Preoperative Care of Pulmonary Patients3

8/17/2019 Preoperative Care of Pulmonary Patients3

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!opics

• !he concepts for performing effective cons

ultation

• Factors related to PPCs

• Preoperative pulmonary evaluations

• "isk indices for preoperative assessment

• "isk reduction strategies• Preoperative care of pulmonary patients:

An e#ample


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!he concepts for performing

effective consultation

• Prompt response (within 24 hours)

• Focus on central issue

• Identified critical recommendations

• Make specific and limit number ofrecommendations(


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+ Referring physician and theconsultant both ha!e

responsibilities to fulfill in order to

ma-imie the effecti!eness of theconsultation in impro!in" the

patient care,

Cohn $%. ptoDate &''&


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!he role of preoperative medical

consultation

• Identif'in" and e!aluation the medical

status

• Pro!ide a clinical risk profile• .o optimie the medical condition in

attempt to reduce risk of PP/s


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Postoperative pulmonary

complications -PPCs

• /ommon complications% 0 of death

related to PP/s

•Incidence and pre!alence !ar' 1 Population

1 .'pe of sur"er'

1 #efinition of complications

(rooks/0runn 1A .2eart %ung *++3


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Factors related to PPCs

• Patients/related risk factors

• 4peration/related risk factors

• Anesthetic/related risk factors

• "isk factors related to postoperative care


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Patient/related risk factors: Aging

Aro5ullah AM,et al. Ann 6ntern Med &''* Ann $urg &'''

3'/3+ 7"s

8 3' 7"s

9'/9+ 7"s

'/+ 7"s

;' 7"s

*' & < = 3 9

Postoperative pneumonia -4"


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Patient/related risk factors: >eneral health


C?A

40esity

A$A ,@&

Partial depend

!otal depend

*' & < = 3 9

Postoperative pneumonia -4"


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Patient/related risk factors: 6mmune status


Alcoholic &

drinkday

Bithin & ks

6DDM

$teroid use

*' & < = 3 9

Postoperative pneumonia

Postoperative pneumonia and respiratory failure

Postoperative pneumonia


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4peration/related risk factors


eurosurgery

?ascular

eck

pper a0domen

AAA/repair

*' & = 9 ; *' *&

Postoperative respiratory failure -4"

*= *9

!horacic


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6nfluence of surgical site on rate of PPC$

$tud' pperA0domen

%oera0domen

%aparoscopic !horacic

.arhan 3 *'

6arce' 33

25 7 *+6arribaldi38

5 ='

$$9 club

334

'.<

Phillips 334 '.=

:rooks 33 28 5

$metana >B, et al e )ngl 1 Med *+++


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Mortality for lung resection

Mitsudomi !, et al. 1 $urg 4ncol *++9E 9*:&*;/&&

Multicenter study *&,'' patients , thoracotomies usually CA

Mortality


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Anesthetic/related risk factors

>eneral anesthesia-thoracic, A0, ?ascular

4peration

time < hrs

*' & < = 3 9

$metana >B, et al e )ngl 1 Med *+++


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euromuscular 0lock and PPCs:

%ong acting ?$ shorter acting

(erg 2, et al Acta Anaesthesiol $cand *++

6ncidence of residual M( &9G, ?$ 3.


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"isk factors related to postoperative care

• > tu0e 1 Postoperati!e ;6 tube not si"nificant

associated with PP/s

1 *mpt' 6I tract ma' decrease aspirationoutwei"h risk of ineffecti!e cou"hin" andorophar'"eal aspiration

• Pain control 1 9de&uate pain control impro!in" outcomes

1 *pidural anal"esia seem to be betteroutcomes than standard opioid anal"esia


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Preoperative pulmonary evaluations

• istor' and ph'sical e-amination

• /hest radio"raph'

• 9rterial blood "as anal'sis

• Pulmonar' function test

• =uantitati!e lun" scan

• *-ercise test


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Chest radiography

.wo potential indication

> .o identified abnormalities

correctin"% modification

cancellation sur"er'

2> $er!e as a base line findin"


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!he value of an a0normal CH"

0efore surgery

$metana >B, et al Med Clin Am &''<


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!he a0normal CH" and aging

$ilvestri %, et al )ur 1 Anaesthesiol *+++


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Recommendation forpreoperative CXR

• 9"e ? 57 'ears

• @nown preAe-istin" cardiopulmonar'

diseases• $$ like hoods of cardiopulmonar' disease

$metana >B, et al Med Clin Am &''<


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Arterial blood gas

• $mall stud' series identified

'percarbia(Pa/B2?45) risk for PP/s

• Cecent s'stematic re!iew b' Fisher :D%

et al 2772 dose not find h'percarbia usefulpredictor for PP/s

Milledge 1", et al. (M1 *+3

$tein M, et al. 1AMA *+9&


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Spirometry


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Pulmonary function testing

-PF!s and PPCs

• ACP guideline *++' 1 Eun" resection

1 /oronar' arter' b'pass sur"er'

1 pper abdominal sur"er' with smokin" ord'spnea

1 Eower abdominal sur"er' if une-plainedpulmonar' diseases with prolon" e-tensi!esur"er'

1 ead% neck% orthopedic sur"er' withune-plained pulmonar' diseases

Anonymous. Ann 6ntern Med *++'E **&:+


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Adapt from $metana >B,et al. e )ngl 1 Med *+++E


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PF!s and PPCs

• /aseAcontrol stud'% electi!e abdominal

sur"er'

1 /GC hi"hl' associated with PP/s (BC 5>8)

1 9bnormal P* associated with PP/s

1 Dhereas PF.s were not predicti!e

%arence ?A, et al. Chest *++9E**':==/3'.


