Raccomandazioni per la val preop mal resp

Raccomandazioni per la valutazione preoperatoria dei pazienti adulti per

chirurgia non cardiacablocco II con enfasi sulle malattie

respiratorie Claudio Melloni

libero professionista

2011-2012

bull Qaseem A Snow V Fitterman N et al Risk assessment for and strategies to reduce perioperative pulmonary complications for patients undergoing noncardiothoracic surgery a guideline from the American College of Physicians Ann Intern Med 2006 144575ndash580

bull Smetana GW Lawrence VA Cornell JE Preoperative pulmonary risk stratification for noncardiothoracic surgery systematic review for the American College of Physicians Ann Intern Med 2006 144581ndash595

Pulmonary complications risk

Pneumoniarespiratoryinsufficiencyhellip

bull Risk Assessment for and Strategies To Reduce Perioperative Pulmonary Complications for PatientsUndergoing Noncardiothoracic Surgery A Guidelinefrom the American College of Physicians

bull Amir Qaseem MD PhD MHA Vincenza Snow MD Nick Fitterman MD E Rodney Hornbake MD ValerieA Lawrence MD Gerald W Smetana MD Kevin Weiss MD MPH Douglas K Owens MD MS for the Clinical Efficacy Assessment Subcommittee of the American College of PhysiciansAnnals of Internal medicine 18 April 2006 | Volume 144 Issue 8 | Pages 575-580

Relazione fra ASA PS e complicanze polmonari

Strategie tese alla riduzione delle complicanze postop

bull Lawrence VA Cornell JE Smetana GW Strategies to reduce postoperative pulmonary complications after noncardiothoracic surgery systematic review for the American College of Physicians Ann Intern Med 2005144596-608

bull Tutte le tecniche di espansione polmonare ndash spirometria incentiva

ndash terapia fisicandash provocazione della tossendash drenaggio posturalendash percussione e vibrazionendash Aspirazionendash Deambulazionendash IPPBndash CPAP

bull hanno dimostrato superioritagrave rispetto ai controlli dopo chirurgia addominale

bull Non differenze fra le diverse modalitagrave di espansione neacute dalla loro combinazione

decompressione nasogastrica selettiva

bull effettuata nei pazienti con PONV incapaci di assumere nutrizione orale o con distensione addominale

ndash diminuisce la frequenza di polmonite ed atelettasia nei confronti della decompressione con sondino routinaria finche cioegrave non ritorni la motilitagrave gastrointestinale

ndash Cheatham ML Chapman WC Key SP Sawyers JL A meta-analysis of selective

versus routine nasogastric decompression after elective laparotomy Ann Surg 1995221469-76

ndash Nelson R Tse B Edwards S Systematic review of prophylactic nasogastric decompression after abdominal operations Br J Surg 200592673-80

ndash Nelson R Edwards S Tse B Prophylactic nasogastric decompression after abdominal surgery Cochrane Database Syst Rev 2005

Pneumonia risk

Development and Validation of a Multifactorial Risk Index forPredicting Postoperative Pneumonia after Major NoncardiacSurgery Arozullah AM Khuri SF Henderson WG Daley J Ann

Intern Med 2001135847-857

bull Background Pneumonia is a common postoperative complication associated with substantial morbidity and mortality

bull Objective To develop and validate a preoperative risk index for predicting postoperative pneumonia

bull Design Prospective cohort study with outcome assessment based on chart review

bull Setting 100 Veterans Affairs Medical Centers performing major surgery

bull Patients The risk index was developed by using data on 160 805 patients undergoing major noncardiac surgery bet ween 1 September 1997 and 31 August 1999 and was validated by using data on 155 266 patients undergoing surgery between 1 September 1995 and 31 August 1997 Patients with preoperative pneumonia ventilator dependence and pneumonia that developed after postoperative respiratory failure were excluded

bull Measurements Postoperative pneumonia was defined by using the Centers for Disease Control and Prevention definition of nosocomial pneumonia

bull Results A total of 2466 patients (15) developed pneumonia and the 30-day postoperative mortality rate was 21 A postoperative pneumonia risk index was developed that included type of surgery (abdominal aortic aneurysm repair thoracic upper abdominal neck vascular and neurosurgery) age functional status weight loss chronic obstructive pulmonary disease general anesthesia

bull impaired sensorium cerebral vascular accident blood urea nitrogen level transfusion emergency surgery long-term steroid use smoking and alcohol use Patients were divided into five risk classes by using risk index scores Pneumonia rates were 02 among those with 0 to 15 risk points 12 for those with 16 to 25 risk points 40 for those with 26 to 40 risk points 94 for those with 41 to 55 risk oints and 153 for those with more than 55 risk points The C-statistic was 0805 for the development cohort and 0817 for the validation cohort

bull Conclusions The postoperative pneumonia risk index identifies patients at risk for postoperative neumonia and may be useful in guiding perioperative respiratory care

Development and Validation of a Multifactorial Risk Index forPredicting Postoperative Pneumonia after Major Noncardiac Surgery Arozullah AM Khuri SF Henderson

WG Daley J Ann Intern Med 2001135847-857

Risk of postop pneumonia

Risk factors for postop pneumoniaDevelopment and Validation of a Multifactorial Risk Index for

Predicting Postoperative Pneumonia after Major Noncardiac Surgery Arozullah AM Khuri SF Henderson WG Daley J Ann Intern Med 2001135847-857

bull Long-term steroid use

bull Age gt60 years

bull dependent functional status

bull weight loss greater than 10 of body mass in the previous 6 months

bull recent alcohol use

bull Recent smoking

bull history of chronic obstructive pulmonary disease

bull history of cerebral vascular accident with a residual deficit

bull impaired sensorium

Fattori di rischio per la polmonite postoppazienteDevelopment and Validation of a Multifactorial Risk Index for

Predicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857

bull Somministrazione di steroidi a lungo termine

bull Etagravegt60 anni

bull Stato funzionale dipendente

bull Perdita di peso gt 10 della massa coroorea nei 6 mesi precedenti

bull uso recente di alcohol

bull Fumo recente

bull Storia di COPD

bull Storia di accidente cerebrovascolare con deficit residuo

bull Disturbo di coscienza

Fattori di rischio per la polmonite postopinterventiDevelopment and Validation of a Multifactorial Risk Index for

Predicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-

857

bull abdominal aortic aneurysm repair

bull thoracic

bull neck

bull upper abdominal

bull peripheral vascular surgery

bull neurosurgery

Am J Respir Crit Care Med 2005 Mar 1171(5)514-7 Incidence of and risk factors for pulmonary complications after nonthoracic

surgeryMcAlister FA Bertsch K Man J Bradley J Jacka M

bull Identifica come fattori di rischiondash lrsquoetagravegt65 anni

ndash il fumo(gt 40 pacchettianno)

ndash la diminuzione del FEV1

ndash Diminuzione del FVC e del FEV1FVC

ndash la durata dellrsquoanestesia gt25 hr

ndash storia di COPD

ndash tosse produttiva giornaliera

ndash incisione nellrsquoaddome sup

ndash presenza di un SNG

bull Solo 4 sono indipendenti dopo una analisi multivariata etagravetest alla tosse positivopresenza periop del SNG e la durata dellrsquoanestesia

a preoperative risk index for predicting postoperative respiratory

failure (PRF)

Ahsan M Arozullah Jennifer Daley William G Henderson Shukri F Khuri for the National Veterans

