Pemeriksaan Preoperative Pulmonary Evaluation.ppt

Pemeriksaan

1. Preoperative Pulmonary Evaluation
Chang Shim, MD
Professor of Medicine
Jacobi Medical Center

2. Postoperative Complications
Pulmonary
Pneumonia/atelectasis: abnormal CXR, fever, leukocytosis, ABG
Respiratory failure/mechanical ventilation
Pulmonary embolism
Cardiovascular
CHF
Arrhythmias
Ischemia/MI
Hypotension/hypertension
Neurological
Stroke
Psychosis
Infection, sepsis
Wound, lines, others
GI
Renal

3. Non-pulmonary Risk Factors for
Post-op Pulmonary Complications
Extent and Location of Surgery
Duration of Anesthesia
Age
Gender
Weight, BMI
ASA (American Society of Anesthesiology)
Score 1 A normal healthy person
2 Mild systemic disease
3 Systemic disease that is not incapacitating. 4 Incapacitating
systemic disease that is threatening to life
5 Moribund, not expected to survive 24 hours
with or without operation.

4. Risk Assessment for and Strategies to Reduce
Perioperative Pulmonary Complications for Patients
Undergoing Noncardiothoracic Surgery (ACP)
Annals Intern Med April 2006
1.All should be evaluated for the presence of COPD, age >60 yrs, ASA class II
or greater, functionally dependent, & CHF. Obesity and mild or mod asthma:
not significant risk factors
2.Higher risk for complications: prolonged surgery (>3H), abdominal surgery,
thoracic surgery, neurosurgery, head and neck surgery, vascular surgery,
aortic aneurysm repair, emergency surgery, and general anesthesia.
3.Low serum albumin level <35 g/L. All those suspected to have low albumin
or those with 1 or more risk factors.
4.Those who have higher risk for complications should have deep breathing
exercise or incentive spirometry and selective use of nasogastric tube post op.
5.Preoperative spirometry and chest radiography should not be used routinely
for predicting risk for postop complications.
6.Right heart cath and total parenteral nutrition should not be used to reduce
pulmonary complications.

5. Patient-Related Risk Factors
•Age: odds ratio 1 for <60, 1.79 for 60-69, 3.04 for 70-79.
•COPD: odds ratio 1.79
•Cigarette Use: OR 1.26
•CHF: OR 2.93
•Functional Dependence: OR 2.51 for total, 1.65 for partial dependence
•ASA Classification I 1.2%, II 5.4%, III 11.4%, IV 10.9%, IV not
available
•Obesity: not a risk factor
•Asthma: not a risk factor
•OSA: airway management issues but not pulmonary complication
•Impaired sensorium, abn chest examination, alcohol use, wt loss: inc

6. Procedure Related Risk Factors
•Surgical Site: inc risk for aortic aneurysm repair,
thoracic surgery, abdominal surgery, upper abd
surgery, neurosurgery, prolonged surgery, head
and neck surgery, emergency surgery, vascular sur
•Duration of Surgery: 3-4 hours increase risks
•Anesthetic Technique: general vs local or regional
•Emergency Surgery: OR 2.21

7. Laboratory Testing to Estimate Risk
•Spirometry: value unproven except in lung
resection and coronary bypass graft
•Chest Radiographs: 23% abn, 3% clin important
•Blood Urea Nitrogen: >21 risk factor, magnitude?
•Oro-pharyngeal Culture:?
•Serum Albumin Measurement:36g/L 27.6% v 7%
–35 g/L threshold value is one of the most
powerful risk factor.

8. Strategies to Reduce Postoperative Pulmonary
Complications
•Preoperative Smoking Cessation
•Lung Expansion Modalities
•Neuromuscular Blockade: avoid pancuronium
•Anesthesia and Analgesia: neuraxial blockade
•Surgical Techniques: laparoscopic vs open?
•Perioperative Care
–Nutritional Support, Pulmonary Artery
Catheterization, Selective Nasogastric
Decompression after Abdominal Surgery

9. Predictors of Post-operative Pulmonary
Complications
McAlister FA, et al. Am J Respir Crit Care Med 2003;167:741
•22 general internists and pulmonologists in 10 groups, a
Canadian study
•272 patients referred for pre-op evaluation
•Exclusion: on ventilator, sleep apnea, known
neuromuscular disease, cognitive impairment, intrathoracic
or severe orthopedic surgery.
•Pulmonary complication before discharge or 7 days post
•Outcome: respiratory failure requiring mechanical vent,
pneumonia, lung or lobar atelectasis requiring
bronchoscop

