9. anaesthesia for copd

8/10/2019 9. Anaesthesia for COPD

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Anaesthesia for Patientswith COPD

Teresa Gabriella Laurauli

Damar Nirwan Alby

Erika Agustina Kasdjono


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COPD:

PATHOPHYSIOLOGY,

DIAGNOSIS, TREATMENT


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Chronic Obstructive Pulmonary Disease

Definition:

Disease state characterised by airflow

limitation that is not fully reversible

The airflow limitation is usually

progressive and is associated with an

abnormal inflammatory response of

the lungs to noxious particles orgases, primarily caused by cigarette

smoking.


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Chronic Obstructive Pulmonary Disease

Definition:

Disease state characterised byairflow

limitation that is not fully reversible

The airflow limitation is usually

progressiveand is associated with an

abnormal inflammatory response of

the lungs to noxious particles orgases, primarily caused by cigarette

smoking.


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COPD:


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COPD

Chronic Bronchitis:(ClinicalDefinition)

Chronic productive cough for 3

months in each of 2 successive yearsin a patient in whom other causes ofproductive chronic cough have beenexcluded.

Emphysema: (Pathological Definition) The presence of permanent

enlargement of theairspaces distal to

the terminal bronchioles, accompanied


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Comparative features of COPD

Feature Chronic Bronchitis Empysema

Mech of Airway

Obstruction

Decreased Lumen d/t

mucus &

inflammation

Loss of elastic recoil

Dysnoea Moderate Severe

FEV1 Decreased Decreased

PaO2 Marked Decrease

(Blue Bloater)

Modest Decrease

(Pink Puffer)

PaCO2 Increased Normal or Decreased

Diffusing capacity Normal Decreased

Hematocrit Increased Normal

Cor Pulmonale Marked Mild

Prognosis Poor Good


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COPD: Risk factors

Host factos:Genetic factors: Eg. 1 Antitrypsin Deficiency

Sex : Prevalence more in males.

?Females more susceptible

Airway hyperactivity,

Immunoglobulin E and asthma

Exposures:

Smoking: Most Important Risk Factor

Socioeconomic statusOccupation

Environmental pollution

Perinatal events and childhood illness

Recurrent bronchopulmonary infections

Diet


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Natural History:

Fig. 1. - The normal course of forced expiratory volume in one second (FEV1) over time

is compared with the result of impaired growth of lung function () an accelerated de

() and a shortened plateau phase (). All three abnormalities can be combined

(Kerstjens HAM, Rijcken B, Schouten JP, Postma DS. Decline of FEV1 by age and

smoking status: facts, figures, and fallacies. Thorax 1997; 52: 820827.)


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Pathophysiology:

Pathological changes are seen in 4major compartments of lungs:

central airways

Peripheral airways

lung parenchyma

pulmonary vasculature.


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Pathogenesis:Tobacco smoke & other

noxious gases

Inflammatoryresponse in

airways

Tissue DestructionImpaired defense against tissue

destruction

Impaired repair mechanisms

Proteinase & Antiproteinase

imbalance

Oxidative

Stress

Alpha 1

antitrypsindef.


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Physiological Effects:

Mucous hypersecretion and cilliary dysfunction Goblet cell hyperplasia & squamous metaplasia

Airflow limitation and hyperinflation Airway remodelling

Loss of eleastic recoil

Destruction of alveolar supports

Accumulation of mucus, inflammatory cells & exudate

Gas exchange abnormalities:(Hypoxemia +/-Hypercapnia)

Abnormal V/Q ratios

Abnormal DLCO Pulmonary hypertension

Hypoxic Vasoconstrictoin,Endothelial dysfunction

Remodelling of arteries & capillary destruction

Systemic effects


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Diagnosi

sClinical Features:

Symptoms:Cough: Initially intermittent

Present throughout the day

Sputum:

Tenacious & mucoidPurulentInfection

Dyspnoea: Progressively worsens

Persistant

Exposure: Smoking, in pack years

Physical Examinat ion :

Respiratory SignsBarrel Chest

Pursed lip breathing

Adventitious Ronchi/Wheez

Systemic SignsCyanosis

Neck vein enlargement

Peripheral edema

Liver enlargement

Loss of muscle mass


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Investigations:SpirometryDiagnosis

Assessment of severity

Following progress

Chest Radiograph: To exclude other

diseasesEmphysematous changes

Bronchodilator ReversibilityExclude Bronchial Asthma


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GOLD ClassificationStage Characteristics

