Evaluation of preoperative pulmonary risk

APPROACH OF PREOPERATIVE PULMONARY RISK ASSESSMENT

Dr Nahid SherbiniPulmonary Fellow

Introduction

• Postoperative pulmonary complications morbidity and mortality.

• In a study of patients undergoing elective abdominal surgery, pulmonary complications >cardiac complications and were associated with significantly longer hospital stays

Incidence and hospital stay for cardiac and pulmonary complications after abdominal surgery.Lawrence VA, Hilsenbeck SG, Mulrow CD, Dhanda R, Sapp J, Page CPJ Gen Intern Med. 1995;10(12):671.

General complications

Atelectasis

Infection

Bronchitis

Pneumonia

Bronchospasm

Pulmonary embolism

Exacerbation of underlying chronic lung disease

Respiratory failure and prolonged invasive or NIV

OSA

ARDS

Specific cardiothoracic surgical complications

Phrenic nerve injury

Pleural effusion

Bronchopleural fistula

Sternal wound infection and empyema

Gastroesophageal anastomotic leak

Postoperative arrhythmias

Incidence • Varies 2- 70%• The rate of postoperative pulmonary complications across

all types of surgery was 6.8 % in a systematic review.

Benefits from surgery ←→ Risk of complications

Preoperative pulmonary risk stratification for noncardiothoracic surgery: systematic review for the American College of Physicians.Smetana GW, Lawrence VA, Cornell JE, American College of PhysiciansAnn Intern Med. 2006;144(8):58

SURGERY PULMONARY COMPLICATION INCIDENCE

Thoracotomy and % 30lung resectionCardiac % 40Esophagectomy % 25 - 50Abdominal % 30

Upper abdominal surgery has a complication risk which is 1,5 x

than lower abdominal surgery

PERIOPERATIVE PULMONARY PHYSIOLOGY

Reduced lung volume after surgery is a major factor

Thoracic and upper abdominal in a restrictive pattern

* (VC) is reduced by 50- 60 % * (FRC) is reduced by about 30%.

Meyers JR, Lembeck L, O'Kane H, Baue AE. Changes in functional residual capacity of the lung after operation. Arch Surg 1975; 110:576.Craig DB. Postoperative recovery of pulmonary function. Anesth Analg 1981

http://www.uptodate.com/contents/evaluation-of-preoperative-pulmonary-risk/abstract/10







• Diaphragmatic dysfunction -postoperative pain and splinting Reduction of the FRC below closing volumes atelectasis, pneumonia, &(V/Q) mismatching.

• Microatelectasis perfused but not ventilated impaired gas exchange with consequent hypoxemia .

Ford GT, Whitelaw WA, Rosenal TW, et al. Diaphragm function after upper abdominal surgery in humans. Am Rev Respir Dis 1983; 127:431. Marshall BE, Wyche MQ Jr. Hypoxemia during and after anesthesia. Anesthesiology 1972; 37:178.


• Residual effects of anesthesia depress the respiratory drive Inhibition of cough and impairment of mucociliary clearance of respiratory secretions.

A decrease in TV

increase in RR

Cough dynamics in oesophageal cancer: prevention of postoperative pulmonary complications.Sugimachi K, Ueo H, Natsuda Y, Kai H, Inokuchi K, Zaitsu ABr J Surg. 1982;69(12):734.

POSTOPERATIVE PULMONARY DYSFUNCTION

Alterations in ventilation and perfusion distrubution, in

respiratory mechanics

Postoperative Pulmonary Dysfunction

Postoperative Pulmonary Complications

Wynne R et al. AJCC 2004; 13: 384 - 93

Outlines of The Approach

• Patient related risk factors• Procedure related risk factors• Preoperative risk assessment• Risk reduction strategies

Patient related risk factors

• Age • Health state• Obesity• Smoking• COPD• Asthma• Pulmonary hypertension• Heart failure• Metabolic factors

Age

• Minor risk factor• Independent predictor

• Surgery should not be declined in elderly patients who are otherwise acceptable surgical candidates.

