CASE DISCUSSION – CHRONIC OBSTRUCTIVE PULMONARY DISEASE

PATIENT POSTED FOR UPPER ABDOMINAL SURGERY

Dr C L Gurudatt,
Professor and Head, Dept of Anaesthesiology
Mysore Medical College and Reasearch Institute
Mysore

A 60years old man was posted for partial gastrectomy for carcinoma of stomach.
He is a chronic smoker and has chronic cough with expectoration and dyspnoea with
moderate exertion. He was admitted 1 year back with severe dyspnoea at rest and was
non invasively ventilated for 2 days. He also gives past h/o pulmonary tuberculosis.
Presently he regularly uses inhaled bronchodilators and steroids. His arterial blood gases
showed the following ; Ph 7.36, PCO260mmHg and PaO2 70mmHg.

1. What is chronic obstructive pulmonary disease

Chronic Obstructive Pulmonary Disease (COPD), a common preventable and treatable
disease, is characterized by persistent airflow limitation that is usually progressive and
associated with an enhanced chronic inflammatory response in the airways and the lung
to noxious particles or gases. Exacerbations and comorbidities contribute to the overall
severity in individual patients.
2. What are the diseases incorporated in COPD
Chronic bronchitis and emphysema are the two main diseases incorporated under COPD.
Chronic bronchitis is defined clinically as chronic productive cough for 3 months in a
year for at least 2 successive years in a patient.
Emphysema is defined as the presence of permanent enlargement of the air spaces distal
to the terminal bronchioles accompanied by destruction of their walls and without
obvious fibrosis.
3. What are the mechanisms underlying airflow limitation in COPD

Mechanisms underlying airflow limitation in COPD

Small airway disease Parenchymal destruction
Airway inflammation Loss of alveolar attachments
Airway fibrosis; luminal plugs Decrease of elastic recoil
Increased airway resistance

4. What are the factors that influence disease development and progression

Exposure to Particles

Across the world, cigarette smoking is the most commonly encountered risk factor for
COPD. Cigarette smokers have a higher prevalence of respiratory symptoms and lung
function abnormalities, a greater annual rate of decline in FEV1, and a greater COPD
mortality rate than nonsmokers. Other types of tobacco (e.g., pipe, cigar, water pipe )
and marijuana are also risk factors for COPD. Passive exposure to cigarette smoke (also
known as environmental tobacco smoke or ETS) may also contribute to respiratory
symptoms and COPD by increasing the lung’s total burden of inhaled particles and
Gases. Although cigarette smoking is the best-studied COPD risk factor, it is not the
only one and there is consistent evidence from epidemiologic studies that nonsmokers
may also develop chronic airflow limitation.
Socioeconomic Status
Poverty is clearly a risk factor for COPD but the components of poverty that contribute to
this are unclear.
There is strong evidence that the risk of developing COPD is inversely related to
socioeconomic status
How COPD is diagnosed
A clinical diagnosis of COPD should be considered in any patient who has dyspnea,
chronic cough or sputum production, and a history of exposure to risk factors for the
disease . Spirometry is required to make the diagnosis in this clinical context
; the presence of a post-bronchodilator FEV1/FVC < 0.70 confirms the presence of
persistent airflow limitation and thus of COPD.
Consider COPD, and perform spirometry, if any of these indicators are present
in an individual over age 40. These indicators are not diagnostic themselves, but
the presence of multiple key indicators increases the probability of a diagnosis of
COPD. Spirometry is required to establish a diagnosis of COPD.

What are the Key Indicators for Considering a Diagnosis of COPD

Dyspnea that is:

Progressive (worsens over time).
Characteristically worse with exercise.
Persistent.
Chronic cough:
May be intermittent and may be unproductive.
Chronic sputum production:
Any pattern of chronic sputum production may indicate COPD.
History of exposure to risk factors:
Tobacco smoke (including popular local preparations).
Smoke from home cooking and heating fuels.
Occupational dusts and chemicals.
Family history of COPD

What are the differences between chronic bronchitis and emphysema

 Feature Chronic Bronchitis Empysema
Mech of Airway Decreased Lumen d/t Loss of elastic recoil
Obstruction mucus &
inflammation
Dyspnoea Moderate Severe
FEV1 Decreased Decreased
PaO2 Marked Decrease Modest Decrease
(Blue Bloater) (Pink Puffer)
PaCO2 Increased Normal or Decreased
Diffusing capacity Normal Decreased
Haematocrit Increased Normal
Cor Pulmonale Marked Mild
Prognosis Poor Good

4. When do you say cough is productive ?

• When the sputum production is > 100 ml/ day

• Seen in conditions like

– Bronchiectasis
– Lung abscess
– Empyema rupturing into bronchus
– Necrotizing pneumonia
– Alveolar cell carcinoma
– Chronic bronchitis

5. Why colour and odour of the sputum are important?

Based on the colour of the sputum one can approximately diagnose the causative factor

Colour of the sputum conditions

Yellow ( purulent) Bacterial infection
Greenish Pseudomonas
Black Aspergillosis,Coal workers’
Pneumoconiosis
Red currant jelly Klebsiella pneumonia
Rusty Pneumococcal pneumonia
 Pink frothy Pulmonary oedema
Blood stained Haemoptysis
Anchovy sauce like Ruptured amoebic lung abscess
White Mucoid, viral

•
Odour of the sputum is offensive and foetid in
– Lung abscess
– Bronchiectasis
– Anaerobic bacterial infections
–
6. How do you grade respiratory dyspnoea?

Roizen’s classification is a simple method of grading the severity of dyspnoea.

