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Evaluation of preoperative pulmonary risk

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Nahid Sherbini

- Pulmonary complications are a major cause of postoperative morbidity and mortality. The risk depends on patient-related factors like age, smoking history, COPD, asthma, obesity, sleep apnea, and heart failure as well as procedure-related factors like the surgical site and duration of anesthesia. - A thorough preoperative evaluation involves reviewing the patient's history, performing a physical exam, and testing like arterial blood gases, chest x-ray, and pulmonary function tests to determine their risk level. Assigning a risk level helps guide risk reduction strategies in high risk patients.

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APPROACH OF PREOPERATIVE PULMONARY RISK ASSESSMENT Dr Nahid Sherbini Pulmonary Fellow
Introduction • Postoperative pulmonary complications morbidity and mortality. • In a study of patients undergoing elective abdominal surgery, pulmonary complications >cardiac complications and were associated with significantly longer hospital stays Incidence and hospital stay for cardiac and pulmonary complications after abdominal surgery. Lawrence VA, Hilsenbeck SG, Mulrow CD, Dhanda R, Sapp J, Page CP J Gen Intern Med. 1995;10(12):671.
General complications Atelectasis Infection Bronchitis Pneumonia Bronchospasm Pulmonary embolism Exacerbation of underlying chronic lung disease Respiratory failure and prolonged invasive or NIV OSA ARDS Specific cardiothoracic surgical complications Phrenic nerve injury Pleural effusion Bronchopleural fistula Sternal wound infection and empyema Gastroesophageal anastomotic leak Postoperative arrhythmias
Incidence • Varies 2- 70% • The rate of postoperative pulmonary complications across all types of surgery was 6.8 % in a systematic review. Benefits from surgery ←→ Risk of complications Preoperative pulmonary risk stratification for noncardiothoracic surgery: systematic review for the American College of Physicians. Smetana GW, Lawrence VA, Cornell JE, American College of Physicians Ann Intern Med. 2006;144(8):58
SURGERY PULMONARY COMPLICATION INCIDENCE Thoracotomy and % 30 lung resection Cardiac % 40 Esophagectomy % 25 - 50 Abdominal % 30  Upper abdominal surgery has a complication risk which is 1,5 x than lower abdominal surgery
PERIOPERATIVE PULMONARY PHYSIOLOGY Reduced lung volume after surgery is a major factor Thoracic and upper abdominal in a restrictive pattern * (VC) is reduced by 50- 60 % * (FRC) is reduced by about 30%. Meyers JR, Lembeck L, O'Kane H, Baue AE. Changes in functional residual capacity of the lung after operation. Arch Surg 1975; 110:576. Craig DB. Postoperative recovery of pulmonary function. Anesth Analg 1981
PERIOPERATIVE PULMONARY PHYSIOLOGY • Diaphragmatic dysfunction -postoperative pain and splinting  Reduction of the FRC below closing volumes atelectasis, pneumonia, &(V/Q) mismatching. • Microatelectasis perfused but not ventilated impaired gas exchange with consequent hypoxemia . Ford GT, Whitelaw WA, Rosenal TW, et al. Diaphragm function after upper abdominal surgery in humans. Am Rev Respir Dis 1983; 127:431. Marshall BE, Wyche MQ Jr. Hypoxemia during and after anesthesia. Anesthesiology 1972; 37:178.
PERIOPERATIVE PULMONARY PHYSIOLOGY • Residual effects of anesthesia depress the respiratory drive Inhibition of cough and impairment of mucociliary clearance of respiratory secretions. A decrease in TV increase in RR Cough dynamics in oesophageal cancer: prevention of postoperative pulmonary complications. Sugimachi K, Ueo H, Natsuda Y, Kai H, Inokuchi K, Zaitsu A Br J Surg. 1982;69(12):734.
POSTOPERATIVE PULMONARY DYSFUNCTION Alterations in ventilation and perfusion distrubution, in respiratory mechanics Postoperative Pulmonary Dysfunction Postoperative Pulmonary Complications Wynne R et al. AJCC 2004; 13: 384 - 93
Outlines of The Approach • Patient related risk factors • Procedure related risk factors • Preoperative risk assessment • Risk reduction strategies
Patient related risk factors • Age • Health state • Obesity • Smoking • COPD • Asthma • Pulmonary hypertension • Heart failure • Metabolic factors
Age • Minor risk factor • Independent predictor • Surgery should not be declined in elderly patients who are otherwise acceptable surgical candidates. Prediction of outcome of surgery and anesthesia in patients over 80.,Djokovic JL, Hedley- Whyte J-JAMA. 1979;242(21):2301. Postoperative intensive care admittance: the role of tobacco smoking.-Møller AM, Maaløe R, Pedersen T-Acta Anaesthesiol Scand. 2001;45(3):345
Age • >50 y was an important independent predictor of risk. • When compared to patients <50 years old, 50 - 59 y, 60 - 69 y 70 - 79 y, & ≥80 y  (OR) of 1.50 , 2.28 , 3.90 , and 5.63 , respectively. • Even healthy older patients carry a substantial risk of pulmonary complications after surgery. Preoperative pulmonary risk stratification for noncardiothoracic surgery: systematic review for the American College of Physicians. Smetana GW, Lawrence VA, Cornell JE, American College of Physicians Ann Intern Med. 2006;144(8):581.
General health status • Functional dependence and impaired sensorium each increase postoperative pulmonary risk . (ASA) classification correlates well with pulmonary risk (significant preexisting lung disease would be classified in a higher ASA class) ASA class >2 confers a 4.87 fold increase in risk . Preoperative pulmonary risk stratification for noncardiothoracic surgery: systematic review for the American College of Physicians. Smetana GW, Lawrence VA, Cornell JE, American College of Physicians Ann Intern Med. 2006;144(8):581.
