Pre operative pulmonary evaluation 2019

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Pre-operative
Pulmonary Evaluation
Dr. Parthiv MEHTA

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Greetings….AHMEDABAD…

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Why to Assess?
Benefits from Surgery V/S Risks
Oct 13th 2019parthivmehta@hotmail.com / 079 2685 4849

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Surgery
• Extra-thoracic and thoracic surgery
• Thoracic surgery with / without Lung
Resection

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RISK
Pulmonary Complications
• Atelectasis
• Broncho-spasm
• Chronic Lung Disease - Exacerbation
• Thromboembolic disease
• Respiratory failure and prolonged mechanical
ventilation
• Infection (Pneumonia or bronchitis)
• ↑ Morbidity , Hospital Stay and Mortality
Assessment is to PREDICT
ABC TRIMM

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Who can PREDICT the Best?

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Postoperative Pathophysiological Features
Leading to Pulmonary Complications
1. Atelectasis and Shunting with Hypoxia
– Striking and persistent decline in VC and FEV1
– Decreased >> Compliance and
Efficiency of Ventilation
– Increased >> Shunting
Pulmonary Dead Space
P(A-a)O2 AND P(A-a)CO2

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1. Atelectasis and Shunting with Hypoxia
– Striking and persistent decline in VC and FEV1
– Decreased >> Compliance and
Efficiency of Ventilation
– Increased >> Shunting
Pulmonary Dead Space
P(A-a)O2 AND P(A-a)CO2
Applicable Mainly to
ABDOMINAL
THORAICIC SURGERIES
ABDOMINAL SURGERIES IN OBESE

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Average Change - Spirometry Values & PO2 ((%)
After Thoracic (T) Or Abdominal (A) Surgeries
-70
-60
-50
-40
-30
-20
-10
0
-1 0 1 2 3 4 5 6 7
A PO2
T PO2
A VC
A FEV1
T VC
T FEV1
Perioperative Day
%
Change
in
Values

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2. Respiratory Failure
Common in Severe COPD
– Decreased Volumes & Flow Rates Added
By Pain, Weakness, Sedation
– Pre Operative Co2 Retention, Sepsis,
Obesity And Shock >> Higher Risk
– Post Operative Infection > Fever > More
Co2 Production

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3. Infection - Pneumonia
– Impaired Transport Of Mucus
– Aspiration
– Pre Existing Lung Infection
– Impaired Coughing

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3. Infection - Pneumonia
– Aspiration
Atelectasis V/Q Mismatch Infection

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Pneumonia
– Aspiration
Right Lung Collapse -Consolidation
RMB -Bronchial plug & Collapse

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Pneumonia
– Aspiration
Right Lung Collapse -Consolidation
RMB -Bronchial plug & Collapse
After treatment

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4. Pulmonary Embolism
Risk factors : Advanced Age Obesity
Malignancy Recent Surgery
H/o DVT Smoker
Risk : 11% w/o any factor
50% with any 3 factors
100% with 4 or more
Despite knowing this, low usage of Thrombo-
embolic prophylaxis (9-56%) in high risk group !!

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What to Assess for?
To Identify - Risk Factors
A. Patient related
B. Procedure related
To assess - immediate Pre-Operative Risk
To plan Risk Reduction Strategies
PREVENT, PROTECT and MITIGATE

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Risk factors
A. Patient Related
• Age
• Obesity
• Smoking
• COPD
• Asthma
• Cardiac Health
• General Health & Nutrition status

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Age
Independent predictor - at advanced age
(> 50 years) – especially ASA Class 3/>
Smetana GW, et al. ACCP. Ann Intern Med 2006; 144: 581.
Surgery should not be declined in elderly patients
who otherwise are acceptable surgical candidates

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Obesity
Obese subjects (BMI ≥ 30) v/s Normal weight (BMI <25)

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Obesity
Obese subjects (BMI ≥ 30) v/s Normal weight (BMI <25)
Normal
Obese
Awake Anaesthesia

