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CASE DISCUSSION - COPD

MODERATOR – DR. KUMARA A B

ASSISTANT PROFESSOR
DEPARTMENT OF ANAESTHESIOLOGY

SPEAKER – DR. SANCHARA

3RD YEAR PG STUDENT
 COPD
 COPD is a disease of progressive airflow obstruction that is not reversible.

 Includes :
 Chronic bronchitis
 Emphysema
Chronic Bronchitis: Emphysema:

Cough with expectoration for at least 3 The presence of permanent enlargement

months a year during a period of 2 of the airspaces distal to the terminal
consecutive years in a patient in whom bronchioles, accompanied by destruction
other causes of chronic productive cough of their walls and without obvious fibrosis
have been excluded.
RISK FACTORS :
Host factors: •Exposures:
 Genetic factors: α1 Antitrypsin Deficiency  Smoking: Most Important risk factor
 Sex : More in males.  Occupation : coal/gold mining, textile
 Recurrent bronchopulmonary infections industry.
 Environmental pollution
 Pathogenesis of chronic bronchitis :

Cigarette smoking, other air pollutants (sulfur dioxide and nitrogen dioxide)

•Hypertrophy of mucous glands in the trachea and bronchi.

•Increase in mucin-secreting goblet cells in the epithelial surfaces of smaller bronchi and bronchioles.
•Infiltration of macrophages, neutrophils and lymphocytes.

Airflow obstruction due to

(1) small airway disease, induced by mucous plugging of the bronchiolar lumen, inflammation, and
bronchiolar wall fibrosis, and
(2) coexistent emphysema
Pathogenesis of emphysema
Colour and Odour of sputum 8
Colour Condition
Yellow( purulent) Bacterial infection
Green Pseudomonas
Black Aspergillosis, Coal workers’ Pneumoconiosis
Red current jelly Klebsiella pneumonia
Rusty Pneumococcal pneumonia
Pink frothy Pulmonary oedema
Blood stained Hemoptysis
Anchovy saucelike Ruptured amoebic lung abscess
White Viral

Odour of the sputum - offensive and foetid

Lung abscess
Bronchiectasis
Anaerobic bacterial infections
Breathlessness 9
Respiratory causes Cardiac causes
COPD Left heart failure
ASTHMA Congenital heart disease
Chronic restrictive lung disease Valvular heart disease
Lung cancer Hypertensive heart disease
Pneumonia cardiomyopathy
Laryngeal obstruction

Haematological
Severe anaemia
Smoking Index and Pack Years 10

Pack years = no. of pack of cigarettes per day × no. of years of smoking
 (>40 pack years indicate high risk for postoperative pulmonary complications)

Smoking index= no. of cigarettes per day × no. of years

 <100 mild smoker
 100-300 moderate smoker
 >300 heavy smoker
Effects of Smoking 11

 Cardiac effects of smoking

 Respiratory effect of smoking
 Effect of carboxy hemoglobin
 Effects on hemostatic system
 Effects on gastrointestinal system
Beneficial effects of smoking cessation and time course 12

 12 –24hr - Fall in Carbon monoxide & nicotine levels

 48–72 hr - Carboxy Hb levels normalized, ciliary function improves
 1-2 wk - Decreased sputum production
 4–6 wk - PFT improve
 6 -8wk - Immune function & metabolism normalizes
 8–12 wk - Decreased overall postop morbidity & mortality
What is the clinical presentation of COPD?
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History- The three most common symptoms of COPD are

Cough, sputum production and exertional dyspnea.
Weight loss and cachexia are common in advanced disease.

Physical Findings-
normal - early stages of COPD
Severe disease - prolonged expiratory phase and expiratory wheezing, signs of hyperinflation including a
barrel chest and enlarged lung volumes.
 