I: Mild FEV1/FVC < 70%

FEV180% predicted, with/without chronic symptoms

II: Moderate FEV1/FVC < 70%

50% FEV180% predicted, with/without chronic

symptoms

III: Severe FEV1/FVC < 70%

30% FEV150% predicted, with/without chronic

symptoms

IV: Verysevere FEV1/FVC < 70%FEV1< 30% predicted or < 50% predicted plus chronic

respiratory failure (PaO2< 60mm Hg &/or PaCO2>

50mm Hg)


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Treatment

Modifying natural history of Disease: Smoking cessation

Long term oxygen therapy

Symptomatic: Bronchodilators

Antibiotics

Others

Pulmonary Rehabilitation

Nutrition


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Treatment: Smoking Cessation

Need: Most important cause

of COPD

Major risk factor foratherosclerotic

vascular disease,cancer, peptic ulcerand osteoporosis.

Quitting smokingslows progressive lossof lung function &reduces symptoms

Motivation,Counselling &behaviouralsupport

Nicotinereplacement Patches

chewing gum

Inhaler nasal spray

lozenges

Bupriopion


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Effect of smoking and smoking

cessation on Lung Function:

Loss of lung function over 11 yrs in the Lung Health Study for continuous smokers

(), intermittent quitters ()and sustained quitters (). FEV1: forced expiratory

volume in one second

(Anthonisen NR et al,Lung Health Study Research Group.

Smoking and lung function of Lung Health Study participants after 11 years.Am J Resp

Care Med 2002; 166: 675

679.


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Treatment: Oxygen Therapy

Long Term Oxygen Therapy(LTOT):

Improves survival, exercise, sleep and

cognitive performance.

Oxygen delivery methods include nasalcontinuous flow, reservoir cannulas and

transtracheal catheter.

Physiological indications for oxygen

include an arterial oxygen tension (PaO2)90% during rest,

sleep and exertion.


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Physiological indications for long-term oxygen therapy

(LTOT)

PaO2 mmHg SaO2 % LTOT ind icat ion Qual i fy ingcond i t ion

55 88 Absolute None

5559 89 Relative with qualifier P Pulmonale,polycythemia >55%

History of edema

60 90 None except with qualifier Exercise

desaturation

Sleep desaturation

not corrected by CPAP

Lung disease with

severe dyspnea

responding to O2


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Treatment: Symptomatic Measures

Bronchodilators: Anticholinergics

Beta Agonists

Methylxanthines

Corticosteroids N-Acetyl Cysteine

1 Antitrypsinaugmentation

Vaccination Others: No proven

effect Leukotriene receptor

antagonists/cromones

Maintenanceantibiotic therapy

Immunoregulators

Vasodilators: NO,CCB


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Surgical Treatment

Bullectomy short-term improvements in

airflow obstruction

lung volumes

hypoxaemia and hypercapnia

exercise capacity dyspnoea

Lung Volume Reduction Surgery potentially long-term improvement in survival

short-term improvements in

Spirometry lung volumes

exercise tolerance

dyspnoea

Lung Transplantation


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COPD: Exacerbations

Definition:An exacerbation of COPD is an event in the

natural course of the disease characterised

by a change in the patients baselinedyspnoea, cough and/or sputum beyond

day-to-day variability sufficient to warrant a

change in management.

Precipitating Causes:

Infections: Bacterial, Viral

Air pollution exposure

Non compliance with LTOT


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COPD: ExacerbationsIndication for Hospitalisation:

The presence of high-risk comorbidconditions

pneumonia,

cardiac arrhythmia,

congestive heart failure,

diabetes mellitus,

renal or liver failure

Inadequate response to outpatientmanagement

Marked increase in dyspnoea, orthopnoea

Worsening hypoxaemia & hypercapnia

Changes in mental status


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COPD: Exacerbations

Indication for ICU admission: Impending or actual respiratory failure

Presence of other end-organ dysfunction

shock renal failure

liver failure

neurological disturbance

Haemodynamic instability


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Treatment Supplemental Oxygen (if SPO2< 90%)

Bronchodilators: Nebulised Beta Agonists,

Ipratropium with spacer/MDI

Corticosteroids Inhaled, Oral

Antibiotics: If change in sputum characteristics

Based on local antibiotic resistance

Amoxycillin/Clavulamate, Respiratory Flouroquinolones

Ventillatory support: NIV, Invasive ventillation


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Optimal disease management entails redesigning standard medical care to integrate rehabilitative elem

into a system of patient self-management and regular exercise

In a nutshell


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. PREPARATION

FOR ANAESTHESIA


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Anaesthetic Considerations in patients

with COPD undergoing surgery:

Patient Factors:Advanced age Poor general condition, nutritional status Co morbid conditions