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Obesity
Obesity has NOT consistently been shown to be a
risk factor for PPCs
Obesity should NOT affect patient selection for
otherwise high-risk procedure

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Obesity - OSA
Snoring, Hypopnoea,
Apnoea

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Smoking
• Important risk factor – Relative Risk = 1.73X
• Smoking history of
20 pack years or more ↑risk
of pulmonary complications
• Stopped smoking < 2 months v/s
Stopped for > 2 months = 4:1
• Quit smoking > 6 months v/s
Never smoked = 1:1

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COPD
Need careful evaluation of patients with COPD
to Identify High Risk and Optimize Treatment
An absolute contraindication is NOT apparent

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Asthma
• Inadequate control of asthma ↑ risk of
postoperative complications
• Well controlled, peak flow measurement
of > 80% of predicted or personal best
average risk
• Asthmatic patients treated with
corticosteroids before surgery have a low
incidence of complications

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Health Status - Cardiac
Goldman Cardiac Risk Index
History
Physical examination
ECG
Laboratory data
Class and scores

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Health Status – Cardiac
HEART FAILURE

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Health Status - General
American Society of Anesthesiologists
(ASA) classification
Physical Status Classification – Aimed to
assess FITNESS of a person to undergo
surgery
Comprehensively includes History and
past treatments

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ASA - Physical Status Classification

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ASA - Physical Status Classification
ASA > 2 Confers 4.87 X Increased Risk

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Risk factors
A. Patient Related
• Age
• Obesity
• Smoking
• COPD
• Asthma
• Cardiac Health
• General Health & Nutrition status

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Risk Factors
B. Procedure Related
• Surgical site
• Anesthesia - Duration and type
• Type of neuromuscular blockade
• Size of Resection - Lung parenchyma

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Surgical site
• The most important predictor of
pulmonary complications
• The incidence of complications is
inversely related to the distance of the
surgical incision from the diaphragm
• The complication rates for upper
abdominal and thoracic surgery are
the highest (range 10% to 30%)

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Surgical site

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Rodgers A, Walker N, Schug S, et al. BMJ 2000; 321: 1493
Duration and type of Anesthesia
Anesthesia time of > 3.5 hours → ↑↑
incidence of pulmonary complications
In a very high risk patient
Be Less Ambitious, Keep Procedure Briefer

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Summary - Risk factors
2.0 X
1.5 X
X
X
1.2 X
1.4 X
X
X
3.0 X
2.5 X
X
X
1.5 X
2.0 X
X
X
3.0 X
4.5 X
X
X
Patient Related + Procedure Related

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What to Assess?
To Identify - Risk Factors
• Patient related
• Procedure related
To assess - immediate Peri-Operative Risk
To plan Risk Reduction Strategies
PREVENT, PROTECT and MITIGATE

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Immediate Peri-Operative
Pulmonary Risk Assessment
What to look for?
– Clinical pointers
– Pulmonary Function
– Infection
– Co-morbidity and impact on pulmonary
Functions
– Risk associated with Pulmonary System

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Assessment Tools…

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Assessment Tools…AT

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AT 1 - Clinical evaluation
Complete history
– Smoking,
– Poor exercise tolerance,
– Unexplained dyspnoea or cough
– Unrecognized chronic lung disease should be
determined
Good physical examination
– Directed toward evidence for Obstructive Lung
Disease - decreased breath sounds, wheeze,
rhonchi or prolonged expiratory phase

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AT 2 - Chest Radiography
Patients With out RISK FACTORS
Patients With RISK FACTORS
(Cardiac, Pulmonary)
Rucker L, Frye EB, Staten MA. JAMA 1983; 40: 1022.

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AT 2 - Chest Radiography

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AT 3 – Pulmonary Function Tests
To be done when the patient is clinically stable and receiving
maximal bronchodilator therapy
NOT to be used as the primary factor to deny surgery
NOT to be routinely ordered
Qaseem A, Snow V, Fitterman N. et al. Ann Intern Med 2006; 144: 575.