AMERICAN SOCIETY OF ANAESTHESIA(ASA) CLINICAL SCORE • ASA- I No systemic disorder • ASA- II Mild disorder • ASA- III Moderate disorder * • ASA- IV Severe disorder • ASA- V Cause of death
ASA
Smoking • Current cigarette smokers have an increased risk ,even in the absence of chronic lung disease . • A prospective cohort study of 410 patients undergoing elective, noncardiac surgery found that smoking was associated with a greater than five-fold increase in the postoperative complication rate (OR = 5.5) . A prospective survey of the incidence of postoperative pulmonary complications. Wightman JA Br J Surg. 1968;55(2):85. Preoperative smoking habits and postoperative pulmonary complications. Bluman LG, Mosca L, Newman N, Simon DG -Chest. 1998;113(4):88
Smoking • Smoking history of 40 pack years or more →↑risk of pulmonary complications • stopped smoking < 2 months : stopped for > 2 months = 4:1 (57% : 14.5%) • quit smoking > 6 months : never smoked = 1:1 (11% : 11.9%) Preoperative smoking habits and postoperative pulmonary complications.Bluman LG, Mosca L, Newman N, Simon DG /Chest. 1998;113(4):883. Relationship between the duration of the preoperative smoke-free period and the incidence of postoperative pulmonary complications after pulmonary surgery./Nakagawa M, Tanaka H, Tsukuma H, Kishi Y/Chest. 2001;120(3):705
COPD • Unadjusted relative risks have ranged 2.7 to 6.0 . • A more recent systematic review  impact was less than previously estimated . multivariable analysis to adjust for patient-related confounders odds ratio for postoperative pulmonary complications was 2.36 (CI 1.90-2.93). Preoperative pulmonary evaluation. /Smetana GW N Engl J Med. 1999;340(12):937. Preoperative pulmonary risk stratification for noncardiothoracic surgery: systematic review for the American College of Physicians. Smetana GW, Lawrence VA, Cornell JE, American College of Physicians Ann Intern Med. 2006;144(8):581.
Asthma • Despite early reports indicating that patients with asthma had higher rate. • Recent studies have found no link for patients with well- controlled asthma. The largest studied 706 patients with asthma undergoing general surgery . Perioperative respiratory complications in patients with asthma. Warner DO, Warner MA, Barnes RD, Offord KP, Schroeder DR, Gray DT, Yunginger JW /Anesthesiology. 1996;85(3):460.
Obesity • Morbid obesity → restrictive lung disease ↓ thoracic compliance alveolar hypoventilation
Obesity • Obesity is not a significant risk factor not affect patient selection for otherwise high-risk procedures • A systematic review found that, among 8 studies using multivariate analysis, only one study identified obesity as an independent predictor . Preoperative pulmonary risk stratification for noncardiothoracic surgery: systematic review for the American College of Physicians. Smetana GW, Lawrence VA, Cornell JE, American College of Physicians Ann Intern Med. 2006;144(8):581.
Obstructive sleep apnea (OSA) • An emerging risk factor for postoperative pulmonary complications. • Increases the risk of critical respiratory events immediately after surgery, including early hypoxemia and unplanned reintubation. Practice guidelines for the perioperative management of patients with obstructive sleep apnea: a report by the American Society of Anesthesiologists Task Force on Perioperative Management of patients with obstructive sleep apnea. Gross JB, Bachenberg KL, Benumof JL, Caplan RA, Connis RT, CotéCJ, Nickinovich DG, Prachand V, Ward DS, Weaver EM, Ydens L, Yu S, American Society of Anesthesiologists Task Force on Perioperative Management Anesthesiology. 2006;104(5):1081.
OSA • The largest study to date ,evaluated 3.4 million general surgical and 2.6 million orthopedic patients from an administrative database . Patients with OSA were more likely to develop respiratory failure (OR 1.95, CI 1.91- 1.98) and aspiration pneumonia (OR 1.37, CI 1.33-1.41). Comparable rates : GS OR 5.20 (CI 5.05-5.37) ORTHOOR 1.41 (CI 1.35-1.47) Screening ?? Perioperative pulmonary outcomes in patients with sleep apnea after noncardiac surgery. Memtsoudis S, Liu SS, Ma Y, Chiu YL, Walz JM, Gaber-Baylis LK, Mazumdar M Anesth Analg. 2011 Jan;112(1):113-21. Epub 2010 Nov 16
Pulmonary hypertension • Increases complication rates after surgery, including in patients with mild to moderate pulmonary hypertension. • Regardless of the underlying etiology. Noncardiothoracic nonobstetric surgery in mild-to-moderate pulmonary hypertension. Price LC, Montani D, Jaïs X, Dick JR, Simonneau G, Sitbon O, Mercier FJ, Humbert M Eur Respir J. 2010;35(6):1294. Impact of pulmonary hypertension on the outcomes of noncardiac surgery: predictors of perioperative morbidity and mortality. Ramakrishna G, Sprung J, Ravi BS, Chandrasekaran K, McGoon MD J Am Coll Cardiol. 2005;45(10):16
Heart failure • The risk higher in patients with heart failure than in those with COPD. • Systematic review pooled adjusted odds ratio for pulmonary complications were 2.93 (95% CI 1.02-8.43) for heart failure patients and 2.36 (1.90-2.93) for patients with COPD. Preoperative pulmonary risk stratification for noncardiothoracic surgery: systematic review for the American College of Physicians. Smetana GW, Lawrence VA, Cornell JE, American College of Physicians Ann Intern Med. 2006;144(8):581.
Metabolic factors • Albumin less than 3 g/dL OR 2.53 • Blood urea nitrogen (BUN) >30 mg/Dl OR 2.29 • A systematic review found that the magnitude of risk associated with a low serum albumin was similar to the degree of the most important patient-related risk factors and a stronger predictor of risk than an elevated BUN
Procedure related risk factors • Surgical site • Duration and type of anesthesia • Type of neuromuscular blockade
Surgical site • The most important predictor of pulmonary complications • The incidence of complications is inversely related to the distance of the surgical incision from the diaphragm • The complication rates for upper abdominal and thoracic surgery are the highest (range 10% to 40%) Preoperative pulmonary risk stratification for noncardiothoracic surgery: systematic review for the American College of Physicians. Smetana GW, Lawrence VA, Cornell JE, American College of Physicians Ann Intern Med. 2006;144(8)
Surgical site (cont.) • Upper abdomen • Incisions cross the abd. muscle,↓ diaphragmatic motility → ↓VC • Lateral thoracotomy • Incision of the intercostal muscle, introduction of a pleural drain → pleural effusion, post-op pain → ↓ thoracic compliance
Surgical site (cont.) Thoracotomy • Without pulmonary disease • VC ↓ to 60~70% of the pre- operative value • With pulmonary disease • The effects of thoracotomy are amplified • Thoractomy → thoracic pain → ↓deep breathing, effective coughing → atelectasis, bronchial mucous retention, worsening of gas exchange
Surgical site (cont.) Video-assisted thoracoscopic surgery (VATS) • Reduced pain ,Postoperative complications, release and responses of proinflammatory cytokines, and better ventilatory function. • VATS lobectomy in NSCLC at clinical stage I could well be acceptable • with 97.2% 8-year survival rate , better than outcomes by thoracotomy.