Administration Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative

Respiratory Failure in Men After Major Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

bull Objective

bull To develop and validate a preoperative risk index for predicting postoperative respiratory failure (PRF)

bull prospective cohort study

bull 44 Veterans Affairs Medical Centers (n 5 81719) were used to develop the models Cases from 132 Veterans Affairs Medical Centers (n 5 99390) were used as a validation sample

bull PRF was defined as mechanical ventilation for more than 48 hours after surgery or reintubation and mechanical ventilation after postoperative extubation

bull Ventilator-dependent comatose do notresuscitate and female patients were excluded

bull respiratory care

Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major Noncardiac Surgery Ahsan M Arozullah Jennifer Daley

William G Henderson Shukri F Khuri for the National Veterans Administration Surgical Quality Improvement Program Multifactorial Risk Index for Predicting

Postoperative Respiratory Failure in Men After Major Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

bull Resultsbull PRF developed in 2746 patients (34) bull The respiratory failure risk index was developed from a simplified logistic

regression model and includedndash abdominal aortic aneurysm repairndash thoracic surgeryndash neurosurgery ndash upper abdominal surgery ndash Peripheral vascular surgery ndash neck surgeryndash emergency surgeryndash albumin level llt than 30 gL ndash BUNgt 30 mgdL ndash dependent functional statusndash chronic obstructive pulmonary disease ndash agegt60

Indici prognostici di insuff resp postop Ahsan M Arozullah MD MPH

Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the National Veterans Administration Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in

Men After Major Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

ndash Aneurismectomia aorta addominale

ndash Chir toracica

ndash neurochir

ndash Chir addominale maggiore

ndash Chir vascolare periferica

ndash Chir del collo

ndash Chir in emergenza

ndash Livelli di albumina lt 30 gL

ndash BUN gt 30 mgdL

ndash Dipendenza funzionale

ndash COPD (chronic obstructive pulmonary disease)

ndash Etagrave gt60

Probability of PRF postoperative resp failureAhsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the National Veterans Administration

Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major Noncardiac Surgery

ANNALS OF SURGERY Vol 232 No 2 242ndash253

bull Classe punti probab PRF

bull 1 lt=10 05

bull 2 11ndash19 22-18

bull 3 20ndash27 53- 42

bull 4 28ndash40 10-119

bull 5 gt40 309 -266

A comparison of risk factors for postoperative pneumonia and respiratory failureAhsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the National Veterans Administration Surgical

Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

ampAhsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDDevelopment and Validation of a Multifactorial Risk

Index for Predicting Postoperative Pneumonia after Major Noncardiac Surgery Ann Intern Med 2001135847-857

How should respiratory disease and obstructive sleep apnoea syndrome be assessed

bull Spirometrybull Many studies on spirometry and pulmonary functionbull tests relate to lung resection surgery or cardiac surgerybull and have been published mainly more than 10 yearsbull ago therefore they have been excluded from thisbull reviewbull Spirometry has value in diagnosing obstructive lungbull disease but it has not been shown to translate intobull effective risk prediction for individual patients Inbull addition there are no data indicating a prohibitivebull threshold for spirometric values below which the riskbull for surgery would be unacceptable Changes in clinicalbull management due to findings from preoperative spirometrybull were also not reported One study (published in 2000) looked at 460 patients whobull underwent abdominal surgery The authors reported thatbull a predicted FEV1 of less than 61 and a PaO2 less thanbull 93 kPa (70mmHg) the presence of ischaemic heartbull disease and advanced age each were independent riskbull factors for postoperative pulmonary complications (levelbull of evidence 2)47

bull Chest radiographybull Chest radiographs are ordered frequently as part of abull routine preoperative evaluation The evidence is poorbull and the related articles again mostly date before 2000bull and therefore were not addressed in this review Howeverbull chest radiographs are not predictive of postoperativebull pulmonary complications in a high percentage ofbull patients A change in management or cancellationbull of elective surgery was reported in only a fraction ofbull patients4849bull A meta-analysis in 2006 on the value of routine preoperativebull testing identified eight studies publishedbull between 1980 and 2000 in which the correspondingbull authors looked at the impact of chest radiographs on abull change on perioperative management In only 3 of thebull cases in these studies the chest radiograph influenced thebull management even though 231 of preoperative chestbull radiographs in that sample were abnormal (level of evidencebull 1thorn)44bull In a systematic review from 2005 the diagnostic yield ofbull chest radiographs increased with age However most ofbull the abnormalities consisted of chronic disorders such asbull cardiomegaly and chronic obstructive pulmonary diseasebull (up to 65) The rate of subsequent investigations wasbull highly variable (4ndash47) When further investigationsbull were performed the proportion of patients who had abull change in management was low (10 of investigatedbull patients) Postoperative pulmonary complications werebull also similar between patients who had preoperative chestbull radiographs (128) and patients who did not (16)bull (level of evidence 1thorn)50

Assessment of patients with obstructive sleep apnoeasyndrome

bull OSAS has been identified as an independent risk factorbull for airway management difficulties in the immediatebull postoperative period44 In a cohort study from 2008 itbull was been demonstrated that patients classified as OSASbull risk have more airway-obstructive events postoperativelybull and more periods of desaturations (SpO2 less than 90) inbull the first 12 h postoperatively (level of evidence 2thorn)51bull Data are scarce regarding the overall pulmonary complicationbull rate One casendashcontrol study with matchedbull patients undergoing hip or knee replacement surgerybull reported that serious complications after surgery suchbull as unplanned days in ICU tracheal reintubations andbull cardiac events occurred significantly more often inbull patients with OSAS (24 compared with 9 of matchedbull control patients) (level of evidence 2thorn)52 A recentcohort study also reported that postoperative cardiorespiratorybull complications were associated with a scorebull indicating the existence of OSAS (level of evidencebull 2thorn)53bull OSAS patients have been identified as having a higherbull risk of difficult airway management (level of evidencebull 2thorn)54 The American Society of Anesthesiologistsbull addressed this issue in 2006 with practice guidelinesbull including assessment of patients for possible OSASbull before surgery and suggested careful postoperativebull monitoring for those suspected to be at high risk55bull Therefore the question of how to correctly identifybull patients with OSAS or at risk for OSAS is of importancebull Of the 25 eligible studies on that topic published betweenbull 2000 and June 2010 10 dealt with measures to correctlybull identify patients with risk factors for OSAS The lsquogoldbull standardrsquo for diagnosis of sleep apnoea is an overnightbull sleep study (polysomnography) However such testing isbull time consuming expensive and unsuitable for screeningbull purposes The literature indicates that the most widelybull used screening tool for detecting sleep apnoea is the Berlinbull questionnaire (level of evidence 2)535657 Overnightbull pulse oximetry may be an additional alternative to detectbull sleep apnoea (level of evidence 2thornthorn)

bull Clin Respir J 2011 Oct5(4)219-26 doi 101111j1752-699X201000223x Epub 2010 Sep 22bull Clinical and functional prediction of moderate to severe obstructive sleep apnoeabull Bucca C Brussino L Maule MM Baldi I Guida G Culla B Merletti F Foresi A Rolla G Mutani R Cicolin Abull Sourcebull Dipartimento di Scienze Biomediche e Oncologia Umana Universitagrave di Torino Italia caterinabuccaunitoitbull Abstractbull INTRODUCTION bull Upper airway inflammation and narrowing are characteristics of obstructive sleep apnoea (OSA) Inflammatory markers have been found to be

increased in exhaled breath and induced sputum of patients with OSAbull OBJECTIVES bull The aim of this study was to investigate if the measurement of exhaled nitric oxide (F(ENO) ) as marker of airway inflammation together with the

forced mid-expiratorymid-inspiratory airflow ratio (FEF(50) FIF(50) ) as marker of upper airway narrowing may help to predict OSAbull METHODS bull Two hundred one consecutive outpatients with suspected OSA were prospectively studied between January 2004 and December 2005 All patients

