Preoperative Pulmonary Evaluation

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Chapter 73 Preoperative Pulmonary Evaluation

Hilary Petersen, Peter Mazzone

Surgery can influence the patient’s pulmonary function. Pulmonary complications of surgery are common, costly, and increase morbidity and mortality in both the near term and the long term. The preoperative assessment of lung function and optimization of the management of preexisting lung conditions can improve outcomes. This chapter discusses surgery-related changes in pulmonary physiology, the impact of common postoperative pulmonary complications, risk factors for these complications, and recommendations for preoperative pulmonary assessment and management, including those related to the evaluation of the lung resection candidate.

Pulmonary Physiology

During and after surgery, ventilation, ventilation-perfusion matching, and airway clearance are altered by many mechanisms. The mechanisms responsible and the degree of impairment are influenced by the type of surgery and the patient’s underlying health. The following is a general description of potential physiologic changes related to surgery.

Ventilation

The supine position leads to decreases in all lung volumes, except tidal volume, because of the loss of the mechanical advantage provided by gravity. General anesthesia can worsen the restrictive defect in part through respiratory muscle relaxation and a shift of the balancing recoil forces of the lung and chest wall. Lung and chest wall mechanics are altered by surgery, particularly sternotomy, thoracotomy, and upper abdominal procedures. Diaphragm dysfunction and basal atelectasis may persist long after surgery. The residual effects of anesthesia can impair ventilatory drive in the immediate postoperative period. Shallow breathing related to pain and the effects of opiate use also contribute. In combination, functional residual capacity (FRC) can fall up to 50% for as long as 1 week in high-risk patients undergoing high-risk procedures.

Ventilation-Perfusion Matching

The reduction in FRC can be significant enough to result in atelectatic areas of the lung. Decreases in mucociliary clearance and the cough reflex secondary to anesthetic and opiate use and shallow breathing as a result of pain further contribute to the development of atelectasis. In atelectatic areas of the lung, ideal ventilation-perfusion matching shifts toward shunting where blood flow continues but ventilation is reduced or absent. This effect can be magnified by volatile anesthetic agents that influence hypoxic vasoconstriction. The end result of these changes is postoperative hypoxemia. Anemia and increased oxygen consumption may also contribute to observed oxygenation problems.

Airway Clearance

Many of these mechanisms impair the postoperative patient’s ability to clear their airways of mucus. Respiratory muscle dysfunction, atelectasis, pain, and medication use, resulting in a decreased cough reflex or decreased mucociliary clearance, are contributing factors.

Postoperative Pulmonary Complications

The frequency of postoperative pulmonary complications (PPCs) varies with type of surgery, the patient’s health, and the definition of the complication. Pulmonary complications of surgery are at least as common as cardiac complications and may result in prolonged hospital stays, increased morbidity and mortality, and increased costs (Table 73-1).

Table 73-1 Postoperative Pulmonary Complications

Surgery in General Lung Resection Surgery

AECOPD*

Acute lung injury

Aspiration events

Atelectasis

Bronchitis and pneumonias

Bronchospasm

Pulmonary embolism

Respiratory failure

Bronchopleural fistulas

Empyema

Nerve injury (phrenic, recurrent laryngeal)

Pleural effusions

Pulmonary edema

Postpneumonectomy syndrome

Pulmonary torsion

* Acute exacerbation of chronic obstructive pulmonary disease.

Risk Factors

The many risk factors for PPCs can be classified as patient or surgery related and assigned a simple rating based on the amount and quality of evidence available for support as a risk factor (Table 73-2).

Table 73-2 Selected Risk Factors for Developing Postoperative Pulmonary Complications

Risk Factor Level of Prediction
Systemic Disease  
Asthma (well controlled) Poor
Congestive heart failure Good
Chronic obstructive pulmonary disease Good
Diabetes mellitus Fair
Human immunodeficiency virus infection I
Obstructive sleep apnea Good
Pulmonary hypertension Fair
Signs and Symptoms  
Abnormal chest auscultation Good
Arrhythmia I
Functionally dependent Good
Impaired mental status Good
Poor exercise capacity Fair
Weight loss Good
Patient Features  
Alcohol user Good
Cigarette smoker Good
Corticosteroid use I
Objective Testing  
Albumin <35 g/L Good
Blood urea nitrogen >25 mg/dL Good
Chest radiography, abnormal finding Good
Spirometry I
Surgical Site  
Aortic aneurysm Good
Abdominal Good
Neurosurgery Good
Vascular Good
Hip Poor
Gynecologic or urologic Poor
Esophageal I
Surgical Factors  
Prolonged surgical duration Good
Emergent surgery Good
General anesthesia Fair
Perioperative transfusion Good

Good, ACP “A” or “B” rating or other data to support; Fair, ACP “C” rating or other data to support; Poor, ACP “D” rating, or is not a risk factor; I, indeterminate (insufficient data to support a rating.

Data from current American Academy of Chest Physicians (AACP) guidelines; Smetana GW et al: Cleve Clin J Med 73(Suppl 1):36–41, 2006; and other sources (see Suggested Readings).

Patient-Related Factors

In several studies, chronic obstructive pulmonary disease (COPD) has been found to double the risk of PPCs. The degree of risk is directly related to the severity of obstruction. One study of patients after upper abdominal surgery found that those with decreased breath sounds or other adventitious sounds (e.g., wheezing, rales) had a sixfold increased rate of PPCs.

In contrast, well-controlled asthma has not been found to be a risk factor for PPCs. A large retrospective analysis found that rates of bronchospasm, laryngospasm, and respiratory failure in patients with well-controlled asthma were comparable to healthy individuals. Those with poorly controlled asthma (e.g., more frequent albuterol use, recent emergency department visit for asthma) do have an increased risk for PPCs.

Pulmonary hypertension (PH), primary and secondary, may be associated with increased rates of PPCs and in-hospital mortality. In one study, 21% of patients with PH developed respiratory failure versus 3% in matched controls after noncardiac surgery.

A patient’s general health may be assessed by using the American Society of Anesthesiologists (ASA) classification system (Table 73-3). Studies have shown a direct correlation between a higher ASA class and increased pulmonary complications. Patients with an ASA Class III or higher have a twofold to threefold increase in PPCs compared with those with ASA Class II or lower. Difficulty or inability to perform activities of daily living has also been linked to increased complications.

Table 73-3 ASA Classification for Surgical Candidates

Class Patient Status
I Normal healthy patient
II Patient with mild systemic disease (e.g., mild asthma)
III Patient with severe systemic disease, but not incapacitated
IV Patient with life-threatening illness who is incapacitated
V Moribund patient
VI “Brain-dead” patient eligible for organ donation

ASA, American Society of Anesthesiologists.

Obesity alone does not seem to increase the risk of PPCs. A wide review of gastric and general surgeries shows that obese and morbidly obese patients have the same risk for PPCs as nonobese patients. However, the presence of a common comorbidity in obese patients, obstructive sleep apnea

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