Specific Considerations With Pulmonary Disease - Chronic Obstructive Pulmonary Disease
Perioperative considerations
Perioperative considerationsCOPD is a leading cause of death worldwide and is associated with exposure to tobacco, biomass, and pollution. The major symptoms of COPD include dyspnea, cough, and or/sputum production. Exacerbations and rates of decline in respiratory mechanics are variable, reflecting the heterogenous nature of this syndrome that is influenced by genetics and environmental issues. The long-term prognosis of patients with COPD is usually assessed when these patients are hospitalized with “exacerbations” or a need for increased medications. Variables associated with poor prognosis include older age, lower body mass index (BMI), more and frequent exacerbations, and poor quality of life.
- Patients should utilize their inhalers on the day of the operation and should be in optimal condition in terms of their baseline lung function. Right heart function should be evaluated prior to the operation, and right heart failure and pulmonary hypertension should be treated since it is a significant risk factor for any procedure.
- Lung protective ventilation using Vt of 6 to 8 mL/kg based on predicted body weight (PBW) should be utilized intraoperatively to limit the risk of lung trauma (volutrauma). Many of these patients have intrinsic auto-PEEP (iPEEP), which is a failure to collapse alveoli at end exhalation. This will require a ventilator setting that allows a longer duration for exhalation. PEEP should be used judiciously; some suggest using PEEP levels to match or be just below auto-PEEP levels. If the patient is hypercapnic at baseline, the hypercapnia should be maintained during and after the operation/procedure. The patient may need supplemental oxygen after the operation, and high flow nasal cannula (HFNC) may be beneficial to decrease the work of breathing. Patients may require noninvasive mechanical ventilation postoperatively. Narcotics should be used judiciously in patients with hypercapnia.
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