10. Predictors of Postoperative Pulmonary Risk
MaAlister FA ,et al Am J Repir Crit Care Med 2003;167:741
•272 referred for evaluation before nonthoracic surgery—22
(8%) had postop pulm complications: 6 respir failure, 9
pneumonia, 7 atelectasis.
•Hypercapnea, pCO2 =>45 mmHg, odds ratio 66
•FVC less than 1.5 liters, OR 11.1
•Maximal laryngeal height =<4 cm, OR 6.9
•Forced expiratory time =>9 seconds, OR 5.7
•Smoking =>40 pack-years, OR 1.9
•BMI =>30, OR 4.1
•Multiple regression analysis: age =>65 OR 1.8,
smoking 40 pk-yrs, OR 1.9, laryngeal height =<4 cm, OR
2.0

11. Postoperative Pneumonia Risk Index
Arozullah, AM et al Multifactorial Risk Index for postop
pneumonia. Ann Intern Med 2001;135:847-57
•100 VA Hosp 160, 805 major non-cardiac surgery 9/97 to 8/99—2466 cases
(1.5%) developed pneumonia.
•Developed risk index to predict post-op pneumonia and validated it by using
cases 1995-97.
•Type of surgery: abd aortic aneurysm, thor, up abd, neck, vasc, neuro
•Age =>80, 70-79, 60-69, 50-59
•Functional status: total dependent, partial dependent
•Wt loss >10% in 6 months
•Hx COPD
•Others: General anesthesia, impaired sensorium, Hx CVA, BUN <8 mg/dl,
Transfusion >4 units, emergency surgery, chronic steroid use, current
smoker, alcohol >2 drinks/d
•Risk point system used to categorize risk class 1-5, 0-15 risk points, 16-25,
26-40, 41-55, >55, Pneumonia rates were 0.24% to 15.9%.

12. Respiratory Effects of General Anesthesia
Control of Ventilation
CO2, Hypoxia, Pattern
COPD
FRC, Airways closure
Diaphragm movement
Atelectasis
Respiratory pattern, O2
Ventilation/perfusion matching
Dead space, shunt
Bronchomotor tone
Mucociliary clearance

16. Postoperative Decline in Lung Function
•TLC and VC declined similarly
•FRC decreased half as much as VC
•RV decreased less than FRC

17. Diaphragmatic Function
Descends during inspiration pushing down
abdominal content.
Lifts up thoracic cage, using inertia of
abdominal content as a fulcrum
Anesthesia, spontaneous respiration
Neuromuscular block
Mechanical ventilation

18. Who should have pre-op PFT
evaluation?
Known pulmonary disease
Planned lung resection
Smoker or heavy smoker?
Tests:Match test: FEV1 of 1.8 liters
Spirometry (FVC,FEV1), PEFR
Diffusion capacity
ABGs

19. Types of Anesthesia
General vs spinal
Regional

20. Atelectasis and Pneumonia
Anesthesia and Surgery
Mucociliary MuscleVentilatory Pain
Clearance Weakness Drive
Narcotics
Shallow breathing Cough
Atelectasis
V/Q mismatch
Hypoxia/infection

21. Lung Hyperinflation Maneuvers
Adequate analgesia and motivation are necessary.
Cough and deep breathing: preferably trained pre-
operatively.
Incentive spirometer: excellent device rarely used
efficiently. Would pre-op training help?
CPAP or BiPAP for a few minutes every 2-4 hours
(10 to 20 cm water pressure) is more effective.

22. COPD
Complications
Atelectasis/pneumonia
Respiratory failure/mechanical ventilation
History
Airflow obstruction/exercise capacity
Smoking
Cough and sputum production
Assessment and intervention
PFTs, ABGs: FEV1of 0.7 liter, pCO2 of >45 mmHg
Smoking cessation
Antibiotics for those who have sputum production, 3-5 days pre-op
Systemic corticosteroids: prednisone 40 mg daily x 3 days
Bronchodilators: beta agonists, anticholinergics, theophylline
Cough and Hyperinflation maneuvers

23. Asthma
History and PEFR
Completely asymptomatic for 6 months or longer
PEFR is normal
Treatment: bronchodilator only peri-operatively
Symptoms present within 6 months
PEFR abnormal <80% predicted
Prednisone 40 mg daily x 3 pre-op and x 3 post-op
If patient is well post-operatively, discontinue it.
If not well, continue prednisone until well.

24. Obesity
Independent risk factor for pulmonary complications
particularly atelectasis
Risk of hypoventilation, hypercapnea
Hypoxia
Obstructive Sleep Apnea (OSA)
Interventions
Upright positioning
Oxygen used sparingly
CPAP, BiPAP, Incentive spirometry

25. Lung Resection Candidate
Goal: adequate remaining lung to sustain independent breathing
(free of ventilator)
Residual FEV1 of at least 800 ml, VC of 1 liter
Possibility of unexpected pneumonectomy
Perfusion scan to estimate lung function loss
FEV1 value x % residual function= FEV1 estimate
ABGs: PCO2 >45mmHg: high risk
Pulmonary artery hypertension mean >25 mmHg
Exercise test: stair climbing, 6 minute walk test: excellent
prognosticator