HTN

Diabetes

Heart Disease

Obesity

Sleep Apnea

Weak HPV, blunted Ventilatoryresponses to hypoxia and CO2retention


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Age Related Pulmonary Changes:

Pathological

changes

Effect Implications

Decreased efficiency

of lung parenchyma

Decreased VC

Increased RV

Respiratory Failure

Decreased Muscle

strength

Decreased

Compliance, FEV1

Poor cough

Infection

Alveolar septaldestruction

Decreased alveolararea

Decreased gasexchange

Brohchiolar damage Increased closing

volume

Air trapping

Decreased PaO2

Dilated upper airways Increased VD Decreased gasexchange

Decreased reactivity Decreased laryngeal

reflexes

Decreased vent

response to hypoxia,

Increased Aspiration

Increased resp. failure


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Problems due to Disease Exacerbation of Bronchial inflammation

d/t Airway instrumentation

preoperative airway infection

surgery induced immunosuppression

increased WOB

Increased post operative pulmonarycomplications


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Problems due to Anaesthesia: GA decreases lung volumes, promotes V/Q

mismatch

FRC reduced during anaesthesia, CC parallelsFRC

Anaesthetic drugs blunt Ventilatory responses tohypoxia & CO2

Postoperative Atelectasis & hypoxemia

Postoperative pain limits coughing & lungexpansion

Problems due to Surgery: Site : most important predictor of Post op

complications

Duration: > 3 hours

Position


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Pre-operative assessment:

History:

Smoking Cough: Type, Progression, Recent RTI

Sputum: Quantity, color, blood

Dyspnea

Exercise intolerance

Occupation, Allergies

Symptoms of cardiac or respiratory failure


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Pre-operative assessment: Examination

Physical Examination: Better at assessing chance of postop complications

Airway obstruction hyperinflation of chest, Barrel chest

Decreased breath sounds

Expiratory ronchi

Prolonged expiration: Watch & Stethoscope test, >4 sec

WOB RR, HR

Accessory muscles used

Tracheal tug

Intercostal indrawing

Tripod sitting posture


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Body HabitusObesity/ Malnourished

Active infection

Sputum- change in quantity,

nature Fever

Crepitations

Respiratory failureHypercapniaHypoxia

Cyanosis

Cor Pulmonale and Rightheart failure

Dependant edema

tender enlarged liver

Pulmonary hypertensionLoud P2Right Parasternal heave

Tricuspid regurgitation

Pre-operative assessment: Examination


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Preoperative Assessment: Investigations

Complete Blood count Serum Electrolytes

Blood Sugar

Urinalysis

ECG Arterial Blood Gases

Diagnostic Radiology Chest X Ray

Spiral CT

Preoperative Pulmonary Function Tests Tool for optimisation of pre-op lung function

Not to assess risk of post op pulmonary complications


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Investigations: Chest X-Ray

Overinflation

Depression or flattening ofdiaphragm

Increase in length of lung

size of retrosternal airspace

lung markings- dirty lung Bullae +/-

Vertical Cardiac silhouette

transverse diameter of chest,

ribs horizontal, square chest

Enlarged pulmonary artery with

rapid tapering in MZ

P l F ti T t


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Pulmonary Function Tests:

Measureme

nt

Normal Obstructive Restrictive

FVC (L) 80% of TLC

(4800)

FEV1(L) 80% of FVC

FEV1/FVC(%) 75- 85% N to N to

FEV25%-

75%(L/sec)

4-5 L/ sec

N to

PEF(L/sec)

450- 700 L/min

N to

Slope of FV

curve

MVV(L/min)

160-180 L/min N to

TLC

6000 ml N to

RV

1500 mL

RV/TLC(%)

0.25

N


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FEV1

FEV1

FVC

seconds21 3 4 5

0

1

2

3

4

Litres

5

COPD

NORMAL

60%39002350COPD

80%52004150Normal

FEV1/FVCFVCFEV1

FVC

Spirometric tracing in COPD patients


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Maximum inspiratory and expiratory flow-volume

curves (i.e., flow-volume loops) in four types of airway

obstruction.