Prediction of outcome of surgery and anesthesia in patients over 80.,Djokovic JL, Hedley-Whyte J-JAMA. 1979;242(21):2301.Postoperative intensive care admittance: the role of tobacco smoking.-Møller AM, Maaløe R, Pedersen T-Acta Anaesthesiol Scand. 2001;45(3):345

Age• >50 y was an important independent predictor of risk.

• When compared to patients <50 years old, 50 - 59 y, 60 - 69 y 70 - 79 y, & ≥80 y (OR) of 1.50 , 2.28 , 3.90 , and 5.63 , respectively.

• Even healthy older patients carry a substantial risk of pulmonary complications after surgery.

Preoperative pulmonary risk stratification for noncardiothoracic surgery: systematic review for the American College of Physicians.Smetana GW, Lawrence VA, Cornell JE, American College of PhysiciansAnn Intern Med. 2006;144(8):581.

General health status• Functional dependence and impaired sensorium each

increase postoperative pulmonary risk .

(ASA) classification correlates well with pulmonary risk

(significant preexisting lung disease would be classified in a higher ASA class)

ASA class >2 confers a 4.87 fold increase in risk .


AMERICAN SOCIETY OF ANAESTHESIA (ASA) CLINICAL SCORE

• ASA- I No systemic disorder

• ASA- II Mild disorder

• ASA- III Moderate disorder *

• ASA- IV Severe disorder

• ASA- V Cause of death

ASA

Smoking• Current cigarette smokers have an increased risk ,even in

the absence of chronic lung disease .

• A prospective cohort study of 410 patients undergoing elective, noncardiac surgery found that smoking was associated with a greater than five-fold increase in the postoperative complication rate (OR = 5.5) .

A prospective survey of the incidence of postoperative pulmonary complications. Wightman JA Br J Surg. 1968;55(2):85.Preoperative smoking habits and postoperative pulmonary complications.Bluman LG, Mosca L, Newman N, Simon DG -Chest. 1998;113(4):88

Smoking

• Smoking history of 40 pack years or more →↑risk of pulmonary complications

• stopped smoking < 2 months : stopped for > 2 months = 4:1 (57% : 14.5%)

• quit smoking > 6 months : never smoked = 1:1 (11% : 11.9%)

Preoperative smoking habits and postoperative pulmonary complications.Bluman LG, Mosca L, Newman N, Simon DG /Chest. 1998;113(4):883.Relationship between the duration of the preoperative smoke-free period and the incidence of postoperative pulmonary complications after pulmonary surgery./Nakagawa M, Tanaka H, Tsukuma H, Kishi Y/Chest. 2001;120(3):705

COPD

• Unadjusted relative risks have ranged 2.7 to 6.0 .

• A more recent systematic review impact was less than previously estimated . multivariable analysis to adjust for patient-related confounders odds ratio for postoperative pulmonary complications was 2.36 (CI 1.90-2.93).

Preoperative pulmonary evaluation. /Smetana GWN Engl J Med. 1999;340(12):937.Preoperative pulmonary risk stratification for noncardiothoracic surgery: systematic review for the American College of Physicians. Smetana GW, Lawrence VA, Cornell JE, American College of PhysiciansAnn Intern Med. 2006;144(8):581.

Asthma

• Despite early reports indicating that patients with asthma had higher rate.

• Recent studies have found no link for patients with well-controlled asthma. The largest studied 706 patients with asthma undergoing general surgery .

Perioperative respiratory complications in patients with asthma.Warner DO, Warner MA, Barnes RD, Offord KP, Schroeder DR, Gray DT, Yunginger JW /Anesthesiology. 1996;85(3):460.

Obesity

• Morbid obesity →

restrictive lung disease

↓ thoracic compliance

alveolar hypoventilation

Obesity

• Obesity is not a significant risk factor not affect patient selection for otherwise high-risk procedures

• A systematic review found that, among 8 studies using multivariate analysis, only one study identified obesity as an independent predictor .


Obstructive sleep apnea (OSA)

• An emerging risk factor for postoperative pulmonary complications.

• Increases the risk of critical respiratory events immediately after surgery, including early hypoxemia and unplanned reintubation.

