Transcript PRE-OPERATIVE PULMONARY RISK STRATIFICATION

URVASHI VAID MD,MS
AUG 2012
PRE-OPERATIVE PULMONARY RISK
STRATIFICATION
OUTLINE
Why do we care?
 At risk population
 Tools for assessment
 Prevention of Post-op complications
 Risk Indices
 Clinical scenarios
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Thoracic Surgery and Lung cancer
 Bariatric Surgery
 Cardiac Surgery
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WHY DO WE CARE?
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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
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Morbidity
Length of stay
Mortality
Prevalence 6.8% across all surgeries
WHY DO WE CARE?
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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
Clin Chest Med 32 (2011) 773–782
SHOW OF HANDS….
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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….
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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
OR 2.0
OR 4.87
OR 1.79
OR 2.51
OR 2.93
ASA CLASSIFICATION
AT RISK POPULATION
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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. ScreeningPulmonary 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
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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
SMOKING- To stop or not to stop
(And when to stop…)
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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.
PROCEDURE RELATED RISK FOR PPC
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Surgical Site- thoracic, AA, abdominal, neurosurgery, head and neck
and vascular
Duration of surgery- >3-4 hours
 Anesthetic technique- GA
 Emergency surgery
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TOOLS FOR ASSESSMENT
History
 Physical
 Stair Climbing
 6 minute walk
 ABG
 PFTs
 CPET
 Quantitative V/Q scan
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HISTORY AND PHYSICAL EXAM
Prior surgeries/anesthesia
 Signs of cor pulmonale
 Laryngeal height in COPD <4cm has OR 2.0 for
PPC*
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*McAlister FA, et al. Am J Resp Crit Care Med 2003; 167:741
FUNCTIONAL ASSESSMENT
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Stair Climbing- height of 20 meters or rate of ascent 15m/min
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(=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
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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
PFTS AND CXR
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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 IN THORACIC SURGERY
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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 30day 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.
CPET
CPET
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
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QUANTITATIVE V/Q SCAN OR CT SCAN
Segments generated by
hounsfield units.
ppo-FEV1 = preoperative
FEV1 X (1-(RFLV/TFLV)).
THORACIC SURGERY ESP LUNG CANCER
ERS/ESTS 2009 guidelines
 BTS/SCTS 2012 guidelines
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Salati M and Brunelli A. Preoperative assessment of patients for lung cancer surgery. Curr Opin
Pulm Med 2012, 18:289–294
Bolliger et al. Functional Evaluation before Lung Resection. Clin Chest Med 32 (2011) 773–
782
TENETS
Operability (Physiologic)
 Resectability (Anatomic)
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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
Assessment of cardiopulmonary reserve before lung resection ERS/ESTS
Risk assessment of post-treatment dyspnea- BTS/SCTS
TAKE HOME FOR LUNG SURGERY CANDIDATES
(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
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RISK INDICES
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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
BARIATRIC SURGERY
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>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)
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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.
CARDIAC SURGERY
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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
PREVENTION OF POST-OP COMPLICATIONS
Lung Specific Strategies
 Anesthetic techniques
 Surgical techniques
 Peri-operative care
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PREVENTION OF POST-OP COMPLICATIONS
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Lung Specific Strategies
Anesthetic techniques
 Surgical techniques
 Peri-operative care
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Smoking Cessation
Lung Expansion
Optimize bronchodilators
LUNG EXPANSION
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172 patients- Celli, B and Snider GL.
ARRD 1984
Control=44 IPPB=45
IS=42
DBE=41
PPC
48%
22%
21%
22%
LOS
13 +- 5
8.6+-3
9.6+-3
9.9+-6
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Prospective, RCT in Abdominal surgery
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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”
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For IS: Same applies to CABG (IPPB may work) and
esophagectomies too! (Cochrane)
PREVENTION OF POST-OP COMPLICATIONS
Lung Specific Strategies
 Anesthetic techniques
NM blockade (longer acting worse)
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Intraoperative PEEP
Surgical techniques
 Peri-operative care
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Cochrane Database Syst Rev. 2010 Sep 8;(9):CD007922
(No effect)
PREVENTION OF POST-OP COMPLICATIONS
Lung Specific Strategies
 Anesthetic techniques
 Surgical techniques
 Peri-operative care
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PREVENTION OF POST-OP COMPLICATIONS
Lung Specific Strategies
 Anesthetic techniques
 Surgical techniques
 Peri-operative care
Selective NOT routine use of
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nasogastric tubes after elective lap
lower rates of pneumonia/atelectasis
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Don’t forget- early ambulation and DVT prophylaxis
THANK YOU!