Surgical site (cont.) • Heart-surgery • usually require median sternotomy • functionally better tolerated than lateral thoracotomy (due to preserves the pleural space) • respiratory function is generally well preserved, except for a transitory reduction in pulmonary volumes.
Duration and type of anaesthesia • Anesthesia time of > 3.5 -4hours →↑incidence of pulmonary complications • in a very high risk patient→ a less ambitious, briefer procedure • general anesthesia > epidural analgesia ,neuromuscular blocker and local anesthesia Postoperative intensive care admittance: the role of tobacco smoking. Møller AM, Maaløe R, Pedersen T Acta Anaesthesiol Scand. 2001;45(3):3
Type of neuromuscular blockade • Pancuronium, a long-acting neuromuscular blocker • a higher incidence of postoperative residual neuromuscular blockade • a higher incidence of postoperative pulmonary complications in those patients with residual neuromuscular blockade Residual neuromuscular blockade and critical respiratory events in the postanesthesia care unit. Murphy GS, Szokol JW, Marymont JH, Greenberg SB, Avram MJ, Vender JS Anesth Analg. 2008;107(1):13
PREOPERATIVE RISKS ASSESSMENT
ASSIGNMENT OF PREOPERATIVE RISKS CLINICAL EVALUATION (Basic rule) • History  Present / history of lung disease  Respiratory symptoms (dyspnea, cough)  Smoking  Other co morbid diseases  Drugs  Atopy (individual or family) history  Exercise intolerance
ASSIGNMENT OF PREOPERATIVE RISKS • Physical Examination  Symptoms of increased sputum secretion (ralles)  Obstruction findings (Wheezing, prolonged expiration)  Symptoms of emphysema  Symptoms of respiratory insufficiency  Hypertension, arrthymia, tachycardia
ASSIGNMENT OF PREOPERATIVE RISKS AND • Arterial blood gas • Chest X-Ray • Functional Evaluation (Spirometry,Diffusion Capacity) • Exercise Tests
ARTERIAL BLOOD GASES –A DIFFERENT POINT OF VİEW • PaO2 < 50 mmHg Risk • PaO2 < 60 mmHg, PaCO2 > 50 mmHg Nagasaki F, Chest 1982; 82: 25-29 • PaCO2 > 45 mmHg resection with high risk Morice RC, Chest 1992; 101: 356-361 Bolliger CT, ERJ 1998; 11:198-212 CCP, Ann Inter Med 1990; 112: 793-794
ARTERIAL BLOOD GASES – GENERAL OPINION • Hypercarbia in patients with COPD (PaCO2 > 45 mmHg), is not a certain contrendication but is believed to be with high surgical risk • Hypoxemia, is not a significiant predictor of complication alone Prediction of postoperative pulmonary complications in oesophagogastric cancer surgery. Fan ST, Lau WY, Yip WC, Poon GP, Yeung C, Lam WK, Wong KK Br J Surg. 1987;74(5):408.
EVALUATION OF PREOPERATIVE RISKS • RADIOLOGICAL EVALUATION  There is no role of CXR in evaluating postoperative risks in healthy persons, but it must be performed.  Preoperative CXR is essential for patients >60Y with cardiac or pulmonary problems Value of routine preoperative chest x-rays: a meta-analysis. Archer C, Levy AR, McGregor M Can J Anaesth. 1993;40(11):102
EVALUATION OF PREOPERATIVE RISKS EXERCISE TESTS • Walking test (6min) • Stair climbing test • Step test • “Shuttle walk” test • Bicycle ergometery ( MVO2 ) * Routine use before general surgery is not recommended EXCEPT FOR LUNG RESECTION
PFT • Two reasonable goals to use of preoperative PFTs 1. Identification of a group of patients for whom the risk of the proposed surgery is not justified by the benefit 2. Identification of a subset of patients at higher risk for whom aggressive perioperative management is warranted
PFT • These tests simply confirm the clinical impression of disease severity in most cases, adding little to the clinical estimation of risk • Overused
ACP GUIDELINES 2006 • Not use preoperative spirometry routinely for predicting the risk of postoperative pulmonary complications . Obtain in: 1. COPD or asthma if clinical evaluation cannot determine if the patient is at their best baseline and that airflow obstruction is optimally reduced. 2. Dyspnea or exercise intolerance that remains unexplained after clinical evaluation. 3. ALL for lung resection PFTs should not be used as the primary factor to deny surgery
SPIROMETERY  Postoperative risk (Gass & Olsen, 1986)  FVC < % 70  FEV1 < % 70 Complication risk  FEV1 / FVC < % 65 • A normal PFT does not demonstrate a lower postoperative complication rate
PREOPERATIVE PULMONARY FUNCTION TESTS Severe COPD (FEV1 < % 50) • Preoperative PFT not predict postoperative pulmonary complication risk • Surgery time • ASA class predict significiantly • Surgery type Kroenke L. Arch Intern Med 1992
PULMONARY RISK INDEXES  Cardiopulmonary Risk Index Epstein SK. Chest 1993;104:694  Lawrence Risk Index Lawrence WA. Chest 1996; 110: 744  Brooks – Brunn Risk Index Brooks-Brunn JA. Chest 1997;111: 564  Multifactorial Risk Index Arozullah AM. Ann Surg 2000; 232: 242
Variant Score BMI > 27 kg/m2 1 Cigarette (last 8 weeks) 1 Productive coughing (last 5 days) 1 Wheezing (last 5 days) 1 FEV1/FVC < % 70 (predicted) 1 PaCO2 > 45 mmHg 1 Total 6 Pulmonary risk index: Factors that increase postoperative pulmonary complications > 4: Pulmonary risk % 73.4 < 4: Pulmonary risk % 11 PULMONARY RISK INDEX
Score History Age > 70 5 MI (last 6 month) 10 Physical examination JVD or S3 11 Aortic valve stenosis 3 ECG Non-sinusoidal rhtym, atrial premature pulse 7 > 5 / min. Ventricular premature pulse 7 Status PO2 < 60 or PCO2 > 50 3 K > 3 or HCO3 < 20 BUN > 50 or Creatinin > 3 Chronic liver disease. Non-cardiac dis. Bed treatment. Surgery Thorac , abdom, aortic 3 Emergency surgery 4 Total 53 Class 1: 0-5 Class 2: 6-12 Class 3: 13-25 Class 4: > 25 GOLDMAN’ S CARDIAC RISK INDEX
CARDIOPULMONARY RISK SCORE • Cardiac risk index score : 1 - 4 • Pulmonary risk index score : 0 – 6 Cardiopulmonary risk index score = 1-10 Cardiac ( 1- 4 ) + Pulmonary ( 0 - 6 ) Index > 4 : Complication risk 22 times higher Index < 2 : No Complication Epstein SK. Chest 1993;104:694.