Practice guidelines for the perioperative management of patients with obstructive sleep apnea: a report by the American Society of Anesthesiologists Task Force on Perioperative Management of patients with obstructive sleep apnea.Gross JB, Bachenberg KL, Benumof JL, Caplan RA, Connis RT, CotéCJ, Nickinovich DG, Prachand V, Ward DS, Weaver EM, Ydens L, Yu S, American Society of Anesthesiologists Task Force on Perioperative ManagementAnesthesiology. 2006;104(5):1081.

OSA• The largest study to date ,evaluated 3.4 million general

surgical and 2.6 million orthopedic patients from an administrative database . Patients with OSA were more likely to develop respiratory failure (OR 1.95, CI 1.91-1.98) and aspiration pneumonia (OR 1.37, CI 1.33-1.41).

Comparable rates :

GS OR 5.20 (CI 5.05-5.37)

ORTHOOR 1.41 (CI 1.35-1.47)

Screening ??

Perioperative pulmonary outcomes in patients with sleep apnea after noncardiac surgery.Memtsoudis S, Liu SS, Ma Y, Chiu YL, Walz JM, Gaber-Baylis LK, Mazumdar MAnesth Analg. 2011 Jan;112(1):113-21. Epub 2010 Nov 16

Pulmonary hypertension

• Increases complication rates after surgery, including in patients with mild to moderate pulmonary hypertension.

• Regardless of the underlying etiology.

Noncardiothoracic nonobstetric surgery in mild-to-moderate pulmonary hypertension.Price LC, Montani D, Jaïs X, Dick JR, Simonneau G, Sitbon O, Mercier FJ, Humbert MEur Respir J. 2010;35(6):1294.Impact of pulmonary hypertension on the outcomes of noncardiac surgery: predictors of perioperative morbidity and mortality.Ramakrishna G, Sprung J, Ravi BS, Chandrasekaran K, McGoon MDJ Am Coll Cardiol. 2005;45(10):16

Heart failure • The risk higher in patients with heart failure than in those

with COPD.

• Systematic review pooled adjusted odds ratio for pulmonary complications were 2.93 (95% CI 1.02-8.43) for heart failure patients and 2.36 (1.90-2.93) for patients with COPD.


Metabolic factors• Albumin less than 3 g/dL OR 2.53• Blood urea nitrogen (BUN) >30 mg/Dl OR 2.29

• A systematic review found that the magnitude of risk associated with a low serum albumin was similar to the degree of the most important patient-related risk factors and a stronger predictor of risk than an elevated BUN

Procedure related risk factors

• Surgical site

• Duration and type of anesthesia

• Type of neuromuscular blockade

Surgical site• The most important predictor of pulmonary complications

• The incidence of complications is inversely related to the distance of the surgical incision from the diaphragm

• The complication rates for upper abdominal and thoracic surgery are the highest (range 10% to 40%)

Preoperative pulmonary risk stratification for noncardiothoracic surgery: systematic review for the American College of Physicians.Smetana GW, Lawrence VA, Cornell JE, American College of PhysiciansAnn Intern Med. 2006;144(8)

Surgical site (cont.)

• Upper abdomen• Incisions cross the abd. muscle,↓ diaphragmatic motility → ↓VC

• Lateral thoracotomy• Incision of the intercostal muscle, introduction of a pleural drain →

pleural effusion, post-op pain → ↓ thoracic compliance

Surgical site (cont.) Thoracotomy

• Without pulmonary disease

• VC ↓ to 60~70% of the pre-operative value

• With pulmonary disease• The effects of thoracotomy

are amplified

• Thoractomy → thoracic pain → ↓deep breathing, effective coughing → atelectasis, bronchial mucous retention, worsening of gas exchange

Surgical site (cont.) Video-assisted thoracoscopic surgery (VATS)

• Reduced pain ,Postoperative complications, release and responses of proinflammatory cytokines, and better ventilatory function.

• VATS lobectomy in NSCLC at clinical stage I could well be acceptable• with 97.2% 8-year survival rate , better than outcomes by

thoracotomy.

