Preoperative Pulmonary Evaluation Research Articles

Comprehensive strategies for preoperative pulmonary risk evaluation and management.

Postoperative pulmonary complications (PPCs) significantly increase morbidity and mortality in surgical patients, particularly those with pulmonary conditions. The incidence of PPCs varies widely, influenced by surgery type, patient age, smoking status, and comorbidities like chronic obstructive pulmonary disease (COPD) and congestive heart failure. Preoperative pulmonary function tests and chest radiographs, while critical for lung resection surgery, should be selectively used based on individual risk factors. Effective risk stratification models, including ASA classification, Arozullah Respiratory Failure Index, Gupta Calculators, and ARISCAT model, aid in predicting PPCs. Key strategies to reduce PPCs involve preoperative optimization of pulmonary conditions, smoking cessation, and respiratory rehabilitation. In COPD and asthma patients, maintaining optimal disease control through inhaled therapies, systemic corticosteroids, and preoperative respiratory exercises is crucial. Anemia and hypoalbuminemia are notable predictors of PPCs, warranting careful management. The type and duration of anesthesia significantly impact PPC risk, with regional anesthesia preferred over general anesthesia when feasible. Comprehensive preoperative evaluation and tailored interventions are essential to improve surgical outcomes and reduce PPC incidence. Further study involving domestic patients is needed to refine national guidelines for managing patients at risk of PPCs.

Pre-operative pulmonary risk assessment in surgery patients

Aims: Postoperative pulmonary complications (PPC) that may develop after surgery are important causes of morbidity and mortality. PPCs cause a prolongation of hospital stays and an increase in hospitalization costs. The study aims to determine factors associated with PPCs to predict PPCs in surgical patients undergoing preoperative evaluation. Methods: A retrospective cohort study was conducted at Şişli Hamidiye Etfal Training and Research Hospital using data from 200 patients referred for preoperative pulmonary evaluation from anesthesia and surgery clinics. This study analyzed the characteristics and outcomes of patients with PPC and those without PPC. The Canet pulmonary risk scores are used for PPC in all preoperative surgery patients. The study’s primary endpoints are to determine the development of respiratory failure, bronchospasm/asthma, COPD exacerbation, atelectasis, pleural effusion, or pneumonia. The study also analyzed the effective respiratory function parameters for PPC development using a logistic regression model. Results: The total study population included 200 patients with a median age of 53.5 years (aged between 19-88), 103 (51.5%) of whom were female. PPCs were observed in 38% (n=76) of the study group. There was a statistically significant difference between the patients in terms of the development of postoperative pulmonary complications according to gender (higher in males, p=0.001) and smoking (p=0.0001). Preoperative oxygen saturation (SpO2) and FEV1/FVC ratio were significant predictors of PPC development, and complications were more frequent in low-saturated patients (p=0.0001, p=0.013 respectively). The relationship between SpO2 and PPC was confirmed via logistic regression analysis. A one-unit increase in saturation reduced the occurrence of postoperative respiratory complications by 0.645-fold. The cut-off value for the saturation value was 97.5%, with a sensitivity of 46.8% and a specificity of 71.1% [p=0.0001, 95% CI, (0.521-0.798)]. Conclusion: In this study, the Canet (ARISCAT) score, a preoperative evaluation scale validated in Turkey that predicts postoperative pulmonary complications and mortality, was used. The Canet risk score is a simple risk score with moderate discriminatory performance for predicting PPCs. It may be useful in identifying individual patients at high risk of PPC and in the design of future studies to evaluate interventions to prevent these complications. However, a customized preoperative risk assessment system is needed for each patient.