MULTIFACTORIAL RISK INDEX (Postoperative respiratoryinsufficiency)  Type of surgery  Abdominal aort aneurisym 27  Thoracic 21  Upper abdom., neurochirurgia, per.vascular 14  Neck 11  Emergency surgery 11  Albumin < 3.0 g/dL 9  BUN > 30 g/dL 8  Functional addiction ( partial or complete) 7  COPD 6  Age > 70 6  Age 60 - 69 4 Arozullah AM. Ann Surg 2000; 232: 242
MULTIFACTORIAL RISK INDEX Degree Score Resp. Insufficiency % 1 < 10 0.5 2 11-19 1.8 3 20-27 4.2 4 28-40 10.1 5 > 40 26.6 Arozullah AM. Ann Surg 2000; 232: 242
RESECTION SURGERY
SPECIFIC EVALUATION OF LUNGS AIM • Severity of existing pathology and its reversibility • Estimation of predicted pulmonary function after resection
RESECTION SURGERY • General Evaluation • Respiratory Function  Spirometry – FEV1  Diffusion Capacity  Postoperative FEV1 (FVC, DLCO, VO2 max) • ABG • Exercise Capacity
Assessment for lung resection
RESECTION SURGERY- SPIROMETRY  FEV1 is primary parameter  Pneumonectomy: Preoperative FEV1 > 2 L ( > % 80 predicted )  Lobectomy : Preoperative FEV1 > 1 L  Wedge and segmental resection = 0.6 L
DIFFUSION CAPACITY • DLCO < % 50 major resection is contrendicated Cander L. A J Cardiol 1963 • DLCO < % 60 mortality risk % 24 • ppoDLCO < % 40 mortality risk % 33 Markos J, Mullan BP, Hillman DR, et al. Preoperative assessment as a predictor of mortality and morbity after lung resection. Am Rev Respir Dis 1989; 139: 902-910
Split lung function studies • Predicting post-resection pulmonary function • Predicted postoperative FEV1 (ppoFEV1) is the most valid single test available • ppoFEV1 = preoperative FEV1 × (1– %functional tissue removed/100) • lung function can be calculated by counting the number of segments removed • The lungs contain 19 segments (3 right upper lobes, 2 right middle lobes, 5 right lower lobes, 3 left upper lobes, 4 left lower lobes, 2 left lingula)
Split lung function studies(cont.) • Ventilation-perfusion(V/Q) scan • Quantitatve CT
FEV1 AFTER RESECTION (QUANTITATIVE SCINTIGRAPHY) PNEUMONECTOMY Estimated Postoperative FEV1 = Preoperative FEV1 X perfusion percent of remaining lung LOBECTOMY Estimated Postoperative FEV1 = Preoperative FEV1 X Remaining segments after resection Total segments of both lungs
FEV1 AFTER RESECTION If a part of resected segments is bronchoscopically obstructed Estimated Postoperative FEV1 = Preoperative FEV1 X [( 19-a ) - b] 19 – b a- Resected obstructed segments b- Resected open segments
CARDIOPULMONARY EXERCISE TESTS • Important in lung resection surgery VO2 max = Aerobic capacity: amount of O2 requirement for major muscle groups for 5-15 minutes • Recommendation of BTS and ACCP  VO2max > 15 ml/kg/d Operable  VO2max < 15 ml/kg/d High risk BTS Guidelines: Guidelines on the selection of patients with lung cancer surgery. Thorax 2001; 56:89-108 Beckles MA, Spiro SG, Colice GL et al. The physiologic evaluation of patients with lung cancer being considered for resectional surgery. Chest 2003; 123: 105S-114S
CARDIOPULMONARY EXERCISE TESTS Resection decision • VO2max > % 75 Good prognosis • VO2max > % 60 More than one lobe is contrendicated • VO2max < % 43 Any type of resection is contrendicated Bolliger CT,Jordan P,Soler M, et al. AJRCCM 1995;151:1472-1480
CARDIOPULMONARY EXERCISE TESTS • Absolute value must be used  Eugene J, Brown SE, Light RV, et al. Surg Forum 1982; 33: 260-262  Smith TP, Kinasewitz GT, Tucker WY, et al. Am Rev Respir Dis 1984: 730-734  Bechard D, Wetstein L. Ann Thorac Surg 1987; 44: 344-349 • Absolute value or % value does not make a difference  Keddissi JI, Kinasewits GT. Chest 2005; 127: 1092-1094
CARDIOPULMONARY EXERCISE TESTS • % value must be used  Bolliger CT, Soler M, Stulz P, et al. Respiration 1994; 61:181-186  Bolliger CT,Jordan P,Soler M, et al. AJRCCM 1995;151:1472-1480  Win T, JacksonA, Sharples L, et al. Chest 2005;127:1159-1165  Morice RC, Peters Ej,Ryan MB,et al.Chest 1992;101:356-361  Richter Larsen K, Svendsen UG, Nilman N, et al. Eur Respir J 1997;10:1559- 1565
Assessment for lung resection
Date of download: 11/11/2012 Copyright © American College of Chest Physicians. All rights reserved. Physiologic Evaluation of the Patient With Lung Cancer Being Considered for Resectional Surgery*: ACCP Evidenced-Based Clinical Practice Guidelines (2nd Edition) CHEST. 2007;132(3_suppl):161S-177S. doi:10.1378/chest.07-1359 Preoperative physiologic assessment of perioperative risk. CXR = chest radiograph.