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To be done when the patient is clinically stable and receiving
maximal bronchodilator therapy
NOT to be used as the primary factor to deny surgery
NOT to be routinely ordered
Qaseem A, Snow V, Fitterman N. et al. Ann Intern Med 2006; 144: 575.
PFT helps confirm and define severity of
disease identified with clinical impression

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• All candidates for lung resection should have
preoperative PFT
• PFTs should not be ordered routinely prior to
abdominal surgery or other high risk surgeries
• PFT is Must for
–Patients undergoing coronary bypass or upper
abdominal surgery with a history of smoking or
dyspnoea.
–Patients undergoing Head & Neck, Orthopedic, or
Lower Abdominal Surgery with unexplained
dyspnoea or pulmonary symptoms

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 Simple Peak Flowmetry
 Computerised Spirometry
 Diffusion Study
 Pulse Oxymetry & ABG
 2D Echo
 6MWT
 Ergometry
 V/Q Scan
 Sleep Study
Testing Pulmonary Functions
PFT
Cardio-Pulm
Relation

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Peak Flow Meter Testing
• Must for all
– Asthma
– COPD
– Evaluation of Dyspnoea
• Easy To Do - Any Where - Any Time

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 SIMPLE PEAK FLOW METERY
 BELL SPIROMETERY
 COMPUTERISED SPIROMETERY
 DIFFUSION STUDY
 PULSE OXYMETRY & ABG
 2D ECHO
 ERGOMETRY
 V/Q SCAN
 SLEEP STUDY
Spirometry and DLCO

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Spirometry

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Spirometry
Typical Curve and Its Interpretation
Obstruction +/- Reversibility
Restriction
Flow and Volumes (VC, FVC, FEV1)
Reproduced from
Conrad SA: Clinical Pulmonary Function Testing

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Spirometry
VC / FVC
VC - if less than 80% of predicted: Lung volume testing can
reveal if caused by restriction
FVC (should be within 150 ml of VC) - Criteria for Acceptability
• Maximal effort; no cough or glottic closure during the first
second; no leaks or obstruction of the mouthpiece.
• Tracing shows 6 seconds of exhalation or an obvious plateau
(<0.025L for ≥1s);
• No early termination or cut off
• Three acceptable spirograms obtained; two largest FVC values
within 150 ml; two largest FEV1 values within 150 ml
• The largest FVC and largest FEV1 (BTPS) should be reported, even
if they do not come from the same curve

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Spirometry
FEV1 / FVC
FEV1 - The volume expired over the first second of an FVC
maneuver
FEV1 / FVC (should be > 75%)
• A decrease FEV1/FVC ratio is the “hallmark” of obstructive
disease FEV1/FVC <75%
• Restrictive diseases will have low FVC and FEV1 but normal
FEV1/FVC
– Neuromuscular disorders, e.g. Myasthenia Gravis, Guillain-Barre
– Chest deformities e.g. scoliosis / kyphoscoliosis
– Obesity or pregnancy
The ability to work or function in daily life is related to
the FEV1, FVC and FEV1 / FVC

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Spirometry
Rapid, deep breathing VT ~50% For 12 – 15 seconds

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Spirometry
MVV
Tests overall function of respiratory system
– Airway resistance
– Respiratory muscles
– Compliance of lungs/chest wall
– Ventilatory control mechanisms
At least 2 acceptable maneuvers should be performed
– Highest MVV (L/min, BTPS) and MVV rate (breaths / min)
should be reported
– Two largest should be within 10% of each other
– Volumes extrapolated out to 60 seconds and corrected to
BTPS
– MVV is approximately equal to 35 time the FEV1
MVV decreases in Moderate to Severe Obstruction,
Neuromuscular disease and with Low Endurance

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DLCO
DLCO

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DLCO
DLCO is recommended as standard PFT to use
routinely in the preoperative evaluation of
patients for Lung Resection.