underwent clinical examination spirometry with measurement of FEF(50) FIF(50) maximum inspiratory pressure arterial blood gas analysis exhaled nitric oxide (F(ENO) ) and overnight polysomnography Linear regression models were used to evaluate the effect of measured variables on the apnoea-hypopnoea index (AHI) Models were cross-validated by bootstrapping

bull RESULTS bull Most of the patients were obese and had severe OSA FEF(50) FIF(50) F(ENO) and an interaction term between smoking and F(ENO) contributed

significantly to the predictive model for AHI in addition to age neck circumference body mass index and carboxyhaemoglobin saturation A nomogram to predict AHI was obtained which converted the effect of each covariate in the model to a 0-100 scale The nomogram showed a good predictive ability for AHI values between 25 and 64

bull CONCLUSIONS bull The measurement of F(ENO) and of FEF(50) FIF(50) improves the ability to predict OSA and may be used to identify patients who require a sleep

study

bull Will optimisation andor treatment alter outcome and if sobull what intervention and at what time should it be done in thebull presence of respiratory disease smoking and obstructivebull sleep apnoeabull Incentive spirometry and chest physical therapybull Most of the relevant studies deal with physical therapybull after the operation Although relevant from a clinicalbull point of view a systematic review from 2009 could notbull show a benefit from incentive spirometry on postoperativebull pulmonary complications after upper abdominalbull surgery as the methodological quality of the includedbull studies was only moderate and RCTs were lacking59bull When it comes to preoperative optimisation there arebull only limited data on possible effects of chest physicalbull therapy or incentive spirometry for optimisation in noncardiothoracicbull surgery In a randomised trial of 50 patientsbull scheduled for laparoscopic cholecystectomy patients inbull one group were instructed to carry out incentive spirometrybull repeatedly for 1 week before surgery whereas inbull the control group incentive spirometry was carried outbull only during the postoperative period Lung function testsbull were recorded at the time of pre-anaesthetic evaluationbull on the day before the surgery postoperatively at 6 24 andbull 48 h and at discharge Significant improvement in lungbull function tests were seen at all study time points afterbull preoperative incentive spirometry compared with patientsbull in the control group (level of evidence 2thorn)60

bull Nutritionbull Patients with severe pulmonary disease and manybull other causes may present for surgery with a very poornutritional status This may be detrimental for twobull reasons First muscle mass may be diminished Thisbull may lead to an early loss of muscle strength followingbull only a few days of immobilisation or assisted ventilationbull in ICUs Second serum albumin concentrations are oftenbull reduced This can lead to severe problems with oncoticbull pressure and fluid shifts A low serum albumin levelbull (lt30 g l1) has been found to be an independent riskbull factor for postoperative pulmonary complications (levelbull of evidence 2thorn)61 In some cases (urgent or emergencybull operations) an improvement in the nutritional status isbull often impossible In scheduled elective surgery on thebull contrary improvements in nutritional status may be ofbull benefit However there are only limited and conflictingbull data in this regard in the non-cardiothoracic surgerybull literature in the last 10 years under review (level ofbull evidence 2)6263

Smoking cessation

bull Smoking is a known risk factor for impaired woundhealing

bull and postoperative surgical sites of infection A

bull RCT of smoking cessation in 120 patients found a significantly

bull reduced incidence of wound-related complications

bull in the intervention (smoking cessation) group

bull (5 vs 31 Pfrac140001) (level of evidence 1)23

bull In 27 eligible studies 17 articles addressed the issue of

bull preoperative smoking cessation Aspects such as duration

bull of cessation necessary methods to motivate cessation and

bull impact on complications were covered In a RCT (smoking

bull cessation 4 weeks prior surgery vs control group with

bull no smoking cessation) an intention-to-treat analysis

bull showed that the overall complication rate in the control

bull group was 41 and in the intervention group 21

bull (Pfrac14003) Relative risk reduction for the primary outcome

bull of any postoperative complication was 49 and

bull number-needed-to-treat was five (95 CI 3ndash40) (level of

bull evidence 1)64

SMOKING

Cochrane Database Syst Rev 2010 Jul 7(7)CD002294Interventions for preoperative smoking cessation

Thomsen T Villebro N Moslashller AM

bull Five trials examined the effect of smoking intervention on postoperative complications

bull Pooled risk ratios were 070 (95 CI 056 to 088) for developing any complication and 070 (95 CI 051 to 095) for wound complications

bull Exploratory subgroup analyses showed a significant effect of intensive intervention on any complications RR 042 (95 CI 027 to 065) and on wound complications RR 031 (95 CI 016 to 062)

bull For brief interventions the effect was not statistically significant but CIs do not rule out a clinically significant effect (RR 096 (95 CI 074 to 125) for any complication RR 099 (95CI 070 to 140) for wound complications)





A U T H O R S rsquo C O N C L U S I O N S Cochrane Database Syst Rev 2010 Jul 7

Implications for practice

bull The results of this updated reviewindicate that preoperative smoking intervention is beneficial for changing smoking behaviourperioperatively and in the long term and for reducing the incidence of complications

bull Exploratory subgroup analyses of two smaller trials suggest that intensive intervention over a period of four to eight weeks before surgery and including NRTmay support smoking cessation and reduce postoperative morbidity

bull Six trials testing brief interventions on the other hand increased smoking cessationbull at the time of surgery but failed to detect a statistically significant effect on

postoperative morbiditybull Based on this evidence intensive interventions for 4-8 weeks before surgery and

including NRT appear relevant for patients scheduled to undergo surgery 4 weeks or more after diagnosis

bull We suggest that smokers scheduled for surgery less than 4 weeks after diagnosis like all smokers be advised to quit and offered effective interventions including behavioural support and pharmacotherapy

Biblio 2327296465bull Theadom A Cropley M Effects of preoperative smoking cessation on thebull incidence and risk of intraoperative and postoperative complications inbull adult smokers a systematic review Tob Control 2006 15352ndash358bull Thomsen T Toslashnnesen H Moslashller AM Effect of preoperative smokingbull cessation interventions on postoperative complication and smokingbull cessation Br J Surg 2009 96451ndash461bull Moslashller A Villebro N Interventions for preoperative smoking cessationbull (review) Cochrane Database Syst Rev 2005CD002294bull 23 Theadom A Cropley M Effects of preoperative smoking cessation on thebull incidence and risk of intraoperative and postoperative complications inbull adult smokers a systematic review Tob Control 2006 15352ndash358bull 24 Moslashller AM Villebro N Pedersen T Toslashnnesen H Effect of preoperativebull smoking intervention on postoperative complications a randomisedbull clinical trial Lancet 2002 359114ndash117bull 25 Sorensen LT Hemmingsen U Jorgensen T Strategies of smokingbull cessation intervention before hernia surgery effect on perioperativebull smoking behaviour Hernia 2007 11327ndash333bull 26 Zaki A Abrishami A Wong J Chung FF Interventions in the preoperativebull clinic for long term smoking cessation a quantitative systematic reviewbull Can J Anaesth 2008 5511ndash21bull 27 Thomsen T Toslashnnesen H Moslashller AM Effect of preoperative smokingbull cessation interventions on postoperative complication and smokingbull cessation Br J Surg 2009 96451ndash461bull 28 Ratner PA Johnson JL Richardson CG et al Efficacy of a smokingcessationbull intervention for elective-surgical patients Res Nurs Healthbull 2004 27148ndash161bull 29 Andrews K Bale P Chu J et al A randomized controlled trial to assess thebull effectiveness of a letter from a consultant surgeon in causing smokers tobull stop smoking preoperatively Public Health 2006 120356ndash358bull 30 Sorensen LT Jorgensen T Short-term preoperative smoking cessationbull intervention does not affect postoperative complications in colorectalbull surgery a randomized clinical trial Colorectal Dis 2002 5347ndash352 64 Lindstrom D Sadr AO Wladis A et al Effects of a perioperative smokingbull cessation intervention on postoperative complications a randomized trialbull Ann Surg 2008 248739ndash745bull 65 Deller A Stenz R Forstner K Carboxyhemoglobin in smokers and abull preoperative smoking cessation Dtsch Med Wochenschr 1991bull 11648ndash51bull 66 Cropley M Theadom A Pravettoni G Webb G The effectiveness ofbull smoking cessation interventions prior to surgery a systematic reviewbull Nicotine Tob Res 2008 10407ndash412

