COPD- Pre-op assessment &

Anaesthetic considerations
Presentors: Dr. Kyizom
Dr. Sangeet
Moderator: Dr. Sinha

PRE-OPERATIVE EVALUATION
History
Physical examination
Investigations
Evaluation of ventilatory functions
Arterial blood gas evaluation

HISTORY

Smoking no. of pack years, interval since stopped

Dyspnoea degree, exercise tolerance
Cough and expectoration colour & amount of sputum
Hemoptysis and chest pain
Triggering factors /allergy
Response to drug therapy
Comorbid conditions heart failure, DM, HT, stroke
Recent hospitalization , need for systemic steroids,
intubation and ventilation

PHYSICAL EXAMINATION

Body Habitus
Obesity/ Malnourished

Airway obstruction

hyperinflation of chest (Barrel chest)

decreased breath sounds
expiratory ronchi
prolonged expiration

Work of Breathing

RR, HR
accessory muscles use
intercostal indrawing
tracheal tug

Active infection
sputum- change in quantity /nature
Fever
crepitations

Respiratory failure
Cyanosis (Hypercapnea, Hypoxia)

Cor Pulmonale and Right heart failure

dependant edema
tender enlarged liver

Pulmonary hypertension
loud P2
right Parasternal heave

INVESTIGATIONS
ROUTINE - Hb ( chronic hypoxia, polycythemia)
- TLC (leucocytosis due to infection)
- S. Electrolytes
- B. Sugar
- S. creatinine
- Sputum culture and sensitivity

SPECIFIC - Chest X-Ray

- ECG
- PFTs
- ABG analysis

CHEST X-RAY

Chronic bronchitis rarely

diagnosed on X-Ray
Emphysematous changes
- Hyperlucent lung fields
- Low, flat diaphragm
- Thin elongated heart
- Enlarged retrosternal airspace
- Sparse peripheral vasculature
- Pulmonary artery prominence
- Bullous lesions

ELECTROCARDIOGRAM
Right axis deviation

Right ventricular hypertrophy

Right atrial hypertrophy (P- pulmonale)
Supraventricular arrythmias common in
exacerbation

PULMONARY FUNCTION TESTS

For diagnosis, severity and reversibility of disease

Not predictive of post-op pulmonary complications
A management tool to optimize pre-op pulm function
Should be repeated three times to take best value
Most useful tests are FVC , FEV1 , PEFR
Reversibility diagnosed if FEV1 increased by > 15%
change

Indications for PFTs

Cardiac, thoracic or upper abdominal surgery
Lower abdominal surgery with history of dyspnoea, smoking
and anticipated prolonged surgery
All patients undergoing lung resection
Morbid obesity
Documented pulmonary disease with age >70yrs

PFT in COPD

FEV1 / FVC
in MMEFR (25% - 75% of VC)
RV , Normal to increased FRC & TLC
MVV normal 160 180 L/min
- < 70% of predicted significant
- measure overall status of respiratory
muscles, compliance & resistance of airways

Arterial Blood Gas Analysis

Not done routinely
Indicated when history suggests arterial hypoxemia or
suspects CO2 retention
In severe disease
- decreased exercise tolerance
- SpO2 < 95% on room air
- peripheral edema, cor pulmonale
PaO2 not as important as PaCO2 as prognostic marker
PaCO2- strong predictor of post-op ventilation
PaO2 > 60mmHg & PaCO2 normal - Pink Puffer
PaO2 < 60mmHg & PaCO2 > 45 mmHg - Blue Bloaters

Predicting risk of Post-operative

Pulmonary Complications
Nunn and Milledge criteria:
FEV1 <1 L, normal PaO2, PaCO2 low risk
FEV1 <1L, low PaO2 and normal PaCO2..pt will need
prolonged oxygen supplementation
FEV1 <1L, low PaO2 and high PaCO2may need
post-op ventilation

PRE-OPERATIVE PREPARATION
Objective to optimize pulmonary functions
- to improve those aspects of the disease
that may be reversible
Smoking cessation
Treat active lung infection
Dilate airway
Loosen/remove secretions
Supplement oxygen therapy
Improve general health
Familiarize with resp therapy, education, motivation

Effects of Smoking

Narrowing of small airways

Mucous hypersecretion
COHb level
Left shift of Oxy-Hb dissociation curve
Tissue hypoxia
Suppression of immune responses
CVS- Hypertension, CAD