Tripod position-.
Patients with predominant emphysema, “pinkpuffers” are thin and noncyanotic at rest and have prominent
use of accessory muscles. Patients with chronic bronchitis “bluebloaters” are likely to be heavy and cyanotic
14
Roizen’s classification 15

 Grade O - No dyspnea while walking on the level at normal pace

 Grade I - Unlimited distance with limited pace "I am able to walk as far as I like
provided I take my time"
 Grade II - Limited pace and distance. Specific street block limitation-"I have to stop
for a while after one or two blocks"
 Grade III - Dyspnea on mild exertion -"I have to stop and rest going from the kitchen
to the bathroom"
 Grade IV - Dyspnea at rest
How do you diagnose COPD?

A chronic productive cough, progressive exercise limitation and expiratory airflow obstruction are
characteristic of COPD.

Pulmonary function test-

 Decrease in the FEV1/FVC ratio
 Greater decrease in the FEF between 25% and 75% of vital capacity (FEF25%–75%).

 An FEV1:FVC less than 70% of predicted that is not reversible with bronchodilators confirms
the diagnosis.
1) PFT : INDICATIONS

 Hypoxemia on room air or the need for home oxygen therapy without a known cause.
 Bicarbonate > 33 mEq/L or Pco2 > 50 mmHg in a patient whose pulmonary disease has not been
previously evaluated
 History of respiratory failure
 Severe shortness of breath attributed to respiratory disease
 Planned for pneumonectomy
 Difficulty in assessing pulmonary function by clinical signs
 The need to determine the response to bronchodilators
 Suspected pulmonary hypertension.
Contraindications for PFT'S 18

 Hemoptysis
 Pneumothorax
 Recent abdominal or thoracic surgery
 Recent eye surgery
 Recent MI or unstable angina
 Thoracic aneurysms
 VC : N to decreased
RV & FRC : Increased
TLC : N to increased
PULMONARY FUNCTION TESTS:
 Flow Volume Loop
.
Normal flow volume loop has a rapid peak expiratory flow rate with a gradual decline in flow back to zero.
Flow Volume Loop in Obstructive lung disease
.
As with a normal curve,

• there is a rapid peak expiratory flow,

•but the curve descends more

quickly than normal and

• takes on a concave shape

 Flow Volume Loop in restrictive lung disease
.
The shape of the flow volume loop:

1.Relatively unaffected in restrictive disease

2.Overall size of the curve will appear smaller when compared to

normal on the same scale.
Chest Radiography 24

 Radiographic abnormalities will be minimal even in the presence of severe COPD

 Hyperlucency and hyperinflation suggest the diagnosis of emphysema.

 Presence of bullae confirms the diagnosis of emphysema.

 Chronic bronchitis is rarely diagnosed by chest radiography.

 CT chest can also be useful in diagnosing emphysema.

BEDSIDE PULMONARY FUNCTION TEST 25

Sabrasez Breath Holding Test :

SNIDER’s MATCH BLOWING TEST:
Greene and Berowitz Cough test
Wheeze test
Forced expiratory time
Single breath count test
Debono‘s whistle blowing test
Wright’s respirometer
Microspirometers
Bed side pulse oximetry
ABG
 SABRASEZ BREATH HOLDING TEST
Ask the patient to take a full but not too deep breath and hold it as long as possible.

>25 Sec.- Normal CPR (3500 ml VC)

15-25 Sec- limited CPR

<15 Sec- very poor CPR(1500 ml VC)

 SNIDER’S MATCH BLOWING TEST

Ask to blow a match stick from a distance of Can not blow out a match - MBC < 60 L/min
6” (15cms) with
Modified match test:
Mouth wide open
Distance MBC
Chin rested/supported
9inch >150 L/MIN.
No pursing lip
6inch >60 L/MIN.
No head movement
No air movement in the room 3inch > 40 L/MIN

Mouth and match at the same level

 .
.
COUGH TEST
Deep breath followed by cough : Ability to cough, muscle strength and
effectiveness of clearance.

*A wet productive cough / self propagated paroxysms of

coughing – patient susceptible for pulmonary complication
Forced expiratory time
After deep breath, exhale maximally and forcefuly and keep stethescope over trachea and listen.