Surgical site (cont.)• Heart-surgery

• usually require median sternotomy• functionally better tolerated than lateral thoracotomy (due to

preserves the pleural space) • respiratory function is generally well preserved, except for a

transitory reduction in pulmonary volumes.

Duration and type of anaesthesia

• Anesthesia time of > 3.5 -4hours →↑incidence of pulmonary complications

• in a very high risk patient→ a less ambitious, briefer procedure

• general anesthesia > epidural analgesia ,neuromuscular blocker and local anesthesia

Postoperative intensive care admittance: the role of tobacco smoking.Møller AM, Maaløe R, Pedersen TActa Anaesthesiol Scand. 2001;45(3):3

Type of neuromuscular blockade

• Pancuronium, a long-acting neuromuscular blocker• a higher incidence of postoperative residual neuromuscular

blockade • a higher incidence of postoperative pulmonary complications in

those patients with residual neuromuscular blockade

Residual neuromuscular blockade and critical respiratory events in the postanesthesia care unit.Murphy GS, Szokol JW, Marymont JH, Greenberg SB, Avram MJ, Vender JSAnesth Analg. 2008;107(1):13

PREOPERATIVE RISKSASSESSMENT

ASSIGNMENT OF PREOPERATIVE RISKS

CLINICAL EVALUATION (Basic rule)

• History

Present / history of lung disease Respiratory symptoms (dyspnea, cough) Smoking Other co morbid diseases Drugs Atopy (individual or family) history Exercise intolerance


• Physical Examination

Symptoms of increased sputum secretion (ralles) Obstruction findings (Wheezing, prolonged expiration) Symptoms of emphysema Symptoms of respiratory insufficiency Hypertension, arrthymia, tachycardia


AND

• Arterial blood gas• Chest X-Ray• Functional Evaluation (Spirometry,Diffusion

Capacity)• Exercise Tests

ARTERIAL BLOOD GASES – A DIFFERENT POINT OF VİEW

• PaO2 < 50 mmHg Risk• PaO2 < 60 mmHg, PaCO2 > 50 mmHg

Nagasaki F, Chest 1982; 82: 25-29

• PaCO2 > 45 mmHg resection with high risk Morice RC, Chest 1992; 101: 356-361 Bolliger CT, ERJ 1998; 11:198-212 CCP, Ann Inter Med 1990; 112: 793-794

ARTERIAL BLOOD GASES – GENERAL OPINION

• Hypercarbia in patients with COPD (PaCO2 > 45 mmHg), is not a certain contrendication but is believed to be with high surgical risk

• Hypoxemia, is not a significiant predictor of complication alone

Prediction of postoperative pulmonary complications in oesophagogastric cancer surgery.Fan ST, Lau WY, Yip WC, Poon GP, Yeung C, Lam WK, Wong KKBr J Surg. 1987;74(5):408.

EVALUATION OF PREOPERATIVE RISKS

• RADIOLOGICAL EVALUATION

There is no role of CXR in evaluating postoperative risks in healthy persons, but it must be performed.

Preoperative CXR is essential for patients >60Y with cardiac or pulmonary problems

Value of routine preoperative chest x-rays: a meta-analysis.Archer C, Levy AR, McGregor MCan J Anaesth. 1993;40(11):102

EVALUATION OF PREOPERATIVE RISKS

EXERCISE TESTS

• Walking test (6min) • Stair climbing test• Step test• “Shuttle walk” test• Bicycle ergometery ( MVO2 )

* Routine use before general surgery is not recommended

EXCEPT FOR LUNG RESECTION

PFT

• Two reasonable goals to use of preoperative PFTs

1. Identification of a group of patients for whom the risk of the proposed surgery is not justified by the benefit

2. Identification of a subset of patients at higher risk for whom aggressive perioperative management is warranted

PFT

• These tests simply confirm the clinical impression of disease severity in most cases, adding little to the clinical estimation of risk

• Overused

ACP GUIDELINES 2006• Not use preoperative spirometry routinely for predicting

the risk of postoperative pulmonary complications .

Obtain in:

1. COPD or asthma if clinical evaluation cannot determine if the patient is at their best baseline and that airflow obstruction is optimally reduced.