LTSI Consensus Guidelines: Preoperative Pulmonary Evaluation in Adult Liver Transplant Recipients

The relationship between chronic liver disease and respiratory symptoms and hypoxia is well recognized. Over the last century, three pulmonary complications specific to chronic liver disease (CLD) have been characterized: hepatopulmonary syndrome, portopulmonary hypertension, and hepatic hydrothorax. Apart from thatcoexisting pulmonary disease like chronic obstructive lung disease and interstitial lung disease also complicate the outcomes after liver transplantation (LT). Assessment for evaluation of underlying pulmonary disorders is essential to improve outcomes in patients with CLD, posted for LT. This consensus guideline of the Liver Transplant Society of India (LTSI) provides a comprehensive review of pulmonary issues in CLD, related and unrelated to underlying liver disease and gives recommendations for pulmonary screening in specific clinical scenarios in adults with chronic liver disease planned for LT. This document also aims to standardize the strategies for preoperative evaluation of these pulmonary issues in this subset of patients. Proposed recommendations were based on selected single case reports, small series, registries, databases, and expert opinion. The paucity of randomized, controlled trials in either of these disorders was noted. Additionally, this review will highlight the lacunae in our current evaluation strategy, challenges faced, and will provide direction to potentially useful futuristic preoperative evaluation strategies.

Congress of Neurological Surgeons Systematic Review and Evidence-Based Guidelines for Perioperative Spine: Preoperative Pulmonary Evaluation and Optimization.

There are no current recommendations for preoperative pulmonary evaluation and management of patients undergoing elective spine surgery. The aim of this guideline is to determine preoperative risk factors for perioperative and postoperative pulmonary adverse events and to determine the optimal preoperative evaluation and management of at-risk patients. A systematic review of the literature was performed using the National Library of Medicine PubMed database and the Cochrane Library for studies relevant to postoperative pulmonary adverse events in patients undergoing spine surgery. Clinical studies evaluating preoperative patient risk factors and preoperative diagnostic and treatment interventions were selected for review. The literature search yielded 152 abstracts relevant to the PICO (patient/population, intervention, comparison, and outcomes) questions included in this chapter. The task force selected 65 articles for full-text review, and 24 were selected for inclusion in this systematic review. Twenty-three articles addressed preoperative patient risk factors. One article addressed preoperative diagnostic studies of pulmonary function. There were no studies meeting the inclusion criteria for preoperative pulmonary treatment. There is substantial evidence for multiple preoperative patient factors that predict an increased risk of a postoperative pulmonary adverse event. Individuals with these risk factors (functional dependence, advanced age [≥65 yr], chronic obstructive pulmonary disease, congestive heart failure, weight loss, and obstructive sleep apnea) who are undergoing spine surgery should be counseled regarding the potential increased risk of a perioperative and postoperative pulmonary adverse events. There is insufficient evidence to support any specific preoperative diagnostic test for predicting the risk of postoperative pulmonary adverse events or any treatment intervention that reduces risk. It is suggested, however, to consider appropriate preoperative pulmonary diagnostic testing and treatment to address active pulmonary symptoms of existing or suspected disease.The full guidelines can be accessed at https://www.cns.org/guidelines/browse-guidelines-detail/5-preoperative-pulmonary-evaluation-optimization.

Relationship between preoperative pulmonary risk assessment and postoperative pulmonary complications in patients undergoing cranial surgery in the presence of chronic disease

Postoperative complications are becoming more and more important than the risk given in preoperative pulmonary evaluation due to the increase in patients requiring surgical intervention. Patients undergoing craniotomy are routinely evaluated preoperatively, but the role of these evaluations in predicting outcomes has not been adequately studied. We aimed to investigate the effect of preoperative pulmonary risk assessment and the type of operation performed on postoperative complications and mortality concerning the presence of chronic disease in patients undergoing cranial surgery in the light of the literature. Preoperative pulmonary consultation data and postoperative pulmonary consultations, if any, of cranial surgery patients who were operated on in the neurosurgery clinic of a tertiary hospital were retrospectively analyzed. 85 (43.8%) of the surgical patients were male and 109 (56.2%) were female, and the average age of 194 people was 74 (35-90). 83 (42.7%) of the patients had at least one chronic disease. Considering the preoperative pulmonary risks, 72 (37.1%) patients were given medium risk. Statistically, the mortality rate was higher in those with ICU beds. Atelectasis in 10 (5.15%) patients, pneumonia in 7 (3.608%) patients, embolism in 3 (1.5%) patients, respiratory failure in 3 (1.5%) and bronchospasm in 2 (1%) patients, respectively. Postoperative pulmonary complications developed in 25 (12.9%) patients. Prediction of respiratory complications with effective preoperative pulmonary evaluation is important in terms of decreasing morbidity and mortality and decreasing the length of hospital stay. Since most of the complications are seen in patients given high risk in the preoperative period, close follow-up of high-risk patients in the postoperative period is important.

