Chronic obstructive pulmonary disease

Learning objectives

Manage patients with chronic obstructive pulmonary disease (COPD) in the pre-, and perioperative period

COPD is an inflammatory lung disease characterized by abnormalities of the airways (bronchitis, bronchiolitis) and alveoli (emphysema), causing chronic dyspnea, cough, excessive sputum production, and progressive airway obstruction

COPD is caused by a complicated interaction between chronic exposure to noxious stimuli, individual risk factors, and socioeconomic risk factors

Noxious stimuli

Individual risk factors

Socio-economic risk factors

1. Assess severity

Use ABCDE approach – take arterial blood gas, perform chest X-ray, apply full ASA-monitoring

2. Treat symptoms

Give supplemental O2 – titrate to achieve SaO2 of 88-92%
Bronchodilators
- ↑ dose and/or frequency of short-acting bronchodilators
- Combine short-acting beta-2-agonists and anticholinergics
- Give long-acting beta-2-agonists when stable
Give corticosteroids
Give antibiotics if signs of bacterial infection
If necessary, start noninvasive ventilation (NIV)

3. Identify and treat associated conditions

e.g., Heart failure, pulmonary embolism, arrhythmia

Preoperative assessment

Assess maximal level of exertion attainable
Perform
- Routine preoperative blood tests
- Electrocardiogram – to exclude concomitant heart disease
- Chest X-ray – if evidence of current infection or recent worsening of symptoms
- Spirometry – to confirm the diagnosis and to assess the severity of COPD
Treat symptoms aggressively
If signs of active respiratory infection, postpone non-emergency surgery
Strict smoking cessation
Preoperative physiotherapy may help reduce the incidence of intraoperative bronchial plugging or pneumonitis
Optimize nutritional status
- Obesity and underweight both increase perioperative risk
- Serum albumin level <35 mg/L is a strong predictor of postoperative pulmonary complications, give preoperative nutritional supplementation

Anesthetic regimen

Regional anesthesia (RA) decreases postoperative pulmonary complications
Light sedation, flexible positioning, or NIV might comfort patients who find it uncomfortable lying supine
General anesthesia in COPD carries higher risk for laryngospasm, bronchospasm, cardiovascular instability, barotraumas, and hypoxemia
To reduce the harmful effects of air trapping when mechanically ventilating
- Reduce the respiratory rate or the I:E ratio (to 1:3–1:5) to lengthen expiration
- Give PEEP to help keep small airways open during late exhalation
- Promptly treat bronchospasm
Fully reverse the neuromuscular blocking agent before extubation
Consider peri-extubation bronchodilator treatment
NIV post-extubation reduces the work of breathing and air trapping and has been shown to reduce the need for reintubation in the postoperative period after major surgery