Carboxyhemoglobin in smokers and apreoperative smoking cessation

bull Benefivi dellrsquoastiennza dal fumo(oltre quelli visti sulle Ko periop)

bull miglioramento della funzione mcucocilairenasale

bull Diminuzione della Carbossi Hb e CO

bull Eur J Anaesthesiol 2010 Sep27(9)812-8bull Assessment of carbon monoxide values in smokers a comparison of carbon monoxide in expired air and carboxyhaemoglobin in arterial bloodbull Andersson MF Moslashller AMbull Sourcebull Department of Anaesthesiology Herlev University Hospital Copenhagen Denmark mf_anderssonhotmailcombull Abstractbull BACKGROUND AND OBJECTIVE bull Smoking increases perioperative complications Carbon monoxide concentrations can estimate patients smoking status and might be relevant in

preoperative risk assessment In smokers we compared measurements of carbon monoxide in expired air (COexp) with measurements of carboxyhaemoglobin (COHb) in arterial blood The objectives were to determine the level of correlation and to determine whether the methods showed agreement and evaluate them as diagnostic tests in discriminating between heavy and light smokers

bull METHODS bull The study population consisted of 37 patients The Micro Smokerlyzer was used to measure COexp it measures COexp in parts per million (ppm) and

converts it to the percentage of haemoglobin combined with carbon monoxide (Hb) COHb in arterial blood was measured by the ABL 725 Correlation analysis and Bland-Altman analysis were performed and 2 x 2 contingency tables and receiver operating characteristic curve analysis were conducted

bull RESULTS bull The correlation between the methods was high (rho = 0964) Bland-Altman analysis demonstrated that the Micro Smokerlyzer underestimated

COHb values The areas under the receiver operating characteristic curves were 0746 (ABL 725) and 0754 (Micro Smokerlyzer) and by comparison no statistically significant difference was found (P = 0815)

bull CONCLUSION bull The two methods showed a high level of correlation but poor agreement The Micro Smokerlyzer systematically underestimated COHb values and in

order to avoid this we suggested an alternative algorithm for converting COexp from ppm to Hb The ABL 725 and Micro Smokerlyzer were fair diagnostic tests in distinguishing between heavy and light smokers but the longer the patients smoking cessation time the poorer the ability as diagnostic tests

bull Regul Toxicol Pharmacol 2010 Jul-Aug57(2-3)241-6 Epub 2010 Mar 15bull Acute effects of cigarette smoking on pulmonary functionbull Unverdorben M Mostert A Munjal S van der Bijl A Potgieter L Venter C Liang Q Meyer B Roethig HJbull Sourcebull Altria Client Services Research Development amp Engineering Richmond VA 23234 USA sbu135livecombull Abstractbull INTRODUCTION bull Chronic smoking related changes in pulmonary function are reflected as accelerated decrease in FEV1 although histologic changes occur in the

peripheral bronchi earlier More sensitive pulmonary function parameters might mirror those early changes and might show a dose responsebull METHODS bull In a randomized three-period cross-over design 57 male adult conventional cigarette (CC)-smokers (age 451+-71 years) smoked either CC (tar11

mg nicotine08 mg carbon monoxide11 mg [Federal Trade Commission (FTC)]) or used as a potential reduced-exposure product the electricallyheated smoking system (EHCSS) (tar5 mg nicotine03 mg carbon monoxide045 mg (FTC)) or did not smoke (NS) After each 3-day exposureperiod hematology and exposure parameters were determined preceding body plethysmography

bull RESULTS bull Cigarette smoke exposure was significantly (plt00001) higher in CC than in EHCSS and in NS (carboxyhemoglobin CC 64+-19 EHCSS 13+-

06 NS 05+-03 serum nicotine CC 189+-74 ngml EHCSS 84+-43 ngml NS 12+-16 ngml) Significantly lower in CC than in EHCSS and NS were specific airway conductance (022+-009 025+-012 025+-01 1cmH(2)O x s CC vs EHCSS plt005 CC vs NS plt001) forced expiratoryflow 25 (76+-17 78+-17 79+-17 Ls CC vs EHCSS or NS plt001) Thoracic gas volume (51+-1 5+-11 5+-11Lmin) changedinsignificantly

bull CONCLUSION bull The data indicate acute and reversible effects of cigarette smoke exposures and no-smoking on mid to small size pulmonary airways in a dose

dependent manner

bull J Clin Gastroenterol 2007 Feb41(2)211-5bull Carboxyhemoglobin and its correlation to disease severity in cirrhoticsbull Tran TT Martin P Ly H Balfe D Mosenifar Zbull Sourcebull Department of Medicine Cedars Sinai Medical Center Los Angeles CA USA TranTcshsorgbull Abstractbull GOAL bull To assess the correlation of serum carboxyhemoglobin (CO-Hb) to severity of liver disease as compared with Model for End Stage Liver Disease

(MELD) score Child Pugh score and clinical parametersbull BACKGROUND bull There are 2 sources of carbon monoxide (CO) in humans exogenous sources include those such as tobacco smoke and inhaled motor vehicle

exhaust The endogenous source is via the heme-oxygenase pathway in which a heme molecule is broken down into biliverdin with release of an iron (Fe) and CO molecule Normal serum CO-Hb levels in nonsmokers is 0 to 15 and 4 to 9 in smokers Activity of the heme-oxygenasepathway may be increased in the cirrhotic patient as measured indirectly by exhaled CO and serum CO-Hb This may be due to alterations in vascular tone in the splanchnic circulation in cirrhotics that may lead to elevated CO production One published study also showed that those with spontaneous bacterial peritonitis had higher levels of both CO and CO-Hb The MELD score uses prothrombin time (INR) creatinine and bilirubin in the prediction of short-term mortality in decompensated cirrhotics while awaiting liver transplant Measurement of endogenous CO-Hb may correlate to severity of liver disease

bull STUDY bull Retrospective analysis was done of 113 adult patients who were evaluated for liver transplantation between September 1996 and July 2003 and had

pulmonary function testing with CO-Hb as part of their evaluation We excluded any patients with a history of smoking Clinical parameters used for comparison included grade of esophageal varices (n=75) spleen size (n=51) measured on abdominal ultrasound or computed tomography scan aminotransferases and disease duration Serum CO-Hb levels were measured from whole blood sent refrigerated to ARUP laboratories (Salt Lake City UT) and analyzed via spectrophotometry Bivariate analysis was performed by means of the Pearson product moment correlation

bull RESULTS bull The mean CO-Hb level was 21 which is higher than the expected normal population controls No correlation was found however with MELD

score Child Turcotte Pugh score or other biochemical or clinical measurements of disease severitybull CONCLUSIONS bull Although CO and CO-Hb production may be increased in the cirrhotic patient in this study no correlation was found to disease severity as measured

by the MELD score Further studies are needed to assess the role of CO in other complications of cirrhosis including infection and circulatory dysfunction

bull PMID 17245222 [PubMed - indexed for MEDLINE]

bull Scand J Public Health 200634(6)609-15bull COHb as a marker of cardiovascular risk in never smokers results from a population-based cohort studybull Hedblad B Engstroumlm G Janzon E Berglund G Janzon Lbull Sourcebull Department of Clinical Sciences in Malmouml Epidemiological Research Group Lund University Malmouml University Hospital Malmouml Sweden