ROIZEN’S CLASSIFICATION

Grade of Dyspnoea Caused by Respiratory Problems (Assessed In Terms of Walking on

a Level Surface at a Normal Pace)
Category Description
No dyspnoea while walking on a level surface at a normal pace( no limitation
0
of distance or pace)
Unlimited distance with limited pace “I am able to walk as far as I like,
I
provided I take my time”
Limited pace and distance - Specific (street) block limitation (“I have to stop
II
for a while after one or two blocks”)
Dyspnea on mild exertion (“I have to stop and rest while going from the
III
kitchen to the bathroom”)
IV Dyspnea at rest

Modified Medical Research Council Questionnaire for Assessing the Severity of

Breathlessness

Description Grade Degree

Only get breathless with strenuous exercise. 0 NONE

Get short of breath when hurrying on the level or walking 1 MILD

up a slight hill
Walk slower than people of the same age on the level 2 MODERATE
because of breathlessness, or I have to stop for breath
when walking on my own pace on the level.

Stop for breath after walking about 100 meters or after a 3 SEVERE
few minutes on the level.

Too breathless to leave the house or I am breathless when 4 VERY

dressing or undressing SEVERE

Higher the grade of dyspnoea more severe will be the disease, decreased
cardiopulmonary reserve and increased incidence of post operative pulmonary
complications.

7. What concurrent medications the patient can be on and anaesthetic importance of

the same?

Patient can be on bronchodilators, steroids, mucolytic and mucokinetic

agents and may also be on digoxin and diuretics if he/she has chronic cor
pulmonale

• BRONCHODILATORS :
• Classified as beta 2 agonists, xanthine derivatives, atropine derivatives, mast cell
inhibitors( used for prevention of an attack of bronchospasm), and steroids

Anaesthetic importance
1) Beta 2 agonists eg. Salbutamol, terbutaline

-chronic use can produce hypokalemia (beta 2 agonists push the potassium
in to the cell), there by prolonging the duration of non depolarizers and also can induce
dysrrhythmias.
-Systemically administered beta 2 agonists can lead to
dysrhythmias

2) Xanthines (theophyllines)

-Interaction with halothane can produce dysrrhythmias

-CNS stimulation can lead to

a)increased seizure activity and

 b) lighter planes of anaesthesia

• STEROIDS :

There can be suppression of adreno cortical axis if the patient is on prednisolone

of > 10mg taken for > than 10 days within 10 weeks. These patients require
supplemental doses of steroids before induction.
Chronic use can also produce Cushing’s syndrome and all the problems
associated with the same.

• ANTIBIOTICS :

Aminoglycoside antibiotics can prolong the duration of action of NDMRs by

blocking the fast calcium channels in the pre junctional nerve ending.

8. Why history of previous tuberculosis disease is important ?

• Sputum for AFB to be sent

• If positive the patient will be in active infectious stage of tuberculosis. Surgery to
be postponed till the patient becomes sputum negative. If emergency surgery has
to be done, regional anaesthesia is the preferred choice. If GA has to be given,
disposable breathing circuits are to be used.
• If patient is on anti tubercular treatment, liver function tests are required as both
isoniazid and rifampicin can produce hepatotoxicity.

9. What details would you like to ask regarding previous admission ?

• Treatment history-especially H/o management with invasive mechanical

ventilation.
• If such history is there, then patient may have tracheal narrowing. Hence a history
of any post extubation stridor or difficulty in breathing should be taken.
• A neck X-ray, AP and lateral view may be taken to know the site and extent of
narrowing.
• Smaller sized endotracheal tubes may have to be kept ready.

10. What important past history you would like to ask in this patient?

• H/o chronic medication

• Previous surgery and anaesthetic exposure and complications if any
• Drug allergy
• Any other co-morbid diseases like hypertension, diabetes mellitus, epilepsy,
bronchial asthma.
12. Anything important in personal history?

H/o Smoking to be taken especially in male patients. Duration and number of cigarates
per day are more important which is expressed as pack years.

• PACK YEARS : number of packs of cigarettes/day × number

of years of smoking
One pack = 20 cigarettes
> 40 pack years is high risk for post operative pulmonary complications

• SMOKING INDEX : number of cigarettes /day × total

duration in years
– SI <100 mild smoker
– SI 100-300 moderate smoker
– SI >300 heavy smoker

Anaesthetic importance of smoking –

Post operative pulmonary complications are very common and sever in smokers and can
lead to increased morbidity and mortality.

• Smoking increases the carboxy haemoglobin levels due to increased carbon

monoxide inhalation. Increase in carboxy haemoglobin levels
(a)decrease the oxygen carrying capacity of haemoglobin,
(b)shift the OD curve to the left and decrease the oxygen release to the tissues,
(c)produce spuriously high pulse oximeter readings (oxy haemoglobin and
carboxy haemoglobin have the same wave length of 940 Nm and hence pulse
oximeter reads carboxy haemoglobin also as oxy haemoglobin. Only Co-oximeter
can differentiate between the two and can give the correct saturation readings).
The half life of carboxy haemoglobin is 4-6 hours and stopping smoking for 24
hours is enough to reduce the problems associated with it. Normal carboxy
haemoglobin levels is < 2% in non-smokers . Whereas it can be as high as 10% in
smokers.
• Smoking produces hypertrophy and hyperplasia of mucus secreting glands
• Impairs ciliary motility and muco ciliary transport mechanism leading to infection,
atelectasis and collapse.
• Inhibits the function of alveolar macrophages and suppresses immune mechanism
• Increases airway resistance due to bronchoconstriction
• Makes the airways Hyperactive .
• Increases Postoperative pulmonary complications
• Induces coronary vasoconstriction producing decreased coronary blood flow.
• 8 weeks of abstinence from smoking is enough to reduce the above problems.

13. What are the main points to be considered in general physical examination ?
• Body Mass Index :
-obesity (BMI >30kg/m2) decreases FRC with relative increase in CC producing
increase in intra pulmonary shunts and decrease in pulmonary reserve.
- Also decreases thoracic and lung compliance producing restrictive lung disease
and exaggerating the problems associated with obstructive disease.
- Increased post operative pulmonary complications due to hypoventilation.
-In elective surgeries, obese patient is asked to reduce body weight pre
operatively in order to reduce post op pulmonary complications.
In this patient BMI is 23kg/m2 and hence normal.

• Signs of respiratory distress : Tachypnoea, use of accessory muscles of

respiration, and cyanosis.

