Dr Gerard MeacheryDr Gerard Meachery

  The objectives of the The objectives of the

pre-anaesthetic assessment pre-anaesthetic assessment • Evaluate the patient’s medical condition from medical history, physical Evaluate the patient’s medical condition from medical history, physical

examination, investigations and, when appropriate, past medical recordsexamination, investigations and, when appropriate, past medical records  • Optimise the patient’s medical condition for anaesthesia and surgeryOptimise the patient’s medical condition for anaesthesia and surgery

• Determine and minimise risk factors for anaesthesiaDetermine and minimise risk factors for anaesthesia

• Plan anaesthetic technique and peri-operative carePlan anaesthetic technique and peri-operative care

• Develop a rapport with the patient to reduce anxiety and facilitate conduct of Develop a rapport with the patient to reduce anxiety and facilitate conduct of anaesthesiaanaesthesia

• Inform and educate the patient about anaesthesia, peri-operative care and Inform and educate the patient about anaesthesia, peri-operative care and pain management pain management

• Obtain consent for anaesthesiaObtain consent for anaesthesia

Guidelines on the radical management Guidelines on the radical management of patients with lung cancer of patients with lung cancer

• Lim E, Baldwin D, Beckles M, et al. Thorax 2010, 65 Lim E, Baldwin D, Beckles M, et al. Thorax 2010, 65 Suppl III, iii1-iii27 Suppl III, iii1-iii27

• A joint initiative by the British Thoracic Society and the Society for Cardiothoracic Surgery in Great Britain and Ireland undertaken to update the 2001 guidelines for the selection and assessment of patients with lung cancer who can potentially be managed by radical treatment

Guidelines on the radical management of on the radical management of patients with lung cancer patients with lung cancer

• 2.1.3 Assessment of lung function 2.1.3 Assessment of lung function

• 43. Offer surgical resection to patients with low risk of43. Offer surgical resection to patients with low risk ofpostoperative dyspnoea. [C]postoperative dyspnoea. [C]

• 44. Offer surgical resection to patients at moderate to high risk44. Offer surgical resection to patients at moderate to high riskof postoperative dyspnoea if they are aware of and accept theof postoperative dyspnoea if they are aware of and accept therisks of dyspnoea and associated complications. [D] risks of dyspnoea and associated complications. [D]

• 47. Consider using shuttle walk testing as functional assessment47. Consider using shuttle walk testing as functional assessmentin patients with moderate to high risk of postoperativein patients with moderate to high risk of postoperativedyspnoea using a distance walked of >400 m as a cut-off fordyspnoea using a distance walked of >400 m as a cut-off forgood function. [C]good function. [C]

• 48. Consider cardiopulmonary exercise testing to measure peak48. Consider cardiopulmonary exercise testing to measure peakoxygen consumption as functional assessment in patients withoxygen consumption as functional assessment in patients withmoderate to high risk of postoperative dyspnoea using >15 ml/moderate to high risk of postoperative dyspnoea using >15 ml/kg/min as a cut-off for good function. [D] kg/min as a cut-off for good function. [D]

Guidelines on the radical management of patients with lung cancer

• 49. RR Further studies with specific outcomes are required to define the role of exercise testing in the selection of patients for surgery

• 51. Avoid taking pulmonary function and exercise tests as sole surrogates for quality of life evaluation. [C]

Pulmonary Function TestingPulmonary Function Testing

Categorise PFTs according to specific purposes

Identify at least one indication for spirometry,

lung volumes, and diffusing capacity

Obstructive and restrictive ventilatory defects

Relate respiratory history to indications for

performing pulmonary function tests

Objectives

Pulmonary Function Testing

• Establish baseline lung function and evaluate the presence or absence of lung disease

• Evaluate symptoms of dyspnoea

• Evaluate if the lung disease is primarily an obstructive, restrictive or mixed ventilatory defect

• Quantify the respiratory impairment and monitor the extent of known disease on lung function

• Monitor effects of therapies used to treat respiratory disease

Pulmonary Function Testing

• Evaluate operative risk

• Perform surveillance for occupational-related lung disease

• Evaluate disability or impairment

• Assess for reversible components to optimise a patient’s clinical status

Spirometry

• Forced expiratory volume in 1 second (FEV1)– Volume exhaled in the first second of an FVC manoeuvre – (forced exhalation from maximal inspiration)