BoHedbladmedlusebull Abstractbull AIM bull Carbon monoxide (CO) in blood as assessed by the COHb is a marker of the cardiovascular (CV) risk in smokers Non-smokers exposed to tobacco

smoke similarly inhale and absorb CO The objective in this population-based cohort study has been to describe inter-individual differences in COHb in never smokers and to estimate the associated cardiovascular risk

bull METHODS bull Of the 8333 men aged 34-49 years from the city of Malmouml Sweden 4111 were smokers 1229 ex-smokers and 2893 were never smokers

Incidence of CV disease was monitored over 19 years of follow upbull RESULTS bull COHb in never smokers ranged from 013 to 547 Never smokers with COHb in the top quartile (above 067) had a significantly higher

incidence of cardiac events and deaths relative risk 37 (95 CI 20-70) and 22 (14-35) respectively compared with those with COHb in the lowest quartile (below 050) This risk remained after adjustment for confounding factors

bull CONCLUSION bull COHb varied widely between never-smoking men in this urban population Incidence of CV disease and death in non-smokers was related to

COHb It is suggested that measurement of COHb could be part of the risk assessment in non-smoking patients considered at risk of cardiac disease In random samples from the general population COHb could be used to assess the size of the population exposed to second-hand smoke

bull BMC Public Health 2006 Jul 186189bull Carboxyhaemoglobin levels and their determinants in older British menbull Whincup P Papacosta O Lennon L Haines Abull Sourcebull Division of Community Health Sciences St Georges University of London London SW17 0RE UK pwhincupsgulacukbull Abstractbull BACKGROUND bull Although there has been concern about the levels of carbon monoxide exposure particularly among older people little is known about COHb levels

and their determinants in the general population We examined these issues in a study of older British menbull METHODS bull Cross-sectional study of 4252 men aged 60-79 years selected from one socially representative general practice in each of 24 British towns and who

attended for examination between 1998 and 2000 Blood samples were measured for COHb and information on social household and individual factors assessed by questionnaire Analyses were based on 3603 men measured in or close to (lt 10 miles) their place of residence

bull RESULTS bull The COHb distribution was positively skewed Geometric mean COHb level was 046 and the median 050 92 of men had a COHb level of 25

or more and 01 of subjects had a level of 75 or more Factors which were independently related to mean COHb level included season (highest in autumn and winter) region (highest in Northern England) gas cooking (slight increase) and central heating (slight decrease) and active smoking the strongest determinant Mean COHb levels were more than ten times greater in men smoking more than 20 cigarettes a day (329) compared with non-smokers (032) almost all subjects with COHb levels of 25 and above were smokers (93) Pipe and cigar smoking was associated with more modest increases in COHb level Passive cigarette smoking exposure had no independent association with COHb after adjustment for other factors Active smoking accounted for 41 of variance in COHb level and all factors together for 47

bull CONCLUSION bull An appreciable proportion of men have COHb levels of 25 or more at which symptomatic effects may occur though very high levels are

uncommon The results confirm that smoking (particularly cigarette smoking) is the dominant influence on COHb levels

bull Br J Clin Pharmacol 2008 Jan65(1)30-9 Epub 2007 Aug 31bull Population pharmacokinetic analysis of carboxyhaemoglobin concentrations in adult cigarette smokersbull Cronenberger C Mould DR Roethig HJ Sarkar Mbull Sourcebull Projections Research Inc Phoenixville PA USAbull Abstractbull AIMS bull To develop a population-based model to describe and predict the pharmacokinetics of carboxyhaemoglobin (COHb) in adult smokersbull METHODS bull Data from smokers of different conventional cigarettes (CC) in three open-label randomized studies were analysed using NONMEM (version V Level

11) COHb concentrations were determined at baseline for two cigarettes [Federal Trade Commission (FTC) tar 11 mg CC1 or FTC tar 6 mg CC2] On day 1 subjects were randomized to continue smoking their original cigarettes switch to a different cigarette (FTC tar 1 mg CC3) or stop smoking COHb concentrations were measured at baseline and on days 3 and 8 after randomization Each cigarette was treated as a unit dose assuming a linear relationship between the number of cigarettes smoked and measured COHb percent saturation Model building used standard methods Model performance was evaluated using nonparametric bootstrapping and predictive checks

bull RESULTS bull The data were described by a two-compartment model with zero-order input and first-order elimination with endogenous COHb Model parameters

included elimination rate constant (k(10)) central volume of distribution (VcF) rate constants between central and peripheral compartments (k(12) and k(21)) baseline COHb concentrations (c0) and relative fraction of carbon monoxide absorbed (F1) The median (range) COHb half-lives were 16 h (0680-276) and 309 h (713-367) (alpha and beta phases respectively) F1 increased with increasing cigarette tar content and age whereas k(12) increased with ideal body weight

bull CONCLUSION bull A robust model was developed to predict COHb concentrations in adult smokers and to determine optimum COHb sampling times in future studies

bull Respirology 2011 Jul16(5)849-55 doi 101111j1440-1843201101985xbull Reversibility of impaired nasal mucociliary clearance in smokers following a smoking cessation programmebull Ramos EM De Toledo AC Xavier RF Fosco LC Vieira RP Ramos D Jardim JRbull Sourcebull Department of Physiotherapy Satildeo Paulo State University (UNESP) Presidente Prudente Satildeo Paulo Brazil ercyfctunespbrbull Abstractbull BACKGROUND AND OBJECTIVE bull Smoking cessation (SC) is recognized as reducing tobacco-associated mortality and morbidity The effect of SC on nasal mucociliary clearance (MC) in

smokers was evaluated during a 180-day periodbull METHODS bull Thirty-three current smokers enrolled in a SC intervention programme were evaluated after they had stopped smoking Smoking history

Fagerstroumlms test lung function exhaled carbon monoxide (eCO) carboxyhaemoglobin (COHb) and nasal MC as assessed by the saccharin transit time (STT) test were evaluated All parameters were also measured at baseline in 33 matched non-smokers

bull RESULTS bull Smokers (mean age 49 plusmn 12 years mean pack-year index 44 plusmn 25) were enrolled in a SC intervention and 27 (n = 9) abstained for 180 days 30 (n =

11) for 120 days 495 (n = 15) for 90 days or 60 days 627 (n = 19) for 30 days and 759 (n = 23) for 15 days A moderate degree of nicotine dependence higher education levels and less use of bupropion were associated with the capacity to stop smoking (P lt 005) The STT was prolonged in smokers compared with non-smokers (P = 0002) and dysfunction of MC was present at baseline both in smokers who had abstained and those who had not abstained for 180 days eCO and COHb were also significantly increased in smokers compared with non-smokers STT values decreased to within the normal range on day 15 after SC (P lt 001) and remained in the normal range until the end of the study period Similarly eCO values were reduced from the seventh day after SC

bull CONCLUSIONS bull A SC programme contributed to improvement in MC among smokers from the 15th day after cessation of smoking and these beneficial effects

persisted for 180 days

Optimisation in obstructive sleep apnoea syndrome

bull improve or optimise an OSAS patientrsquos perioperativephysical statusndash preoperative continuous positive airway pressure (CPAP)

or bi-level positive airway pressurendash preoperative use of oral appliances for mandibular

advancement ndash or preoperative weight loss

bull There is insufficient literature(ESA 2011) to evaluate the impact of any of these measures on perioperativeoutcomes although expert opinion recommends these interventions (level of evidence4)

bull BP control

RecommendationsESA 2011(1) Preoperative diagnostic spirometry in non-cardiothoracic patients cannot be

recommended to evaluate the risk of postoperative complications (grade of ecommendationD)

