Surgical Management of Women with Chronic Obstructive Airway Disease and Asthma
Editor: Ches Thompson, M.D.
The overall incidence of postoperative pulmonary complications is 5-10%, but patients with poorly controlled chronic obstructive airway disease (COPD) and asthma are at increased risk with up to 40% risk for pneumonia and 70% for atelectasis. Patient related risks include poorly controlled COPD or asthma, age greater than 65, functional dependence, American Society of Anesthesiologists class 2 or higher, pulmonary hypertension, obesity, smoking, steroid use, congestive heart failure, obstructive sleep apnea (OSA), excessive alcohol intake, serum albumin < 3g/dl, and current upper respiratory tract infection. Procedure related risk factors include abdominal (especially upper abdominal) surgery, emergency or prolonged surgery (>3-4 hours), use of general anesthesia, and use of long acting neuromuscular blockade.
There is insufficient evidence to support routine use of preoperative pulmonary function tests, arterial blood gases, or chest radiographs in well controlled COPD/asthma patients. However, those with worsening pulmonary symptoms or multiple risk factors may benefit from pre-operative testing and should be referred to a pulmonary specialist.
Risk reducing strategies for patients with multiple risk factors should be initiated in the peri-operative period. Multiple strategies should be employed in high risk patients including smoking cessation beginning at least 8 weeks before the procedure, delaying elective surgery for 2 to 3 weeks in those with recent or ongoing respiratory infections, and completing treatment with appropriate antibiotics. Underlying COPD or asthma should be optimized, which may require intensifying therapy with inhaled bronchodilators and steroids. Patients should be free of wheezing, bronchitis flares, and bronchiectasis at the time of surgery. Use of systemic glucocorticoids is recommended if peak expiratory flow (PEF) is <80% of predicted or the patient’s personal best.
Intra-operative management of patients with COPD or asthma involves use of rapid acting beta agonists at time of intubation to prevent bronchospasm (2-4 puffs inhaled or nebulized 30 minutes prior) and administration of stress dose steroids for women taking prednisone 20mg/day or greater for at least 3 weeks prior to surgery. Obese patients and those with OSA using continuous positive airway pressure (CPAP) machines may not tolerate laparoscopy due to effects of pneumoperitoneum and Trendelenburg position, and should be counseled about potential for conversion to open surgery. Use of epidural or spinal anesthesia when feasible may confer lower risk. Routine use of nasogastric tubes should be avoided.
Effective risk reducing strategies in the post- operative period include early ambulation, optimal pain control, lung expansion via deep breathing exercises and incentive spirometry, and CPAP. CPAP therapy is particularly advantageous in patients with OSA and those who are unable to perform effort dependent lung expansion maneuvers.
Smetana GW, Lawrence VA, Cornell JE, American College of Physicians. Preoperative pulmonary risk stratification for noncardiothoracic surgery: systematic review for the American College of Physicians. Ann Intern Med. 2006;144(8):581-95.
Cereda M. Pulmonary risk assessment. In Newman M, Fleisher LA, Fink MP, eds. Perioperative Medicine: Managing Outcomes. Philadelphia: Saunders; 2008:105-19.
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