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DLCO
DLCO is recommended as standard PFT to use
routinely in the preoperative evaluation of
patients for Lung Resection.
DLCO has been shown to be an independent
predictor of postoperative outcome specifically
of mortality and postoperative complications

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PFT Values - Severity Scales

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Blood Gas Analysis
MUST in Moderate -Severe Respiratory Disease
with Hypoxemia: SPO2 < 90% @ Room Air
Hypercapnoea: PaCO2 > 45mmHg
– Not necessarily an absolute contraindication for
surgery
– Suggests reassessment of the indication for the
proposed procedure and aggressive preoperative
preparation
ABG provides vital information on
METABOLIC Balance and Respiratory Compensation

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AT 3 – PFT - Summary
Non-Resective Surgery - Risks
Test Parameter
Risk Level
Increased
Risk
High Risk
Spirometry
FEV1 < 50% or < 2 lit < 1 litre
MVV < 50%
Diffusion
Capacity
DLCO < 60% < 40%
Blood Gas
Analysis
SaO2 < 95% <90%
PaCO2 > 45 mm Hg

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AT 3 – PFT - Summary
Lung Resection - Risks
Test Parameter
Lobectomy Pneumonectomy
Safe Limit High Risk
Spirometry
FEV1
> 60%
or
> 1.5 lit
> 80%
or
> 2.0 lit
> 60%
or
< 2.0 lit
MVV > 60% < 50%
Diffusion
Capacity DLCO > 60% < 60%
Blood Gas
Analysis
SaO2 > 95% <90%
PaCO2 <45 mm Hg > 45 mm Hg

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AT 4 – RISK INDICES
ASA Classification
ASA > 2 Confers 4.87 X Increased Risk

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Arozullah Respiratory Failure Index

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Arozullah Respiratory Failure Index
Scores and Risk Stratification
Arozullah AM, Daley J, Handerson WG, Khuri S. Ann Surg 2000; 232: 242.

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Canet Risk Index
Canet J, Gallart L, Gomar C, et al. Anesthesiology 2010; 113: 1338.
Pre Op SPO2 > 95%

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Canet Risk Index
Canet J, Gallart L, Gomar C, et al. Anesthesiology 2010; 113: 1338.
Pulmonary Complication Risk

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Gupta Calculator - QXMD
http://www.qxmd.com/calculate-online/respirology/postoperativerespiratoryfailure-risk-calculator
Gupta H, Gupta PK, Fang X, et al. Chest 2011; 140(5): 1207-15

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Obstructive Sleep Apnoea
Gross JB, Bachenberg KL, Benumof JL, et al. Anesthesiology 2006; 104: 1081-93.

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Obstructive Sleep Apnoea
Total Score = A + (Greater of B or C)
Gross JB, Bachenberg KL, Benumof JL, et al. Anesthesiology 2006; 104: 1081-93.

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Risk Assessment – Flow
NON-RESECTIVE (T/A) Surgery

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Risk Assessment – Flow
Lung RESECTION Surgery
Methodical Evaluation and Values for Safety

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AT-Resection SX
Split lung function studies
Predicting post-resection pulmonary function
FEV1ppo =
X – -
Lung function can be calculated by counting the number of
segments removed – As Lungs contain total 19 segments,
Each segment approximates 5%
Pre-Operative
FEV1
1
% Functional Tissue Removed
------------------------------------------
100
Predicted Post-Operative FEV1 (FEV1ppo) is
the most valid single test available

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AT-Resection SX
Split lung function studies
• FEV1ppo > 40%, DLCOppo > 40%
– Widely accepted as a predictor of average risk for
complications
• FEV1ppo < 40%, DLCOppo < 40%
– High risk of Perioperative complications including
death
• FEV1ppo < 1.0L → Sputum retention
• FEV1ppo < 0.8L → Preclude resection , dependent
on a ventilator
If Predicted Post-operative lung function show
borderline values → Cardio-Pulmonary Exercise Test