• Vital capacity (VC)– Total volume exhaled by a exhalation from maximal

inspiration– Can be a forced exhalation (FVC) or a relaxed exhalation

(RVC) – best one taken as VC

• FEV1/VC– Ratio between FEV1 and VC

Pulmonary Function Testing

• In normal spirometry, FVC, FEV1, and FEV1 -to-FVC ratio are above the lower limit of normal

• The lower limit of normal is defined as the result of the mean predicted value (based on the patient's sex, age, and height)

Spirometry

Reduction in FEV1Reduction in FEV1

• Airway obstruction is the most common cause of reduction in FEV1

• Airflow obstruction may be secondary to

Bronchospasm (Asthma/ COPD)Airway inflammation (Asthma/ COPD/ Bronchiectasis) Loss of lung elastic recoil (Emphysema)Increased secretions in the airway (Bronchitis/ Bronchiectasis/ Infection)

Assessing reversibility in airway obstruction

• Response of FEV1 to inhaled bronchodilators is used to assess the reversibility of airway obstruction (Post (Post

Bronchodilator challengeBronchodilator challenge))

• Methacholine Challenge – used to assess possible Methacholine Challenge – used to assess possible underlying asthma, (ie reversible airway obstruction).underlying asthma, (ie reversible airway obstruction).

Baseline lung function may be normal when the patient Baseline lung function may be normal when the patient is clinically stable.is clinically stable.

Assessing reversibility in airway obstruction

• Gibson Resp MedGibson Resp Med– 12% or 200ml12% or 200ml

Reversible Airway Obstruction

SpirometrySpirometry PredictedPredicted MeasuredMeasured Post BDPost BD

FEV 1 (l)FEV 1 (l) 2.82.8 2.432.43

VC (l)VC (l) 3.793.79 3.753.75

Reversible Airway Obstruction

SpirometrySpirometry PredictedPredicted MeasuredMeasured Post BDPost BD

FEV 1 (l)FEV 1 (l) 2.82.8 2.432.43 2.732.73

VC (l)VC (l) 3.793.79 3.753.75 4.024.02

Indications for Lung Volume Tests

• Diagnose or assess the severity of restrictive lung disease

• Differentiate between obstructive and restrictive disease patterns

• Assess the response to therapy

• Make preoperative assessments of patients with compromised lung function

Static lung volumes

• Total lung capacity (TLC)– Total volume of air in the lungs at the end of an

maximal inspiration

• Residual volume (RV)– Volume of air remaining in the lungs at the end of a

maximal expiration

• Functional residual volume (FRC)– Volume of air remaining in the lungs at the end of tidal

expiration

Lung Volumes

Reduction in FVC

• A reduced FVC on spirometry in the absence of a A reduced FVC on spirometry in the absence of a reduced FEV1 -to-FVC ratio suggests a restrictive reduced FEV1 -to-FVC ratio suggests a restrictive ventilatory defectventilatory defect

• An inappropriately shortened exhalation during An inappropriately shortened exhalation during spirometry can (and often does) result in a reduced FVCspirometry can (and often does) result in a reduced FVC

(i.e. Patient effort is important)(i.e. Patient effort is important)

Causes of Abnormal Lung Volumes

• Raised TLC– COPD esp. emphysema– Transiently raised during an asthma exacerbation or in the

recovery phase of an asthma exacerbation

• Increased RV– Airways disease (air-trapping), e.g. asthma or emphysema

• Reduced TLC/ FVC/ RV– Restrictive defect (intrapulmonary or

extrapulmonary)

Diffusion Capacity/ Transfer Factor

• The diffusing capacity is a measure of the conductance of the CO molecule from the alveolar gas to Haemoglobin in the pulmonary capillary blood

• CO (and oxygen) must pass through the alveolar epithelium, tissue interstitium, capillary endothelium, blood plasma, red cell membrane and cytoplasm before attaching to the Haemoglobin molecule