• Pallor – anaemia can exacerbate the respiratory problems by increasing the work
of breathing due to anaemic hypoxia.
• Cyanosis
If cyanosis is present, the arterial haemoglobin saturation with oxygen is 80% or
less (Pao2 <50 to 52 mm Hg), which indicates an increased ventilation perfusion
mismatch and limited margin of respiratory reserve. It may also indicate the
presence of respiratory failure and requirement of oxygen therapy/ mechanical
ventilatory support.
• Pedal oedema and raised JVP - indication of Right heart failure as a result of cor
pulmonale.
• Clubbing – may be present and should be graded

Grade 1 Increased fluctuation of the nail

Grade 2 Obliteration of the angle between nail
and nail bed
Grade 3 Parrot beak appearance
Grade 4 Drum stick appearance
Grade 5 associated with hypertrophic
osteoarthropathy
Table 2

Causes of clubbing can be classified as

 Pulmonary Cardiac GIT causes Others
causes causes

[Link] [Link] [Link] Familial, Trauma,

lung disorders heart disease bowel disease- AV fistula
-Lung abscess [Link] Crohn’s disease
-Empyema endocarditis [Link] malignancy
-Bronchiectasis [Link] disorders
[Link] like biliary
tuberculosis cirrhosis
[Link]
carcinoma

Table 3

VITALS

• Fever : indicates infection

• Pulse rate
May be irregularly irregular if the patient is in Atrial fibrillation and missed beats
which can occur as a result of chronic hypoxia.
• Blood pressure- postural hypotension if on diuretics for failure.

[Link] important findings you would like to get from systemic examination?

Respiratory system
– Position of trachea
If collapse or fibrosis of the lung is present ,the trachea may be pulled to
the same side. It is likely in this patient as she had pulmonary tuberculosis.

– Respiratory rate and pattern

Rate more than 30 with use of accessory muscles of respiration indicates
respiratory distress.

-Measurements of chest- barrel chest in emphysematous patients.

Chest expansion is normally 5cms which can be reduced to < 2cms in
COPD patients.
-obliteration of liver dullness on percussion may be present.

– Breath sounds
Bronchial breath sounds may indicate pneumonic consolidation or cavity.
Distant sounds are an indication of emphysema
Decreased breath sounds heard over fibrosis, collapse, pleural effusion,
and pneumothorax.
 – Added sounds
• Wet sounds (crackles /coarse crepitations) are usually caused by
excessive fluid in the airways and indicate sputum retention or
edema. Commonly heard over the areas of bronchiectasis.
• Dry sounds (wheezes/rhonchi) are produced by high-velocity gas
flow through narrowed bronchi and are a sign of airway
obstruction.
• Cardiovascular system

– Pulmonary hypertension to be ruled out, signs of which include a palpable

P2, narrowly split second heart sound, increased intensity of the
pulmonary component of the second heart sound, and para sternal
heave( right ventricular hypertrophy).
If present can be a bad prognostic sign.
• Per abdomen

In right heart failure

– Epigastric pulsations
– Tender hepatomegaly
– Hepatojugular reflex

15. What investigations should you ask for this patient ?

Laboratory tests
-haemoglobin, total count and differential count,
absolute eosinophilic count( >2000/cmm – tropical
eosinophilia, >300/cmm in asthmatics indicate
increased risk of peri op broncho spasm).
-random blood sugar
-blood grouping, typing and cross maching.
-urine routine
-renal function tests
-12 lead ECG to look for P-pulmonale( P waves with
height of > 3 small squares or 0.3 Mv amplitude) and
RVH( R/S ratio >1 in V1 and V2)
- chest x-ray to rule out pneumonic consolidation
- Sputum for culture and sensitivity and for AFB
- PulmonaryFunctionTests(PFT) – bed side tests &
using spirometry
16. What findings you will look for in the x-ray chest ?
 Emphysematous changes like horizontally placed ribs with wide intercostal
spaces, flattened domes of the diaphragm, hyper lucent lung shadows and tubular
heart will be present .
 X ray chest should not be taken to confirm these changes as one can expect these
changes after clinical examination alone.
  Main aim is to rule out pneumonitis or malignancy.

Fig 1

17 . What ECG findings may be present ?

• Features of right atrial and right ventricular hypertrophy with strain.

• Low-voltage QRS complex due to lung hyperinflation and poor R-wave
progression across the precordial leads.
• An enlarged P wave (“P pulmonale” ) of amplitude > 3 small squares in standard
lead II is diagnostic of right atrial hypertrophy.
Right ventricular hypertrophy , R/S ratio of greater than 1.0 in lead V1 and V2 (i.e., R-
wave voltage exceeds S-wave voltage).

18 .Enumerate the static and dynamic lung function tests

STATIC TESTS
Force is not used by the patient and not time based

• Divided into 4 lung volumes and 4 lung capacities .

• 2 or more lung volumes together comprise a capacity

Lung volumes Lung capacities

[Link] volume [Link] capacity

[Link] reserve volume 2. Total lung capacity

[Link] reserve volume [Link] residual capacity

[Link] volume 4. Inspiratory capacity

Table 4

DYNAMIC TESTS
Force is used and they are time based.

Includes
• Maximum breathing capacity
• Forced vital capacity
• Forced expiratory volume in first second (FEV1)
• Maximum mid expiratory flow rate
• Peak expiratory flow rate
• Respiratory muscle strength

19 . Describe the bed side lung function tests ?