(2) Routine preoperative chest radiographs rarely alter perioperative management of these cases Therefore it cannot be recommended on a routine basis (grade of recommendation B)

(3) Preoperative chest radiographs have a very limited value in patients older than 70 years with established risk factors (grade of recommendation A)

(4) Patients with OSAS should be evaluated carefully for a potential difficult airway and special attention is advised in the immediate postoperative period (grade ofrecommendation C)

(5) Specific questionnaires to diagnose OSAS can be recommended when polysomnography is not available (grade of recommendation D)

(6) Use of CPAP perioperatively in patients with OSAS may reduce hypoxic events (grade of recommendationD)

(7) Incentive spirometry preoperatively can be of benefit in upper abdominal surgery to avoid postoperative pulmonary complications (grade of recommendationD)

(8) Correction of malnutrition may be beneficial (grade of recommendation D)

(9) Smoking cessation before surgery is recommended It must start early (at least 6ndash8 weeks prior to surgery 4 weeks at a minimum) (grade of recommendation B)A short-term cessation is only beneficial to reduce the amount of carboxyhaemoglobin in the blood in heavy smokers (grade of recommendation D)

FINESegue lavori in dettagliohellip

Development and Validation of a Multifactorial Risk Index forPredicting Postoperative Pneumonia after Major Noncardiac Surgery

Ahsan M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857bull Postoperative pulmonary complications are associatedbull with substantial morbidity and mortality It hasbull been estimated that nearly one fourth of deaths occurringbull within 6 days of surgery are related to postoperativebull pulmonary complications (1) Postoperative infectionsbull are also a major source of the morbidity and mortalitybull associated with undergoing surgery Pneumonia is thebull most serious postoperative complication that is includedbull in both of these categories Pneumonia ranks as thebull third most common postoperative infection behind urinarybull tract and wound infection (2) According to thebull National Nosocomial Infection Surveillance systembull pneumonia occurred in 18 of patients after surgerybull (3) Postoperative pneumonia occurs in 9 to 40 ofbull patients and the associated mortality rate is 30 tobull 46 depending on the type of surgery (1 4)bull Previous studies of risk factors used various definitionsbull of postoperative pulmonary complications Atelectasisbull (1 4ndash7) postoperative pneumonia (1ndash2 4ndash6bull 8ndash11) the acute respiratory distress syndrome (9 12)bull and postoperative respiratory failure (6 9 11 13) havebull been classified as postoperative pulmonary complicationsbull Although the clinical significance of each of thesebull complications varies greatly they were grouped togetherbull as a single outcome in previous studies (6) Some studiesbull were limited to examination of risk factors in patientsbull undergoing abdominal or thoracic procedures or in patientsbull with specific medical conditions such as chronicbull obstructive pulmonary disease (2 4 6 10ndash12 14)bull These studies were often based on a small sample frombull one institution and studies of independent samples didbull not validate their findings (15 16

Table 1 Definition of Postoperative PneumoniaDevelopment and Validation of a Multifactorial Risk Index for


bull Patient met one of the following two criteria postoperativelybull 1 Rales or dullness to percussion on physical examination of chest AND any

of the followingbull New onset of purulent sputum or change in character of sputumbull Isolation of organism from blood culturebull Isolation of pathogen from specimen obtained by transtracheal aspirate

bronchial brushing or biopsybull 2 Chest radiography showing new or progressive infiltrate consolidation

cavitation or pleural effusion AND any of the followingbull New onset of purulent sputum or change in character of sputumbull Isolation of organism from blood culturebull Isolation of pathogen from specimen obtained by transtracheal aspirate

bronchial brushing or biopsybull Isolation of virus or detection of viral antigen in respiratory secretionsbull Diagnostic single antibody titer (IgM) or fourfold increase in paired serum

samples (IgG) for pathogenbull Histopathologic evidence of pneumonia

Postoperative pneumonia risk indexDevelopment and

Validation of a Multifactorial Risk Index forPredicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD

William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857

Development and Validation of a Multifactorial Risk Index forPredicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M

Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857

bull DISCUSSIONbull Our results confirm several previously described riskbull factors for postoperative pneumonia including the typebull of surgery performed The patient-specific risk factorsbull were related to general health and immune status respiratorybull status neurologic status and fluid status Thesebull risk factors were used to develop a preoperative risk assessmentbull model for predicting postoperative pneumoniabull the postoperative pneumonia risk indexbull We found that patients undergoing abdominal aorticbull aneurysm repair thoracic neck upper abdominal orbull peripheral vascular surgery or neurosurgery had an increasedbull likelihood of developing postoperative pneumoniabull Previous studies focused on the increased incidencebull of postoperative pulmonary complications in patientsbull undergoing these types of surgery (2 4 5 8 9 11 12bull 14 29) Impairment of normal swallowing and respiratorybull clearance mechanisms may be responsible for somebull of the increased risk in these patients

Patient specific risk factor for postop pneumoniaDevelopment and Validation of a Multifactorial Risk Index for


bull Long-term steroid use (30)

bull Age older than 60 years (2 4 5 11 12)




bull Further studies are needed to assess the effect of interventions such as preoperative optimization of nutritional status and perioperative physical therapy in reducing the incidence of postoperative pneumonia

bull Our definition of current smoking included patients who smoked up to 1 year before surgery Before 1995 the NSQIP definition for ldquocurrent smokingrdquo was smoking in the 2 weeks before surgery Using this definitio nwe found that smoking was not significantly associated with postoperative mortality or overall morbidity (22 23) On closer examination it appeared that sicker patients tended to quit smoking more than 2 weeks before surgery and were therefore being classified as nonsmokers To capture the effect of recent smoking the NSQIP definition was modified in September 1995 to include patients who smoked up to 1 year before surgery

Development and Validation of a Multifactorial Risk Index forPredicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan

M Arozullah MD MPH Shukri F Khuri MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857

bull Recent smoking and history of chronic obstructivebull pulmonary disease were previously found to be pulmonarybull risk factors for postoperative pneumonia (2 4bull 9ndash12 14) Chumillas and colleagues (31) found thatbull preoperative and postoperative respiratory rehabilitationbull protected against postoperative pulmonary complicationsbull in moderate-risk and high-risk patients undergoingbull upper abdominal surgery Use of an incentive spirometerbull or intermittent positive-pressure breathing and controlbull of pain that interferes with coughing and deepbull breathing have been recommended for preventing postoperativebull pneumonia in high-risk patients (32)



bull We found two risk factors related to neurologic statusbull history of cerebral vascular accident with a residualbull deficit and impaired sensorium Previously identifiedbull neurologic risk factors for postoperative pneumonia

includedbull impaired cognitive function (4) These risk factorsbull are often associated with a decreased ability to protectbull onersquos airway and may increase the risk forbull aspiration Other risk factors related to aspiration in

previousbull studies included the use of nasogastric tubes andbull H2 receptor antagonists (6)

bullAPPENDIX DEFINITIONS OF RISK FACTORS IN THEPOSTOPERATIVE PNEUMONIA RISK INDEX

Type of Surgery Development and Validation of a Multifactorial Risk Index forPredicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri

