ANESTHESIA IN PATIENTS WITH RESPIRATORY DISEASES

Department of Anesthesiology
Faculty of Medicine
Atma Jaya Catholic University
Effects of Anesthesia on
Respiratory Physiology

• Effects on Cell Metabolism

• Effects on Respiratory Pattern
• Effects on Lung Volumes &
Compliance
• Effects on Airway Resistance
• Effects on Work of Breathing
• Effects on Gas Exchange
• Effects on The Control of
Breathing
Effects on Cell Metabolism

• Reduction of Oxygen
Consumption and Carbon
Dioxide Production by 15%
• Especially in Heart and Brain
• Hypothermia accentuated this
effect
Effects on Respiratory
Pattern

• Complex Related to changes

in position and anesthetic agents
• Light Anesthesia Irregular
pattern, breath holding is
common
• Deep Anesthesia regular
pattern
• At 1,2 MAC Inhalation
agentsdecreased tidal volume
& increased rate
Effects on Lung Volumes &
Compliance

• Supine position reduce FRC

• Induction add 15-20% reduction
in FRC
• Closing Capacity generally
reduced to the same extent as
FRC
• Increased risk of intrapulmonary
shunting similar to concious state
• Greatest risk of intrapulmonary
shunting : Eldery, obese
patients, patients with underlying
pulmonary disease.
Effects on Lung Volumes &
Compliance
Effects on Lung Volumes &
Compliance
Effects on Lung Volumes &
Compliance
Anesthesia for Patients with Respiratory Disease
PULMONARY RISK FACTORS & ANESTHETIC
APPROACH TO PATIENTS WITH MOST
COMMON RESPIRATORY DISEASES
 Pulmonary Risk Factors

• Preexisting pulmonary disease

• Thoracic or upper abdominal
surgery
• Smoking
• Obesity
• Age (> 60 years)
• Prolonged general anesthesia (>
3 h)
Pulmonary Risk Factors
Pulmonary Function Test
 Obstructive Pulmonary
Disease

Resistance to airflow
• Early Abnormality : MMEF
(FEF25-75%) <70%
Late course :
• FEV1 <70% predicted
• FEV1/FVC <70% predicted
Obstructive Pulmonary
Disease
 Obstructive Pulmonary
Disease

Clinical Significance :
• Elevated airway resistance & air
trappingincreased work of
breathing
• Impaired respiratory gas
exchange due to
Ventilation/Perfusion (V/Q)
imbalance
Obstructive Pulmonary
Disease
Obstructive Pulmonary
Disease
 Asthma

Preoperative Considerations
• Common disorder; 5-7%
populations
• Bronchiolar inflammation &
hyperreactivity in response to
various stimulation.
• Trigger :
Airborne, Ingestion, Exercise,
Emotional, Viral
• Intermittent (mild), Moderate,
Persistent (severe)
 Asthma

Pathophysiology

Chemical mediators

Parasympathetic Nervous Systems

Histamine + Multiple noxious

stimulation Activation of cGMP
Bronchoconstriction
Asthma

• Increased severity in adult

females
• Careful with patients with
decreased wheezing – may be
due to greatly decreased air
exchange and worsening of
disease
• Pt coughing and no wheeze –
may be crashing and very little
air exchange
Asthma

• Tx: O2, nebulized albuterol, deepen level of anesthesia –

all inhaled agents cause bronchodilation, epinephrine,
terbutaline preferred in pregnant patients
• Other tx’s: corticosteroids, ipratropium bromide (Atrovent),
theophylline, helium/O2, cromolyn,
• Ketamine is induction drug of choice due to powerful
bronchodilation, but it will increase secretions- pretx with
Robinul (glycopyrrolate)
C.O.P.D.

• Chronic Obstructive Pulmonary Disease

• A clinical spectrum of diseases consisting of
emphysema, chronic bronchitis, and asthmatic bronchitis
• Most common symptoms are cough, dyspnea, and
wheezing
• Causes: Smoking, occupational or environmental
exposure, recurrent infections and genetic factors
• Maldistribution of V/Q areas
COPD preop history

• Smoking history:
– Always 2 questions
• Do you smoke?
• Have you ever smoked / when did you quit?
– PPD and duration
• Dyspnea: presence, severity, exercise tolerance,
home O2 requirement, baseline SpO2 on room air
• Productive cough: how often, fever?
• Wheezing: how often, reversible?
• Admissions to hospital / ER: intubated?, length?,
prolonged ventilation? infection?
• PSHx
 Preop studies for COPD

• SpO2 on room air

• ABG: hypoxemia, hypercarbia, acid-base status
• CXR: hyperinflation, blebs or bullae, flattened
diaphragms, infiltrates, effusions, CA, atelectasis, PTX.
• CBC: WBC count (infection), may have elevated Hct
(chronic hypoxia)
• PFT’s: degree of obstruction and bronchodilator
response
• Electrolytes: elevated bicarb levels to compensate for
respiratory acidosis
High risk PFT results

