05. Perioperative Pulmonary Evaluation

General Considerations

  • Postoperative pulmonary complications are as common as postoperative cardiac complications and are associated with increased morbidity, mortality, and prolonged hospitalization
  • Common Complications: Infections, respiratory failure, atelectasis, aspiration, pleural effusions, bronchospasm, pneumothorax, and worsening of chronic lung disease
  • Pathophysiology: Often due to reduced lung volumes (VC and FRC) after surgery due to increased respiratory rate, splinting due to inadequate pain management, volume overload
     

Pulmonary Risk Assessment

  • History and Physical: Goal is to uncover unexplained or suboptimally managed pulmonary processes
    • Ask: Exercise tolerance, chronic cough, and dyspnea
    • Evaluate: Tachypnea, accessory muscles, prolonged expiratory phase, abnormal auscultation

 

PATIENT RISK FACTORS

SURGICAL RISK FACTORS

Age > 60

Obesity & general health status

Smoking

COPD, asthma

Heart failure & pulmonary hypertension

ASA class ≥ II

Nutritional deficiency, albumin < 3.5 g/dL

Thoracic surgery and abdominal surgery

Emergency surgery

Prolonged surgery >3-4 hours

General anesthesia

 

Pulmonary Testing

Additional testing is not routinely indicated. Below are tests to consider for certain patients.

TEST

CONSIDER IF

PFTs

Planned lung resection

Known or suspected lung disease for risk stratification

CXR

Known cardiopulmonary disease

Age >50 undergoing high risk surgery

ABG

NOT INDICATED

 

Risk Factor Modification

Preoperative:

  • Smoking cessation ideally at least 8 weeks prior to surgery
  • Optimize any underlying chronic pulmonary disease
  • Delay surgery during acute exacerbation of COPD, asthma, or respiratory infection

Postoperative:

  • Lung expansion maneuvers and patient education
  • Incentive spirometry, CPAP, Ez-PAP, deep breathing
  • Early ambulation
  • Elevate head of bed 30 degrees
     

Canet J et al. Pulmonary Complications in a Population-based Surgical Cohort. Anesthesiology 2010; 113: 1338-1350.

Qaseem A et al. Risk assessment for and strategy to reduce perioperative pulmonary complications for patients undergoing noncardiothoracic surgery: a guideline from the American College of Physicians. Ann Intern Med 2006;144(8):575-80.

Bapoje et al. Preoperative Evaluation of the Patient with Pulmonary Disease. Chest  2007; 132(5):1637-45

Cassidy MR et al. I COUGH Reducing Postoperative Pulmonary Complications with a Multidisciplinary Patient Care Program. JAMA Surg. 2013: 148(8): 740-745.