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PRE-OPERATIVE PULMONARY RISK STRATIFICATION

URVASHI VAID MD,MS AUG 2012. PRE-OPERATIVE PULMONARY RISK STRATIFICATION. Why do we care? At risk population Tools for assessment Prevention of Post-op complications Risk Indices Clinical scenarios Thoracic Surgery and Lung cancer Bariatric Surgery Cardiac Surgery. OUTLINE.

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PRE-OPERATIVE PULMONARY RISK STRATIFICATION

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  1. URVASHI VAID MD,MS AUG 2012 PRE-OPERATIVE PULMONARY RISK STRATIFICATION

  2. Why do we care? • At risk population • Tools for assessment • Prevention of Post-op complications • Risk Indices • Clinical scenarios • Thoracic Surgery and Lung cancer • Bariatric Surgery • Cardiac Surgery OUTLINE

  3. What are PPC? • VC reduced by 50-60% after thoracic/upper abdominal Sx- remains or a week, FRC reduced by 30% • As prevalent as cardiac complications • Morbidity • Length of stay • Mortality • Prevalence 6.8% across all surgeries WHY DO WE CARE?

  4. In most cases of operable lung cancer, a substantial part of functional lung tissue has to be resected which leads to a permanent loss of pulmonary function • An estimated 90% of all patients with lung cancer have underlying COPD and cardiovascular disorders in varying degrees caused by the shared risk factor from tobacco smoking thus at higher risk of intraoperative and postoperative complications • Resection in patients with insufficient pulmonary reserves can result in permanent respiratory disability • The assumption that there is a level of respiratory impairment beyond which resection bears a high risk and is prohibitive drives the ongoing search for the ideal test to predict postoperative lung function and identify the patients at high risk • ClinChest Med 32 (2011) 773–782 Why Do We Care?

  5. Which of the following is not a significant risk factor for PPC in non-cardiothoracic surgery? • Age>60 • ASA class II or greater • COPD • Functionally dependant • Mild to moderate Asthma • CHF • Obesity SHOW OF HANDS….

  6. Which of the following is not a significant risk factor for PPC in non-cardiothoracic surgery? • Age>60 OR 2.0 • ASA class II or greater OR 4.87 • COPD OR 1.79 • Functionally dependant OR 2.51 • Mild to moderate Asthma • CHF OR 2.93 • Obesity SHOW OF HANDS….

  7. ASA CLASSIFICATION

  8. Malnutrition(albumin <3g/dL) reduces ventilatory drive to hypoxia and hypercapnia, contributes to respiratory muscle dysfunction, alters lung elasticity, and impairs immunity but nutritional intervention before surgery has not been shown to attenuate the risk • Renal impairment (blood urea >30 mg/dl) carries an OR of 2.3 for PPC • Obstructive sleep apnea –early hypoxemia and unplanned reintubation. 9/172 patients had PPC esp if ODI4% >15. Screening- • Pulmonary HTN- • ??? • Smetana GW. Preoperative pulmonary evaluation. N Engl J Med 1999;340(12):937–44. • Smetana GW, Lawrence VA, Cornell JE. Preoperative pulmonary risk stratification for noncardiothoracic surgery: systematic review for the American College of Physicians. Ann Intern Med 2006;144(8):581–95 • Association of sleep-disordered breathing with postoperative complications.AUHwang D, Shakir N, Limann B, Sison C, Kalra S, Shulman L, Souza Ade C, Greenberg HSOChest. 2008;133(5):1128 AT RISK POPULATION

  9. Age (more comorbidities) • COPD- RR of 4.7 • The OR for in patients ASA class III or higher is 2.6 compared with patients with ASA class I and II • Malnutrition (albumin <3g/dL) reduces ventilatory drive to hypoxia and hypercapnia, contributes to respiratory muscle dysfunction, alters lung elasticity, and impairs immunity but nutritional intervention before surgery has not been shown to attenuate the risk • Smetana GW. Preoperative pulmonary evaluation. N Engl J Med 1999;340(12):937–44. • Smetana GW, Lawrence VA, Cornell JE. Preoperative pulmonary risk stratification for noncardiothoracic surgery: systematic review for the American College of Physicians. Ann Intern Med 2006;144(8):581–95 AT RISK POPULATION

