Perioperative medical management of patients with COPD

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Authors: Marc Licker, Alexandre Schweizer, Christoph Ellenberger, Jean-Marie Tschopp, John Diaper, et al

Published Date January 2007 Volume 2007:2(4) Pages 493 - 515

DOI: http://dx.doi.org/10.2147/COPD.S

Marc Licker¹, Alexandre Schweizer¹, Christoph Ellenberger¹, Jean-Marie Tschopp^2,3, John Diaper¹, François Clergue¹

¹Service d’Anesthésiologie, Hôpitaux Universitaires de Genève, Genève, Switzerland; ²Service de Médecine Interne, Réseau Hospitalier du Valais, Sion, Switzerland; ³Centre Valaisan de Pneumologie, Montana, Switzerland

Abstract: Chronic obstructive pulmonary disease (COPD) and heart diseases are considered independent risk factors for mortality and major cardiopulmonary complications after surgery. Coronary artery disease, heart failure and COPD share common risk factors and are often encountered, - isolated or combined -, in many surgical candidates. Perioperative optimization of these high-risk patients deserves a thorough understanding of the patient cardiopulmonary diseases as well as the respiratory consequences of surgery and anesthesia.

In contrast with cardiac risk stratification where the extent of heart disease largely influences postoperative cardiac outcome, surgical-related factors (ie, upper abdominal and intra-thoracic procedures, duration of anesthesia, presence of a nasogastric tube) largely dominate patient’s comorbidities as risk factors for postoperative pulmonary complications.

Although most COPD patients tolerate tracheal intubation under “smooth” anesthetic induction without serious adverse effects, regional anesthetic blockade and application of laryngeal masks or non-invasive positive pressure ventilation should be considered whenever possible, in order to provide optimal pain control and to prevent upper airway injuries as well as lung baro-volotrauma. Minimally-invasive procedures and modern multimodal analgesic regimen are helpful to minimize the surgical stress response, to speed up the physiological recovery process and to shorten the hospital stay. Reflex-induced bronchoconstriction and hyperdynamic inflation during mechanical ventilation could be prevented by using bronchodilating volatile anesthetics and adjusting the ventilatory settings with long expiration times. Intraoperatively, the depth of anesthesia, the circulatory volume and neuromuscular blockade should be assessed with modern physiological monitoring tools to titrate the administration of anesthetic agents, fluids and myorelaxant drugs. The recovery of postoperative lung volume can be facilitated by patient’s education and empowerment, lung recruitment maneuvers, non-invasive pressure support ventilation and early ambulation.

Keywords: anesthesia, surgery, COPD, atelectasis, functional residual capacity