1)SABRASEZ BREATH HOLDING TEST:

This is done mainly to test the cardio pulmonary reserve of the patient.
Patient is asked to take deep inspiration and hold the breath as long as possible.
Listen by keeping a stethoscope over the trachea to identify early expiration.
• normal>40 secs
• <25 secs indicates decreased ventilatory capacity
• <15 secs – poor cardiopulmonary reserve

• 2) SNIDER’s MATCH BLOWING TEST :

Mainly reveals expiratory capacity and maximum breathing capacity of the
patient.
A lighted candle is kept in front of the patient at a
distance of 6 inches. Patient is asked to blow the candle with
the mouth open without pursing the lips.
• If patient can’t blow out the candle at 6 inches, MBC< 100 lts/min and FEV1
<1.6 litres
• Can also be done by keeping the lighted candle at 9 inches and 3 inches
• If the patient can blow at 9 inches, MBC > 150lts/min
• If the patient can blow at only 3 inches then MBC is 50lts/min

2) DE BONO’S WHISTLE:
Used to calculate the PEFR of the pateint
• It is a whistle with adjustable diametered aperture. Patient is asked to blow the
whistle with the aperture maximally open.
 • If not possible then the aperture size can be reduced and patient is again asked to
blow the whistle. The size of the aperture at which the patient can blow the
whistle is noted. For each size of the aperture PEFR values are given on the
whistle.

4) AUSCULTATION OVER THE TRACHEA FOR FORCED EXPIRATORY TIME:

• performed during a forced expiration after a deep inspiration using a stethoscope
placed over the trachea and starting a stop watch at the start of expiration and
stopping the same till no more expiratory sound is heard.
• normal is 3 to 4 secs
• > 6 secs indicates obstructive airway disease with FEV1 less than 50 percent
5) WRIGHT’S RESPIROMETER
For measuring tidal volume and minute volume.
6) WRIGHT’S PEAK FLOW METER
For measuring peak expiratory flow rate - PEFR.
Normal values – MALES- 450-700 L/MIN.
FEMALES- 350-500 L/MIN.
<200 L/ MIN. – inadequate cough efficiency
.

7 . GREENE & BEROWITZ COUGH TEST

Performed by asking the patient to take a deep inspiration and cough once. Gives an
indication of -
 ABILITY TO COUGH
 STRENGTH
 EFFECTIVENESS
Inadequate cough if: FVC<20 ML/KG
FEV1 < 15 ML/KG
PEFR < 200 L/MIN.
VC ~ 3 TIMES TV FOR EFFECTIVE COUGH.
A wet productive cough / self propagated paraoxysms of coughing – patient susceptible
for pulmonary Complication.
8. The wheeze test – The patient is asked to take 5 deep inspirations/ expirations; the
patient is then ascultated between the shoulder blades posteriorly to determine the
presence or absence of wheezing.
9. Single breath count test -- patient is asked to count out loud numbers from 1 onwards
after a maximal inspiration.
Individuals with normal respiratory function can count to 50 or more. A single breath
count of less than 15 indicates severe decrease of vital capacity.

What are the indications for spirometry ?

 Indicated in thoracic and upper abdominal surgeries .
 Helps in the diagnosis of COPD.
 Helps in knowing the reversibility of the airflow limitation.
 Helps to know adequacy of preparation of the patient.
  Helps in risk stratification

20. What are the differences between obstructive and restrictive lung disease?

Parameter Obstructive Restrictive

Vital capacity Normal or decreased Decreased
Total lung capacity Normal or increased Decreased
Residual volume Increased Decreased
FEV1/FVC Decreased Normal
Max mid expiratory flow Decreased Normal
rate
MBC Decreased Normal
Table 5

21. What are the three legged stool assessment of pulmonary function ?

Tests are done to assess the respiratory mechanics, parenchymal functions of the lung and
cardiopulmonary reserve of the patient.

3 legged stool
Prethorocotmy
respiratory
assessment

Lung mechanics Pulmonary Cardiopulmonary

FEV1 (ppo > 40%) parenchymal functions reserve
MVV DLCO (ppo >40%) VO2max
FVC Pao2 >60 >15ml/kg/min
RV/TLC Paco2<45 Stair climbing >2
flights
6 min walk test
Exercise SPO2 <4%
Table 6

22. Based on PFT, how do you assess the severity of COPD patients ?

Stages Characteristics
Stage 0 Normal spirometry
 At risk Chronic symptoms ( cough, sputum
production)
Stage 1 FEV1/FVC < 70%
Mild FEV1> 80% predicted
With or without symptoms
Stage 2 FEV1/FVC < 70%
Moderate FEV1 50-80% predicted
With or without symptoms
Stage 3 FEV1/FVC < 70%
Severe FEV1 30-50% predicted
With or without symptoms
Stage 4 FEV1/FVC < 70%
Very severe FEV1<30% predicted or FEV1 <50% with
chronic respiratory failure
With or without symptoms
Table 7

23. What is Shapiro et al scoring system for respiratory disease patients posted for
thoracic and upper abdominal surgeries?

PARAMETER SCORING
1. EXPIRATORY SPIROGRAM
a. % FVC + FEV1 /FVC > 150 0
b. % FVC + FEV1 /FVC 100 -150 1
c. % FVC + FEV1 /FVC < 100 2
d. Preop FVC < 20ml/kg 3
e. Post bronchodilator FEV1/FVC <50% 3
2. CVS
a. normal 0

b. controlled HTN, recent MI without sequel > 2yr 0

c. signs of CCF
1
3. CNS
a. normal 0
b. confusion,disoriented, obtunded, spasticity, agitation, 1
bulbar malfunction
c. significant muscle weakness, paraplegia, hemiplegia
1
4. ABG
a. normal 0
b. PaCO2 >50, PaO2 <60 1
c. ph >7.5 or <7.3 1
5. POST OP AMBULATION
[Link] 36 hours 0
b. bed confinement >36hours 1
Table 8

Pre operative score zero - minimal incidence of post op pulmonary complications

Score 1 to 2 – moderate risk, require post op supplemental oxygen and incentive
spirometry.
Score >3 – high risk patient, requires management in the intensive care unit post
operatively, with intensive monitoring and assisted with pulmonary toileting at least for
24 hours.