Diffusion Capacity

Indications for Diffusion Capacity

• Evaluate or follow the progress of parenchymal/ interstitial lung disease

• Evaluate pulmonary involvement in systemic disease

• Evaluate obstructive lung disease

• Quantify disability associated with interstitial lung disease

• Evaluate pulmonary hemorrhage

Diffusion capacity

• TLCO = transfer factor for the lung for carbon monoxide TLCO = transfer factor for the lung for carbon monoxide i.e. Total diffusing capacity for the lungi.e. Total diffusing capacity for the lung– Same as DLCOSame as DLCO

• KCO = transfer coefficent i.e. Diffusing capacity of the KCO = transfer coefficent i.e. Diffusing capacity of the lung per unit volume, standardised for alveolar volume lung per unit volume, standardised for alveolar volume (VA)(VA)

• VA = Lung volume in which carbon monoxide diffuses VA = Lung volume in which carbon monoxide diffuses into during a single breath-hold techniqueinto during a single breath-hold technique

Abnormal Diffusion Capacity

• Low TLC

• Low TLCO

• Low/normal KCO

• = Intrapulmonary restrictive defect Intrapulmonary restrictive defect – Interstitial lung diseasesInterstitial lung diseases– Pulmonary oedemaPulmonary oedema

• High TLC

• Low TLCO

• Low KCO– emphysemaemphysema

Abnormal Diffusion CAbnormal Diffusion Capacity

• Low TLCO

• but high/N KCO

• = extrapulmonary restrictive defect– ObesityObesity– Neuromuscular disease (respiratory muscle Neuromuscular disease (respiratory muscle

weakness)weakness)– Pleural disease e.g. effusion, thickening, tumorPleural disease e.g. effusion, thickening, tumor– Skeletal deformitySkeletal deformity– Post pneumonectomyPost pneumonectomy

Abnormal Diffusion CAbnormal Diffusion Capacity

• Normal/raised TLCO

• Raised KCO– AsthmaAsthma– Pulmonary haemorrhage Pulmonary haemorrhage

Obstructive Lung Disease

• Chronic Obstructive Pulmonary Disease (COPD)

• Chronic BronchitisChronic Bronchitis““Excessive mucus production, with a productive cough on most Excessive mucus production, with a productive cough on most days, for at least 3 months for 2 years or more.”days, for at least 3 months for 2 years or more.”

• EmphysemaEmphysema– Primarily caused by cigarette smoking.– Alpha -1-antitrypsin deficiencyAlpha -1-antitrypsin deficiency– Environmental pollutantsEnvironmental pollutants

Working Definition of COPD

Chronic obstructive pulmonary disease (COPD) is characterised by airflow obstruction. The airflow obstruction is usually progressive, not fully reversible and does not change markedly over several months. The disease is predominantly caused by smoking.

Airflow obstruction is defined as a reduced FEV1 (forced expiratory volume in 1 second) and a reduced FEV1/FVC ratio (where FVC is forced vital capacity), such that FEV1 is less than 80% predicted and FEV1/FVC is less than 0.7.

(www.nice.org.uk/CG012NICEguideline)

Chronic Obstructive Pulmonary Disease (COPD)

Characterized by:Characterized by:– Dyspnoea at rest or with exertionDyspnoea at rest or with exertion– Productive coughProductive cough

– Barrel-chest (↑AP to Transverse diameter)Barrel-chest (↑AP to Transverse diameter)– Chest percussion: Hyper resonant Chest percussion: Hyper resonant – Chest auscultation: Breath sounds distant or absentChest auscultation: Breath sounds distant or absent

– Chest X-RayChest X-Ray• Flattened diaphragmsFlattened diaphragms• Hyperinflated lung fields/ bullaeHyperinflated lung fields/ bullae

Emphysema

• Spirometry

Reduction in FEV1

Reduction in FEV1/ VC ratio

• Lung Volumes

Increased lung volumes (“air trapping”)

• Diffusing Capacity

Reduced

Obstructive Lung Disease

• Asthma Airway oAirway obstruction is characterized by inflammation of the mucosal lining of the airways, bronchospasm and increased airway secretions