Role of spirometry for preoperative evaluation of stable COPD patients before elective laparoscopic cholecystectomy

Introduction: Postoperative pulmonary complications (PPC) are the main source of postoperative morbidity and mortality. Chronic Obstructive pulmonary Disease (COPD) patients are at 3 times more risk for the development of PPCs. Spirometry is commonly done as a part of preoperative evaluation. Our objective is to assess role of spirometry to predict PPCs in patients with stable COPD following laparoscopic Cholecystectomy. Material and Methods: This is a prospective observational study at a tertiary care centre. The study was approved by institutional ethics committee. 134 stable COPD patients posted for elective laparoscopic cholecystectomy under combined general epidural anaesthesia were included. Detailed clinical history was taken, physical examination was done, quality of life was assessed by COPD Assessment Test (CAT) score, chest X-ray, ABG, ECG, 2 D Echo, Spirometry, 6 minute walk test (6MWT) were done. Patients were followed up till discharge. Data of was analyzed by SPSS 11. Results: Out of 134 patients 112 (83.6%) were males and 22 (16.4%) were females. All were of more than 40yrs. All patients had CAT score > 10. 68 males and 16 females had FEV1 (Forced expiratory volume in 1 second) Conclusion: In patients with stable COPD of known severity, preoperative spirometry may not provide additional information in predicting PPC. Routine spirometry and arterial blood gases are not required for preoperative pulmonary evaluation in patients with stable COPD prior to laparoscopic cholecystectomy. Keywords: Preoperative; Spirometry; Pulmonary disease; Chronic obstructive; Postoperative complications.

Preoperative Pulmonary Evaluation and Evaluation of Postoperative Pulmonary Complications in Geriatric Patients Undergoing Spinal Surgery

Preoperative Pulmonary Evaluation and Evaluation of Postoperative Pulmonary Complications in Geriatric Patients Undergoing Spinal Surgery

Rethinking respiratory function laboratories in the era of coronavirus disease 2019: Considerations for today and the day after

Rethinking respiratory function laboratories in the era of coronavirus disease 2019: Considerations for today and the day after

Preoperative Pulmonary Evaluation

The purpose of this article is to provide a brief review of the preoperative pulmonary evaluation of patients undergoing non-thoracic surgery, focusing on risk factor identification, assessment of specific high-risk populations, and strategies to minimize postoperative pulmonary complications (PPCs). Along with traditional risk factors, recent risk stratification indices have been developed and validated to help quantify risk of PPCs. Careful history and physical examination are key elements in the pulmonary evaluation of all pre-surgical patients. Patients with chronic obstructive pulmonary disease (COPD) are at increased risk and require more intensive optimization and perioperative monitoring. Well-controlled asthma has not been associated with increased risk of PPCs but the potential for life-threatening bronchospasm and status asthmaticus cannot be ignored. In general, the literature does not support delaying surgery for preoperative diagnosis and management of obstructive sleep apnea (OSA). Exceptions to this rule are patients presenting with evidence of obesity-hypoventilation syndrome or pulmonary hypertension. Recent literature provides more evidence of benefits of regional anesthesia and analgesia to decrease the risk of pulmonary complications, particularly in COPD patients. PPCs are major contributors to perioperative morbidity and mortality. A thorough preoperative evaluation must identify high-risk patients, optimize chronic and acute respiratory diseases, and establish a clear perioperative plan to minimize PPCs.

Preoperative pulmonary evaluation for lung resection.

Preoperative assessment is a very crucial step in anesthesia management. Anatomical resection (lobectomy or pneumonectomy) offers best long-term prognosis to a lung cancer patient. At the same time, surgery cannot be offered to a patient who is expected to become ventilator dependent, postoperatively. Hence, it is very important to have an objective preoperative assessment for risk stratification. This review article provides a systematic approach for the prognostication of patients planned for pulmonary resection.

Neoadjuvant and adjuvant therapy for Stage III non-small cell lung cancer.

