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Anaesthesia for Patients with COPD. Dr Sajith Damodaran. University College of Medical Sciences & GTB Hospital, Delhi. COPD: Pathophysiology, Diagnosis, Treatment. Chronic Obstructive Pulmonary Disease. Definition:

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Anaesthesia for patients with copd

Anaesthesia for Patients with COPD

Dr SajithDamodaran

University College of Medical Sciences & GTB Hospital, Delhi


Copd pathophysiology diagnosis treatment

COPD: Pathophysiology, Diagnosis, Treatment


Chronic obstructive pulmonary disease

Chronic Obstructive Pulmonary Disease

Definition:

Disease state characterised by airflow limitation that is not fully reversible

The airflow limitation is usually progressive and is associated with an abnormal inflammatory response of the lungs to noxious particles or gases, primarily caused by cigarette smoking.


Chronic obstructive pulmonary disease1

Chronic Obstructive Pulmonary Disease

Definition:

Disease state characterised by airflow limitation that is not fully reversible

The airflow limitation is usually progressive and is associated with an abnormal inflammatory response of the lungs to noxious particles or gases, primarily caused by cigarette smoking.


Anaesthesia for patients with copd

COPD:

Includes:

  • Chronic Bronchitis

  • Emphysema

  • Peripheral Airways disease

Doesn’t include

  • Asthma, Asthmatic Bronchitis

  • Cystic Fibrosis

  • Bronchiactesis

  • Pulmonary fibrosis due to other

  • causes


Anaesthesia for patients with copd

COPD

Chronic Bronchitis: (Clinical Definition)

  • Chronic productive cough for 3 months in each of 2 successive years in a patient in whom other causes of productive chronic cough have been excluded.

    Emphysema: (Pathological Definition)

  • The presence of permanent enlargement of theairspaces distal to the terminal bronchioles, accompanied by destruction of their walls and without obvious fibrosis


Comparative features of copd

Comparative features of COPD


Copd risk factors

COPD: Risk factors

  • Host factos:

  • Genetic factors: Eg. α1 Antitrypsin Deficiency

  • Sex : Prevalence more in males.

    • ?Females more susceptible

  • Airway hyperactivity,

  • Immunoglobulin E and asthma

  • Exposures:

  • Smoking: Most Important Risk Factor

  • Socioeconomic status

  • Occupation

  • Environmental pollution

  • Perinatal events and childhood illness

  • Recurrent bronchopulmonary infections

  • Diet


Natural history

Natural History:

Fig. 1. - The normal course of forced expiratory volume in one second (FEV1) over time (–––)

is compared with the result of impaired growth of lung function (––– ) an accelerated decline

(–––) and a shortened plateau phase (–––). All three abnormalities can be combined

(KerstjensHAM, Rijcken B, Schouten JP, Postma DS. Decline of FEV1 by age and

smoking status: facts, figures, and fallacies. Thorax 1997; 52: 820–827.)


Pathophysiology

Pathophysiology:

Pathological changes are seen in 4 major compartments of lungs:

  • central airways

  • Peripheral airways

  • lung parenchyma

  • pulmonary vasculature.


Pathophysiology1

Pathophysiology:

Excessive Mucus production

  • Central Airways: (cartilaginous airways >2mm of internal diameter)

  • Bronchial glands hypertrophy

  • Goblet cell metaplasia

  • Airway Wall Changes:

  • Inflammatory Cells

Loss of cilia and ciliary dysfunction

Squamousmetaplasia of the airway epithelium

Increased smooth muscle and connective tissue

  • Peripheral airways (noncartilaginous airways<2mm internal diameter)

  • Bronchiolitis

  • Pathological extension of goblet cells and squamousmetaplasia

  • Inflammatory cells

  • Fibrosis and increased deposition of collagen in the airway walls

Airflow limitation and hyperinflation


Pathophysiology2

Pathophysiology:

  • Lung parenchyma (respiratory bronchioles, alveoli and capillaries)

  • Emphysema (abnormal englagement of air spaces distal to terminal bronchioles)

  • occurs in the parenchyma:

  • 2 Types: Centrilobular and Panlobular

    • Early microscopic lesion progress to Bullae over time.