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Preoperative Assessment: InvestigationsECG

Signs of RVH: RAD

p Pulmonale in Lead II

Predominant R wave in V1-3

RS pattern in precordial leads

Arterial Blood Gases:

In moderate-severe disease

Nocturnal sample in cor Pulmonale

Increased PaCO2is prognostic marker Strong predictor of potential intra op respiratory failure &

post op Ventilatory failure

Also, increased d/t post op pain, shivering, fever,respiratorydepressants


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Pre-operative preparation

Cessation of smoking

Dilation of airways

Loosening & Removal of secretions

Eradication of infection

Recognition of Cor Pulmonale and treatment Improve strength of skeletal muscles

nutrition, exercise

Correct electrolyte imbalance

Familiarization with respiratory therapy,education, motivation & facilitation of patientcare


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Effects of smoking:

Cardiac Effects: Risk factor for development of cardiovascular disease

CO decreases Oxygen delivery & increases myocardialwork

Catecholamine release, coronary vasoconstriction

Decreased exercise capacity

Respiratory Effects: Major risk factor for COPD

Decreased Mucociliary activity

Hyperreactive airways

Decreased Pulmonary immune function Other Systems

Impairs wound healing


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Dilatation of Airways:

Bronchodilators: Only small increase in FEV1

Alleviate symptoms by decreasing

hyperinflation & dyspnoea

Improve exercise tolerance

Anticholinergics

Beta Agonists

Methylxanthines


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Anticholinergics:

Block muscarinic receptors Onset of action within 30 Min Ipratropium

40-80 g by inhalation 20 g/ puff2 puffs X 3-4 times 250 g / ml respirator soln. 0.4- 2 ml X 4

times daily

Tiotropium - long lasting Side Effects:

Dry Mouth, metallic taste Caution in Prostatism & Glaucoma


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Beta Blockers:

Act by increasing cAMP Specific 2agonist

Salbutamol : oral 2-4 mg/ 0.250.5 mg i.m /s.c 100-200 g

inhalation

muscle tremors, palpitations, throat irritation

Terbutaline : oral 5 mg/ 0.25 mg s.c./ 250 g inhalation

Salmeterol : Long acting (12 hrs) 50 g BD- 200 g BD

Formeterol, Bambuterol


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I h l d C ti t id


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Inhaled Corticosteroids:

Anti-inflammatory

Restore responsiveness to 2agonist Reduce severity and frequency of

exacerbations

Do not alter rate of decline of FEV1 Beclomethasone, Budesonide, Fluticasone

Dose: 200 g BD upto 400 g QID

> 1600 g / day- suppression of HPA axis


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. ANAESTHETICTECHNIQUE


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Anaesthetic Technique

COPD is not a limitation on the choiceof anaesthesia.

Type of Anaesthesia doesnt predictably

influence Post op pulmonarycomplications.


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Concerns in RANeuraxial Techniques:

No significant effect on Resp function: Level above T6 not

recommended

No interference with airway Avoids bronchospasm

No swings in intrathoracic pressure

No danger of pneumothorax from N2OSedation reqd. May compromise expiratory fn.

Peripheral Nerve Blocks:

Suitable for peripheral limb surgeriesMinimal respiratory effects

Supraclavicular techniques contraindicated in severe

Pulmonary disease


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Concerns in RA

Improved Surgical outcome:

Better pain control

Attenuation of neuroedocrine respones to

surgery

Improvement of tissue oxygenationMaintenance of immune function

Fewer episodes of DVT, PE, stroke, blood Tx

Technique of choice in perineal, pelvicextraperitoneal

& lower extremities

No benefit over GA in Intraperitoneal surgery,

or when high levels are needed


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Concerns in GA

Airway instrumentation & bronchospasmResidual NMB

Nitrous Oxide

Attenuation of HPV

Respiratory depression with opioids, BZDs

Airway humidification


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Premedication

Sensitivity to the effect of respiratorydepressants Opioids & Benzodiazepines - response to

hypoxia, hypercarbia

Bronchodilator puff / nebulisation, inhaledsteroids

Atropine ?: Should be individualised Decreases airway resistance

Decreases secretion-induced airway reactivity

Decreases bronchospasm from reflex vagalstimulation

Cause drying of secretions, mucus plugging

General Anaesthesia:


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General Anaesthesia:

Induction

Opioids: Fentanyl(DoC)

Morphine ,Pethidine

Respiratory Depression, Histamine release, Chesttightness

Propofol (DoC)

Better suppression of laryngeal reflexes

Hemodynamic compromise

Agent of choice in stable patient

Ketamine

BronchodilatorCatecholamine release, neuralinhibition

Tachycardia and HT, may increase PVR


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Maintenance

Muscle relaxant

Prefer Vecuronium, Rocuronium, Cisatracurium

Avoid Atracurium, Mivacurium, Doxacurium (histamine release)

Volatile anaesthetic

NOCaution in pulmonary bullae, dilution ofdelivered O2

Inhalational agents attenuate HPV

Sevoflurane: non pungent, bronchodilator Halothane: Non pungent, bronchodilator.