The treatments for advanced non-small cell lung cancer (NSCLC) should control both local and microscopic systemic disease, because the 5-year survival of patients with Stage III NSCLC who underwent surgical resection alone has been dismal. One way to improve surgical outcome is the administration of chemotherapy before or after the surgical procedure. During the last two decades, many clinical studies have focused on developing optimal adjuvant or neoadjuvant chemotherapy regimens that can be combined with surgical treatment and/or radiotherapy. Based on the results of those clinical studies, multimodality therapy is considered to be an appropriate treatment approach for Stage IIIA NSCLC patients; although, optimal treatment strategies are still evolving. When N2 nodal involvement is discovered postoperatively, adjuvant cisplatin-based chemotherapy confers an overall survival benefit. The addition of postoperative radiotherapy might be considered for patients with nodal metastases. Although definitive chemoradiation remains a standard of care for cN2 NSCLC, alternative approaches such as induction chemotherapy or chemoradiotherapy and surgery can be considered for a selective group of patients. When surgical resection can be performed after induction therapy with low risk and a good chance of complete resection, the outcome may be optimal. The decision to proceed with resection after induction therapy must include a detailed preoperative pulmonary function evaluation as well as a critical intraoperative assessment of the feasibility of complete resection.

Pre-operative pulmonary evaluation in the patient with suspected respiratory disease.

Post-operative pulmonary complications (POPC) occur frequently, especially in patients with pre-existing pulmonary disease and have a significant effect on post-surgical morbidity and mortality. By understanding the patient's existing pulmonary diseases that have a significant effect on post-operative morbidities a combination of information has to be gathered from a thorough history and physical exam as well as selected laboratory and diagnostic tests. Evidence based scores can then be employed to predict the risk of significant POPC. Numbers and testing alone, however, such as diagnosis of chronic obstructive pulmonary disease based on spirometry, may not provide as clear a picture as of the true risk of POPC that is determined by a combination of estimations of the patient's functional status, (b) measured by the patient's estimates of activity and (c) confirmed by the patient's ability to perform simple tasks such as the 6-minute walk test. This information can then be used to rationalize perioperative interventions and improve the safety of the perioperative experience.

Cardiopulmonary function and scoliosis severity in idiopathic scoliosis children.

PurposeIdiopathic scoliosis is a structural lateral curvature of the spine of unknown etiology. The relationship between degree of spine curvature and cardiopulmonary function has not yet been investigated. The purpose of this study was to determine the association between scoliosis and cardiopulmonary characteristics.MethodsNinety children who underwent preoperative pulmonary or cardiac evaluation at a single spine institution over 41 months were included. They were divided into the thoracic-dominant scoliosis (group A, n=78) and lumbar-dominant scoliosis (group B, n=12) groups. Scoliosis severity was evaluated using the Cobb method. In each group, relationships between Cobb angles and cardiopulmonary markers such as forced vital capacity (FVC), forced expiratory volume in one second (FEV1), FEV1/FVC, left ventricular ejection fraction, pulmonary artery flow velocity, and tissue Doppler velocities (E/E', E'/A') were analyzed by correlation analysis linear regression.ResultsIn group A, 72 patients (92.3%) underwent pulmonary function tests (PFTs), and 41 (52.6%) underwent echocardiography. In group B, 9 patients (75.0%) underwent PFT and 8 (66.7%) underwent echocardiography. Cobb angles showed a significant negative correlation with FVC and FEV1 in group A (both P<0.05), but no such correlation in group B, and a significant negative correlation with mitral E/A ratio (P<0.05) and tissue Doppler E'/A' (P<0.05) in group A, with a positive correlation with mitral E/A ratio (P<0.05) in group B.ConclusionPulmonary and cardiac function was significantly correlated with the degree of scoliosis in patients with thoracic-dominant scoliosis. Myocardial diastolic function might be impaired in patients with the most severe scoliosis.

Presurgical pulmonary evaluation in renal transplant patients.