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AT-Resection SX
Cardio-Pulmonary Exercise Test
Tests the entire cardiopulmonary and oxygen delivery
system under controlled stress → helps to predict expected
functional reserve after pulmonary resection
Maximal Oxygen Uptake (VO2max)
VO2max
RISK
Complication / Death
> 20 mL/kg/min Not increased
VO2max < 15 mL/kg/min Increased
VO2max < 10 mL/kg/min Very High

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Assessment - Flow for
Thoracic / Abdominal Surgery

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• Active Upper Respiratory Tract Infection – G/A?
• Active Bacterial Infection
– Prophylactic Empirical Antibiotic
• Koch’s – Always A Trouble??
• Malaria – Pre Operative
• Viral Infection
– HIV / Hepatitis
• Local site Infection
Special Conditions
Infection..

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• Active Upper Respiratory Tract Infection – G/A?
• Active Bacterial Infection
– Prophylactic Empirical Antibiotic
• Koch’s – Always A Trouble??
• Malaria – Pre Operative
• Viral Infection
– HIV / Hepatitis
• Local site Infection
Special Conditions
Infection..
DEALING WITH EMERGENCY??
Infection Is Not A Contraindication

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Special Conditions
Renal Dysfunction..
• BUN is necessity.. Not optional
• CREATININE CLEARANCE is a better marker
• RENAL SHUTDOWN? Simply Dialyse..
• AMINOGLYCOSIDES?
• FLUID replacement?
• Watch for ELECTROLYTES…
Keep an EYE on..
METABOLIC ACIDOSIS
Leading to
Tachypnoea and Fatigue

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Special Conditions
Renal Dysfunction..
• BUN is necessity.. Not optional
• CREATININE CLEARANCE is a better marker
• RENAL SHUTDOWN? Simply Dialyse..
• AMINOGLYCOSIDES?
• FLUID replacement?
• Watch for ELECTROLYTES…

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Special Conditions
Hepatic Dysfunction..
• Active Viral Hepatitis?..
• Obstructive Jaundice??
• Chronic Active Hepatitis?
• Past H/O Hepatitis?
Get complete bleeding profile done..
Simply, “Altered P.T.” is NOT
Contraindication for Emergency surgery

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• Patient in ICU, “SERIOUSLY ILL” – needs “LIGHT
DIET / CLEAR LIQUIDS”..
• I.V. FLUIDS – Dextrose / Saline with Multi-
vitamins gives “ENOUGH ENERGY”..
• “Pre-formulated Feeds” are “total Solution”.
Special Conditions
Nutrition..

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• Patient in ICU, “SERIOUSLY ILL” – needs “LIGHT
DIET / CLEAR LIQUIDS”..
• I.V. FLUIDS – Dextrose / Saline with Multi-
vitamins gives “ENOUGH ENERGY”..
• “Pre-formulated Feeds” are “total Solution”.
Special Conditions
Nutrition..
Nutrition is a science - critically ill PRE OPERATIVE
patients require PROPER assessment and
Supplementation of protein- caloric needs.
Negative Nitrogen balance – increases morbidity,
mortality.
Glutamine, Omega 3 fatty acids, Amino acids and
Lipids if supplemented, Reduces Post Op ICU stay &
mortality.

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RECAP
Role of Pulmonologist
PPC

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RECAP
Role of Pulmonologist

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RECAP….
FORGET NOT

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PULMOCARE ASSOCIATES
Pulmonologists – Intensivists – Physicians
Dr. Parthiv Mehta MD FCCP
Senior Pulmonologist – Intensivist
Hon. Pulmonologist to H.E. Governor of Gujarat
U N Mehta Institute of Cardiology
Mehta Hospital & Cardiopulmonary Care Centre
Central United Hospital
Ahmedabad, Gujarat, INDIA
Dr. Jigar Parikh Dr. Komal Kothari Dr. Pankaj Vyas
Dr. Divyang Patel Dr. Kaushal Gandhi Dr. Saurabh Vanzara

Pre operative pulmonary evaluation 2019

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Pre operative pulmonary evaluation 2019