Slower onset & elimination, Sensitises tocatecholamines


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Maintenance

Ventialatory Strategy: Aim: Maximise alveolar gas emptying

Minismise dynamic hyperinflation, iPEEP

Settings:

Decrease minute ventLow frequencyAdequate Exp time, Low I:E ratio, minimal exp

pause

Reduce exp flow resistance

Recruitment maneuvers

Acceptance of mild hypercapnia & acidemia Humidification of gases

Pressure Cycled mode with decelerating flow.


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Management of intraoperative


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Management of intraoperative

bronchospasm

Increase FiO2 Deepen anaesthesia

Commonest cause is surgical stimulation under lightanaesthesia

Incremental dose of Ketamine or Propofol

Relieve mechanical stimulation endotracheal suction

Stop surgery

2agonistsNebulisation or MDI s/c Terbutaline, iv Adrenaline

intravenous Aminophyline Intravenous corticosteroid indicated if severe

bronchospasm


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Reversal/ Recovery: Neostigmine - may provoke bronchospasm

Atropine 1.2-1.8mg or Glycopyrrolate 0.6mg before

Neostigmine

Tracheal toileting

Extubation : deep or awake?

Deep extubation may reduce chance of

bronchospasm

Deep

Difficult airway

Difficult

intubation

Residual NMB

Full stomach

Good airway - accessible

Easy intubation

No Residual NMB

Normothermic

Not at increased risk of

aspiration

NO YE

S


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Post operative care

Risk of Post op pulmonary complications

Postoperative analgesia Parenteral NSAIDS

Neuraxial drugs Nerve blocks

PCA

Postoperative respiratory therapy Chest physiotherapy & postural drainage Voluntary Deep Breathing

Incentive Spirometry


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Post operative care

Mechanical Ventilation: Indications: Severe COPD undergoing major surgery

FEV1/FVC 50mm Hg

FiO2 & Ventillator settings adjusted tomaintain PaO260-100 mm Hg & PaCO2inrange that maintains pH at7.35-7.45

Continue Bronchodilators Oxygen therapy

Lung Expansion maneuvers

Post Operative Pulmonary


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Complications: Incidence: 6.8% (Range 2-19%)

(Sementa et al,Annals of internal Medicine, 2006,144:581

95)

Include:

Atelectasis Bronchopneumonia

Hypoxemia

Respiratory Failure

Bronchopleural fistula

Pleural effusion


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Complications:

Specific Risk Factors: COPD Bronchial Asthma GA OSAAdvanced age Morbid Obesity(BMI > 40) Functional limitation Smoking > 20 Pack yearAlcohol consumption (>60ml

ethanol/day)



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Complications:

Risk Reduction Strategies:

Preoperative:

Smoking cessation

Bronchodilatation

Control infectionsPatient Education

Intraoperative:

Minimally invasive surgery

Regional Anaesthesia

Duration < 3 Hrs

Post operative:

Lung Volume Expansion Maneuvers

Adequate Analgesia



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Complications:

Post Operative Analgesia: Opioids

Paravertebral/Intercostal N Blocks

Epidural Analgesia LA

Opioids

NSAIDSBronchospasm



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Complications:

Lung Expansion maneuvers: Incentive spirometry

Deep breathing exercises

Chest Physiotherapy & posturaldrainage

Intermittant Positive Pressure

Ventilation CPAP, BiPAP

Early Ambulation


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Summary:

COPD is a progressive disease with increasingirreversible airway obstruction.

Cigarette smoking is the most important causativefactor for COPD

Smoking cessation & LTOT are the only measurescapable of altering the natural history of COPD.

COPD is not a contraindication for any particularanaesthsia technique if patients have beenappropriately stabilised.

COPD patients are prone to develop intraoperative andpostoperative pulmonary complications.

Preoperative optimisation should include control ofinfection and wheezing.

Postoperative lung expansion maneuvers and adequatepost op analgesia have been proven to decreaseincidence of post op complications.


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References: StoeltingsAnaesthesia & Coexisting Disease, 5thEd.

Standards for Diagnosis & Management of COPD Patients,American Thoracic Society & European Respiratory Society

Global Initiative for COPD

Refresher course lectures, 57thNational Conference of ISA

COPD: Perioperative management, M.E.J. Anesth 2008 19(6)

Post Operative Pulmonary Complications, IJA April 2006

Periop Management of patients with COPD: Review, IJCOPD 2007:2(4) 493:515

Harrisons Principles of Medicine, 16thEd

Principles of respiratory Care, Egans, 9thEd

Millers Anaesthsia, 7thEd Irwin & RippesIntensive care medicine, 6thEd.

Clinical Application of Mechanical Ventilation, David WChang, 3rdEd


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9. anaesthesia for copd

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