  10. Cigarette smoking increases the risk of PPC irrespective of the presence of COPD A significant reduction of this risk is only noted after 8 weeks of cessation Recent meta-analyses confirm that smoking cessation before surgery does not increase the risk for PPC The data indicate that stopping smoking before surgery might lower the risk of complications, with a growing effect with longer duration of smoking cessation Mills E, Eyawo O, Lockhart I, et al. Smoking cessation reduces postoperative complications: a systematic review and meta-analysis. Am J Med 2011;124(2):144.e8–54.e8. Myers K, Hajek P, Hinds C, et al. Stopping smoking shortly before surgery and postoperative complications: a systematic review and meta-analysis. Arch Intern Med 2011;171(11):983–9. SMOKING- To stop or not to stop(And when to stop…)

  11. Surgical Site- thoracic, AA, abdominal, neurosurgery, head and neck and vascular Duration of surgery- >3-4 hours Anesthetic technique- GA Emergency surgery PROCEDURE RELATED RISK FOR PPC

  12. History • Physical • Stair Climbing • 6 minute walk • ABG • PFTs • CPET • Quantitative V/Q scan TOOLS FOR ASSESSMENT

  13. Prior surgeries/anesthesia Signs of cor pulmonale Laryngeal height in COPD <4cm has OR 2.0 for PPC* *McAlister FA, et al. Am J Resp Crit Care Med 2003; 167:741 HISTORY AND PHYSICAL EXAM

  14. Stair Climbing- height of 20 meters or rate of ascent 15m/min (=VO2 max of 20ml/kg/min) and 12m/min (= VO2 max of 15ml/kg/min) Brunelli study-5 year survival (97 vs 74; 77% vs 54%, p < 0.001) Stair climb > 44 steps (Holden, Chest, 1992) 6 minute walk- >400m ABG ?? PaCO2 >45mmHg Brunelli A, Pompili C, Salati M. Low-technology exercise test in the preoperative evaluation of lung resection candidates. Monaldi Arch Chest Dis 2010; 73:72–78 Brunelli et al. Performance at Preoperative Stair-Climbing Test Is Associated With Prognosis After Pulmonary Resection in Stage I Non-Small Cell Lung Cancer Ann Thorac Surg 2012;93:1796–801 Kasymjanova G, Correa JA, Kreisman H, et al. Prognostic value of the six-minute walk in advanced non-small cell lung cancer. J Thorac Oncol 2009;4:602–7. FUNCTIONAL ASSESSMENT

  15. No role in non-thoracic surgery unless you suspect COPD or asthma “Recommendation 5: Preoperative spirometry and chest radiography should not be used routinely for predicting risk for postoperative pulmonary complications” PFTs and CXR

  16. Role of ppoFEV1 and ppoDLCO preoperative FEV1 X [19 - patent segments to be removed/19] Group A, patients with ppoFEV1 and ppoDLCO > 40% predicted, and group B, patients with either ppoFEV1 or ppoDLCO < 40% predicted or both between 30 and 40% predicted and ppoVO2 peak > 10 ml/kg per min Found a similar complication rate among the two groups, but a higher 30-day mortality (1.9 vs. 13.5%) in group B. Puente-Maestu´ L, Villar F, Gonza´ lez-Casurra´n G, et al. Early and long-term validation of an algorithm assessing fitness for surgery in patients with postoperative FEV1 and diffusing capacity of the lung for carbon monoxide <40%. Chest 2011; 139:1430–1438. PFTS in thoracic surgery

  17. CPET

  18. For thoracic surgery VO2max >75% or >20ml/kg/min for pneumonectomy VO2 max >15ml/kg/min for lobectomy No surgery if <35% or <10ml/kg/min CPET

  19. QUANTITATIVE V/Q SCAN or ct scan Segments generated by hounsfield units. ppo-FEV1 = preoperative FEV1 X (1-(RFLV/TFLV)).