Patients with chronic renal failure (CRF) due to various mechanisms are prone to significant pulmonary comorbidities. With the improvements in renal replacement therapy (RRT), patients with CRF are now expected to live longer, and thus may develop complications in the lung from these processes. The preferred treatment of CRF is kidney transplantation and patients who are selected to undergo transplant must have a thorough preoperative pulmonary evaluation to assess pulmonary status and to determine risk of postoperative pulmonary complications. A MEDLINE®/PubMed® search was performed to identify all articles outlining the course of pre-surgical pulmonary evaluation with an emphasis on patients with CRF who have been selected for renal transplant. Literature review concluded that in addition to generic pre-surgical evaluation, renal transplant patients must also undergo a full cardiopulmonary and sleep evaluation to investigate possible existing pulmonary pathologies. Presence of any risk factor should then be aggressively managed or treated prior to surgery.

Management of Acute Spinal Fractures in Ankylosing Spondylitis

Ankylosing Spondylitis (AS) is a multifactorial and polygenic rheumatic condition without a well-understood pathophysiology (Braun and Sieper (2007)). It results in chronic pain, deformity, and fracture of the axial skeleton. AS alters the biomechanical properties of the spine through a chronic inflammatory process, yielding a brittle, minimally compliant spinal column. Consequently, this patient population is highly susceptible to unstable spine fractures and associated neurologic devastation even with minimal trauma. Delay in diagnosis is not uncommon, resulting in inappropriate immobilization and treatment. Clinicians must maintain a high index of suspicion for fracture when evaluating this group to avoid morbidity and mortality. Advanced imaging studies in the form of multidetector CT and/or MRI should be employed to confirm the diagnosis. Initial immobilization in the patient's preinjury alignment is mandatory to prevent iatrogenic neurologic injury. Both nonoperative and operative treatments can be employed depending on the patient's age, comorbidities, and fracture stability. Operative techniques must be individually tailored for this patient population. A multidisciplinary team approach is best with preoperative nutritional assessment and pulmonary evaluation.

Preoperative pulmonary evaluation of liver transplant candidates: Results from 341 adult patients

Pulmonary disorders are among the commonly encountered and prognostically important problems in patients with chronic liver disease. To define the prevalence and types of respiratory disorders in patients with advanced liver disease evaluated for liver transplant (LT) candidacy, and to determine factors affecting postoperative outcome. The records of 341 adult patients evaluated for LT candidacy were retrospectively examined. Demographic, clinical and laboratory data including chest X-ray, spirometry and echocardiography results were collected. Postoperative pulmonary complications and mortality rates were determined. With a mean age of 45.1 years, 73 (21.4%) patients presented with respiratory symptoms or signs. The most common radiographic abnormality on chest X-ray was right diaphragm elevation (53.2%). Hypoxemia was detected in 38.1% of the patients. Pulmonary hypertension was detected in 100 of 327 (30.6%) patients on Doppler echocardiography. There were 141 patients who underwent surgery. Postoperative pulmonary complications developed in 60 patients, with pneumonia being the most prevalent complication (n=28). Smoking, emphysema, abnormal spirometry, pulmonary hypertension, hypoxia and orthodeoxia were found to be factors associated with increased postoperative pulmonary complications (P<0.05 for all). Mortality rate was 24.1% (n=34) and found to be significantly higher in patients who developed a postoperative complication than in those who did not (38.7% vs. 13.8%, respectively; p=0.001). The authors' findings indicate that pulmonary disorders impact prognosis and are common in patients evaluated for LT candidacy. Postoperative pulmonary complication is one of the major factors affecting mortality. Therefore, in order to increase the success of the transplant operation, a thorough preoperative pulmonary evaluation is of paramount importance.

Valor dos achados clínicos e da avaliação funcional pulmonar pré-operatórios como preditores das complicações pulmonares pós-operatórias

