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  • image In a patient with an acute asthma attack, a normal or high PaCO2 indicates that the patient can no longer maintain the work of breathing and is often a sign of impending respiratory failure. A pulsus paradoxus and electrocardiographic signs of right ventricular strain (ST-segment changes, right axis deviation, and right bundle-branch block) are also indicative of severe airway obstruction.

  • image Asthmatic patients with active bronchospasm presenting for emergency surgery should be treated aggressively. Supplemental oxygen, aerosolized β2-agonists, and intravenous glucocorticoids can dramatically improve lung function in a few hours.

  • image Intraoperative bronchospasm is usually manifested as wheezing, increasing peak airway pressures (plateau pressure may remain unchanged), decreasing exhaled tidal volumes, or a slowly rising waveform on the capnograph.

  • image Other causes can simulate bronchospasm: These include obstruction of the tracheal tube from kinking, secretions, or an overinflated balloon; bronchial intubation; active expiratory efforts (straining); pulmonary edema or embolism; and pneumothorax.

  • image Chronic obstructive pulmonary disease (COPD) is currently defined as a disease state characterized by airflow limitation that is not fully reversible. The chronic airflow limitation of this disease is due to a mixture of small and large airway disease (chronic bronchitis/bronchiolitis) and parenchymal destruction (emphysema), with the representation of these two components varying from patient to patient.

  • image Cessation of smoking is the long-term intervention that has been shown to reduce the rate of decline in lung function.

  • image Preoperative interventions in patients with COPD aimed at correcting hypoxemia, relieving bronchospasm, mobilizing and reducing secretions, and treating infections may decrease the incidence of postoperative pulmonary complications. Patients at greatest risk of complications are those with preoperative pulmonary function measurements less than 50% of predicted.

  • image Restrictive pulmonary diseases are characterized by decreased lung compliance. Lung volumes are typically reduced, with preservation of normal expiratory flow rates. Thus, both forced expiratory volume in the first second of exhalation (FEV1) and forced vital capacity (FVC) are reduced, but the FEV1/FVC ratio is normal.

  • image Intraoperative pulmonary embolism usually presents as sudden cardiovascular collapse, hypoxemia, or bronchospasm. A decrease in end-tidal CO2 concentration is also suggestive of pulmonary embolism but is not specific.

The increased risks posed by preexisting pulmonary disease during anesthesia and in the postoperative period are well known: Greater degrees of preoperative pulmonary impairment are associated with increased intraoperative alterations in respiratory function and higher rates of postoperative pulmonary complications. Failure to recognize patients who are at increased risk may result in patients not receiving optimal perioperative care. This chapter examines pulmonary risk and reviews the anesthetic approach for patients with the more common types of respiratory disease.


Certain risk factors (Table 24–1) may predispose patients to postoperative pulmonary complications. Atelectasis, pneumonia, pulmonary embolism, and respiratory failure are common following surgery, but the incidence varies widely, depending on the patient population studied and the surgical procedures performed. In ...

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