Evaluation of preoperative pulmonary risk
Stepwise approach to preoperative pulmonary assessment. Bapoje S R et al. Chest 2007;132:1637-1645 ©2007 by American College of Chest Physicians
Risk reduction strategies • Pre-operative strategies • Intra-operative strategies • Post-operative strategies
Evaluation of preoperative pulmonary risk
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Evaluation of preoperative pulmonary risk

  • 1. APPROACH OF PREOPERATIVE PULMONARY RISK ASSESSMENT Dr Nahid Sherbini Pulmonary Fellow
  • 2. Introduction • Postoperative pulmonary complications morbidity and mortality. • In a study of patients undergoing elective abdominal surgery, pulmonary complications >cardiac complications and were associated with significantly longer hospital stays Incidence and hospital stay for cardiac and pulmonary complications after abdominal surgery. Lawrence VA, Hilsenbeck SG, Mulrow CD, Dhanda R, Sapp J, Page CP J Gen Intern Med. 1995;10(12):671.
  • 3. General complications Atelectasis Infection Bronchitis Pneumonia Bronchospasm Pulmonary embolism Exacerbation of underlying chronic lung disease Respiratory failure and prolonged invasive or NIV OSA ARDS Specific cardiothoracic surgical complications Phrenic nerve injury Pleural effusion Bronchopleural fistula Sternal wound infection and empyema Gastroesophageal anastomotic leak Postoperative arrhythmias
  • 4. Incidence • Varies 2- 70% • The rate of postoperative pulmonary complications across all types of surgery was 6.8 % in a systematic review. Benefits from surgery ←→ Risk of complications Preoperative pulmonary risk stratification for noncardiothoracic surgery: systematic review for the American College of Physicians. Smetana GW, Lawrence VA, Cornell JE, American College of Physicians Ann Intern Med. 2006;144(8):58
  • 5. SURGERY PULMONARY COMPLICATION INCIDENCE Thoracotomy and % 30 lung resection Cardiac % 40 Esophagectomy % 25 - 50 Abdominal % 30  Upper abdominal surgery has a complication risk which is 1,5 x than lower abdominal surgery
  • 6. PERIOPERATIVE PULMONARY PHYSIOLOGY Reduced lung volume after surgery is a major factor Thoracic and upper abdominal in a restrictive pattern * (VC) is reduced by 50- 60 % * (FRC) is reduced by about 30%. Meyers JR, Lembeck L, O'Kane H, Baue AE. Changes in functional residual capacity of the lung after operation. Arch Surg 1975; 110:576. Craig DB. Postoperative recovery of pulmonary function. Anesth Analg 1981
  • 7. PERIOPERATIVE PULMONARY PHYSIOLOGY • Diaphragmatic dysfunction -postoperative pain and splinting  Reduction of the FRC below closing volumes atelectasis, pneumonia, &(V/Q) mismatching. • Microatelectasis perfused but not ventilated impaired gas exchange with consequent hypoxemia . Ford GT, Whitelaw WA, Rosenal TW, et al. Diaphragm function after upper abdominal surgery in humans. Am Rev Respir Dis 1983; 127:431. Marshall BE, Wyche MQ Jr. Hypoxemia during and after anesthesia. Anesthesiology 1972; 37:178.
  • 8. PERIOPERATIVE PULMONARY PHYSIOLOGY • Residual effects of anesthesia depress the respiratory drive Inhibition of cough and impairment of mucociliary clearance of respiratory secretions. A decrease in TV increase in RR Cough dynamics in oesophageal cancer: prevention of postoperative pulmonary complications. Sugimachi K, Ueo H, Natsuda Y, Kai H, Inokuchi K, Zaitsu A Br J Surg. 1982;69(12):734.
  • 9. POSTOPERATIVE PULMONARY DYSFUNCTION Alterations in ventilation and perfusion distrubution, in respiratory mechanics Postoperative Pulmonary Dysfunction Postoperative Pulmonary Complications Wynne R et al. AJCC 2004; 13: 384 - 93
  • 10. Outlines of The Approach • Patient related risk factors • Procedure related risk factors • Preoperative risk assessment • Risk reduction strategies
  • 11. Patient related risk factors • Age • Health state • Obesity • Smoking • COPD • Asthma • Pulmonary hypertension • Heart failure • Metabolic factors
  • 12. Age • Minor risk factor • Independent predictor • Surgery should not be declined in elderly patients who are otherwise acceptable surgical candidates. Prediction of outcome of surgery and anesthesia in patients over 80.,Djokovic JL, Hedley- Whyte J-JAMA. 1979;242(21):2301. Postoperative intensive care admittance: the role of tobacco smoking.-Møller AM, Maaløe R, Pedersen T-Acta Anaesthesiol Scand. 2001;45(3):345
  • 13. Age • >50 y was an important independent predictor of risk. • When compared to patients <50 years old, 50 - 59 y, 60 - 69 y 70 - 79 y, & ≥80 y  (OR) of 1.50 , 2.28 , 3.90 , and 5.63 , respectively. • Even healthy older patients carry a substantial risk of pulmonary complications after surgery. Preoperative pulmonary risk stratification for noncardiothoracic surgery: systematic review for the American College of Physicians. Smetana GW, Lawrence VA, Cornell JE, American College of Physicians Ann Intern Med. 2006;144(8):581.
  • 14. General health status • Functional dependence and impaired sensorium each increase postoperative pulmonary risk . (ASA) classification correlates well with pulmonary risk (significant preexisting lung disease would be classified in a higher ASA class) ASA class >2 confers a 4.87 fold increase in risk . Preoperative pulmonary risk stratification for noncardiothoracic surgery: systematic review for the American College of Physicians. Smetana GW, Lawrence VA, Cornell JE, American College of Physicians Ann Intern Med. 2006;144(8):581.
  • 15. AMERICAN SOCIETY OF ANAESTHESIA(ASA) CLINICAL SCORE • ASA- I No systemic disorder • ASA- II Mild disorder • ASA- III Moderate disorder * • ASA- IV Severe disorder • ASA- V Cause of death
  • 16. ASA
  • 17. Smoking • Current cigarette smokers have an increased risk ,even in the absence of chronic lung disease . • A prospective cohort study of 410 patients undergoing elective, noncardiac surgery found that smoking was associated with a greater than five-fold increase in the postoperative complication rate (OR = 5.5) . A prospective survey of the incidence of postoperative pulmonary complications. Wightman JA Br J Surg. 1968;55(2):85. Preoperative smoking habits and postoperative pulmonary complications. Bluman LG, Mosca L, Newman N, Simon DG -Chest. 1998;113(4):88
  • 18. Smoking • Smoking history of 40 pack years or more →↑risk of pulmonary complications • stopped smoking < 2 months : stopped for > 2 months = 4:1 (57% : 14.5%) • quit smoking > 6 months : never smoked = 1:1 (11% : 11.9%) Preoperative smoking habits and postoperative pulmonary complications.Bluman LG, Mosca L, Newman N, Simon DG /Chest. 1998;113(4):883. Relationship between the duration of the preoperative smoke-free period and the incidence of postoperative pulmonary complications after pulmonary surgery./Nakagawa M, Tanaka H, Tsukuma H, Kishi Y/Chest. 2001;120(3):705
  • 19. COPD • Unadjusted relative risks have ranged 2.7 to 6.0 . • A more recent systematic review  impact was less than previously estimated . multivariable analysis to adjust for patient-related confounders odds ratio for postoperative pulmonary complications was 2.36 (CI 1.90-2.93). Preoperative pulmonary evaluation. /Smetana GW N Engl J Med. 1999;340(12):937. Preoperative pulmonary risk stratification for noncardiothoracic surgery: systematic review for the American College of Physicians. Smetana GW, Lawrence VA, Cornell JE, American College of Physicians Ann Intern Med. 2006;144(8):581.