To assess the relationship of clinical data and the results of preoperative pulmonary functional evaluation with postoperative pulmonary complications. We conducted a retrospective cohort study with patients who underwent pulmonary functional evaluation over a period of 5 years. We analyzed clinical, demographic and spirometric data, surgical procedures performed and postoperative pulmonary complications. We analyzed the medical records of 521 patients. Mean age was 59.5 ± 14 years, 65.8% were male, and 93.4% were white. Mean FEV1 was 76.6 ± 24.6% of predicted. There were clinical comorbidities in 73.5% of all cases (COPD in 29.8%). The most common surgical sites were thorax (n = 122; 23.4%) and upper abdomen (n = 117; 22.5%). Postoperative pulmonary complications occurred in 99 patients (19.0%), with respiratory failure being the most common (4.6%). Forty-three (8.3%) patients died. Rates of pulmonary complications were higher after thoracic (28.9%), cardiac (28%) and upper abdomen surgery (24.3%) (p ≤ 0.0001). Most patients (66.7%) with pulmonary complications were classified as ASA III or IV (p<0.01), and in 70.2% of operations, time on anesthesia was > 3.5 hours (p ≤ 0.0001). The difference in median length of hospital stay between patients with and without pulmonary complications was statistically significant (23.5 [15.8-34] days vs. 10 [6-18] days; p<0.001). Patients who had never smoked had fewer complications than those with current or past smoking history (p=0.04). We did not detect significant associations between postoperative pulmonary complications and presence of COPD, FEV1 or body mass index (p>0.05). The most important factors associated with postoperative pulmonary complications were surgical site, time of anesthesia, and ASA classification.

Pre-operative pulmonary evaluation of lung cancer patients: a review of the literature

Complete anatomical resection of the primary tumour is still the standard of care in patients with early stage lung cancer. Because these patients are usually smokers who also suffer from chronic obstructive pulmonary disease, regional differences in pulmonary function due to lung tissue destruction exist. The purpose of the present article is to evaluate the currently available guidelines and to discuss novel methods for the pre-operative functional and anatomical pulmonary evaluation in lung cancer patients. Despite the fact that knowledge on the pre-operative evaluation of the pulmonary function has substantially increased during the past decade, the majority of the studies are small, underpowered and, with exception of a proposed algorithm, not prospectively validated in independent cohorts. The future harmonisation of guidelines is required and novel imaging techniques should be incorporated in the pre-operative evaluation in chronic obstructive pulmonary disease patients with borderline pulmonary function.

Preoperative pulmonary assessment of children for liver transplantation

Pulmonary assessment should be part of the preoperative investigation of pediatric patients with chronic liver disease undergoing liver transplantation, as it allows the identification of pulmonary alterations that influence candidacy for transplantation and survival. To describe pulmonary changes found in pediatric patients who were candidates for liver transplantation. Retrospective study of 17 pediatric liver transplant candidates undergoing preoperative pulmonary evaluation assessing pulmonary clinical data, arterial blood gas analysis, CXR, respiratory function test by spirometry, pulmonary scintigraphy, and CEE. Ten patients presented normal chest roentgenograms. The most common radiographic change was interstitial infiltrate in the lung bases. Of the five patients with PaO(2) <70 mmHg, four had cyanosis and dyspnea and two were diagnosed with HPS with intrapulmonary shunt evidenced by contrast echocardiogram. Two patients presented with intrapulmonary shunt but without hypoxemia. Spirometry was normal in six patients, restrictive disturbance was evidenced in one patient, obstructive in three, and combined in two. The most common scintigraphic change was heterogeneous pulmonary perfusion. Pulmonary assessment should be performed routinely in pediatric patients prior to liver transplantation, even in asymptomatic patients. Pulmonary assessment may indicate changes such as HPS that can increase postoperative morbidity/mortality.

Lung Cancer: Preoperative Pulmonary Evaluation of the Lung Resection Candidate

Lung resection provides the best chance of cure for individuals with early-stage non-small-cell lung cancer. Lung resection will lead to a decrease in lung function. The population that develops lung cancer often has concomitant lung disease and a reduced ability to tolerate further losses in lung function. The goal of the preoperative pulmonary assessment of individuals with resectable lung cancer is to identify those individuals whose short- and long-term morbidity and mortality would be unacceptably high if surgical resection were to occur. Pulmonary function measures such as the forced expiratory volume in 1 second (FEV1) and the diffusing capacity for carbon monoxide (DLCO) are useful predictors of postoperative outcome. When lung function in not normal, the prediction of postoperative lung function from preoperative results, and the assessment of exercise capacity, can help to clarify the risks. Testing algorithms and published guidelines help to direct the order of testing. Interventions that allow us to consider resection outside of the guidelines, or to maximize the potential to tolerate lung resection, help us to offer potentially curative treatment to as many as possible. Knowledge of alternative treatment options will help to guide those deemed unfit for resection.