7.

RESPIRATORY DISEASE

Respiratory disease often occurs in patients presenting for anaesthesia and surgery.
Common respiratory diseases include asthma, chronic obstructive pulmonary disease
(COPD), and upper and lower respiratory tract infections, tuberculosis, obstructive sleep
apnoea (OSA) and smoking. General anaesthesia has several effects on the patient’s
respiratory function. These effects begin at induction of anaesthesia and continue into the
postoperative period, including a decrease in lung volume, decreased respiratory rate
response to hypoxia and hypercarbia, V/Q mismatch, atelectasis, and sputum retention.
Respiratory function will be further decreased by poorly treated postoperative pain. 

Preoperative Assessment

The anaesthesia provider must undertake a full history, examination and order relevant
investigations. The history and examination may reveal significant risk factors (as listed
below) for perioperative pulmonary complications. Perioperative pulmonary complications
include developing atelectasis, infection, respiratory failure, hypoxaemia and exacerbation
of underlying chronic respiratory disease.

Risk factors for developing postoperative pulmonary complications include age greater than
80 years, frailty, preoperative SaO2 less than 96%, recent lower respiratory tract infection,
anaemia, congestive heart failure, altered GCS, ASA >2, obstructive sleep apnoea and the
nature of the surgery. Surgery greater than 3 hours, emergency surgery and
intrathoracic/upper abdominal surgery are all associated with increased risk of
postoperative complications. Patients with oxygen saturations of 91 -9 5% have twice the
risk and with oxygen saturations <91% a tenfold increase in risk compared to those with
oxygen saturations > 95%. Smoking cessation at least 4 weeks prior to surgery reduces risk.
Well-controlled asthma and obesity do not appear to be an independent risk factor for
postoperative pulmonary complications.

Pulmonary function testing (PFT) is useful in predicting which patients may not survive a
pneumonectomy but is unreliable in predicting postoperative pulmonary complications for
other surgical procedures. PFT may be useful in patients with asthma or COPD to determine
if the patient is at their best baseline respiratory function. Although an abnormal chest X-ray
is predictive of postoperative pulmonary complications, the anaesthesia clinician must
always also rely on clinical findings.

Bacterial and viral respiratory infections will have an adverse effect on respiratory function,
increasing airflow obstruction for up to 5 weeks after the infection. Wheezing is usually
reversible and should be treated with bronchodilators however the anaesthesia provider
must also check and treat for non-respiratory causes of wheezing such as cardiac failure.
Smoking should be stopped. 

The anaesthesia provider must treat any potentially reversible respiratory disease before
surgery. They should encourage the patient to stop smoking, treat acute bacterial infections,
humidify inhaled gases, encourage chest physiotherapy and treat bronchospasm and right
heart failure. 
Regional anaesthesia and local anaesthesia are good alternatives to general anaesthesia.
Multimodal analgesia will reduce the dose of opioids required. For patients at risk of airway
hyper-reactivity, airway manipulation should be kept minimal. Where appropriate, the use
of supraglottic airways, rather than laryngoscopy and intubation, may reduce the incidence
of laryngospasm and bronchospasm.

Patients at risk of postoperative pulmonary complications should be cared for in an area of

higher acuity. Of importance in postoperative care are physiotherapy, incentive spirometry,
early mobilisation, humidification, and good analgesia.

Respiratory Infections

90% of upper respiratory tract infections are likely to be viral. If bacterial infection is
suspected the patient should be treated with antibiotics prior to surgery. Even viral
infections will increase the risk of laryngospasm and bronchospasm and it is wise to delay
surgery if possible, for 5 weeks. A careful history and examination looking for fever, cough,
pyrexia, shortness of breath and lethargy or signs on chest auscultation will allow the
anaesthesia provider to assess the severity of the infection and consider postponement of
elective procedures.

Tuberculosis

Early pulmonary tuberculosis (TB) may be asymptomatic. Cough, haemoptysis, chest pain
and shortness of breath occur late in the disease. The important considerations for the
anaesthesia provider are the overall condition of the patient, current medications and
possible drug interactions and appropriate infection control to prevent transmission to
health care workers. The presence of a cough, productive sputum, lung cavitation and
laryngeal TB all increase the risk of transmission. Aerosol generating procedures (e.g.
intubation and extubation, bronchoscopy and administering aerosolised medications) also
significantly increase risk. The anaesthesia provider must also be aware of non-pulmonary
symptoms. Tuberculosis can affect many organs including the pleura, pericardium, central
nervous system, kidney and bone marrow. Hyponatraemia may occur with pulmonary
tuberculosis. If time allows, active tuberculosis must be treated before any surgery. 