Smoking cessation
Time after smoking

Beneficial Effects

12-24 Hrs

Fall in CO & Nicotine levels

48-72 Hrs

COHb levels normalise

Airway function improves

1-2 Weeks

Decreased sputum production

4-6 Weeks

PFTs improve

6-8 Weeks

Normalisation of Immune function

8-12 Weeks

Decreased overall post operative morbidity

DILATATION OF AIRWAYS

2 Agonists
Anti-cholinergics
Steroids
Theophylline

 Loosen secretions

- Hydration systemic, jet humidifier or ultrasonic

nebulizer
- Mucolytic agents acetylcysteine role controversial
Remove secretions
- Postural drainage
- encouraging coughing
- Chest physiotherapy (percussion and vibration)

Elimination of infections

- appropriate antibiotic therapy prophylactic also

Treatment of Cor pulmonale

- O2 supplementation
- diuretics, digitalis
- correction of acidemia

Motivation, education and facilitation

of post-op care

- psychological preparation
- deep breathing exercises, incentive spirometry
- secretion removal maneuvers- hydration, coughing,
chest physiotherapy
- stabilize other medical problems

ANAESTHETIC
MANAGEMENT

PREMEDICATION
Goals

- to allay anxiety
- to facilitate smooth induction
Oxygen therapy should be continued
Continuation of bronchodilator therapy
Benzodiazepines - cause excessive sedation & resp
depression in compromised pts.
- Small dose of SA BDZ (temazepam 10-20
mg)

Pre-operative steroids
For known or suspected adrenal insufficiency.
Perioperatively 300 mg of hydrocortisone per day
Not advised if
<1 week of systemic steroid therapy
> 6 months previously
No signs of adrenal insufficiency

INTRA-OPERATIVE MANAGEMENT
REGIONAL ANAESTHESIA
Advantages
Avoids upsetting pts ventilatory control (related to
post-op spontaneous ventilatory efforts)
No reduction of FRC (as occurs in GA)
No change in intra-thoracic pressures
No risk of pneumothorax from N2O
Avoids residual NM blockade

REGIONAL ANAESTHESIA
Disadvantages
High levels > T6 - loss of ability to cough, exhale
forcefully
Need for sedation impair ventilation, ability to remove
secretions causing atelectasis, hypoxia
Difficult to lie flat for long duration without
coughing, may be too dyspnoeic to lie flat
Hypotension increases dead space, reduces lung blood
flow
Hypothermia, shivering

GENERAL ANAESTHESIA

Advantages
Good ventilation and oxygenation
ETT - reduction in dead space
- suction of secretions
Avoid high airway pressures
Provide adequate expiratory time
Post op resp support major thoracic and abdominal
surgery

Disadvantages
Intra-operative
Risk of bronchospasm hyper reactive airways
Risk of pneumothorax IPPV, N2O
Inhalational ventilatory response & HPV inhibited
Post-operative
- spontaneous respiration
- ability to cough
Residual NM blockade

Induction
Pre-oxygenation - to prevent rapid desaturation

Propofol
Better suppression of laryngeal reflexes
Watch for hemodynamic compromise
Agent of choice in stable patient
Ketamine
Tachycardia and HT, may increase PVR
Agent of choice in unstable / wheezing patient
Avoid thiopentone
Thiobarbiturates may cause histamine release
Prefer oxybarbiturates (methohexitone)

Airway instrumentation or other stimulation under light

thiopentone anaesthesia may provoke bronchospasm

 Attenuation of Intubation Response:

IV lignocaine (1- 1.5 mg/kg)

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
Nitrous oxide
- enlargement and rupture of bullae
Muscle relaxants
- rocuronium, vecuronium, cisatracurium preferred
(no histamine release)
- avoid atracurium, mivacurium, doxacurium

Opioids
Short acting opioids preferred
prolonged ventilatory depression

 Volatile anaesthetic
Halothane- most potent bronchodilator
Halothane > Enflurane > Isoflurane > Sevoflurane
Sensitises myocardium
Isoflurane comparable at higher MACs
Enflurane, Isoflurane - Irritant smell, may provoke
bronchospasm

 Humidification of inspired gases and use of low gas

flows - to keep airway secretions moist
Controlled Mechanical Ventilation
- TV 6-8 ml/kg and rate 6 10 bpm
- complete exhalation
- minimal air trapping

Monitoring

ECG
NIBP
Pulse Oximetry
Capnography
Neuromuscular Monitoring
Depth of Anaesthesia