24. What is Nunn and Milledge assessment for post operative management, in
respiratory cripples(FEV1<35%)?

For post operative O2 supplementation & mechanical ventilation

FEV1 <1L PaO2 >60mmHg No post op O2

PaCO2 <50mmHg supplementation

FEV1 <1L PaO2 <60mmHg Post op O2

PaCO2 <50mmHg supplementation

FEV1 <1L PaO2 <60mmHg Post operative

PaCO2 >50mmHg Mechanical
ventilation

Table 9

25. What is Hirshmann classification of respiratory disease patients with hyper

reactive airways?
• Group I – H/o wheeze sometime in past
No recent H/o wheeze
At present not wheezing
Not on medication, PFT normal

• Group II – Recent H/o wheeze present

At present not wheezing
May or may not be on medication
PFT normal
 • Group III – Recent H/o wheeze
At present wheezing
On medication
PFT abnormal

Group 1 and group 2 patients are accepted for elective cases after taking complete
precautions that are taken for a bronchial asthma patient.
Group 3 patients are accepted for only life threatening emergencies.

26. What are flow volume loops ?

Flow volume loop is a plot of inspiratory and expiratory flow in the vertical axis
against volume in the horizontal axis, during the performance of maximally
forced inspiratory and expiratory maneuvers.

Fig 2 - Normal flow-volume loop- V 75, V50, and V25 represent flow at 75%,
50%, and 25% of vital capacity, respectively. RV, residual volume

27 . How will the flow volume loop looks in this patient ?

It will be of obstructive disease type of flow volume loop

Fig 3
28. How ABG analysis will help in this patient ?

• Arterial blood gas data such as PaO2 less than 60 mm Hg or PaCO2 greater than
45 mm Hg have been used as cut off values for pulmonary resection
• It also helps in pre operative preparation and deciding about post operative care
regarding supplemental oxygenation / mechanical ventilation as per Nunn and
Milledge classification.

32. What is the importance of VO2 max , 6 min walk test and stairs climbing ?

• Formal laboratory exercise testing is currently the “gold standard” for assessment
of cardiopulmonary function, and the maximal oxygen consumption (VO2max) is
the most useful predictor of post-thoracotomy outcome.
• The risk of morbidity and mortality is unacceptably high if the preoperative
VO2max is less than 15 mL/kg/min.
• Post resection exercise capacity can be estimated based on the amount of
functioning lung tissue removed . An estimated ppoVO2max less than 10
mL/kg/min may be an absolute contraindication to pulmonary resection.
(mortality 100%)

• The distance that a patient can walk during a 6-minute walk test (6MWT) also
shows an excellent correlation with VO2max and requires little or no laboratory
equipment.
 • A 6MWT distance of less than 2000 ft (610 m) correlates to a VO2max less than
15 mL/kg/min
• Stair climbing is done at the patient's own pace but without stopping and is
usually documented as a certain number of flights.
• There is no exact definition for a “flight,” but 20 steps at 6 inches /step is a
frequent value.

PERFORMANCE VO2 MAX INTERPRETATION

EQUIVALENT
> 5 FLIGHT OF STAIRS > 20 ml/kg/min FEV1 >2L – low mortality
after pnuemonectomy

>3 FLIGHT OF STAIRS >15 ml/kg /min FEV1 of 1.7l – low mortality
after lobectomy

<2 FLIGHT OF STAIRS <12ml/kg/min Correlates with high mortality

< 1 FLIGHT OF STAIRS <10ml/kg/min

6min walk test 610m 15ml/kg/min

Table 11

36. How do you prepare this patient for surgery ?

RESPIRATORY PREPARATION MANEUVERS

1. Abstinence from smoking :

- cessation for > 4-8wks - ↓incidence of postop
complications
- 12-48hrs ↓ COHb concentration - ↑O2 carrying
capacity & ODC shifted back to right.

Beneficial effects of smoking cessation & time course

TIME COURSE BENEFICIAL EFFECT

12 – 24 hr ↓ CO & nicotine levels

48 – 72 hr COHb levels normalized , ciliary
fuction improves

1-2 wk ↓ sputum production

4 – 6 wk PFT’S improve

6 -8 wk Immune function & metabolism

normalizes

8 – 12 wk ↓ overall postop morbidity & mortality

Table 12

2. DILATING AIRWAYS
[Link] & sympathomimetics
b. Parasympatholytics
c. PDE inhibitors
Aminophylline –
Loading dose 5 mg/kg
Smokers 7mg/kg( smokers require increased doses as there will be
hepatic microenzyme induction and hence increased metabolism)
Under GA reduce by 2mg/kg( under GA there is a reduction in the hepatic
blood flow and hence decreased requirement.)
Infusion – 0.5 mg/kg/hr
Smokers -- 0.7 mg/kg /hr
Under GA reduce by 0.2mg/kg/hr

Therapeutic concentration 10-20 mg/L

ADVANTAGES :
 Stimulates respiratory centre and improves respiration.
 Increases the contractility of the diaphragm
 Direct bronchodilatory effect
 Bronchodilatation through PDE inhibition and
increasing cAMP and also by increasing the endogenous catecholamine levels
by anti adenosine effect
 Improves the inotropy of the heart and decreases the
peripheral vascular resistance, thereby improves the cardiac output and decreases
the dead space.

DISADVANTAGES :
 By increasing the endogenous catecholamine levels by anti adenosine effect,
increases the automaticity of the heart and increases the incidence of
dysrhythmias.
  Interacts with halothane producing cardiac dysrhythmias . Halothane can be
safely used 4 hours after the last dose of aminophylline.
 Aminophylline is not routinely used as a bronchodilator nowadays due to its
dysrhythmogenic effect.

d. Steroids
e. Cromolyn sodium as a prophylactic drug.

3. LOOSEN SECRETIONS
a. Mucolytics : N- acetyl cysteine
potassium iodide
b. Airway hydration
c. Humidification by ultrasonic nebulizers
d. Systemic hydration to correct hypovolemia &
electrolyte imbalance

4. REMOVING SECRETIONS
a. Postural drainage
b. Coughing
c. Chest percussion & vibration
d. Forced expiration technique

5. ADJUNCT MEDICATIONS
a. Antibiotics after culture & sensitivity
b. Antacids – H2 blockers or proton pump
inhibitors’s – if symptomatic reflux is present .