• FEV1 < 2L
• FEV1/FVC < 0.5
• VC < 15cc/Kg in
adult & < 10cc/Kg
in child
• VC < 40 to 50%
than predicted
Signs and Symptoms of
Chronic Obstructive
Pulmonary Disease

Feature Chronic Emphysema

Bronchitis
Cough Frequent With exertion
Sputum Copious Scant
Hematocrit Elevated Normal
PaCO2 (mm Hg) Often elevated (> 40) Usually normal or < 40

Chest radiograph Increased lung markings Hyperinflation

Elastic recoil Normal Decreased
Airway resistance Increased Normal to slightly increased
Cor pulmonale Early Late
 Blue-bloaters

• Predominately have chronic bronchitis or asthmatic

bronchitis
• Chronic productive cough
• Cyanotic
• Obese, obstructive sleep apnea (OSA), pickwickian
syndrome (obesity, decreased pulmonary function,
polycythemia)
• Short, fat neck
• Frequent wheeze
• Relatively young
 Emphysema

• Progressive dyspnea
• Variable cough
• Destruction of elastic and collagen network of alveolar walls
without fibrosis leads to abnormal enlargement of air spaces
• Loss of airway support leads to airway narrowing and collapse
during exhalation – air trapping
• Loss of pulmonary elastic recoil
• “Pink-puffers”
• Causes: Smoking, coal miners, alpha-1 antitrypsin deficiency
= autodigestion of pulmonary tissue by proteases
Pink-puffers

• Predominately have emphysema

• Thin
• Older
• Minimal cough
• Pink color
• Dyspnea, hyperinflation and
distant breath sounds
• Pursed lips = auto-PEEP, air
trapping
Asthmatic Bronchitis

• Chronic productive cough

• Episodic bronchospasm
• Airway obstruction
• Only partially reversible – some
degree of obstruction will always
remain
• Can be a progression of asthma
 Smoking

• 50 million in USA (1/4 to 1/3 of all adults)

• 2X increased CAD risk
• 6X increased risk of post-op pulmonary complications
• COHb can be elevated up to 15%
• 25 pack-yr increases physiologic age by 8 years
 Smoking

• Nicotine stimulates sympathetic ganglia –

catecholamines released from adrenal medulla –
increasing HR, BP, and SVR – persists 30 minutes
after last cigarette
• Irritant to airway – mucus production, decreased ciliary
activity, decreased pulmonary macrophage activity,
increased inflammatory response, proteolytic enzyme
release, reduces surfactant integrity
• Pre-O2 well and avoid instrumentation of airway until
deep level of anesthesia
 Preop smoking cessation

• Advise stopping at least 12 hours prior to surgery

• Stopped night before surgery (12-24 hrs) – will reduce COHb
and nicotine levels to that of nonsmokers
• Airway reactivity decreases after 2 days of cessation and is
near the level of a nonsmoker after 10 days of cessation
• Cessation of > 8 weeks will reduce post-op pulmonary
complications
• Cessation of > 2 years will reduces risk of MI to that of
nonsmoking population
C.O.P.D.

preoperative interventions in
patients with COPD :

•correcting hypoxemia
•relieving bronchospasm
•mobilizing and reducing
secretions
•treating infections

 decrease the incidence of

postoperative pulmonary
complications.
C.O.P.D.

Patients at greatest risk for

complications :
preoperative PFT < 50% of
predicted.

The possibility that

postoperative ventilation may be
necessary in high-risk patients
should be discussed with both
the patient and the surgeon.
 COPD Intraoperatively

• Ventilator adjustments
– Severe emphysema requires longer expiratory times (normal I:E is 1:2,
so in COPD  1:3)
– Closely monitor peak inspiratory pressures (PIP) to avoid rupturing an
emphysematous bleb or bullae, PTX
– CO2 retainers: EtCO2 should be keep near the pt’s baseline, a rapid
correction will lead to metabolic alkalosis
• Large gradient between EtCO2 & PaCO2
• N2O may expand bullae, worsens pulmonary HTN
 COPD Intraoperatively
• Airway stimulation with light anesthesia – DES, ISO
• A-line to monitor ABG’s
• Laryngospasm due to secretions – suction ETT frequently
• Mucociliary clearance worsened after inhalation agents
• Bronchospasm: avoid *histamine releasing drugs
– Pentothal (STP), Morphine (MSO4), Atracurium, Mivacurium,
Neostigmine
– Tx with nebulized albuterol especially before extubation
 Regional anesthesia and
COPD

• Good choice for extremity surgery, perineum, and lower

abdomen
• Neuraxial block above T10 will diminish ability to cough and
begin motor and sensory loss of external intercostals
• An interscalene block will frequently block the ipsilateral
phrenic nerve (C 3,4,5)
• Continuous regional – can be used in post-op period for pain
control and improved pulmonary mechanics
Anesthesia for Patients with Respiratory Disease
THANK YOU...
DEO GRATIAS........