MD William G Henderson PhD and Jennifer Daley MDAnn Intern Med 2001135847-857

bull Abdominal aortic aneurysm repair Surgeries to repair ruptured or unruptured aortic aneurysm involving only abdominal incisions

bull Neck surgery Surgeries related to the thyroid parathyroidand larynx tracheostomy cervical and axillary lymph node excision and cervical and axillary lymphadenectomy

bull Neurosurgery Application of a halo central nervous system injection central nervous system drainage creation of a bur holecraniectomy craniotomy arteriovenous malformation or aneurysm repair stereotaxis neurostimulator placement skull repair and cerebral spinal fluid shunt

bull Thoracic surgery Esophageal resection esophageal repair mediastinoscopy pleural biopsy pneumocentesis chest wall excision incision and drainage of neck and thorax excision of neck and thorax repair of fractured ribs diaphragmatic hernia repair bronchoscopy catheterization of trachea trachea repair thoracotomy pericardium pacemaker placement heart wound repair valve repair thoracic or abdominothoracic aortic aneurysm repair

bull and pulmonary artery procedures bull Upper abdominal surgery Gastrectomy vagotomy intestinal surgery partial hepatectomy

subfascial abdominal excision splenectomy excision of abdominal masses laparoscopic appendectomy and cholecystectomy shunt insertion ventral umbilical and spigelian hernia repair and liver gallbladder and pancreas surgery

bull Vascular surgery Any surgery related to the arteries or veins except central nervoussystem aneurysm or abdominal aortic aneurysm repair

APPENDIX DEFINITIONS OF RISK FACTORS IN THEPOSTOPERATIVE PNEUMONIA RISK INDEX

Functional StatusDevelopment and Validation of a Multifactorial Risk Index for

Predicting Postoperative Pneumonia after Major Noncardiac Surgery Ahsan M Arozullah MD MPH Shukri F Khuri MD


bull Functional status The level of self-care demonstrated by the patient on admission to the hospital reflecting his or her prehospitalizationfunctional status

bull Totally dependent The patient cannot perform any activities of daily living for himself or herself includes patients who are totally dependent on nursing care such as a dependent nursing home patient

bull Partially dependent The patient requires use of equipment or devices plus assistance from another person for some activities of daily living Patients admitted from a nursing home setting who are not totally dependent would fall into this category as would any patient who requires kidney dialysis or home ventilator support yet maintains some independent function

bull Independent The patient is independent in activities of daily living ncludes those who are able to function independently with a prosthesis equipment or devices


OtherhellipDevelopment and Validation of a Multifactorial Risk Index for


bull History of chronic obstructive pulmonary disease The patient has chronic obstructive pulmonary disease resulting in functional disability hospitalization in the past to treat chronic obstructive pulmonary disease need for bronchodilator therapy with oral or inhaled agents or FEV1 of less than 75 of predicted value

bull Patients excluded from this category were those in whom the only pulmonary disease was acute asthma an acute and chronic inflammatory disease of the airways resulting in bronchospasm

bull History of cerebrovascular accident The patient has a history of cerebrovascular accident (embolic thrombotic or hemorrhagic) with persistent motor sensory or cognitive dysfunction

bull Impaired sensorium The patient is acutely confused or delirious and responds to verbal or mild tactile stimulation patient with mental status changes or delirium in the context of the current illness Patients with chronic mental status changes secondary to chronic mental illness or chronic dementing llnesses were excluded from this category

bull Steroid use for chronic condition The patient has required the regular administration of parenteral or oral corticosteroid medication in the month before admission Patients using only topical rectal or inhalational corticosteroids were excluded from this category

Ahsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the National Veterans Administration Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After Major

Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253

Ahsan M Arozullah MD MPH Jennifer Daley MDdagger William G Henderson PhDDagger and Shukri F Khuri MDsect for the National Veterans Administration Surgical Quality Improvement Program Multifactorial Risk Index for Predicting Postoperative Respiratory Failure in Men After

Major Noncardiac Surgery ANNALS OF SURGERY Vol 232 No 2 242ndash253



bull The most common postoperative complications in phase I were postoperative pneumonia (36) urinary tract infection (35) and respiratory failure (34) Notably two of the top three postoperative complications were pulmonary complications

bull The 30-day death rate for patients with PRF was 27 versus 1 for patients without PRF

bull In contrast cardiac arrest requiring cardiopulmonary resuscitation occurred in 15 of total patients myocardial infarction occurred in only 07 of patients

bull Thirty-seven percent of patients with PRF had the inability to be extubated 29 had unplanned intubation and 34 had both

bull For all three groups the most commonly associated postoperative complications were pneumonia pulmonary edema systemic sepsis and cardiac arrest

bull The 30-day death rate was 31 for reintubation patients and 23 for patients with the inability to be extubated



bull Despite these limitations the respiratory failure risk index may be helpful to clinicians and researchers in targeting perioperative testing and respiratory care to high-risk patients

bull Prior studies have been limited to patients undergoing specific types of operations2ndash7910 or patients with particular risk factors110

bull The respiratory failure risk index is unique in that it includes several patient-specific and operation- specific risk factors simultaneously allowing for an accurate assessment of the preoperative risk of PRF associated with each individual risk factor

bull We found that the type of surgery performed has the highest associated risk for developing PRF and that the major patient-specific risk factors are related to general health status renal and fluid status and respiratory status

bull We hope that an increased awareness of the importance of postoperative pulmonary complications will develop through the clinical use of the respiratory failure risk index We also hope that by using the models developed in this study researchers will be able to evaluate future interventions aimed at reducing the rate of PRF

bull Qaseem A Snow V Fitterman N et al Risk assessment for and strategies to reduce perioperative pulmonary complications for patients undergoing noncardiothoracic surgery a guideline from the American College of Physicians Ann Intern Med 2006 144575ndash580

bull Smetana GW Lawrence VA Cornell JE Preoperative pulmonary risk stratification for noncardiothoracic surgery systematic review for the American College of Physicians Ann Intern Med 2006 144581ndash595



















Pneumonia risk


Intern Med 2001135847-857
















bull Age gt60 years




bull Recent smoking











bull Fumo recente

bull Storia di COPD





857


bull thoracic

bull neck



bull neurosurgery














failure (PRF)




bull Objective
















ndash Chir toracica

ndash neurochir









ndash Etagrave gt60





bull 1 lt=10 05


bull 3 20ndash27 53- 42

bull 4 28ndash40 10-119

bull 5 gt40 309 -266

















study



Smoking cessation


















bull evidence 1)64

SMOKING






































dependent manner










































bull BP control












































































































Pneumonia risk


Intern Med 2001135847-857
















bull Age gt60 years




bull Recent smoking











bull Fumo recente

bull Storia di COPD





857


bull thoracic

bull neck



bull neurosurgery














failure (PRF)




bull Objective
















ndash Chir toracica

ndash neurochir









ndash Etagrave gt60





bull 1 lt=10 05


bull 3 20ndash27 53- 42

bull 4 28ndash40 10-119

bull 5 gt40 309 -266

















study



Smoking cessation


















bull evidence 1)64

SMOKING






































dependent manner










































bull BP control










































































































Pneumonia risk


Intern Med 2001135847-857
















bull Age gt60 years




bull Recent smoking











bull Fumo recente

bull Storia di COPD





857


bull thoracic

bull neck



bull neurosurgery














failure (PRF)




bull Objective
















ndash Chir toracica

ndash neurochir









ndash Etagrave gt60





bull 1 lt=10 05


bull 3 20ndash27 53- 42

bull 4 28ndash40 10-119

bull 5 gt40 309 -266

















study



Smoking cessation


















bull evidence 1)64

SMOKING






































dependent manner










































bull BP control








































































































Pneumonia risk


Intern Med 2001135847-857
















bull Age gt60 years




bull Recent smoking











bull Fumo recente

bull Storia di COPD





857


bull thoracic

bull neck



bull neurosurgery














failure (PRF)




bull Objective
















ndash Chir toracica

ndash neurochir









ndash Etagrave gt60





bull 1 lt=10 05


bull 3 20ndash27 53- 42

bull 4 28ndash40 10-119

bull 5 gt40 309 -266

















study



Smoking cessation


















bull evidence 1)64

SMOKING






































dependent manner










































bull BP control







































































































Pneumonia risk


Intern Med 2001135847-857
















bull Age gt60 years




bull Recent smoking











bull Fumo recente

bull Storia di COPD





857


bull thoracic

bull neck



bull neurosurgery














failure (PRF)