Reversible airway obstruction

Obstructive Lung Disease• Asthma Triggers

• Exercise/ Cold air

• Allergic agents– Pollens, house dust mite, animal dander, moulds

• Non-allergic agents– Viral infections, environmental pollutants,

medication, food additives, emotional upset

• Occupational exposure– Cotton/ wood dusts, grains, metal salts,

insecticides

Obstructive Lung Disease• AsthmaAsthma

During AttacksDuring Attacks– Peak Flow (PEF) is reduced/ HypoxiaPeak Flow (PEF) is reduced/ Hypoxia– Response to bronchodilatorsResponse to bronchodilators

• Spirometry Reduced FEV1

• Lung VolumesIncreased (Hyperinflation)

• Diffusion Capacity Normal

During stable state: Spirometry may be normalDuring stable state: Spirometry may be normal

Causes of Restrictive Spirometry

• Pulmonary fibrosis• Pleural effusion• Pleural tumors• Lung resection (lobectomy/ pneumonectomy)• Diaphragm weakness or paralysis• Neuromuscular disease• Kyphoscoliosis• Obesity• Inadequate respiration secondary to pain• Congestive heart failure• Ascites • Pregnancy

Restrictive Lung Disease• Idiopathic Pulmonary Fibrosis

Or secondary to

• Treatment with bleomycin, cyclophosphamide, methotrexate or amiodarone• Autoimmune diseases: Rheumatoid arthritis, systemic lupus

erythematousus (SLE), scleroderma• Sarcoidosis• PneumoconiosisPneumoconiosis

– Silicosis – Silica dustSilicosis – Silica dust– Asbestosis – Asbestos fibersAsbestosis – Asbestos fibers

Restrictive Lung Disease

• Idiopathic Pulmonary FibrosisIdiopathic Pulmonary Fibrosis

– Increasing exertional dyspnoeaIncreasing exertional dyspnoea– Dry coughDry cough– Finger clubbingFinger clubbing– Inspiratory crackles on auscultationInspiratory crackles on auscultation

– Chest X-RayChest X-Ray• Interstitial infiltrates are visibleInterstitial infiltrates are visible• Honeycombing patternHoneycombing pattern

Restrictive Lung Disease

• Idiopathic Pulmonary FibrosisIdiopathic Pulmonary Fibrosis

• SpirometrySpirometry

ReducedReduced VC VC

• Lung volumesLung volumes

ReducedReduced TLC/ RV TLC/ RV

• Diffusion capacityDiffusion capacity

ReducedReduced

Diseases of Chest Wall and Pleura

Disorders involving the chest wall or pleura of the lungs Disorders involving the chest wall or pleura of the lungs result in restrictive ventilatory defects on pulmonary result in restrictive ventilatory defects on pulmonary function testing. But, lung parenchyma is not affected. function testing. But, lung parenchyma is not affected.

• SpirometrySpirometryReduced FEV1 and FVCReduced FEV1 and FVC

• Lung VolumesLung VolumesReduced TLCReduced TLC

• Diffusion CapacityDiffusion CapacityReducedReduced

• KCoKCoNormal Normal

Diseases of Chest Wall and Pleura

Obstructive v. Restrictive

Mixed Picture

• Bronchiectasis

Pathologic and irreversible dilatation of the bronchi, resulting from destruction of the bronchial wall by severe, repeated infections and inflammation

Bronchiectasis

Post infective: Post infective: Whooping cough/ TBWhooping cough/ TB

Genetic: Genetic: Cystic Fibrosis/ Primary Cliliary Dyskinesia (PCD)Cystic Fibrosis/ Primary Cliliary Dyskinesia (PCD)

ImmunodeficiencyImmunodeficiency

Bronchiectasis

– Dyspnoea– Significant productive cough– Purulent, foul smelling sputum– Haemoptysis– Frequent pulmonary infections– Chronically unwell– Chest X-Ray / CT Scan

• Airway Dilation

Airway Function Tests Function Tests

Flow Volume Loop (FVL)Flow Volume Loop (FVL)

Airway Function TestsAirway Function Tests

Flow Volume Loop (FVL)Flow Volume Loop (FVL)

Respiratory History• Dyspnoea: Do you get short of breath at the following times:Dyspnoea: Do you get short of breath at the following times:

• At rest? On exertion? At night?At rest? On exertion? At night?• Progression of dyspnoeaProgression of dyspnoea