  • 20. Asthma • Despite early reports indicating that patients with asthma had higher rate. • Recent studies have found no link for patients with well- controlled asthma. The largest studied 706 patients with asthma undergoing general surgery . Perioperative respiratory complications in patients with asthma. Warner DO, Warner MA, Barnes RD, Offord KP, Schroeder DR, Gray DT, Yunginger JW /Anesthesiology. 1996;85(3):460.
  • 21. Obesity • Morbid obesity → restrictive lung disease ↓ thoracic compliance alveolar hypoventilation
  • 22. Obesity • Obesity is not a significant risk factor not affect patient selection for otherwise high-risk procedures • A systematic review found that, among 8 studies using multivariate analysis, only one study identified obesity as an independent predictor . Preoperative pulmonary risk stratification for noncardiothoracic surgery: systematic review for the American College of Physicians. Smetana GW, Lawrence VA, Cornell JE, American College of Physicians Ann Intern Med. 2006;144(8):581.
  • 23. Obstructive sleep apnea (OSA) • An emerging risk factor for postoperative pulmonary complications. • Increases the risk of critical respiratory events immediately after surgery, including early hypoxemia and unplanned reintubation. Practice guidelines for the perioperative management of patients with obstructive sleep apnea: a report by the American Society of Anesthesiologists Task Force on Perioperative Management of patients with obstructive sleep apnea. Gross JB, Bachenberg KL, Benumof JL, Caplan RA, Connis RT, CotéCJ, Nickinovich DG, Prachand V, Ward DS, Weaver EM, Ydens L, Yu S, American Society of Anesthesiologists Task Force on Perioperative Management Anesthesiology. 2006;104(5):1081.
  • 24. OSA • The largest study to date ,evaluated 3.4 million general surgical and 2.6 million orthopedic patients from an administrative database . Patients with OSA were more likely to develop respiratory failure (OR 1.95, CI 1.91- 1.98) and aspiration pneumonia (OR 1.37, CI 1.33-1.41). Comparable rates : GS OR 5.20 (CI 5.05-5.37) ORTHOOR 1.41 (CI 1.35-1.47) Screening ?? Perioperative pulmonary outcomes in patients with sleep apnea after noncardiac surgery. Memtsoudis S, Liu SS, Ma Y, Chiu YL, Walz JM, Gaber-Baylis LK, Mazumdar M Anesth Analg. 2011 Jan;112(1):113-21. Epub 2010 Nov 16
  • 25. Pulmonary hypertension • Increases complication rates after surgery, including in patients with mild to moderate pulmonary hypertension. • Regardless of the underlying etiology. Noncardiothoracic nonobstetric surgery in mild-to-moderate pulmonary hypertension. Price LC, Montani D, Jaïs X, Dick JR, Simonneau G, Sitbon O, Mercier FJ, Humbert M Eur Respir J. 2010;35(6):1294. Impact of pulmonary hypertension on the outcomes of noncardiac surgery: predictors of perioperative morbidity and mortality. Ramakrishna G, Sprung J, Ravi BS, Chandrasekaran K, McGoon MD J Am Coll Cardiol. 2005;45(10):16
  • 26. Heart failure • The risk higher in patients with heart failure than in those with COPD. • Systematic review pooled adjusted odds ratio for pulmonary complications were 2.93 (95% CI 1.02-8.43) for heart failure patients and 2.36 (1.90-2.93) for patients with COPD. Preoperative pulmonary risk stratification for noncardiothoracic surgery: systematic review for the American College of Physicians. Smetana GW, Lawrence VA, Cornell JE, American College of Physicians Ann Intern Med. 2006;144(8):581.
  • 27. Metabolic factors • Albumin less than 3 g/dL OR 2.53 • Blood urea nitrogen (BUN) >30 mg/Dl OR 2.29 • A systematic review found that the magnitude of risk associated with a low serum albumin was similar to the degree of the most important patient-related risk factors and a stronger predictor of risk than an elevated BUN
  • 28. Procedure related risk factors • Surgical site • Duration and type of anesthesia • Type of neuromuscular blockade
  • 29. Surgical site • The most important predictor of pulmonary complications • The incidence of complications is inversely related to the distance of the surgical incision from the diaphragm • The complication rates for upper abdominal and thoracic surgery are the highest (range 10% to 40%) Preoperative pulmonary risk stratification for noncardiothoracic surgery: systematic review for the American College of Physicians. Smetana GW, Lawrence VA, Cornell JE, American College of Physicians Ann Intern Med. 2006;144(8)
  • 30. Surgical site (cont.) • Upper abdomen • Incisions cross the abd. muscle,↓ diaphragmatic motility → ↓VC • Lateral thoracotomy • Incision of the intercostal muscle, introduction of a pleural drain → pleural effusion, post-op pain → ↓ thoracic compliance
  • 31. Surgical site (cont.) Thoracotomy • Without pulmonary disease • VC ↓ to 60~70% of the pre- operative value • With pulmonary disease • The effects of thoracotomy are amplified • Thoractomy → thoracic pain → ↓deep breathing, effective coughing → atelectasis, bronchial mucous retention, worsening of gas exchange
  • 32. Surgical site (cont.) Video-assisted thoracoscopic surgery (VATS) • Reduced pain ,Postoperative complications, release and responses of proinflammatory cytokines, and better ventilatory function. • VATS lobectomy in NSCLC at clinical stage I could well be acceptable • with 97.2% 8-year survival rate , better than outcomes by thoracotomy.