  20. ERS/ESTS 2009 guidelines • BTS/SCTS 2012 guidelines • Salati M and Brunelli A. Preoperative assessment of patients for lung cancer surgery. CurrOpinPulm Med 2012, 18:289–294 • Bolliger et al. Functional Evaluation before Lung Resection. ClinChest Med 32 (2011) 773–782 THORACIC SURGERY ESP LUNG CANCER

  21. Operability (Physiologic) Resectability (Anatomic) Preoperative Evaluation of Patients with Lung Cancer Undergoing Thoracic Surgery Batra, Vikas MD; Kane, Gregory C. MD; Weibel, Sandra MD . Clin Pulm Med 2002;9(1):46–52 tenets

  22. Assessment of cardiopulmonary reserve before lung resection ERS/ESTS

  23. Risk assessment of post-treatment dyspnea- BTS/SCTS

  24. (1) limited role of traditional spirometry and predicted postoperative FEV1 (2) importance of a systematic measurement of carbon monoxide lung diffusion capacity (3) global approach in fitness evaluation, by assessing the entire oxygen transport system with CPET Take home for lung surgery candidates

  25. Arozullah AM, Daley J, Henderson WG, Khuri SF. Multifactorial risk index for predicting postoperative respiratory failure in men after major noncardiac surgery. The National Veterans Administration Surgical Quality Improvement Program. Ann Surg. 2000;232:242-53. Risk indices

  26. Risk indices

  27. >32,000 patients 2006-2008 0.6% developed PRF and 0.6% PP 30 day mortality greater if developed either (4.3% versus 0.16% and 13.7% versus 0.10%, P < .0001) CHF OR 5.3 (1.2-23) Stroke OR 4.1 (1.4-11) Dyspnea at rest OR 2.64 (1.1-6) Age, COPD, smoking, diabetes, anesthesia time, increasing weight, type of surgery Gupta et al. Predictors of pulmonary complications after bariatric surgery. Surg Obes Relat Dis. 2011 May 13. BARIATRIC SURGERY

  28. 1997-2010 >11,000 patients 3 groups- normal or mild (<70%, FEV1 >80%), moderate 50-80%, Severe <50% Early mortality: 1.4% vs 2.9% vs 5.7% (p<0.001) Similar trend for post-op complications Saleh et al. Impact of chronic obstructive pulmonary disease severity on surgical outcomes in patients undergoing non-emergent coronary artery bypass grafting. Eur J Cardiothorac Surg. 2012 Jul;42(1):108-13. OTHERS: h/o CABG, emergent surgery, infiltrate on CXR, BUN>30, acute MI on admission CARDIAC SURGERY

  29. Lung Specific Strategies Anesthetic techniques Surgical techniques Peri-operative care PREVENTION OF POST-OP COMPLICATIONS

  30. Lung Specific Strategies Smoking Cessation Lung Expansion Optimize bronchodilators Anesthetic techniques Surgical techniques Peri-operative care PREVENTION OF POST-OP COMPLICATIONS

  31. 172 patients- Celli, B and Snider GL. ARRD 1984 Prospective, RCT in Abdominal surgery Cochrane review 2009: “We found no evidence regarding the effectiveness of the use of incentive spirometry for prevention of postoperative pulmonary complications in upper abdominal surgery. This review underlines the urgent need to conduct well-designed trials in this field” For IS: Same applies to CABG (IPPB may work) and esophagectomies too! (Cochrane) Lung expansion

  32. Lung Specific Strategies Anesthetic techniques NM blockade (longer acting worse) Intraoperative PEEP (No effect) Surgical techniques Peri-operative care Cochrane Database Syst Rev. 2010 Sep 8;(9):CD007922 PREVENTION OF POST-OP COMPLICATIONS

  33. Lung Specific Strategies Anesthetic techniques Surgical techniques Peri-operative care PREVENTION OF POST-OP COMPLICATIONS

  34. Lung Specific Strategies Anesthetic techniques Surgical techniques Peri-operative care Selective NOT routine use of nasogastric tubes after elective lap lower rates of pneumonia/atelectasis Don’t forget- early ambulation and DVT prophylaxis PREVENTION OF POST-OP COMPLICATIONS

  35. THANK YOU!

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