2. Dyspnea or exercise intolerance that remains unexplained after clinical evaluation.

3. ALL for lung resection

PFTs should not be used as the primary factor to deny surgery

SPIROMETERY

Postoperative risk (Gass & Olsen, 1986)

FVC < % 70 FEV1 < % 70 Complication risk FEV1 / FVC < % 65

• A normal PFT does not demonstrate a lower postoperative complication rate

PREOPERATIVE PULMONARY FUNCTION TESTS

Severe COPD (FEV1 < % 50)

• Preoperative PFT not predict postoperative pulmonary complication risk

• Surgery time• ASA class predict significiantly• Surgery type

Kroenke L. Arch Intern Med 1992

PULMONARY RISK INDEXES

Cardiopulmonary Risk Index Epstein SK. Chest 1993;104:694

Lawrence Risk Index Lawrence WA. Chest 1996; 110: 744

Brooks – Brunn Risk Index Brooks-Brunn JA. Chest 1997;111: 564

Multifactorial Risk Index

Arozullah AM. Ann Surg 2000; 232: 242

Variant Score

BMI > 27 kg/m2 1

Cigarette (last 8 weeks) 1

Productive coughing (last 5 days) 1

Wheezing (last 5 days) 1

FEV1/FVC < % 70 (predicted) 1

PaCO2 > 45 mmHg 1

Total 6

Pulmonary risk index: Factors that increase postoperative pulmonary complications

> 4: Pulmonary risk % 73.4

< 4: Pulmonary risk % 11

PULMONARY RISK INDEX

Score

History Age > 70 5

MI (last 6 month) 10

Physical examination JVD or S3 11

Aortic valve stenosis 3

ECG Non-sinusoidal rhtym, atrial premature pulse

7

> 5 / min. Ventricular premature pulse 7

Status PO2 < 60 or PCO2 > 50 3

K > 3 or HCO3 < 20

BUN > 50 or Creatinin > 3

Chronic liver disease.

Non-cardiac dis. Bed treatment.

Surgery Thorac , abdom, aortic 3

Emergency surgery 4

Total 53

Class 1: 0-5

Class 2: 6-12

Class 3: 13-25

Class 4: > 25

GOLDMAN’ S CARDIAC RISK INDEX

CARDIOPULMONARY RISK SCORE

• Cardiac risk index score : 1 - 4

• Pulmonary risk index score : 0 – 6

Cardiopulmonary risk index score = 1-10 Cardiac ( 1- 4 ) + Pulmonary ( 0 - 6 )

Index > 4 : Complication risk 22 times higherIndex < 2 : No Complication

Epstein SK. Chest 1993;104:694.

MULTIFACTORIAL RISK INDEX (Postoperative respiratory insufficiency)

Type of surgery Abdominal aort aneurisym 27 Thoracic 21 Upper abdom., neurochirurgia, per.vascular 14 Neck 11

Emergency surgery 11 Albumin < 3.0 g/dL 9 BUN > 30 g/dL 8 Functional addiction ( partial or complete) 7 COPD 6 Age > 70 6 Age 60 - 69 4


MULTIFACTORIAL RISK INDEX

Degree Score Resp. Insufficiency %

1 < 10 0.5

2 11-19 1.8

3 20-27 4.2

4 28-40 10.1

5 > 40 26.6


RESECTION SURGERY

SPECIFIC EVALUATION OF LUNGS

AIM

• Severity of existing pathology and its reversibility

• Estimation of predicted pulmonary function after resection

RESECTION SURGERY

• General Evaluation• Respiratory Function

Spirometry – FEV1

Diffusion Capacity Postoperative FEV1 (FVC, DLCO, VO2 max)

• ABG• Exercise Capacity

Assessment for lung resection

RESECTION SURGERY - SPIROMETRY

FEV1 is primary parameter

Pneumonectomy: Preoperative FEV1 > 2 L ( > % 80 predicted )

