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Chapter 10: The Patient With Pulmonary Disease

Christopher L. Cropsey; Matthew D. McEvoy

KEY POINTS

KEY POINTS

  1. Routine pulmonary function tests are not usually necessary for patients with chronic obstructive pulmonary disease. Elective surgery may need to be postponed for acute exacerbations.

  2. In patients with asthma, pretreatment with bronchodilators can mitigate the risks of bronchospasm in the perioperative period.

  3. Obstructive sleep apnea is associated with important systemic comorbidities, and patients should be encouraged to use continuous positive airway pressure (CPAP) whenever feasible.

  4. Smoking cessation should be attempted in any perioperative patient, even in the immediate preoperative period.

  5. Intraoperative mechanical ventilation should optimize both pressures and volumes to minimize the risk for additional lung injury in patients with preexisting pulmonary disease.

  6. Optimal postoperative analgesia, including thoracic epidural catheterization, may improve adjunct pulmonary markers.

  7. Pulmonary recruitment with early ambulation and incentive spirometry should be encouraged in the postoperative period.

INTRODUCTION

One of the most fundamental tasks of the anesthesiologist is to ensure normal, or at least best-case, function of the respiratory system throughout the entire perioperative period. In addition to a solid foundation in normal pulmonary physiology and mechanics, this necessitates a thorough understanding of common lung disease and optimization of pulmonary status throughout the perioperative care arc (pre-, intra-, and postoperatively).1 Although perioperative major adverse cardiac events and complications receive prominent attention, postoperative pulmonary complications (PPCs) are more common and costly (see Table 10-1 for a definition of PPCs).1-3 Accordingly, this chapter has three objectives: (1) discuss the preoperative pathophysiology, evaluation, and optimization of patients with common lung diseases and risk factors for PPCs; (2) outline intraoperative management strategies to improve pulmonary status and decrease the risk of PPCs; and (3) describe the prevention and treatment of PPCs in the postoperative period.

Table 10-1Accepted Definitions of Postoperative Respiratory Failure and Postoperative Pulmonary Complications
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Table 10-1 Accepted Definitions of Postoperative Respiratory Failure and Postoperative Pulmonary Complications
Respiratory Failure

Failure to wean from mechanical ventilation for > 48 after surgery

Unplanned intubation/reintubation postoperatively

Postoperative PaO2 < 60 mm Hg on room air

SaO2 < 90% and requiring supplemental oxygen therapy
Suspected Pulmonary Infection

Antibiotic treatment for respiratory infection, plus 1 or more of the following:

 New or changed sputum

New or changed lung opacities on a clinically indicated CXR

Temperature > 38.3°C

WBC > 12,000/mm3
Pleural Effusion

CXR showing blunting of the costophrenic angle

Loss of the sharp silhouette of the ipsilateral hemidiaphragm (upright)

Evidence of displacement of adjacent anatomical structures, OR

Hazy opacity in one hemithorax with preserved vascular shadows (supine)
Atelectasis

Lung opacification with shift of the mediastinum, hilum, or hemidiaphragm toward the affected side, AND

Compensatory overinflation in the adjacent nonatelectatic lung
Pneumothorax
Air in the pleural space with no vascular bed surrounding the visceral pleura
Bronchospasm
Newly detected expiratory wheeze requiring treatment with bronchodilators
Aspiration pneumonitis
Respiratory failure (as in first definition) after the inhalation of regurgitated gastric contents

Abbreviations: CXR ...

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