  • 33. Surgical site (cont.) • Heart-surgery • usually require median sternotomy • functionally better tolerated than lateral thoracotomy (due to preserves the pleural space) • respiratory function is generally well preserved, except for a transitory reduction in pulmonary volumes.
  • 34. Duration and type of anaesthesia • Anesthesia time of > 3.5 -4hours →↑incidence of pulmonary complications • in a very high risk patient→ a less ambitious, briefer procedure • general anesthesia > epidural analgesia ,neuromuscular blocker and local anesthesia Postoperative intensive care admittance: the role of tobacco smoking. Møller AM, Maaløe R, Pedersen T Acta Anaesthesiol Scand. 2001;45(3):3
  • 35. Type of neuromuscular blockade • Pancuronium, a long-acting neuromuscular blocker • a higher incidence of postoperative residual neuromuscular blockade • a higher incidence of postoperative pulmonary complications in those patients with residual neuromuscular blockade Residual neuromuscular blockade and critical respiratory events in the postanesthesia care unit. Murphy GS, Szokol JW, Marymont JH, Greenberg SB, Avram MJ, Vender JS Anesth Analg. 2008;107(1):13
  • 37. ASSIGNMENT OF PREOPERATIVE RISKS CLINICAL EVALUATION (Basic rule) • History  Present / history of lung disease  Respiratory symptoms (dyspnea, cough)  Smoking  Other co morbid diseases  Drugs  Atopy (individual or family) history  Exercise intolerance
  • 38. ASSIGNMENT OF PREOPERATIVE RISKS • Physical Examination  Symptoms of increased sputum secretion (ralles)  Obstruction findings (Wheezing, prolonged expiration)  Symptoms of emphysema  Symptoms of respiratory insufficiency  Hypertension, arrthymia, tachycardia
  • 39. ASSIGNMENT OF PREOPERATIVE RISKS AND • Arterial blood gas • Chest X-Ray • Functional Evaluation (Spirometry,Diffusion Capacity) • Exercise Tests
  • 40. ARTERIAL BLOOD GASES –A DIFFERENT POINT OF VİEW • PaO2 < 50 mmHg Risk • PaO2 < 60 mmHg, PaCO2 > 50 mmHg Nagasaki F, Chest 1982; 82: 25-29 • PaCO2 > 45 mmHg resection with high risk Morice RC, Chest 1992; 101: 356-361 Bolliger CT, ERJ 1998; 11:198-212 CCP, Ann Inter Med 1990; 112: 793-794
  • 41. ARTERIAL BLOOD GASES – GENERAL OPINION • Hypercarbia in patients with COPD (PaCO2 > 45 mmHg), is not a certain contrendication but is believed to be with high surgical risk • Hypoxemia, is not a significiant predictor of complication alone Prediction of postoperative pulmonary complications in oesophagogastric cancer surgery. Fan ST, Lau WY, Yip WC, Poon GP, Yeung C, Lam WK, Wong KK Br J Surg. 1987;74(5):408.
  • 42. EVALUATION OF PREOPERATIVE RISKS • RADIOLOGICAL EVALUATION  There is no role of CXR in evaluating postoperative risks in healthy persons, but it must be performed.  Preoperative CXR is essential for patients >60Y with cardiac or pulmonary problems Value of routine preoperative chest x-rays: a meta-analysis. Archer C, Levy AR, McGregor M Can J Anaesth. 1993;40(11):102
  • 43. EVALUATION OF PREOPERATIVE RISKS EXERCISE TESTS • Walking test (6min) • Stair climbing test • Step test • “Shuttle walk” test • Bicycle ergometery ( MVO2 ) * Routine use before general surgery is not recommended EXCEPT FOR LUNG RESECTION
  • 44. PFT • Two reasonable goals to use of preoperative PFTs 1. Identification of a group of patients for whom the risk of the proposed surgery is not justified by the benefit 2. Identification of a subset of patients at higher risk for whom aggressive perioperative management is warranted
  • 45. PFT • These tests simply confirm the clinical impression of disease severity in most cases, adding little to the clinical estimation of risk • Overused
  • 46. ACP GUIDELINES 2006 • Not use preoperative spirometry routinely for predicting the risk of postoperative pulmonary complications . Obtain in: 1. COPD or asthma if clinical evaluation cannot determine if the patient is at their best baseline and that airflow obstruction is optimally reduced. 2. Dyspnea or exercise intolerance that remains unexplained after clinical evaluation. 3. ALL for lung resection PFTs should not be used as the primary factor to deny surgery
  • 47. SPIROMETERY  Postoperative risk (Gass & Olsen, 1986)  FVC < % 70  FEV1 < % 70 Complication risk  FEV1 / FVC < % 65 • A normal PFT does not demonstrate a lower postoperative complication rate
  • 48. PREOPERATIVE PULMONARY FUNCTION TESTS Severe COPD (FEV1 < % 50) • Preoperative PFT not predict postoperative pulmonary complication risk • Surgery time • ASA class predict significiantly • Surgery type Kroenke L. Arch Intern Med 1992
  • 49. PULMONARY RISK INDEXES  Cardiopulmonary Risk Index Epstein SK. Chest 1993;104:694  Lawrence Risk Index Lawrence WA. Chest 1996; 110: 744  Brooks – Brunn Risk Index Brooks-Brunn JA. Chest 1997;111: 564  Multifactorial Risk Index Arozullah AM. Ann Surg 2000; 232: 242
  • 50. Variant Score BMI > 27 kg/m2 1 Cigarette (last 8 weeks) 1 Productive coughing (last 5 days) 1 Wheezing (last 5 days) 1 FEV1/FVC < % 70 (predicted) 1 PaCO2 > 45 mmHg 1 Total 6 Pulmonary risk index: Factors that increase postoperative pulmonary complications > 4: Pulmonary risk % 73.4 < 4: Pulmonary risk % 11 PULMONARY RISK INDEX
  • 51. Score History Age > 70 5 MI (last 6 month) 10 Physical examination JVD or S3 11 Aortic valve stenosis 3 ECG Non-sinusoidal rhtym, atrial premature pulse 7 > 5 / min. Ventricular premature pulse 7 Status PO2 < 60 or PCO2 > 50 3 K > 3 or HCO3 < 20 BUN > 50 or Creatinin > 3 Chronic liver disease. Non-cardiac dis. Bed treatment. Surgery Thorac , abdom, aortic 3 Emergency surgery 4 Total 53 Class 1: 0-5 Class 2: 6-12 Class 3: 13-25 Class 4: > 25 GOLDMAN’ S CARDIAC RISK INDEX
  • 52. CARDIOPULMONARY RISK SCORE • Cardiac risk index score : 1 - 4 • Pulmonary risk index score : 0 – 6 Cardiopulmonary risk index score = 1-10 Cardiac ( 1- 4 ) + Pulmonary ( 0 - 6 ) Index > 4 : Complication risk 22 times higher Index < 2 : No Complication Epstein SK. Chest 1993;104:694.