Normal - 3-5 sec

Obstructive - > 6 sec

Restrictive - < 3 sec

Single breath count test

After deep breath, hold it and start counting till next breath.

Normal – 30 to 40 count. Helps to assess vital capacity.

WRIGHT RESPIROMETER

• Measures MV, TV
•Instrument- compact, light and portable. Can be connected to endotracheal tube or face mask.

• MV- instrument records for 1 min and is read directly.

• TV-calculated and dividing MV by counting Respiratory Rate.

• Disadvantage: It under- reads at low flow rates and over reads at high flow rates.
 DE-BONO WHISTLE BLOWING TEST

Measures PEFR

Patient blows down a wide bore tube at the end of which is a whistle, on the side
is a hole with adjustable knob.

As subject blows → whistle blows, leak hole is gradually increased till the
intensity of whistle disappears. At the last position at which the whistle can be
blown , the PEFR can be read over the scale.
•Hand held spirometers or microspirometers -
measure FEV1, FVC.
•Bed side pulse oximetry.
Spirometric Classification Of COPD?
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Investigations
Hb%
 and hematocrit- chronic hypoxia causes polycythemia
Total leukocyte count- to ruleout infections

Sputum examination

Chest Radiograph: emphysematous changes,to exclude other diseases like

pneumonitis or underlying malignancy

ABG
 analysis- reveals hypoxemia, hypercarbia and acidosis
ECG

Preoperative
 Pulmonary Function Tests, Spirometry

Bronchodilator Reversibility- to exclude bronchial asthma

Alpha-1 Antitrypsin
 levels
PREOPERATIVE ASSESSMENT : contd..

ECG
 Signs of RVH:
• RAD
• p Pulmonale in Lead II
• Predominant R wave in V1-3
• RSR1 pattern in precordial leads

Arterial Blood Gases: remain normal until severe COPD ensues,

 Cor Pulmonale
• Increased PaCO2 is prognostic marker
• Strong predictor of potential intra-op respiratory failure & post-op Ventilatory failure
Chest radiograph 36
Preoperative Preparation 37

Non pharmacological therapy:

 Cessation of smoking, avoid pollutants
 Adequate hydration : Systemic and airway (humidifier)
 Nutrition ( Weight loss / gain)
 Chest physiotherapy-to promote bronchial hygiene and improve breathing efficiency.
 Deep breathing exercises
 Incentive spirometry
 Positive pressure breathing technique
Preoperative Preparation 38

Pharmacological therapy

 Broad spectrum antibiotics: Treatment of respiratory infections

 Bronchodilators: Only small increase in FEV1
 Anticholinergics
 Beta Agonists
 Methylxanthines
 
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Pharmacological therapy

 Steroids- Systemic steroids should be used as pre-op medication in patients with moderate to severe
COPD who are not on any steroids before.
 40 mg prednisolone on day 1
 20 mg prednisolone on day 2
 10 mg prednisolone on day 3
 Patients who are on steroids should continue till day of surgery and supplement a dose of
hydrocortisone 100 mg iv before surgery and100 mg 8th hourly for 2-3 postopdays
 
Treatment of patients with COPD
1. Smoking cessation
2. Annual vaccination against Influenza
3. Vaccination against Pneumococcus
4. Inhaled long-acting bronchodilators
5. Inhaled corticosteroids
6. Inhaled long-acting anticholinergic drugs
7. Home oxygen therapy if pao2 < 55 mm hg, hematocrit > 55%, or there is evidence of cor pulmonale
8. Diuretics : Right heart failure
9. Lung volume reduction surgery
10. Lung transplantation
11. Physical training
Treatment of Patients With Acute COPD
Exacerbation

 Supplemental oxygen ± non-invasive positive pressure ventilation or mechanical ventilation

 Increased dose and frequency of bronchodilator therapy

 Systemic corticosteroids

 Antibiotics
Choice of anaesthesia 42

 The preferred anaesthetic technique in this patient is regional anaesthesia. Spinal/ epidural/ CSE
Advantages of regional anaesthesia 43