 Intraoperative IV Fluids
as per calculations and over-loading to be avoided
excessive IV volume water accumulation & tissue
edema respiratory/ heart failure

Reversal
Neostigmine preceded by anticholinergic no
bronchoconstriction

Deep extubation reduces chances of bronchospasm

Lidocaine bolus 1.5 2 mg/kg or a continuous infusion ( 1 2
mg/min ) - obtund airway reflexes during emergency

Post-operative mechanical ventilation

Patients with severe COPD
- pre-op FEV1 / FVC ratio < 0.5 or
- PaCO2 > 50 mmHg or PaO2 < 60 mmHg with
0.5 FiO2
FiO2 & ventilator settings adjusted to maintain
- PaO2 between 60 70 mmHg
- PaCO2 in range that maintains pH at 7.35 7.45
- reduction of RR & I:E ratio to allow time for exhalation

POST-OPERATIVE MANAGEMENT

Monitor vitals - SpO2 , EtCO2

Nurse in propped up position
Oxygenate with ventmask- low FiO2 (0.24-0.36)
Continue drug therapy nebulization, antibiotics
Lung expansion maneuvres deep breathing, incentive
spirometry, chest physiotherapy, Postural drainage
DVT prophylaxis
Early ambulation

Post Operative Analgesia

Paravertebral/Intercostal N Blocks
Epidural Analgesia
LA
Short acting Opioids
Patient controlled analgesia

Avoid NSAIDS Bronchospasm

Summary of maneuvers to reduce

pulmonary complications
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

RESTRICTIVE LUNG
DISEASE

PRE-OPERATIVE
Optimise the cardio-respiratory functions
- breathing exercises, incentive spirometry , breath
holding techniques, bronchodilators if obstructive
elements is present, good hydration
Large pleural effusions need drainage
Arrangement for post-op mechanical ventilation
- in pts with persistent hypoxemia
- mechanical ventilation and PEEP
- VC < 40%

Intra-operative
Pre-oxygenation
- FRC is reduced, lower O2 stores avail during apneic
periods, tolerates apnoea poorly.
RLD does not influence the choice of anesthesia for
induction and maintenance.
Avoid drugs with prolonged respiratory depression
that might persist into post-operative period
Avoid or discontinue nitrous oxide if suspicion of
pneumothorax
Regional anesthesia for peripheral surgeries for
below T10 levels

INTRA-OPERATIVE
Under GA, mechanical ventilation facilitates optimal
oxygenation and ventilation
Increased inspiratory pressure may be necessary since
lungs are poorly compliant
Diminished FRC persists in the post-op period so may
require PEEP or CPAP.
Risk of post-operative pulmonary complications

Kyphoscoliosis
Lateral curvature of the spine
>10 with rotation of the
vertebral bodies as measured
by Cobbs method on standing
X-ray of thoraco-lumbar spine
(Scoliosis Research Society)

Kyphoscoliosis- Causes
Idiopathic MC 80%
Congenital
- abnormal development of vertebrae- hemivertebra
Neuromuscular
- cerebral palsy, spina bifida, muscular dystrophies
Traumatic
- irradiation, surgery
Poor posture

Clinical features
Backache
Uneven shoulder
heights/hips/waits
Prominence of shoulder blades
Increased space between body
and the elbow while standing
in natural posture
One leg appears longer than
the other
Appearance of leaning to one
side
Chest or rib prominence

Cobb s angle

Cobbs angle and importance

< 10 normal curvature

>40 surgical intervention
>60 impaired pulmonary function
>100 respiratory failure

Summary
Mild to moderate kyphoscoliosis (angle <60)
- minimal to mild restrictive ventilatory defects
- dyspnoea on exercise

Severe kyphoscoliosis (>100)

-

respiratory failure with VC < 40% of predicted

chronic alveolar hypoventilaton
hypoxemia
secondary erythrocytosis
pulmonary hypertension
cor pulmonale

Pre-operative assessment

Spirometry the extent of respiratory compromise

Chest X-Ray assess lung fields
ECG cardiac ischaemia and axis deviation
Echo- cardiac function and structural abnormalities

Problems specific to kyphoscoliosis

Difficulty in positioning for regional and GA

- Pillow support for appropriate positioning for
induction
Awake fibre-optic intubation preferred
Regional anaesthesia
- unpredictable height of block
- not approriate for surgeries above T10 sensory level

THANK YOU