    • Results in significant loss of alveolar attachments, which contributes

  • to peripheral airway collapse

  • Inflammatory cells

Airflow limitation and hyperinflation

  • Pulmonary HTN

  • RV dysfunction (cor Pulmonale)

  • Pulmonary Vasculature:

  • Thickening of the vessel wall and endothelial dysfunction

  • Increased vascular smooth muscle & inflammatory infiltration of the vessel wall

  • Collagen deposition and emphysematous destruction of the capillary bed


Pathogenesis

Pathogenesis:

Alpha 1 antitrypsin def.

Tobacco smoke & other noxious gases

Proteinase & Antiproteinase imbalance

Increased Neutrophils, Lymphocytes & Macrophages

Inflammatory response in airways

Oxidative Stress

Tissue Destruction

Impaired defense against tissue destruction

Impaired repair mechanisms


Physiological effects

Physiological Effects:

  • Mucous hypersecretion and cilliary dysfunction

    • Goblet cell hyperplasia & squamousmetaplasia

  • Airflow limitation and hyperinflation

    • Airway remodelling

    • Loss of eleastic recoil

    • Destruction of alveolar supports

    • Accumulation of mucus, inflammatory cells & exudate

  • Gas exchange abnormalities: (Hypoxemia +/- Hypercapnia)

    • Abnormal V/Q ratios

    • Abnormal DLCO

  • Pulmonary hypertension

    • Hypoxic Vasoconstrictoin,Endothelial dysfunction

    • Remodelling of arteries & capillary destruction

  • Systemic effects


Diagnosis

Diagnosis

Clinical Features:

  • Physical Examination:

  • Respiratory Signs

    • Barrel Chest

    • Pursed lip breathing

    • Adventitious Ronchi/Wheeze

  • Systemic Signs

    • Cyanosis

    • Neck vein enlargement

    • Peripheral edema

    • Liver enlargement

    • Loss of muscle mass

Symptoms:

Cough: Initially intermittent

Present throughout the day

Sputum:

Tenacious & mucoid

Purulent Infection

Dyspnoea: Progressively worsens

Persistant

Exposure:Smoking, in pack years


Anaesthesia for patients with copd

Diagnosis

  • Investigations:

  • Spirometry

    • Diagnosis

    • Assessment of severity

    • Following progress

  • Chest Radiograph: To exclude other diseases

    • Emphysematous changes

  • Bronchodilator Reversibility

    • Exclude Bronchial Asthma

    • <20%

  • Alpha-1 Antitrypsin levels

    • Young COPD with Family History


Gold classification

GOLD Classification


Treatment

Treatment

  • Modifying natural history of Disease:

    • Smoking cessation

    • Long term oxygen therapy

  • Symptomatic:

    • Bronchodilators

    • Antibiotics

    • Others

  • Pulmonary Rehabilitation

  • Nutrition


Treatment smoking cessation

Treatment: Smoking Cessation

  • Need:

    • Most important cause of COPD

    • Major risk factor for atherosclerotic vascular disease, cancer, peptic ulcer and osteoporosis.

    • Quitting smoking slows progressive loss of lung function & reduces symptoms

  • Motivation, Counselling & behavioural support

  • Nicotine replacement

    • Patches

    • chewing gum

    • Inhaler

    • nasal spray

    • lozenges

  • Bupriopion


Effect of smoking and smoking cessation on lung function

Effect of smoking and smoking cessation on Lung Function:

Loss of lung function over 11 yrs in the Lung Health Study for continuous smokers

(–––), intermittent quitters (–––) and sustained quitters (–––). FEV1: forced expiratory

volume in one second

(AnthonisenNR et al,LungHealth Study Research Group.

Smoking and lung function of Lung Health Study participants after 11 years. Am J RespirCrit

Care Med 2002; 166: 675–679.


Treatment oxygen therapy

Treatment: Oxygen Therapy

Long Term Oxygen Therapy(LTOT):

  • Improves survival, exercise, sleep and cognitive performance.

  • Oxygen delivery methods include nasal continuous flow, reservoir cannulas and transtracheal catheter.

  • Physiological indications for oxygen include an arterial oxygen tension (PaO2) <7.3 kPa (55 mmHg). The therapeutic goal is to maintain SpO2 >90% during rest, sleep and exertion.