• Cough: Do you ever cough?Cough: Do you ever cough?• In the morning? At night?In the morning? At night?• Dry or productive? Dry or productive? • Blood?Blood?• Sputum/ Phlegm? (Color, volume, consistency)Sputum/ Phlegm? (Color, volume, consistency)

• Chest pain/ Orthopnoea/ Paroxysmal Nocturnal DyspnoeaChest pain/ Orthopnoea/ Paroxysmal Nocturnal Dyspnoea

• Family history of lung diseaseFamily history of lung disease

• Past History Past History • TB/ Emphysema/ Chronic Bronchitis/ AsthmaTB/ Emphysema/ Chronic Bronchitis/ Asthma• Recurrent lung infection/ Pneumonia or pleurisyRecurrent lung infection/ Pneumonia or pleurisy• Allergies or hay feverAllergies or hay fever• Previous chest injury or chest surgeryPrevious chest injury or chest surgery

• Current Medications Current Medications • Inhalers/ Steroids/ Nebulised bronchodilators or antibiotics/ Inhalers/ Steroids/ Nebulised bronchodilators or antibiotics/

Oxygen/ MucolyticsOxygen/ Mucolytics• Cardiac medicationsCardiac medications• Oncology drugs or immunosuppressivesOncology drugs or immunosuppressives

• Smoking HabitsSmoking Habits• Cigarettes/ Cigars/ Pipe/ Illicit drugsCigarettes/ Cigars/ Pipe/ Illicit drugs• How many years?How many years?• Current or ex smoker?Current or ex smoker?

• OccupationOccupation• Asbestos (Direct/ Bystander exposure)Asbestos (Direct/ Bystander exposure)• Mining, quarry, foundryMining, quarry, foundry

Respiratory History

1. The disease is far from invisible statistically: it is the UK’s fifth biggest killer disease, claiming more lives than breast, bowel or prostate cancer (estimated 30 000 lives/ year)

2. The second most common cause of emergency admission to hospital and one of the most costly inpatient conditions treated by the NHS

3. It is estimated that the direct cost of providing care in the NHS for people with COPD is almost £500 million a year – more than half of which relates to hospital care

Invisible Lives Report - BLF

1. The epidemiological evidence published in 2006 suggesting that out of an estimated 3.7 million people in the UK with COPD, only 900,000 were currently diagnosed and receiving treatment and care

2. The remaining 2.8 million people were still unaware they had a disease which, if left untreated, could severely restrict their lives and would eventually kill them

Invisible Lives Report - BLF

DiagnosisDiagnosis

• Clinical suspicion in patients (usually smokers or ex-Clinical suspicion in patients (usually smokers or ex-smokers, age >35yrs) with:smokers, age >35yrs) with:– exertional breathlessnessexertional breathlessness– chronic coughchronic cough– regular sputum productionregular sputum production– frequent “winter bronchitis”frequent “winter bronchitis”– wheeze with a risk factor (usually smoking)wheeze with a risk factor (usually smoking)

• Airflow obstruction should be confirmed with Airflow obstruction should be confirmed with spirometryspirometry

Spirometry for COPD Diagnosis: Spirometry for COPD Diagnosis: NICE 2010NICE 2010

– FEVFEV11 <80% predicted <80% predicted

– Post Bronchodilator FEVPost Bronchodilator FEV11:FVC ratio <0.7:FVC ratio <0.7

– Stage 1 Mild:Stage 1 Mild: FEV FEV11 80% (+ Symptoms) 80% (+ Symptoms)

– Stage 2 Moderate:Stage 2 Moderate: FEV FEV11 50-79% 50-79%

– Stage 3 Severe:Stage 3 Severe: FEV FEV11 30-49% 30-49%

– Stage 4 Very Severe: Stage 4 Very Severe: FEVFEV11 <30% <30%

oror

– Stage 4 Very Severe: Stage 4 Very Severe: FEVFEV11 <50% <50%

(+Respiratory Failure)(+Respiratory Failure)

General principles of management General principles of management of stable COPD – NICE guidelinesof stable COPD – NICE guidelines

• Lifestyle modificationLifestyle modification– Smoking cessation Smoking cessation (Behavioural support/ Nicotene replacement/ (Behavioural support/ Nicotene replacement/