6 . MEASURES TO ↑ MOTIVATION
a. Psychological preparation
b. Preop pulmonary care training
-incentive spirometry
-secretion removal maneuver
c. Pre op excercises
[Link] loss/gain
e. Stabilize other medical problems

Fig.6 Schematic representation of two-lung ventilation versus one-lung ventilation (OLV).

49. What drugs are used for premedication before lung surgeries?

• On the day before surgery

– Anxiolytics
– H2 receptor blockers
– Continue bronchodilator nebulization
 – Continue steroids

• On the day of surgery

– Steroid supplementation : if the patient is on steroids before.
1. For minor surgery 100mg hydrocortisone IV one hour before
induction and 100 mg infusion over 24 hours
2. For major surgery 100 mg one hour before induction and 100mg
8th hourly for 48 hours .
– Bronchodilators : 2 puffs of inhalations before shifting onto the operating
table . The same bronchodilator device to be kept near the patient for use
during surgery if required.
– Opioids : Long acting drugs like morphine to be avoided as they produce
post operative respiratory depression.
Short acting drugs like fentanyl 1-2 ug/kg body weight given
intravenously before induction.
– Benzodiazepines : Diazepam 10 mg oral previous night
Midazolam 0.01 to 0.05 mg/kg IV
before induction
– Anticholinergics : to be avoided as they increase the viscosity of the
secretions and also increase the dead space. They may also produce
unwanted tachycardia and dry mouth.

Type of anesthesia
The type of anesthesia and neuromuscular blockade affect the incidence of postoperative
pulmonary complications. Intermediate- and shorter-acting agents (eg, vecuronium,
rocuronium) are preferred, because residual neuromuscular blockade from longer-acting
agents may contribute to pulmonary complications.
Spinal or epidural anesthesia in combination with general anesthesia is associated with
less postoperative respiratory depression, but no difference in the incidence of
postoperative pneumonia, compared with general anesthesia alone. Adjunctive neuraxial
anesthesia should therefore be considered for high-risk patients. Depending on the type
and duration of surgery, endotracheal intubation and mechanical ventilation may be
preferable because of the ability to monitor and control the respiratory rate and tidal
volume.

50. What induction agents are used and their advantages and disadvantages ?

PROPOFOL
Advantages :
• Rapid onset
• Airway reflexes obtunded
• Direct bronchodilator
• Reduces post op nausea and vomiting
• Antiarrhythmic
• Suppression of intubation responses
Dis advantages:
  Pain on injection
 Hypotension
 Bradycardia

KETAMINE
Advantages :
 Profound analgesia
 Good bronchodilator
 Maintains HR ,BP
 Decreases post op shivering

Disadvantages:
 Increased secretions
 Airway reflexes exaggerated
 Emergence delirium
 Hypertension, tachycardia.
 Increased systemic and pulmonary vascular resistance,
increased O2 demand by the myocardium worsening the
coronary artery disease
 Dysrhythmias

THIOPENTONE SODIUM
Advantages :
• Rapid onset
• No pain on injection
• Cost effective

Disadvantages:
 Sensitises airways ( bronchospasm) under lighter planes of
anaesthesia
 No bronchodilatation
 Hypotension
 No supression of intubation response

Inhalational induction

Used in children and in patients with difficult airway.

Potent inhalational anaesthetics may prevent development of bronchospasm by

– Blocking airway reflexes
– Direct relaxation of smooth muscles of airway
– Inhibition of mediator release
Halothane and sevoflurane are preferred

51. What are the monitors used for this patient?

Non invasive monitors -
 Pulse oximetry, ECG, end tidal CO2, NIBP, temperature,and neuromuscular monitoring.
Invasive monitoring –
direct arterial line, central venous pressure and transoesophageal echocardiography may
be required in major surgeries in patients with cardiovascular compromise

52. How do you ventilate this patient?

Ventilatory Strategy:
 Aim: Maximise alveolar gas emptying
Minismise dynamic hyperinflation, iPEEP
 Settings:
 Decrease minute vent Low frequency
 Adequate Exp time,
 Reduce exp flow resistance
 Recruitment maneuvers
 Acceptance of mild hypercapnia & acidemia
 Humidification of gases
 Pressure Controlled mode with decelerating flow.

PARAMETERS SUGGESTED GUIDELINES/EXCEPTIONS

TIDAL VOLUME 5 – 6 ml/kg Maintain peak airway pressure

<35cmH2O
Plateau pressure< 25 cm of H20

PEEP 5cm of H2 O With COPD, not added

RR 12 bpm Maintain normal PaCO2 (30-40 mm hg)

MODE VCV/PCV PCV for patients with risk of lung injury

( bullae, spontaneous pneumothorax)

Table 16

53. Methods of perioperative fluid management for this patient

• Total positive fluid balance in first 24hr peri-op period should not exceed 20ml/kg
• Average adult patient – crystalloid administration should be limited to < 3lts in
first 24 hr
• There should be no fluid administration for 3rd space loss during resection
• Urine output > 0.5ml/kg/hr is unnecessary
 • If increased tissue perfusion is needed postoperatively, it is preferable to use
invasive monitoring & ionotropes rather than to cause overload

54. Use of N2O in the peri opeartive period

• The use of N2O/O2 mixtures is associated with a higher incidence of post-

thoracotomy radiographic atelectasis (51%) in the dependent lung than when
air/oxygen mixtures are used (24%).
• Nitrous oxide also tends to increase pulmonary artery pressures in patients who
have pulmonary hypertension,[
• N2O inhibits HPV
• N2O is contraindicated in patients with blebs or bullae.
• For these reasons N2O is usually avoided during thoracic anesthesia.

