac complications	Strength of evidence*	Type of complications studied
Clinical risk stratification	B	MI, CHF, arhythmia, operative mortality
Smoking cessation	?	MIsch
Drugs
– Beta-adrenergic antagonists	A and B	MIsch, MI, CHF, arhythmia, short-long-term mortality
– Alpha2-adrenergic agonists	B	Misch, MI, short-term mortality
– Calcium-channel blockers	C	MI, CHF, arhythmia, short-term mortality
– Statines	C	MI, short-long-term mortality
– Aspirine	C	MI, short-long-term mortality
Regional analgesia
– Thoracic epidural analgesia (intra-postoperative)	B	MI (mortality)
– Spinal/Epidural analgesia	C	Mortality, deep venous thrombosis, PTE, (MI, stroke)
Rewarming, normothermia	B	Misch
Hematocrit > 28%	C	Misch, serious cardiac adverse events
Right heart catheterization	D	Mortality, arhythmia, thromboembolism
Risk reduction strategy for postoperative pulmonary complications
Clinical risk stratification	C	Atelectasis, BPN, respiratory failure
Smoking cessation preoperatively	I	postoperative ventilator support
Monitoring of neuromuscular blockade and/or short-acting myorelaxants	B	Atelectasis, BPN
Intraoperative neuraxial blockade vs general anesthesia	C	Mortality, BPN, respiratory failure
Patient-controlled vs on-demand analgesia	C	pain score, overall complication, hospital length of stay
Neuraxial blockade post(-intra-) operative	C	miscellaneous PPCs
Laparoscopic vs open procedures	C	Spirometry, atelectasis, BPN, overall PPC
Selective nasogastric drainage	B	Atelectasis, BPN, bronchoaspiration
Postoperative lung expansion modalities	B	Atelectasis, BPN, bronchitis, severe hypoxemia
Nutrition
– routine parenteral or enteral nutrition	D
– immunonutrition	I
Right heart catheterization	D	Pneumonia
Risk reduction strategy for postoperative nonpulmonary INFECTIONS
Hand washing (medical and nursing team)	A	Wound infection
Antibiotic prophylaxis	A	Wound infection
Blood glucose control	B	Wound infection
Supplemental oxygen (intra-postop)	B	Wound infection
Rewarming, normothermia	C	Wound infection
Avoidance of indwelling catheters (central venous line, bladder)	C	Bacteriema, catheter-related sepsis, urinary infection
Smoking cessation preop	C	Wound infection

Abbreviations: MI, myocardial infarct; Misch, myocardial ischemia; CHF, congestive heart failure; PTE, pulmonary thromboembolism; BPN, bronchopneumonia.

A = good evidence that the strategy reduces complications and that benefits outweighs harms;

B = at least fair evidence that the strategy reduces complications;

C = at least fair evidence of positive impact although the harm and benefit balance is too close to justify a general recommendation;

D = at least fair evidence that the strategy does not reduce complications or harmd outweigh benefit;

I = insufficient data.

Figure 2 Progressive hyperdynamic inflation in COPD patients during mechanical ventilation and its treatment.

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