bull Objective
















ndash Chir toracica

ndash neurochir









ndash Etagrave gt60





bull 1 lt=10 05


bull 3 20ndash27 53- 42

bull 4 28ndash40 10-119

bull 5 gt40 309 -266

















study



Smoking cessation


















bull evidence 1)64

SMOKING






































dependent manner










































bull BP control

































































































Pneumonia risk


Intern Med 2001135847-857
















bull Age gt60 years




bull Recent smoking











bull Fumo recente

bull Storia di COPD





857


bull thoracic

bull neck



bull neurosurgery














failure (PRF)




bull Objective
















ndash Chir toracica

ndash neurochir









ndash Etagrave gt60





bull 1 lt=10 05


bull 3 20ndash27 53- 42

bull 4 28ndash40 10-119

bull 5 gt40 309 -266

















study



Smoking cessation


















bull evidence 1)64

SMOKING






































dependent manner










































bull BP control


























































































Pneumonia risk


Intern Med 2001135847-857
















bull Age gt60 years




bull Recent smoking











bull Fumo recente

bull Storia di COPD





857


bull thoracic

bull neck



bull neurosurgery














failure (PRF)




bull Objective
















ndash Chir toracica

ndash neurochir









ndash Etagrave gt60





bull 1 lt=10 05


bull 3 20ndash27 53- 42

bull 4 28ndash40 10-119

bull 5 gt40 309 -266

















study



Smoking cessation


















bull evidence 1)64

SMOKING






































dependent manner










































bull BP control



























































































Intern Med 2001135847-857
















bull Age gt60 years




bull Recent smoking











bull Fumo recente

bull Storia di COPD





857


bull thoracic

bull neck



bull neurosurgery














failure (PRF)




bull Objective
















ndash Chir toracica

ndash neurochir









ndash Etagrave gt60





bull 1 lt=10 05


bull 3 20ndash27 53- 42

bull 4 28ndash40 10-119

bull 5 gt40 309 -266

















study



Smoking cessation


















bull evidence 1)64

SMOKING






































dependent manner










































bull BP control
































































































bull Age gt60 years




bull Recent smoking











bull Fumo recente

bull Storia di COPD





857


bull thoracic

bull neck



bull neurosurgery














failure (PRF)




bull Objective
















ndash Chir toracica

ndash neurochir









ndash Etagrave gt60





bull 1 lt=10 05


bull 3 20ndash27 53- 42

bull 4 28ndash40 10-119

bull 5 gt40 309 -266

















study



Smoking cessation


















bull evidence 1)64

SMOKING






































dependent manner










































bull BP control





























































































bull Age gt60 years




bull Recent smoking











bull Fumo recente

bull Storia di COPD





857


bull thoracic

bull neck



bull neurosurgery














failure (PRF)




bull Objective
















ndash Chir toracica

ndash neurochir









ndash Etagrave gt60





bull 1 lt=10 05


bull 3 20ndash27 53- 42

bull 4 28ndash40 10-119

bull 5 gt40 309 -266

















study



Smoking cessation


















bull evidence 1)64

SMOKING






































dependent manner










































bull BP control

































































































bull Fumo recente

bull Storia di COPD





857


bull thoracic

bull neck



bull neurosurgery














failure (PRF)




bull Objective
















ndash Chir toracica

ndash neurochir









ndash Etagrave gt60





bull 1 lt=10 05


bull 3 20ndash27 53- 42

bull 4 28ndash40 10-119

bull 5 gt40 309 -266

















study



Smoking cessation


















bull evidence 1)64

SMOKING






































dependent manner










































bull BP control




























































































857


bull thoracic

bull neck



bull neurosurgery














failure (PRF)




bull Objective
















ndash Chir toracica

ndash neurochir









ndash Etagrave gt60





bull 1 lt=10 05


bull 3 20ndash27 53- 42

bull 4 28ndash40 10-119

bull 5 gt40 309 -266

















study



Smoking cessation


















bull evidence 1)64

SMOKING






































dependent manner










































bull BP control







































































































failure (PRF)




bull Objective
















ndash Chir toracica

ndash neurochir









ndash Etagrave gt60





bull 1 lt=10 05


bull 3 20ndash27 53- 42

bull 4 28ndash40 10-119

bull 5 gt40 309 -266

















study



Smoking cessation


















bull evidence 1)64

SMOKING






































dependent manner










































bull BP control



























































































failure (PRF)




bull Objective
















ndash Chir toracica

ndash neurochir









ndash Etagrave gt60





bull 1 lt=10 05


bull 3 20ndash27 53- 42

bull 4 28ndash40 10-119

bull 5 gt40 309 -266

















study



Smoking cessation


















bull evidence 1)64

SMOKING






































dependent manner










































bull BP control





























































































bull Objective
















ndash Chir toracica

ndash neurochir









ndash Etagrave gt60





bull 1 lt=10 05


bull 3 20ndash27 53- 42

bull 4 28ndash40 10-119

bull 5 gt40 309 -266

















study



Smoking cessation


















bull evidence 1)64

SMOKING






































dependent manner










































bull BP control



































































































ndash Chir toracica

ndash neurochir









ndash Etagrave gt60





bull 1 lt=10 05


bull 3 20ndash27 53- 42

bull 4 28ndash40 10-119

bull 5 gt40 309 -266

















study



Smoking cessation


















bull evidence 1)64

SMOKING






































dependent manner










































bull BP control






























































































ndash Chir toracica

ndash neurochir









ndash Etagrave gt60





bull 1 lt=10 05


bull 3 20ndash27 53- 42

bull 4 28ndash40 10-119

bull 5 gt40 309 -266

















study



Smoking cessation


















bull evidence 1)64

SMOKING






































dependent manner










































bull BP control






























































































bull 1 lt=10 05


bull 3 20ndash27 53- 42

bull 4 28ndash40 10-119

bull 5 gt40 309 -266

















study



Smoking cessation


















bull evidence 1)64

SMOKING






































dependent manner










































bull BP control










































































































study



Smoking cessation


















bull evidence 1)64

SMOKING






































dependent manner










































bull BP control






































































































study



Smoking cessation


















bull evidence 1)64

SMOKING






































dependent manner










































bull BP control




































































































study



Smoking cessation


















bull evidence 1)64

SMOKING






































dependent manner










































bull BP control



































































































study



Smoking cessation


















bull evidence 1)64

SMOKING






































dependent manner










































bull BP control

































































































study



Smoking cessation


















bull evidence 1)64

SMOKING






































dependent manner










































bull BP control




























































































Smoking cessation


















bull evidence 1)64

SMOKING






































dependent manner










































bull BP control



























































































Smoking cessation


















bull evidence 1)64

SMOKING






































dependent manner










































bull BP control


























































































Smoking cessation


















bull evidence 1)64

SMOKING






































dependent manner










































bull BP control


























































































SMOKING






































dependent manner










































bull BP control































































































































dependent manner










































bull BP control

























































































































dependent manner










































bull BP control























































































































dependent manner










































bull BP control





















































































































dependent manner










































bull BP control













































































































dependent manner










































bull BP control












































































































dependent manner










































bull BP control








































































































dependent manner










































bull BP control
































































































dependent manner










































bull BP control



































































































































bull BP control


























































































































bull BP control


















































































































bull BP control











































































































bull BP control






































































































bull BP control































































































bull BP control











































































































































































































































































































































































































































































































































































































































































































































































































































































































Date post:	05-Jul-2015
Category:	Health & Medicine
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Raccomandazioni per la val preop mal resp

Health & Medicine