  • 53. MULTIFACTORIAL RISK INDEX (Postoperative respiratoryinsufficiency)  Type of surgery  Abdominal aort aneurisym 27  Thoracic 21  Upper abdom., neurochirurgia, per.vascular 14  Neck 11  Emergency surgery 11  Albumin < 3.0 g/dL 9  BUN > 30 g/dL 8  Functional addiction ( partial or complete) 7  COPD 6  Age > 70 6  Age 60 - 69 4 Arozullah AM. Ann Surg 2000; 232: 242
  • 54. MULTIFACTORIAL RISK INDEX Degree Score Resp. Insufficiency % 1 < 10 0.5 2 11-19 1.8 3 20-27 4.2 4 28-40 10.1 5 > 40 26.6 Arozullah AM. Ann Surg 2000; 232: 242
  • 56. SPECIFIC EVALUATION OF LUNGS AIM • Severity of existing pathology and its reversibility • Estimation of predicted pulmonary function after resection
  • 57. RESECTION SURGERY • General Evaluation • Respiratory Function  Spirometry – FEV1  Diffusion Capacity  Postoperative FEV1 (FVC, DLCO, VO2 max) • ABG • Exercise Capacity
  • 58. Assessment for lung resection
  • 59. RESECTION SURGERY- SPIROMETRY  FEV1 is primary parameter  Pneumonectomy: Preoperative FEV1 > 2 L ( > % 80 predicted )  Lobectomy : Preoperative FEV1 > 1 L  Wedge and segmental resection = 0.6 L
  • 60. DIFFUSION CAPACITY • DLCO < % 50 major resection is contrendicated Cander L. A J Cardiol 1963 • DLCO < % 60 mortality risk % 24 • ppoDLCO < % 40 mortality risk % 33 Markos J, Mullan BP, Hillman DR, et al. Preoperative assessment as a predictor of mortality and morbity after lung resection. Am Rev Respir Dis 1989; 139: 902-910
  • 61. Split lung function studies • Predicting post-resection pulmonary function • Predicted postoperative FEV1 (ppoFEV1) is the most valid single test available • ppoFEV1 = preoperative FEV1 × (1– %functional tissue removed/100) • lung function can be calculated by counting the number of segments removed • The lungs contain 19 segments (3 right upper lobes, 2 right middle lobes, 5 right lower lobes, 3 left upper lobes, 4 left lower lobes, 2 left lingula)
  • 62. Split lung function studies(cont.) • Ventilation-perfusion(V/Q) scan • Quantitatve CT
  • 63. FEV1 AFTER RESECTION (QUANTITATIVE SCINTIGRAPHY) PNEUMONECTOMY Estimated Postoperative FEV1 = Preoperative FEV1 X perfusion percent of remaining lung LOBECTOMY Estimated Postoperative FEV1 = Preoperative FEV1 X Remaining segments after resection Total segments of both lungs
  • 64. FEV1 AFTER RESECTION If a part of resected segments is bronchoscopically obstructed Estimated Postoperative FEV1 = Preoperative FEV1 X [( 19-a ) - b] 19 – b a- Resected obstructed segments b- Resected open segments
  • 65. CARDIOPULMONARY EXERCISE TESTS • Important in lung resection surgery VO2 max = Aerobic capacity: amount of O2 requirement for major muscle groups for 5-15 minutes • Recommendation of BTS and ACCP  VO2max > 15 ml/kg/d Operable  VO2max < 15 ml/kg/d High risk BTS Guidelines: Guidelines on the selection of patients with lung cancer surgery. Thorax 2001; 56:89-108 Beckles MA, Spiro SG, Colice GL et al. The physiologic evaluation of patients with lung cancer being considered for resectional surgery. Chest 2003; 123: 105S-114S
  • 66. CARDIOPULMONARY EXERCISE TESTS Resection decision • VO2max > % 75 Good prognosis • VO2max > % 60 More than one lobe is contrendicated • VO2max < % 43 Any type of resection is contrendicated Bolliger CT,Jordan P,Soler M, et al. AJRCCM 1995;151:1472-1480
  • 67. CARDIOPULMONARY EXERCISE TESTS • Absolute value must be used  Eugene J, Brown SE, Light RV, et al. Surg Forum 1982; 33: 260-262  Smith TP, Kinasewitz GT, Tucker WY, et al. Am Rev Respir Dis 1984: 730-734  Bechard D, Wetstein L. Ann Thorac Surg 1987; 44: 344-349 • Absolute value or % value does not make a difference  Keddissi JI, Kinasewits GT. Chest 2005; 127: 1092-1094
  • 68. CARDIOPULMONARY EXERCISE TESTS • % value must be used  Bolliger CT, Soler M, Stulz P, et al. Respiration 1994; 61:181-186  Bolliger CT,Jordan P,Soler M, et al. AJRCCM 1995;151:1472-1480  Win T, JacksonA, Sharples L, et al. Chest 2005;127:1159-1165  Morice RC, Peters Ej,Ryan MB,et al.Chest 1992;101:356-361  Richter Larsen K, Svendsen UG, Nilman N, et al. Eur Respir J 1997;10:1559- 1565
  • 69. Assessment for lung resection
  • 70. Date of download: 11/11/2012 Copyright © American College of Chest Physicians. All rights reserved. Physiologic Evaluation of the Patient With Lung Cancer Being Considered for Resectional Surgery*: ACCP Evidenced-Based Clinical Practice Guidelines (2nd Edition) CHEST. 2007;132(3_suppl):161S-177S. doi:10.1378/chest.07-1359 Preoperative physiologic assessment of perioperative risk. CXR = chest radiograph.
  • 72. Stepwise approach to preoperative pulmonary assessment. Bapoje S R et al. Chest 2007;132:1637-1645 ©2007 by American College of Chest Physicians
  • 73. Risk reduction strategies • Pre-operative strategies • Intra-operative strategies • Post-operative strategies