55. How do you diagnose and manage peri operative bronchospasm?

Sudden increase in resistance to ventilation or peak inspiratory pressure on
ventilator

Management – cut off N2O,

- give 100% O2
- deepening the anaesthesia with volatile agents and
muscle relaxant top up dose

If bronchospasm persists institution of bronchodilator therapy

• Subcutaneous terbutaline
• Corticosteroids
• Xanthines
• Inj Lignocaine
• Ketamine infusion
• MgSO4
Postoperative Strategies
Lung expansion maneuvers
Lung expansion maneuvers include incentive spirometry, deep breathing exercises,
postural drainage, percussion and vibration, cough, suctioning, mobilization, intermittent
positive pressure breathing (IPPB), and CPAP. A meta-analysis of 48 trials suggested that
the routine use of incentive spirometry provides no benefit following abdominal and
cardiac surgery. No conclusions could be reached concerning the use of incentive
spirometry following thoracic surgery, as none of the studies addressing that question met
the quality criteria for inclusion in this review.
A recent preintervention/postintervention trial attributed a significant reduction in
postoperative complications following thoracotomy to the introduction of a perioperative
chest physiotherapy program (consisting of bicycle or treadmill exercise, cough and deep
breathing maneuvers, and upper extremity exercise), although this result may not be
generalizable as the nursing ratio was 1:12 at the study institution during the course of the
trial. High-frequency chest wall oscillation (with use of a percussive vest every 8 h)
resulted in a more rapid improvement in pulmonary function and better oxygenation than
chest physiotherapy (performed every 6 h) in patients who had undergone pulmonary
resection for lung cancer.
In most of the studies that were included in the large meta-analysis, incentive spirometry
was compared to some other lung expansion modality rather than to no therapy. Among
those studies with a control group, some demonstrated a reduction in complications with
incentive spirometry, and others did not. These conflicting results may be due to
disparities in patient populations, as incentive spirometry and other lung expansion
maneuvers appear to be effective in higher risk patients.
Comparisons between modalities suggest that most are equally effective in reducing the
risk of complications in such patients. For example, early mobilization was equivalent to
early mobilization plus either incentive spirometry or deep breathing following cardiac
surgery. Incentive spirometry, deep breathing, and IPPB were equivalent, and superior to
no treatment, following abdominal surgery.
Studies suggest that CPAP is the most effective lung expansion maneuver. A notable
benefit of this modality is that it does not require patient cooperation or effort.
Disadvantages include higher cost and greater risk of adverse events. CPAP administered
for 12-24 hours following thoracoabdominal aortic aneurysm repair reduced pulmonary
complications, compared with intermittent CPAP [Link] chest physical therapy and
early ambulation were employed in all patients. Prophylactic use of continuous positive
airway pressure (CPAP) or noninvasive positive-pressure ventilation (NIPPV) has been
shown to decrease postoperative complications in patients following cardiac surgery,
lung resection, and esophagectomy.
In conclusion, lung expansion maneuvers, aside from early mobilization, may not be
required in most patients. Other methods are likely equivalent in moderate- and high-risk
patients, so selection should focus on cost, availability, and expertise. CPAP may be
targeted to high-risk patients, particularly those who are not able to cooperate with other
modalities. Preoperative initiation and/or patient education improve the efficacy of these
maneuvers.
Pain control
Pain is a highly complex process involving specialized nociceptor fibers in the peripheral
tissues; neurotransmitters and neuromodulators at all levels of neuraxis; integration of
information in central nervous system; and learned behavior, affect, and cognitive status.
Adequate postoperative pain control helps minimize pulmonary complications by
encouraging earlier ambulation and performance of lung expansion maneuvers.
Management of postoperative pain includes administration of opioid and/or anesthetic
agents into the intrathecal, epidural, or paravertebral space, or in proximity to intercostal
nerves. Intrathecal administration of narcotics is associated with a longer duration of
analgesia (15-22 h), respiratory depression, and headaches. Paravertebral blocks may be
associated with fewer pulmonary complications than epidural analgesia. Intercostal nerve
blocks have been shown to be beneficial in upper abdominal, as well as thoracic, surgery.
Some studies have popularized the use of epidural analgesia as an alternative to
parenteral narcotics. In upper abdominal procedures, patients who received epidural
analgesia had lower rates of pulmonary complications and a shorter duration of hospital
stay. Epidural catheters can be used for patients undergoing thoracic or upper abdominal
surgery by placing the catheter at the thoracic vertebral level. Epidural narcotics provide
a longer duration of action, a lack of excessive sedation and respiratory depression, and a
minimum of or no sensory motor loss. The addition of a local anesthetic provides a more
rapid onset of action and may help localize correct catheter placement; however,
hypotension and motor blockade are potential adverse effects.
Epidural narcotics are morphine, fentanyl, sufentanil, and hydroxymorphine; the local
anesthetics used for epidural analgesia are bupivacaine and ropivacaine. Adding small
doses of local anesthetics to narcotics is a preferred approach. This potentiates pain relief,
minimizes nerve blockade, and reduces adverse effects from both agents. Postoperative
epidural analgesia and intercostal nerve blocks improve pain control and help reduce
postoperative complications, with little risk.
Cuschieri et al reported a postoperative pulmonary complication rate of 24% in
postoperative patients receiving epidural analgesia, compared with a rate of 64% in those
randomized to receive intramuscular morphine. Results from other studies provide
conflicting results, with one possible conclusion being that patient-controlled analgesia
and epidural analgesia are both superior to on-demand analgesia. A recent meta-analysis
supports this conclusion, but also indicates a decreased incidence of pneumonia and
respiratory failure among patients receiving epidural analgesia following thoracic or
abdominal surgery.
Epidural hematoma is a rare complication, except when concomitant anticoagulation is
prescribed. Epidural hematomas have been reported in patients receiving low molecular
weight heparin (LMWH) who had epidural catheters. Warnings have been issued on this
issue by the national advisory panels. A safe practice is to not place the epidural catheter
for at least 12 hours after the last dose of LMWH.
Perioperative use of nonsteroidal anti-inflammatory drugs (NSAIDs) may complement
other pain management strategies. Nonsteroidal agents are known to decrease the narcotic
requirement in the postoperative period. The agent ketorolac may be administered
intramuscularly as needed. Other nonsteroidal agents are given orally or rectally. Caution
is advised in patients at risk for bleeding, with a history of peptic ulcer disease, and
established renal dysfunction.
Fast track protocol
A fast track regimen that included early mobilization and enteral feeding and epidural (vs.
intercostal) analgesia resulted in fewer postoperative pulmonary complications,
specifically atelectasis and pneumonia, than standard care.
Glycemic control
Glycemic control was associated with a reduced duration of mechanical ventilation in a
mixed medical-surgical population, but the impact of this intervention specifically on
postoperative pulmonary complications is unclear. Additionally, the optimal blood
glucose target range remains a matter of debate.
Nasogastric decompression
Routine use of nasogastric tubes until bowel function returns following abdominal
surgery is associated with higher rates of pneumonia and atelectasis relative to selective
use of nasogastric tubes in patients who develop postoperative nausea or vomiting,
inability to tolerate oral intake, or symptomatic abdominal distention. Selective
nasogastric use was associated with a shorter time to oral intake without an increase in
the risk of aspiration.
Total parenteral nutrition
Although poor nutrition is a risk factor for postoperative pulmonary complications, the
routine use of total parenteral nutrition demonstrates no benefit over total enteral nutrition
or no hyperalimentation, except perhaps in patients with severe malnutrition (>10%
weight loss over 6 mo) or prolonged (10-14 d) inadequate enteral feeding.
Postanesthesia care unit monitoring
Identification of postanesthesia care unit events (bradypnea, apnea, desaturation, or
pain/sedation mismatch) is a better predictor of subsequent pulmonary complications than
a multivariable clinical score in patients with obstructive sleep apnea.
Prevention of thromboembolism
Although not technically considered a postoperative pulmonary complication, brief
mention should be made of venous thromboembolic disease (VTE). Surgery is a well-
recognized risk factor for the development of deep vein thrombosis and subsequent
pulmonary embolism. Much as postoperative pulmonary complications, the risk of VTE
is influenced by patient- and procedure-related factors. Risk assessment and
recommendations for prevention of VTE in surgical patients (stratified by orthopedic and
nonorthopedic) are revised annually. .
Summary
The following postoperative measures help minimize pulmonary complications in at-risk
patients:
 Early mobilization
 Lung expansion maneuvers - Consider CPAP in high-risk patients
 Adequate pain control - Consider epidural analgesia in at-risk patients
 Selective use of nasogastric decompression and total parenteral nutrition
 DVT prophylaxis