Bupropion/ Varenicline)Bupropion/ Varenicline)– Pulmonary rehabilitationPulmonary rehabilitation

• Optimisation of pharmacological therapiesOptimisation of pharmacological therapies– InhalersInhalers

• Short-acting bronchodilators Short-acting bronchodilators • Long-acting bronchodilators regularly, often Long-acting bronchodilators regularly, often

combined with…combined with…

• Corticosteroids (FEVCorticosteroids (FEV11 <<//== 50% with 2+ 50% with 2+ exacerbations requiring antibiotics or oral exacerbations requiring antibiotics or oral steroids in 1 year)steroids in 1 year)

Maintenance therapy with budesonide and formoterol in chronic obstructive pulmonary diseaseCalverley et al. Eur Respir J 2003;22:912–919.

Seretide reduces the rate of exacerbations needing medical intervention

Adapted from: Calverley PM. et al.N Engl J Med 2007;356:775-89.

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General Principles of GuidelinesGeneral Principles of Guidelines

• Theophylline, oral steroids, diuretics, mucolyticsTheophylline, oral steroids, diuretics, mucolytics

• Prophylaxis Prophylaxis – Immunisations (influenza, pneumococcus, H1N1)Immunisations (influenza, pneumococcus, H1N1)

• Long Term Oxygen Therapy (LTOT)Long Term Oxygen Therapy (LTOT)

• SurgerySurgery– Bullectomy, lung volume reduction, transplantBullectomy, lung volume reduction, transplant

• Management of anxiety and depressionManagement of anxiety and depression

• Palliation and end of life supportPalliation and end of life support

• Early detection + Early detection + Patient education + Smoking cessation Patient education + Smoking cessation

• Treatment of acute exacerbationsTreatment of acute exacerbations

• Pulmonary Rehabilitation: Pulmonary Rehabilitation: IIncreases threshold for perception of dyspnoeancreases threshold for perception of dyspnoeaImproves quality of lifeImproves quality of lifeSubstantially reduces health care costsSubstantially reduces health care costsUnder resourcedUnder resourced

• NIPPV:NIPPV:Reduces need for invasive ventilationReduces need for invasive ventilationReduces admissionsReduces admissionsBridging measure prior to surgeryBridging measure prior to surgeryUnder resourcedUnder resourced

General Principles - in additionGeneral Principles - in addition

Referral for Specialist advice - NICEReferral for Specialist advice - NICE

• Diagnostic uncertainty

• Suspected severe COPD

• Onset of cor pulmonale

• Assessment for oxygen therapy, long-term nebuliser

therapy or oral corticosteroid therapy

• Bullous lung disease

• Rapid decline in FEV1

• Assessment for pulmonary rehabilitation

• Assessment for lung volume reduction surgery or transplantation

• Patient aged under 40 years or a family history of alpha-1

antitrypsin deficiency

• Symptoms disproportionate to lung function deficit

• Frequent infections

• Haemoptysis

Complications of COPDComplications of COPD

• Respiratory failureRespiratory failure

• Cor pulmonaleCor pulmonale

• BullaeBullae

• PneumothoraxPneumothorax

• PneumoniaPneumonia

• Increased risk of malignancy (shared risk factor)Increased risk of malignancy (shared risk factor)

Preoperative measures

• Cessation of cigarette smoking for at least 8 weeks before surgery • Treat airflow obstruction • Treat respiratory infection if present • Educate for lung-expansion manouvres • Mucolytics/ Physiotherapy and chest clearance

• Postoperative measures • Epidural analgesia or intercostals nerve bloc for pain control • Early mobilization • Chest physical therapy (including deep breathing and incentive

spirometry) • Continuous positive airway pressure in selected patients

Pre Operative Assessment

• Be wary of a “presumed diagnosis” of lung disease Be wary of a “presumed diagnosis” of lung disease

• Beware of “no previous diagnosis of known lung disease”Beware of “no previous diagnosis of known lung disease”

• Evaluate lung function systematicallyEvaluate lung function systematically

• Careful history and examinationCareful history and examination

• If in doubt…..If in doubt…..

• Find a friendly respiratory physicianFind a friendly respiratory physician