Lobectomy : Preoperative FEV1 > 1 L

Wedge and segmental resection = 0.6 L

DIFFUSION CAPACITY

• DLCO < % 50 major resection is contrendicated

Cander L. A J Cardiol 1963

• DLCO < % 60 mortality risk % 24

• ppoDLCO < % 40 mortality risk % 33

Markos J, Mullan BP, Hillman DR, et al. Preoperative assessment as a predictor of mortality and morbity after lung resection. Am Rev Respir Dis 1989; 139: 902-910

Split lung function studies• Predicting post-resection pulmonary function

• Predicted postoperative FEV1 (ppoFEV1) is the most valid single test available• ppoFEV1 = preoperative FEV1 × (1– %functional tissue

removed/100)• lung function can be calculated by counting the number of

segments removed • The lungs contain 19 segments (3 right upper lobes, 2 right

middle lobes, 5 right lower lobes, 3 left upper lobes, 4 left lower lobes, 2 left lingula)

Split lung function studies(cont.)

• Ventilation-perfusion(V/Q) scan

• Quantitatve CT

FEV1 AFTER RESECTION (QUANTITATIVE SCINTIGRAPHY)

PNEUMONECTOMY Estimated Postoperative FEV1 = Preoperative FEV1 X perfusion percent of remaining lung

LOBECTOMY Estimated Postoperative FEV1 = Preoperative FEV1 X Remaining segments after resection

Total segments of both lungs

FEV1 AFTER RESECTION

If a part of resected segments is bronchoscopically obstructed

Estimated

Postoperative FEV1 = Preoperative FEV1 X [( 19-a ) - b]

19 – b

a- Resected obstructed segments

b- Resected open segments

CARDIOPULMONARY EXERCISE TESTS

• Important in lung resection surgery VO2 max = Aerobic capacity: amount of O2 requirement for major muscle groups for 5-15 minutes

• Recommendation of BTS and ACCP

VO2max > 15 ml/kg/d Operable

VO2max < 15 ml/kg/d High risk

BTS Guidelines: Guidelines on the selection of patients with lung cancer surgery. Thorax 2001; 56:89-108Beckles MA, Spiro SG, Colice GL et al. The physiologic evaluation of patients with lung cancer being considered for resectional surgery. Chest 2003; 123: 105S-114S


Resection decision

• VO2max > % 75 Good prognosis

• VO2max > % 60 More than one lobe is contrendicated

• VO2max < % 43 Any type of resection is contrendicated

Bolliger CT,Jordan P,Soler M, et al. AJRCCM 1995;151:1472-1480


• Absolute value must be used

Eugene J, Brown SE, Light RV, et al. Surg Forum 1982; 33: 260-262 Smith TP, Kinasewitz GT, Tucker WY, et al. Am Rev Respir Dis 1984: 730-734 Bechard D, Wetstein L. Ann Thorac Surg 1987; 44: 344-349

• Absolute value or % value does not make a difference Keddissi JI, Kinasewits GT. Chest 2005; 127: 1092-1094


• % value must be used

Bolliger CT, Soler M, Stulz P, et al. Respiration 1994; 61:181-186 Bolliger CT,Jordan P,Soler M, et al. AJRCCM 1995;151:1472-1480 Win T, JacksonA, Sharples L, et al. Chest 2005;127:1159-1165 Morice RC, Peters Ej,Ryan MB,et al.Chest 1992;101:356-361 Richter Larsen K, Svendsen UG, Nilman N, et al. Eur Respir J 1997;10:1559-

1565

Assessment for lung resection

Date of download: 11/11/2012

Copyright © American College of Chest Physicians. All rights reserved.

Physiologic Evaluation of the Patient With Lung Cancer Being Considered for Resectional Surgery *: ACCP Evidenced-Based Clinical Practice Guidelines (2nd Edition)

CHEST. 2007;132(3_suppl):161S-177S. doi:10.1378/chest.07-1359

Preoperative physiologic assessment of perioperative risk. CXR = chest radiograph.

Stepwise approach to preoperative pulmonary assessment.

Bapoje S R et al. Chest 2007;132:1637-1645

©2007 by American College of Chest Physicians

Risk reduction strategies

• Pre-operative strategies

• Intra-operative strategies

• Post-operative strategies

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Evaluation of preoperative pulmonary risk

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