60. How do you provide post operative analgesia ?

• 1. SYSTEMIC ANALGESIA
a. opioids
– Intermittent IM /IV
- continuous IV infusion
- subcutaneous infusions
- PCA
- Transdermal fentanyl & sufentanil
- sublingual buprenorphine

b. NSAIDs –Acetaminophen – 4g/day

orally/rectally

c. ketamine – low dose IM or 1mg/kg IV

IV infusion
[Link] 2 agonists -Dexmedetomidine 0.3-0.7µg/kg/hr
Clonidine - 150µg IV infusion

2. INTRAPLEURAL ANALGESIA
 - produce multi-level intercostal block
- less reliable

3. TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION

4. CRYOANALGESIA
- -20 ͦc – degeneration of nerve axons
5. EPIDURAL ANALGESIA
- Thoracic epidural T3 – T8
- Bupivacaine
- Opiates combined with LA
- Fentanyl, dimorphine, sufentanil,
morphine are effective
- Bupivacaine – 0.0625 – 0.125%
- Morphine – 0.05-0.1mg/ml
- Fentanyl – 2µg/ml
- Mixed agonist/antagonist like
butorphanol, buprenorphine & nalbuphine also used

6. PARAVERTEBRAL BLOCK
- catheter can be placed in the paravertebral space either percutaneously or
by direct when chest is open

61. what are the common post operative complications?

1. PULMONARY COMPLICATIONS
• Infections – atelectasis, pnuemonia, empyema & mediastinitis
• Pnuemothorax & tension pneumothorax
• Postpnuemonetomy pulmonary edema
• Torsion of residual lobe
• Postop respiratory failure
[Link] COMPLICATIONS
• Right sided heart failure
• Dysrhythmias
• Right – left shunting through foramen ovale
• Myocardial ischemia & infarction
• Postop hypertension
• Herniation of heart
3. ANATOMICAL STRUCTURE INJURIES
• Phrenic nerve injury
• Recurrent laryngeal nerve
• Spinal cord
• Brachial plexus
• Thoracic duct
• Injuries related to lateral decubitus position
4. WOUND INFECTION & SEPSIS
61. What are the causes of post operative hypoxemia ?

1. Diffusion hypoxia or Fink effect

2. Increased V/Q mismatch – anaesthesia produces a reduction in FRC as a result of
decrease in the tone of the diaphragm and diaphragm rests high in the thorax due
to relative increase in the intra abdominal pressure. The consequences of this are
more in the elderly and smokers. There is an increase in closing capacity which
will be higher than FRC which increases intrapulmonary shunt.
3. Reduced cardiac output – causes decrease in the oxygen fluxwhich may be
insufficient to meet the patient’s O2 demand especially if he is shivering. The fall
in mixed venous PO2will then produce a fall in arterial PO2 with further
reduction in O2 flux. The situation will be made worse if the patient is anaemic as
well.
4. Hypoventilation
(a) Drugs – most anaesthetic drugs depress ventilation. The residual effects of
premedicnts, induction agents, maintainance agents, and analgesics can
produce post op hypoventilation .Opioids and muscle relaxants are the
most common causes of drugs causing post op hypoventilation .
(b) Obstruction - Partial respiratory obstruction in the post op period is often
not recognized immediately.
(c) Pain – may prevent from deep breathing and also from coughing. This
causes both hypoventilation as well as atelectasis and collapse of the
alveoli.
(d) Intra operative hyperventilation – producing considerable total body
deficit of CO2 producing hypoventilation when patient is made to breath
spontaneously.
(e) Tight abdominal binders after abdominal surgeries.

References -