 No significant effect on Respiratory function

 No airway manipulation –Minimizes risk of bronchospasm
 No swings in intrathoracic pressure
 No danger of pneumothorax from N2O
 Avoids polypharmacy
 Better pain control
 Attenuation of neuro endocrine responses to surgery
 Improvement of tissue oxygenation
 Maintenance of immune function
 Disadvantages of general anaesthesia

•Airway instrumentation & bronchospasm

•Residual neuro-muscular blockade
•Nitrous Oxide
•Respiratory depression with opioids, BZDs
•Airway humidification
Intraop Ventilatory Strategy 45

Aim :
 Maximize alveolar gas emptying
 Minimize dynamic hyperventilation
 Minimize auto PEEP
 Desirable level of PaO2 and PaCO2 should be maintained intraoperatively.
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The ideal ventilatory setting should include:

 Optimal tidal volume 6-8ml/kg
 RR-12/min, depending on PaO2 and PaCO2
 Sufficient time for expiration so as to prevent air trapping.

 VCV/PCV
 Humidification and warming of the inspired gases is beneficial
Intraoperative Bronchospasm 47

Bronchospasm: constriction of smooth musclesof bronchi and bronchioles

Signs and symptoms:

 Increased peak airway pressure during IPPV.
 Wheeze(Expiratory) / Silent chest.
 Hypotension due to development of auto PEEP.
 Falling oxygen saturation.
 Increased ETCO2
 Differential diagnosis for ↑PIP
Bronchospasm
 Obstruction in the circuit : Blocked / kinked tube
 Endobronchial intubation
 Pneumothorax
 Pulmonary embolism
 Major Atelectasis
 Pulmonary edema/embolus
 aspiration
MANAGEMENT OF INTRAOPERATIVE BRONCHOSPASM

 Increase fio2
 Deepen anaesthesia
 Commonest cause is surgical stimulation under light anaesthesia
 Incremental dose of volatile anaesthetic or propofol
 Short acting bronchodilator through ET tube
 Relieve mechanical stimulation
 Endotracheal suction
 Stop surgery
Drug therapy for Bronchospasm :
1st Line Drug Therapy
 Salbutamol
 Metered Dose Inhaler: 6-8 puffs repeated
as necessary (using in-line adaptor/barrel
of 60ml syringe with tubing or down ETT
directly)
 Nebulised: 5mg (1ml 0.5%) repeated as
necessary
 IV : 250mcg slow IV then 5mcg.min-1 up
to 20mcg.min-1
2nd Line Drug Therapy
 Ipratropium bromide: 0.5mg nebulised 6
hourly
 Magnesium sulphate: 50mg.kg-1 IV over 20min
(max 2g)
 Hydrocortisone: 200mg IV 6 hourly
 Ketamine: Bolus 10-20mg. Infusion 1-3mg.kg-
1.h-1
 Adrenaline :
 Nebulised: 5mls 1:1000
 IV: 10mcg (0.1ml 1:10,000) to 100mcg (1ml
1:10,000) tirtrated to response
Post Operative Analgesia:

 Short acting opioids

 Paravertebral/Intercostal Nerve Blocks
 Epidural Analgesia
 NSAIDS – avoided Bronchospasm
POST OPERATIVE PULMONARY
COMPLICATIONS :
 Incidence: 6.8% (Range 2-19%)
 Include:
 Bronchospasm
 Atelectasis
 Bronchopneumonia
 Hypoxemia
 Respiratory Failure
 Bronchopleural fistula
 Pleural effusion
 Patient Related:
•Age > 70 yrs
•ASA Class II or above
•CHF
•Pre-existing Pulmonary Disease
•Cigarette smoking
•Hypo-albuminemia <3.5g/dL

Predictors of POPCs : Procedure Related:

•Emergency Surgery
•Duration > 3 Hrs
•GA
•Abd, Thoracic, Head & Neck, Neuro, Vascular
Surgery
Strategies to decrease PPC:

Pre-operative:
•Smoking cessation
•Bronchodilatation Intra-operative:
•Control infections •Minimally invasive
•Patient Education
surgery
•Regional Anaesthesia
•Duration < 3 Hrs
Post operative:
•Lung Volume Expansion
Maneuvers
•Adequate Analgesia
Postoperative mechanical ventilation in a COPD 55

Indications
 Severe COPD undergoing upper abdominal or thoracic surgery
 Preoperative FEV1/FVC < 50%
 Pre-operative PaCO2 >50 mmof Hg.