Physiological indications for long term oxygen therapy ltot

Physiological indications for long-term oxygen therapy (LTOT)

PaO2 mmHg SaO2 % LTOT indicationQualifying condition

≤55 ≤88 Absolute None

55–59 89 Relative with qualifier “P” Pulmonale, polycythemia >55%

History of edema

≥60 ≥90 None except with qualifier Exercise desaturation

Sleep desaturation not corrected by CPAP

Lung disease with severe dyspnea responding to O2


Treatment symptomatic measures

Treatment: Symptomatic Measures

  • Bronchodilators:

    • Anticholinergics

    • Beta Agonists

    • Methylxanthines

  • Corticosteroids

  • N-Acetyl Cysteine

  • α1 Antitrypsin augmentation

    • Vaccination

  • Others: No proven effect

    • Leukotriene receptor antagonists/cromones

    • Maintenance antibiotic therapy

    • Immunoregulators

    • Vasodilators: NO, CCB


Surgical treatment

Surgical Treatment

Bullectomy

  • short-term improvements in

    • airflow obstruction

    • lung volumes

    • hypoxaemia and hypercapnia

    • exercise capacity

    • dyspnoea

      Lung Volume Reduction Surgery

  • potentially long-term improvement in survival

  • short-term improvements in

    • Spirometry

    • lung volumes

    • exercise tolerance

    • dyspnoea

      Lung Transplantation


Copd exacerbations

COPD: Exacerbations

Definition:

  • An exacerbation of COPD is an event in the natural course of the disease characterised by a change in the patient’s baseline dyspnoea, cough and/or sputum beyond day-to-day variability sufficient to warrant a change in management.

    Precipitating Causes:

  • Infections: Bacterial, Viral

  • Air pollution exposure

  • Non compliance with LTOT


Copd exacerbations1

COPD: Exacerbations

Indication for Hospitalisation:

  • The presence of high-risk comorbid conditions

    • pneumonia,

    • cardiac arrhythmia,

    • congestive heart failure,

    • diabetesmellitus,

    • renal or liverfailure

  • Inadequate response to outpatient management

  • Marked increase in dyspnoea, orthopnoea

  • Worsening hypoxaemia & hypercapnia

  • Changes in mental status

  • Uncertain diagnosis.


Copd exacerbations2

COPD: Exacerbations

Indication for ICU admission:

  • Impending or actual respiratory failure

  • Presence of other end-organ dysfunction

    • shock

    • renal failure

    • liver failure

    • neurological disturbance

  • Haemodynamic instability


Treatment1

Treatment

  • Supplemental Oxygen (if SPO2 < 90%)

  • Bronchodilators:

    • Nebulised Beta Agonists,

    • Ipratropium with spacer/MDI

  • Corticosteroids

    • Inhaled, Oral

  • Antibiotics:

    • If change in sputum characteristics

    • Based on local antibiotic resistance

    • Amoxycillin/Clavulamate, Respiratory Flouroquinolones

  • Ventillatory support: NIV, Invasive ventillation


Anaesthesia for patients with copd

In a nutshell

Optimal disease management entails redesigning standard medical care to integrate rehabilitative elements

into a system of patient self-management and regular exercise


Preparation for anaesthesia

………. Preparation for Anaesthesia


Anaesthetic considerations in patients with copd undergoing surgery

Anaesthetic Considerations in patients with COPD undergoing surgery:

Patient Factors:

  • Advanced age

  • Poor general condition, nutritional status

  • Co morbid conditions

    • HTN

    • Diabetes

    • Heart Disease

    • Obesity

    • Sleep Apnea

  • Weak HPV, blunted Ventilatory responses to hypoxia and CO2 retention


Age related pulmonary changes

Age Related Pulmonary Changes:


Anaesthetic considerations in patients with copd undergoing surgery1

Anaesthetic Considerations in patients with COPD undergoing surgery:

  • Problems due to Disease

    • Exacerbation of Bronchial inflammation

      • d/t Airway instrumentation

    • preoperative airway infection

    • surgery induced immunosuppression

    • increased WOB

    • Increased post operative pulmonary complications


Anaesthetic considerations in patients with copd undergoing surgery2

Anaesthetic Considerations in patients with COPD undergoing surgery:

  • Problems due to Anaesthesia:

    • GA decreases lung volumes, promotes V/Q mismatch

    • FRC reduced during anaesthesia, CC parallels FRC

    • Anaesthetic drugs blunt Ventilatory responses to hypoxia & CO2

    • Postoperative Atelectasis & hypoxemia

    • Postoperative pain limits coughing & lung expansion

  • Problems due to Surgery:

    • Site : most important predictor of Post op complications

    • Duration: > 3 hours

    • Position


Pre operative assessment

Pre-operative assessment:

History:

  • Smoking

  • Cough: Type, Progression, Recent RTI

  • Sputum: Quantity, color, blood

  • Dyspnea

  • Exercise intolerance

  • Occupation, Allergies

  • Symptoms of cardiac or respiratory failure


Pre operative assessment examination

Pre-operative assessment: Examination

Physical Examination: Better at assessing chance of post op complications

Airway obstruction

  • hyperinflation of chest, Barrel chest

  • Decreased breath sounds

  • Expiratory ronchi

  • Prolonged expiration: Watch & Stethoscope test, >4 sec

    ↑WOB

  • ↑ RR, ↑HR

  • Accessory muscles used

  • Tracheal tug

  • Intercostal indrawing

  • Tripod sitting posture


Anaesthesia for patients with copd

Pre-operative assessment: Examination

  • Respiratory failure

    • Hypercapnia

    • Hypoxia

    • Cyanosis

  • Cor Pulmonale and Right heart failure

    Dependant edema

    tender enlarged liver

  • Pulmonary hypertension

    • Loud P2

    • Right Parasternal heave

    • Tricuspid regurgitation

  • Body Habitus

    Obesity/ Malnourished

  • Active infection

    • Sputum- change in quantity, nature

    • Fever

    • Crepitations


Preoperative assessment investigations

Preoperative Assessment: Investigations

  • Complete Blood count

  • Serum Electrolytes

  • Blood Sugar

  • Urinalysis

  • ECG

  • Arterial Blood Gases

  • Diagnostic Radiology

    • Chest X Ray

    • Spiral CT

  • Preoperative Pulmonary Function Tests

    • Tool for optimisation of pre-op lung function

    • Not to assess risk of post op pulmonary complications


Investigations chest x ray

Investigations: Chest X-Ray

  • Overinflation

  • Depression or flattening of diaphragm

  • Increase in length of lung

  • ↑ size of retrosternal airspace

  • ↑ lung markings- dirty lung

  • Bullae +/-

  • Vertical Cardiac silhouette

  • ↑ transverse diameter of chest, ribs horizontal, square chest

  • Enlarged pulmonary artery with rapid tapering in MZ


Pulmonary function tests

Pulmonary Function Tests:


Spirometric tracing in copd patients

Litres

0

FEV1

FVC

FEV1/FVC

1

Normal

4150

5200

80%

COPD

2350

3900

60%

2

FEV1

3

COPD

FVC

4

FEV1

NORMAL

FVC

5

seconds

1

2

3

4

5

Spirometric tracing in COPD patients


Anaesthesia for patients with copd

Maximum inspiratory and expiratory flow-volume curves (i.e., flow-volume loops) in four types of airwayobstruction.


Preoperative assessment investigations1

Preoperative Assessment: Investigations

ECG

  • Signs of RVH:

    • RAD

    • p Pulmonale in Lead II

    • Predominant R wave in V1-3

    • RS pattern in precordial leads

      Arterial Blood Gases:

  • In moderate-severe disease

  • Nocturnal sample in cor Pulmonale

    • Increased PaCO2 is prognostic marker

    • Strong predictor of potential intra op respiratory failure & post op Ventilatory failure

    • Also, increased d/t post op pain, shivering, fever,respiratory depressants


Pre operative preparation

Pre-operative preparation

  • Cessation of smoking

  • Dilation of airways

  • Loosening & Removal of secretions

  • Eradication of infection

  • Recognition of Cor Pulmonale and treatment

  • Improve strength of skeletal muscles – nutrition, exercise

  • Correct electrolyte imbalance

  • Familiarization with respiratory therapy, education, motivation & facilitation of patient care


Effects of smoking

Effects of smoking:

  • Cardiac Effects:

    • Risk factor for development of cardiovascular disease

    • CO decreases Oxygen delivery & increases myocardial work

    • Catecholamine release, coronary vasoconstriction

    • Decreased exercise capacity

  • Respiratory Effects:

    • Major risk factor for COPD

    • Decreased Mucociliary activity

    • Hyperreactive airways

    • Decreased Pulmonary immune function

  • Other Systems

    • Impairs wound healing


Anaesthesia for patients with copd

Smoking cessation and time course of beneficial Effects


Dilatation of airways

Dilatation of Airways:

  • Bronchodilators:

    • Only small increase in FEV1

    • Alleviate symptoms by decreasing hyperinflation & dyspnoea

    • Improve exercise tolerance

  • Anticholinergics

  • Beta Agonists

  • Methylxanthines


  • Anticholinergics

    Anticholinergics:

    • Block muscarinic receptors

    • Onset of action within 30 Min

    • Ipratropium –

      • 40-80 μg by inhalation

      • 20 μg/ puff – 2 puffs X 3-4 times

      • 250 μg / ml respirator soln. 0.4- 2 ml X 4 times daily

    • Tiotropium - long lasting

    • Side Effects:

      • Dry Mouth, metallic taste

      • Caution in Prostatism & Glaucoma


    Beta blockers

    Beta Blockers:

    • Act by increasing cAMP

    • Specific β2 agonist –

      • Salbutamol :

        • oral 2-4 mg/ 0.25 – 0.5 mg i.m /s.c 100-200 μg inhalation

        • muscle tremors, palpitations, throat irritation

    • Terbutaline :

      • oral 5 mg/ 0.25 mg s.c./ 250 μg inhalation

    • Salmeterol :

      • Long acting (12 hrs)

      • 50 μg BD- 200 μg BD

    • Formeterol, Bambuterol


    Bronchodilators methylxathines

    Bronchodilators: methylxathines

    • Mode of Action

      – inhibition of phospodiesterase,↑ cAMP, cGMP – Bronchodilatation

      • Adenosine receptor antagonism

      • ↑ Ca release from SR

    • Oral(Theophyllin) & Intravenous (Aminophylline, Theophyllin)

      • loading – 5-6 mg/kg

      • Previous use – 3 mg/kg

      • Maintenace –

        • 1.0mg/kg h for smokers

        • 0.5mg/kg/h for nonsmokers

        • 0.3 mg/kg/h for severely ill patients.


    Inhaled corticosteroids

    Inhaled Corticosteroids:

    • Anti-inflammatory

    • Restore responsiveness to β2 agonist

    • Reduce severity and frequency of exacerbations

    • Do not alter rate of decline of FEV1

    • Beclomethasone, Budesonide, Fluticasone

    • Dose: 200 μg BD ↑ upto 400 μg QID

    • > 1600 μg / day- suppression of HPA axis


    Anaesthetic technique

    ………. AnaestheTIC Technique


    Anaesthetic technique1

    Anaesthetic Technique

    COPD is not a limitation on the choice of anaesthesia.

    Type of Anaesthesia doesn’t predictably influence Post op pulmonary complications.


    Concerns in ra

    Concerns in RA

    • Neuraxial Techniques:

    • No significant effect on Resp function: Level above T6 not

      • recommended

      • No interference with airway  Avoids bronchospasm

    • No swings in intrathoracic pressure

    • No danger of pneumothorax from N2O

    • Sedation reqd. May compromise expiratory fn.

    • Peripheral Nerve Blocks:

    • Suitable for peripheral limb surgeries

    • Minimal respiratory effects

    • Supraclavicular techniques contraindicated in severe

      • Pulmonary disease


    Concerns in ra1

    Concerns in RA

    • Improved Surgical outcome:

      • Better pain control

      • Attenuation of neuroedocrinerespones to surgery

      • Improvement of tissue oxygenation

      • Maintenance of immune function

      • Fewer episodes of DVT, PE, stroke, blood Tx

    • Technique of choice in perineal, pelvic extraperitoneal

    • & lower extremities

    • No benefit over GA in Intraperitoneal surgery,

    • or when high levels are needed


    Concerns in ga

    Concerns in GA

    • Airway instrumentation & bronchospasm

    • Residual NMB

    • Nitrous Oxide

    • Attenuation of HPV

    • Respiratory depression with opioids, BZDs

    • Airway humidification


    Premedication

    Premedication

    • ↑ Sensitivity to the effect of respiratory depressants

    • Opioids & Benzodiazepines - ↓ response to hypoxia, hypercarbia

    • Bronchodilator puff / nebulisation, inhaled steroids

    • Atropine ?: Should be individualised

      • Decreases airway resistance

      • Decreases secretion-induced airway reactivity

      • Decreases bronchospasm from reflex vagal stimulation

      • Cause drying of secretions, mucus plugging


    General anaesthesia induction

    General Anaesthesia: Induction

    • Opioids:

      • Fentanyl(DoC)

      • Morphine ,Pethidine

      • Respiratory Depression, Histamine release, Chest tightness

    • Propofol (DoC)

      • Better suppression of laryngeal reflexes

      • Hemodynamic compromise

      • Agent of choice in stable patient

    • Ketamine

      • Bronchodilator  Catecholamine release, neural inhibition

      • Tachycardia and HT, may increase PVR


    Intubation

    Intubation

    • NMB :

      • Succinyl Choline (1-2mg/kg)

      • Vecuronium(0.08-0.10 mg/kg)

      • Rocuronium (0.6-1.2 mg/kg )

    • Attenuation of Intubation Response:

      • IV lignocaine (1- 1.5 mg/kg) 90s prior to laryngoscopy

      • Fentanyl 1-5 microgram/Kg

      • Esmolol 100-150mg bolus

      • Adequate plane of anaesthesia prior to intubation

    • LMA Vs Endotracheal Tube

      • Avoids tracheal stimulation

      • P-LMA also allows for suctioning


    Maintenance

    Maintenance

    • Muscle relaxant

      • Prefer Vecuronium, Rocuronium, Cisatracurium

      • Avoid Atracurium, Mivacurium, Doxacurium ( histamine release)

    • Volatile anaesthetic

      • NO  Caution in pulmonary bullae, dilution of delivered O2

      • Inhalational agents attenuate HPV

      • Sevoflurane: non pungent, bronchodilator

      • Halothane: Non pungent, bronchodilator.

        Slower onset & elimination, Sensitises to catecholamines


    Maintenance1

    Maintenance

    Ventialatory Strategy:

    • Aim: Maximise alveolar gas emptying

      Minismise dynamic hyperinflation, iPEEP

    • Settings:

      • Decrease minute vent Low frequency

      • Adequate Exp time, Low I:E ratio, minimal exp pause

      • Reduce exp flow resistance

      • Recruitment maneuvers

      • Acceptance of mild hypercapnia & acidemia

    • Humidification of gases

    • Pressure Cycled mode with decelerating flow.


    Maintenance2

    Maintenance

    • Monitoring

      • ECG, NIBP

      • Pulse Oximetry

      • Capnography

      • Neuromuscular Monitoring

      • Depth of Anaesthesia

    • Intraoperative IV Fluids

      • Excessive IV volume  Water accumulation & tissue edema  Respiratory/heart failure

      • Haemodynamic goal directed fluid loading

      • Restrictive fluid administration


    Intraoperative increased pip

    Intraoperative Increased PIP

    • Bronchospasm

    • Light anaesthesia, coughing, bucking

    • Obstruction in the circuit

    • Blocked / kinked tube

    • Endobronchial intubation

    • Pneumothorax

    • Pulmonary embolism

    • Major Atelectasis

    • Pulmonary edema

    • Aspiration pneumonia

    • Head down position, bowel packing


    Management of intraoperative bronchospasm

    Management of intraoperative bronchospasm

    • Increase FiO2

    • Deepen anaesthesia

      • Commonest cause is surgical stimulation under light anaesthesia

      • Incremental dose of Ketamine or Propofol

    • Relieve mechanical stimulation

      • endotracheal suction

      • Stop surgery

    • β2agonists – Nebulisation or MDI

      • s/c Terbutaline, iv Adrenaline

    • intravenous Aminophyline

    • Intravenous corticosteroid indicated if severe bronchospasm


    Reversal recovery

    Reversal/ Recovery:

    • Neostigmine - may provoke bronchospasm

    • Atropine 1.2-1.8mg or Glycopyrrolate 0.6mg before Neostigmine

    • Tracheal toileting

    • Extubation : deep or awake?