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PF! Diagram in Preoperative )valuation

PFT(FEV1,MVV,DLCO)Cleared for any

resection

High ris considere!ercise test

Perf"sion #canning PPO$FEV1

Consider %Lesser& resection

'on s"rgical theray

Cleared for any resection High ris considere!ercise test

FEV1 >2L

MVV>50%DLCO>60%

FEV1 > 2L

MVV


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Preoperative PF!s : $ummary

• .horacic sur"er'

• pper abdominal sur"er' with respirator'

s'mptoms remain une-plained after

careful e!aluation

• Coutine PF.s should not ordered solel'

without clinical assessment

Aro5ullah AM. Med Clin Am &''


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uantitati!e lun" scan


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6nterpretation of Iuantitative

lung scan


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)#ercise testing

• 9ssessin" the risk in pts under"oin"

thoracotom' is contro!ersial

• 9cceptable !alueH ma-imum o-'"en

consumption ? 5 mlk"min


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"isk indices for preoperative assessment

Ciskclass

Pneumonia"isk

-total point

PredictedPro0.

pneumonia

-

"espiratoryFailure

-total point

PredictedPro0.

"es. failure

-

*

7A5 '.& 7A7 '.3& A25 *.& A3 &.&

< 2A47 =.' 27A2 3.'

= 4A55 +.= 28A47 **.9

3 ?55 *3.= ?47


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*+-. /0/232456789:-;


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%imitation of risk indicies

• #e!eloped from male% hi"h co morbid

le!el ma' not "eneralied to health'

population

• ospital based stud' from Keterans

ospital



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"isk reduction strategies-*

• $mokin" cessation at least 8 weeks

• Perioperati!e lun" e-pansion maneu!er

1 Incenti!e spirometr'

1 /hest ph'sical therap'

1 Intermittent positi!e pressure breathin"

(IPP:)

1 /ontinuous positi!e airwa' pressure (/P9P)


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Preoperative smoking cessation and

PPCs

Barner MA,et al. Mayo Clin Proc *+;+

Prospective study &'' patients, CA(>

Complication


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Preoperative smoking cessation and

PPCs

akagaa M, et al Chest &''*E*&':'3/*'

"etrospective study &;; patients, pulmonary surgery

Complication


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Parado#ical increase PPCs after

short/term a0stinence

• $icker pts tend to &uit smokin" closer to

sur"er'

• $top smoking decrease irritation

decrease stimulus for cou"h

$till ha!e bronchial h'persecretion

increase sputum retention

(luman %>, et al. chest *++;Barner MA et al. Ma o Clin Proc *+;+


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$hort term smoking cessation

• #ecrease carbo-'hemo"lobin and nicotine

le!el

Impro!ed mucocilliar' function and upper

airwa' h'persensiti!it'

(uist A$, et al. Am "ev "espir Dis *+9Camner P, et al. Chest *+<


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"isk reduction strategies-&

• $mokin" cessation at least 8 weeks

• Perioperati!e lun" e-pansion maneu!er

1 Incenti!e spirometr'

1 /hest ph'sical therap'

1 Intermittent positi!e pressure breathin" (IPP:)

1 /ontinuous positi!e airwa' pressure (/P9P)


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Perioperative lung e#pansion

maneuvers

• 9 metaAanal'sis e!aluatin" upper

abdominal sur"er'

1 Incenti!e spirometr' (I$)

1 #eep breathin" e-ercise (#:)

1 Intermittent positi!e pressure breathin" (IPP:)

• $imilar in efficac'

• :etter than no respirator' therap'

!homas 1A, et al. Physical !herapy *++=E =:


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Perioperative lung e#pansion

maneuvers: $ummary

• ;o specific lun" e-pansion maneu!er is

clearl' superior

• /P9P ma' be benefit in patients unable

to perform #: or I$

• Initiati!e lun" e-pansion maneu!er

preoperati!el' is more effecti!e in

reducin" PP/s than postoperati!el'

Aro5ullah AM. Med Clin Am &''


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"isk/reduction strategies:

preoperatively

• )ncourage smoking cessation at least 8 weeks

• Delay operation if respirator' infection is

present% producti!e cou"h (se!eral weeks)

• *ducation lun" e-pansion maneu!ers • Ma#imi5e pulmonary function

1 :ronchodilator

1 Inhaled corticosteroid 1 .heoph'lline

1 9ntibiotic

$metana >B, et al. e )ngl 1 Med *+++E


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6ntraoperatively

• Eimit duration of sur"er' to B, et al. e )ngl 1 Med *+++E


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postoperatively

• 9de&uate pain control

• *arl' ambulation

• se lun" e-pansion maneu!er • Ma-imied pulmonar' function

(medication)

$metana >B, et al. e )ngl 1 Med *+++E


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Preoperative Care of Pulmonary

Patients: )#ample-*

• Male 7 'rs>

• #- ;$/E/ sta"e Ib % CE

• nderl'in" /BP#• 9ssessment

1 ;ot ur"ent sur"er'% hi"h benefit

1 Cisk H elderl'% /BP# 1 istor' Ph'sical e-amination

1 Eaborator'


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Pre/"H-

Post J"H-

C2>

F)?*F?C-

33 9'

F)?* -% *.


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Further evaluation• PPBAF*K

CE CEEL 7>55 7>45

CE L 24>J

CEEL 27>J

EE L 55J


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Preoperative Care of Pulmonary Patients:

Conclusion

• Man' factors related to PP/s

• Dorkin" as a team pla's maor roles

• 9ssessment of the risks %do appropriatedtestin" and modif'in" are the ke's of

preoperati!e carin"


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Thank you

Preoperative Care of Pulmonary Patients3

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