Asthma

The key features of asthma are airway inflammation, airway hyper-responsiveness and
narrowing leading to airway obstruction. The risk of perioperative pulmonary complications
is very low in well-controlled asthmatics. The main preoperative goal is to assess whether
the patient’s pulmonary function is optimal. Elective surgery should be postponed if the
patient has signs and symptoms of exacerbation of their asthma. Patients should not be
wheezing at the time of surgery. A careful history, examination and simple investigations
will allow the anaesthesia provider to determine how severe a patient’s asthma usually is
and if the patient’s asthma could be improved before surgery. 
To establish how severe a patient’s asthma usually is, the anaesthesia clinician needs to
know how often the patient has asthma attacks, what maintenance medication they are
taking, how often they take short acting beta-agonist therapy, the frequency and use of
recent oral glucocorticoids, recent upper respiratory infections, their history of
hospitalisation and history of intubations, what their best exercise tolerance is, and the
patient’s own assessment of their asthma. 

Preoperative physical assessment should concentrate on the patient’s respiratory rate, use
of accessory muscles, and the presence of a wheeze and signs of current respiratory
infection. The well-controlled asthmatic does not require routine pulmonary function
testing, arterial blood gas analysis or chest x-ray prior to surgery. Often patients are
monitoring their asthma control with a hand-held peak expiratory flow meter. A peak flow >
80 percent of what is predicted suggests that asthma is well controlled.

All patients with asthma should continue their usual asthma treatment medications and
may benefit from nebulised salbutamol immediately before anaesthesia. Patients taking
high dose oral/inhalation steroids may need supplementary glucocorticoid at induction of
anaesthesia to prevent adrenal insufficiency.

The anaesthesia provider should avoid histamine-releasing drugs. If possible, endotracheal

intubation, which can precipitate bronchospasm, should also be avoided. Mask ventilation,
supraglottic airways or regional/local anaesthesia are good alternatives. However,
anaesthesia providers must be aware that patients with asthma may depend on accessory
muscles for active exhalation and mid-thoracic neuraxial anaesthesia may not be tolerated.
Regional anaesthesia techniques, which could potentially cause phrenic nerve palsy, must
be avoided.

If endotracheal intubation is necessary, administration of lignocaine 1 to 2 mg/kg I.V or

fentanyl 50 to 100 μg I.V at induction may help suppress airway reflexes and attenuate
bronchospasm. Ketamine, which has bronchodilatory properties, may be a suitable choice
for induction, but it also causes increased secretions. The synthetic opioid fentanyl releases
little histamine, compared to pethidine and morphine, and has been safely used for
intraoperative and postoperative analgesia. Most common inhalation agents are
bronchodilators, however desflurane can cause increased secretions, coughing and
bronchospasm. Neuromuscular blocking agents that release histamine (atracurium and
suxamethonium) should be avoided if there is an alternative. Theoretically
acetylcholinesterase inhibitors carry a risk of precipitating bronchospasm but clinically this is
not an issue and all muscle relaxation should be reversed. Non-steroidal analgesics may
result in a relative excess of leukotriene production and can result in exacerbation of
asthma.

Patients with expiratory airflow obstruction need prolonged expiration. With controlled
ventilation, if the expiratory time is too short, the next tidal volume may be delivered before
exhalation is complete, resulting in “breath stacking”. This will result in progressive
hyperinflation, severe hypotension from decreased venous return and eventually
barotrauma. Asthmatic patients require “lung protective ventilation” with reduced tidal
volumes (6 mL/kg), reduced respiratory rates with a longer expiratory time, and cautious
use of PEEP.

Intraoperative bronchospasm may be recognised by auscultation, decreased tidal volume,

high inspiratory pressures and changes in endtidal CO2 waveform (upsloping or decreased
plateau). Decreased oxygen saturations are a late sign. Management includes increasing the
inspired oxygen percentage, deepening anaesthesia and administering a beta-2 agonist, 8-
10 puffs by metered dose inhaler or 2.5 mg by nebuliser.

Chronic Obstructive Pulmonary Disease (COPD)

Chronic obstructive pulmonary disease encompasses both emphysema and chronic

bronchitis. The main preoperative goal is to assess whether the patient’s pulmonary
function is optimal. Elective surgery should be postponed if the patient has signs and
symptoms of exacerbation of COPD (dyspnoea at rest, wheezing, copious sputum
production, tachypnoea) or evidence of active infection. The chest X-ray may be normal in
early disease. 

The patient should stop smoking and be treated for any chest infections. These patients may
have some reversible lung disease and may benefit from preoperative bronchodilators,
steroids, antibiotics and chest physiotherapy. The patient’s usual inhaled beta-agonists and
anticholinergic bronchodilators, as well as glucocorticoids, should be continued throughout
the perioperative period. Patients receiving more than the equivalent of 20 mg/day of
prednisone (or 80 mg/day of hydrocortisone, 16 mg/day of methylprednisolone or 2 mg/day
of dexamethasone) for more than 3 weeks are at risk of hypothalamic pituitary axis
suppression and should receive a stress dose of glucocorticoid before induction of
anaesthesia.