      • Deep extubation may reduce chance of bronchospasm

    Deep

    NO

    YES

    Good airway - accessible

    Easy intubation

    No Residual NMB

    Normothermic

    Not at increased risk of aspiration

    Difficult airway

    Difficult intubation

    Residual NMB

    Full stomach


    Post operative care

    Post operative care

    • ↑ Risk of Post op pulmonary complications

    • Postoperative analgesia –

      • Parenteral NSAIDS

      • Neuraxial drugs

      • Nerve blocks

      • PCA

    • Postoperative respiratory therapy –

      • Chest physiotherapy & postural drainage

      • Voluntary Deep Breathing

      • Incentive Spirometry


    Post operative care1

    Post operative care

    • Mechanical Ventilation:

      • Indications:

        • Severe COPD undergoing major surgery

        • FEV1/FVC<70%

        • Preop PaCO2 > 50mm Hg

      • FiO2 & Ventillator settings adjusted to maintain PaO2 60-100 mm Hg & PaCO2 in range that maintains pH at7.35-7.45

    • Continue Bronchodilators

    • Oxygen therapy

    • Lung Expansion maneuvers


    Post operative pulmonary complications

    Post Operative Pulmonary Complications:

    • Incidence: 6.8% (Range 2-19%)

      (Sementa et al,Annals of internal Medicine, 2006,144:581–95)

    • Include:

      • Atelectasis

      • Bronchopneumonia

      • Hypoxemia

      • Respiratory Failure

      • Bronchopleural fistula

      • Pleural effusion


    Post operative pulmonary complications1

    Post Operative Pulmonary Complications:

    • Patient Related:

    • Age > 70 yrs

    • ASA Class II or above

    • CHF

    • Pre-existing Pulmonary Disease

    • Functionally Dependent

    • Cigarette smoking

    • Hypoalbuimnemia , 3.5g/dL

    Predictors of

    PPCs:

    • Procedure Related:

    • Emergency Surgery

    • Duration > 3 Hrs

    • GA

    • Abd, Thoracic, Head & Neck,

    • Nuero, Vascular Surgery


    Post operative pulmonary complications2

    Post Operative Pulmonary Complications:

    Specific Risk Factors:

    • COPD

    • Bronchial Asthma

    • GA

    • OSA

    • Advanced age

    • Morbid Obesity(BMI > 40)

    • Functional limitation

    • Smoking > 20 Pack year

    • Alcohol consumption (>60ml ethanol/day)


    Post operative pulmonary complications3

    Post Operative Pulmonary Complications:

    Risk Reduction Strategies:

    • Preoperative:

    • Smoking cessation

    • Bronchodilatation

    • Control infections

    • Patient Education

    • Intraoperative:

    • Minimally invasive surgery

    • Regional Anaesthesia

    • Duration < 3 Hrs

    • Post operative:

    • Lung Volume Expansion Maneuvers

    • Adequate Analgesia


    Post operative pulmonary complications4

    Post Operative Pulmonary Complications:

    Post Operative Analgesia:

    • Opioids

    • Paravertebral/Intercostal N Blocks

    • Epidural Analgesia

      • LA

      • Opioids

    • NSAIDS  Bronchospasm


    Post operative pulmonary complications5

    Post Operative Pulmonary Complications:

    Lung Expansion maneuvers:

    • Incentive spirometry

    • Deep breathing exercises

    • Chest Physiotherapy & postural drainage

    • Intermittant Positive Pressure Ventilation

    • CPAP, BiPAP

    • Early Ambulation


    Summary

    Summary:

    • COPD is a progressive disease with increasing irreversible airway obstruction.

    • Cigarette smoking is the most important causative factor for COPD

    • Smoking cessation & LTOT are the only measures capable of altering the natural history of COPD.

    • COPD is not a contraindication for any particular anaesthsia technique if patients have been appropriately stabilised.

    • COPD patients are prone to develop intraoperative and postoperative pulmonary complications.

    • Preoperative optimisation should include control of infection and wheezing.

    • Postoperative lung expansion maneuvers and adequate post op analgesia have been proven to decrease incidence of post op complications.


    References

    References:

    • Stoelting’s Anaesthesia & Coexisting Disease, 5th Ed.

    • Standards for Diagnosis & Management of COPD Patients, American Thoracic Society & European Respiratory Society

    • Global Initiative for COPD

    • Refresher course lectures, 57th National Conference of ISA

    • COPD: Perioperative management, M.E.J. Anesth 2008 19(6)

    • Post Operative Pulmonary Complications, IJA April 2006

    • Periop Management of patients with COPD: Review, IJ COPD 2007:2(4) 493:515

    • Harrison’s Principles of Medicine, 16th Ed

    • Principles of respiratory Care, Egan’s, 9th Ed

    • Miller’s Anaesthsia, 7th Ed

    • Irwin & Rippe’s Intensive care medicine, 6th Ed.

    • Clinical Application of Mechanical Ventilation, David W Chang, 3rd Ed


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