Ventilator settings
Set moderate FiO2, usually 50%.
Target a SpO2 of 88-92%
 Mode– volume controlled
Tidal volume –6 ml/ kg RR–12 /min
I : E ratio of 1 : 3
PIP of < 40 cm of H2O and Ppl <30 cm of H2O
Low levels of Extrinsic PEEP helps to improve synchrony and reduce work of breathing by off-setting the auto-
PEEP
Indications for invasive mechanical ventilation
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Major criteria (any1) Minor criteria (Any 2)

Loss of consciousness RR->35breaths/min

Psychomotor agitation Worsening acidemia or pH<7.25
Requiring sedation PaO2 <40mmhg or
Haemodynamic instability PaO2/FiO2 <200
Gasping for air Decreasing level of consciousness
GENERAL ANAESTHESIA: INDUCTION
 Opioids:
 Remifentanyl (DOC) : attenuates intubation response
 Propofol dose can be reduced

 Propofol (DOC) : TIVA

 Better suppression of laryngeal reflexes
 Hemodynamic compromise (hypotension)
 Agent of choice in hemo-dynamically stable patient
 INTUBATION

•NMB :
• Succinyl Choline (1-2mg/kg)
• Vecuronium(0.08-0.10 mg/kg)
Attenuation of Intubation Response:
• Rocuronium (0.6-1.2 mg/kg )
• IV lignocaine (1- 1.5 mg/kg) 90s prior to
laryngoscopy
• Fentanyl 1-5 microgram/Kg
• Esmolol 100-150mg bolus
•LMA > Endotracheal Tube • Adequate plane of anaesthesia prior to
intubation
• Avoids tracheal stimulation
• P-LMA : allows for suctioning
MAINTENANCE

Volatile anaesthetic
Muscle relaxant • Rapidly eliminated
• Prefer vecuronium, • NO : enlargement or rupture of bullae >
rocuronium, cisatracurium tension pneumothorax, dilution of delivered
• Avoid atracurium, mivacurium,
O2
doxacurium ( histamine release) • Sevoflurane: non pungent, bronchodilator
• Attenuate regional HPV > intrapulmonary
shunting.
MAINTENANCE contd., :
 Monitoring
 ECG, NIBP, SPO2, Capnography
 Neuromuscular Monitoring
 Depth of Anaesthesia
 Graphical representations on the monitor (flow and PEEP)

 Intraoperative IV Fluids
 Excessive IVF > fluid accumulation & tissue edema > Respiratory/heart failure
REVERSAL/ RECOVERY:
 Neostigmine - may provoke bronchospasm
 Atropine 1.2-1.8mg or Glycopyrrolate 0.6mg before Neostigmine
 Tracheal suctioning
 Extubation : deep or awake?
 Deep extubation may reduce chance of bronchospasm

Deep
No Yes

Good airway - accessible

Difficult airway Easy intubation
Difficult intubation No Residual NMB
Residual NMB Normothermic
Full stomach Not at increased risk of aspiration
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COR PULMONALE
 RV enlargement and/or altered function resulting from primary lung disease, leads to RV hypertrophy
and eventually toRVfailure.
 Symptoms-dyspnea, cough, fatigue and sputum production
 Physical examination-Tachypnea, parasternal heave, loudP2.
 Cyanosis and clubbing are late features
 Signs-elevatedJVP
 Hepatomegaly with ascites Pedal edema
 Murmur of TR
 ECG-RV hypertrophy and RA enlargement
 CXR- Right ventricular and pulmonary artery enlargement.
 
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