Posted: April 30th, 2022

A narrative review of the importance of pre-surgery evaluation for chronic obstructive pulmonary disease

A narrative review of the importance of pre-surgery evaluation for chronic obstructive pulmonary disease

Chronic obstructive pulmonary disease (COPD) is a common and progressive respiratory disorder that affects millions of people worldwide. COPD is characterized by airflow limitation, chronic inflammation, and structural changes in the lungs. COPD patients often have comorbidities such as cardiovascular disease, diabetes, and osteoporosis, which increase their morbidity and mortality. COPD is also a major risk factor for postoperative pulmonary complications (PPCs), which are associated with increased hospital stay, costs, and mortality.

PPCs are defined as any respiratory adverse event that occurs within the first 30 days after surgery, such as atelectasis, pneumonia, respiratory failure, bronchospasm, or pulmonary embolism. The incidence of PPCs varies depending on the type of surgery, the patient’s characteristics, and the perioperative management. In general, thoracic and upper abdominal surgeries have the highest risk of PPCs, followed by lower abdominal and vascular surgeries. The risk of PPCs in COPD patients is estimated to be two to four times higher than in non-COPD patients.

Therefore, pre-surgery evaluation for COPD patients is essential to identify and optimize their respiratory status, to estimate their perioperative risk of PPCs, and to plan appropriate preventive and therapeutic strategies. The pre-surgery evaluation consists of a careful history and physical examination, focusing on the severity and control of COPD symptoms, the presence and treatment of comorbidities, the functional capacity and exercise tolerance, and the history of previous surgeries and anesthesia. Additionally, some laboratory tests may be indicated to assess the lung function, gas exchange, cardiac function, nutritional status, and infection risk of COPD patients.

The most commonly used test to measure lung function is spirometry, which provides information on the degree of airflow obstruction and its reversibility. Spirometry is recommended for all COPD patients before surgery, especially if they have dyspnea or a history of smoking. However, spirometry alone is not sufficient to predict the risk of PPCs or the effect of lung resection on postoperative lung function. Other tests that may be useful in selected cases are arterial blood gas analysis, chest radiography, lung volumes, diffusion capacity, cardiopulmonary exercise testing, and ventilation-perfusion scan.

The main goals of pre-surgery optimization for COPD patients are to reduce airway inflammation and bronchial hyperresponsiveness, to improve gas exchange and oxygen delivery, to prevent and treat respiratory infections, to correct nutritional deficiencies, and to manage comorbidities. The optimization strategies include pharmacological therapy (such as bronchodilators, corticosteroids, antibiotics, anticoagulants), non-pharmacological therapy (such as smoking cessation, pulmonary rehabilitation, oxygen therapy), and preoperative education (such as breathing exercises, incentive spirometry).

The perioperative management of COPD patients should be tailored according to their individual risk factors and the type of surgery. The choice of anesthesia technique (general or regional), the mode of ventilation (invasive or non-invasive), the use of prophylactic antibiotics or steroids, the pain control method (systemic or regional), and the postoperative care (monitoring, mobilization, physiotherapy) should be discussed among the multidisciplinary team involved in the care of COPD patients. The aim is to minimize the stress response to surgery, to avoid hypoventilation and hypoxemia, to prevent atelectasis and infection, to facilitate early extubation and recovery.

In conclusion, pre-surgery evaluation for COPD patients is important to improve their outcomes after surgery. A thorough assessment of their respiratory status and perioperative risk of PPCs should be performed before surgery. An individualized optimization plan should be implemented before surgery. A close perioperative monitoring and management should be provided during and after surgery.

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