The anaesthesia provider faces several challenges in providing anaesthesia. COPD patients
are at risk of respiratory depression and poor cough with even low doses of sedatives and
opioids. Oxygen saturations should be maintained as close as possible to preoperative
values. Administering high oxygen concentrations in a spontaneously breathing COPD
patient may result in hypoventilation with subsequent hypercarbia and worsening V/Q
mismatch. The risk of bronchospasm is reduced with the use of a supraglottic airway rather
than laryngoscopy and intubation. Regional anaesthesia, including central neuraxial block,
eliminates the need for airway manipulation. For airway manipulation, administration of
lignocaine 1 to 2 mg/kg I.V or fentanyl 50 to 100 μg I.V at induction may help attenuate
bronchospasm. Ketamine has both bronchodilatory and analgesia properties. For the
maintenance of anaesthesia, selecting an inhalation agent with bronchodilatory properties
(e.g. sevoflurane, halothane or isoflurane), short acting neuromuscular blocking agents,
complete reversal of muscle relaxation and small doses of opioids is appropriate. Desflurane
should be used with caution, as it is an airway irritant.
 
Patients with COPD are at risk of “breath stacking” during controlled ventilation leading to
hyperinflation, profound hypotension and pneumothorax. Breath stacking occurs when
expiratory airflow limitation causes inspiration to occur prior to full exhalation of the
previous breath. Controlled ventilation will need to be tailored to protect the patient’s lung
but also avoid hypoxia and hypercarbia. Ideally tidal volumes should be with low/normal
tidal (6 mL/kg predicted body weight) maintaining plateau pressures < 20 cmH 2O, but also at
reduced respiratory rates (8-10 breaths per minute) with longer expiratory time. Fractional
inspired oxygen should be the lowest required to maintain SaO2 > 92%. Postoperative pain
control is very important in any patient with respiratory disease.

Obstructive Sleep Apnoea

Obstructive sleep apnoea (OSA) is the repetitive collapse of the upper airway during sleep.
The collapse may be complete, leading to cessation of airflow (apnoea), or partial, leading to
a reduction in airflow (hypopnoea). The severity of OSA is usually determined by the
frequency of obstructive respiratory events and defined by the Apnoea Hypopnoea Index
(AHI), which is the average number of respiratory disturbances per hour of sleep. Moderate
to severe OSA has an AHI > 15 events/hour.

OSA can have a considerable impact on morbidity and mortality. The risk increases with the
severity of OSA. Patients may have a history of snoring, daytime somnolence, and impaired
concentration. They frequently have comorbidities including hypertension, arrhythmias,
pulmonary hypertension, congestive cardiac failure, ischaemic heart disease,
cerebrovascular disease, insulin resistance and gastro-oesophageal reflux. Patients with OSA
need a thorough preoperative assessment including a detailed history of co-morbidities,
OSA severity scoring, adherence to treatment and clinical examination focusing on the
airway. A “difficult airway” is 8 times more common with OSA patients.

OSA is formally diagnosed with polysomnography, however this may not be readily
available. There are several screening questionnaires developed to identify high-risk
patients. The STOP-BANG questionnaire consists of eight yes/no questions: snoring,
tiredness, observed apnoea, BMI > 35 kg/m2, age > 50 years, neck circumference > 40 cm
and male gender. A score of 3 or more has a sensitivity of 94% but also has a large number
of false positives (specificity 32%).

The OSA50 questionnaire uses four items to diagnose OSA. A score of 5 or more has 94%
sensitivity and 31% specificity.

Item Description Score

Obesity Waist circumference >102cm males or > 88cm females 3
Snoring Does snoring bother other people? 3
Apnoea Has anyone noticed apnoea during sleep?
2
s
50 Are you aged 50 years or over? 2
OSA50 /10

Patients with suspected OSA may proceed to surgery without a formal diagnosis, unless
there is evidence of an associated significant or uncontrolled disease or additional problems
with respiratory function. Additional preoperative cardiopulmonary evaluation should be
considered in patients with diagnosed, partially treated/untreated and suspected OSA if
there is an indication of an associated significant or uncontrolled comorbidity.
Intraoperatively regional or local anaesthetic techniques should be preferentially used
where appropriate. Sedation/analgesia should be administered with care, as OSA patients
are often sensitive to respiratory depression. Patients with OSA should be induced and
intubated in the head-up position and after adequate preoxygenation. General anaesthetic
techniques should allow rapid restoration of consciousness and return to baseline
respiratory function. Tracheal extubation should be done carefully after adequate
assessment for the recovery of muscle strength following appropriate reversal of
neuromuscular blocking agents. Pulmonary hypertension is a known complication of chronic
OSA. Intraoperative events which elevate pulmonary artery pressures, namely hypercarbia,
hypoxaemia, hypothermia, and acidosis should be avoided.

Optimal postoperative OSA management includes continuation of CPAP, extended

monitoring in recovery, increased acuity of postoperative nursing care, multimodal opioid
sparing analgesia, avoidance of the supine position, early mobilisation and cautious
intravenous fluid administration.