Chronic obstructive airways disease

Clinical cases

Dr Abdullah Alsailamy

A 75-year-old man w ith chronic obstructive airways d ise a se requires a transurethral resection of the prostate. Out line the advantages and disadvantages of suba ra ch no id anaesthesia for this patient.
This q uestion does no t require a genera l ge ne ric discu ssion of the ad vantages and disad vantages of sp inal anaesthesia. You shou ld focu s yo ur answer round the fact , 5 ch ronic obstructive pu lmonary d isease. Both the su rgica l cond ithat the patient h,1 tion an d the medical di sease arc com m o n.

Intro d u ct io n Transurethra l uro logy lends itself well to reg iona l anaesthesia, bu t despite this not all urolog ical su rgeons share the anaes thetlsts' enth usias m and if given a choice prefer general an aesthesia. Coexisting pu lmonary d isease makes the argu ments in favour of subarach noid or ex trad ural analgesia more pers ua siv e, although there rem ain some d isadvantages.
In the patient with CO PD: main advantages lie in avoida nce of ge neral anaesthesia Full control of the airway and b rea thing. No airway instrumen tati on w ith the atte ndan t risk of provoking b ronchoconstrict i on. No risk of barotrauma (pneumothorax) with IPPV. No respirato ry dep ression. No d ifficulty in resum ptio n of adequate spon taneous ventilation . Lower risk of postoperative chest infection . Advan tages s peci fic for TU RP Earlier and easier detection of the TUR P synd rome. Ge neric ad va ntages of th e technique Possible lower risk of venous e mbolism. Good postopera tive analgesia (although pain after TURP is not usually severe). In th e patien t with COP D th e disadvantage s of spinal ana esth esia include: Respiratory compromise if the b lock sp reads to involve the intercosta l muscles. Patien ts w ith COPD may find it d ifficult to lie flat. Persistent coughing wi ll interfere with surgery. C ":I'I1l'riC di sadva ntages of th e techniq ue: I lypotension (in an elderly age group). Unsuitable fo r the restless or uncooperati ve patient. Stuno suggestion that there is increased fibrinolysis under suba rachnoid b lock (SAIl). Rlsk of postd ural puncture headache (small).

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How w ould you assess a patient with chronic obstructive pul m o nary disease (CO PO) who presents for laparotomy? Wha t a re the major perioperative risks and how may they be reduced?
A patient w ith se ve re COPD can p rese n t significan t anaesthetic challenges, the m ain one being how to ens ure that they may be kept off a ventilato r and o ut of an intensive care u nit. COPD is a spectrum o f d isease and the questio n is assessing your know ledge of the cond ition and yo u r judgement in its management.

Introduction
The cardina l feature of chronic obs truct ive pulmona ry d isease is increased ai rways resista nce to fl ow (hence th e alternative title of chronic obs tructive airways di sease). COPD is cha racterised by a disease spectru m tha t ranges from chronic bronchitis w hich lim its activity only m ildl y, to severe and incapacitating em ph ysema.

Preoperative assessment: history

Exercise tolerance (stair clim bing is a more reliabl e ind icator than wa lking on th e flat). Dyspnoe a (on se vere, mod erate o r minimal exe rtion, o r at rest). Spu tum and cough : chronic, o r is th ere evidence of acu te in tercurren t infection? Medica tion: steroids, b ron ch od ilators, d om icilia ry o xygen. Hospital and es pecially lTV ad m iss io ns for exacerba tions. Smoking history.

Preoperative assessment: signs

Body habi tus: are th ey barrel-chested, plethoric, asthenic? Dyspnoea : are they able to talk in sent ences at res t? Respi ra to ry pattern: is there ' fish mouth' b reath ing. use o f accesso ry muscles? Auscu lta tion: a re th ere wheeze s , crackles, adven titious sou nds? Right heart failu re: is th ere perip he ra l oede ma, jugu lar venous distension, hepato megaly?

Preoperative assessment: investigations

May just confirm the clinical im p ress ion ga ined fro m his tory and exa m ination, b ut may help qu antify the problem and assist in p red ictio n o f outcome. CXR: m ay show em physema tous b ullae, h yperinfla tio n, pa tch y atelectasis, fibrosis. fCG: m ay show righ t heart s train, low voltage. FBC: polycythaemia, leucocy tosis. Arteri al blood gases o n air: evaluation of baseline preoperative status and confirma tion of CO 2 retention if suspected. Pulmonary fu nction tests: spiro metry typically sho ws decreased FEV, and d ecreased FEV, : FVC (forced vita l capacity ) ratio. A large number 01 variabl es can be defined . Flo w- volume loops m ay be o f m o re use in characteris ing airway obs truction. An FEV1 : FVC ra tio o f <50% is associa ted w ith increased morbidity and mo rtality after all forms o f body cavity su rgery. Pred ictors: FEV 1 < 1 L. p.C02 > 7 kl'a , FEV! : rvc ra tio <50'>:111 predict n-quin- rm-nt for posto pera tive ve ntilatory su p po rt (p.trlkul.trly .,fhr u !'pt.r
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Perioperative risks: anaest hesia and surge ry

Anaesthesia Pulmonary fu nctio n . Exerts a generally d eleterious effect. Dec rease in FRC (33%), VC (u p to 50%), pulmonary comp liance etc. follow all for ms of general anaesthesia. Atelectas is, h ypoxaemia, h ypoventila tion are com mon. Barotrauma Assoc iated w ith IFPV and airways resis tance. Use of N 20 in presence of bullae or emphysematous blebs. Airways reactivity Associa ted w ith intubat ion, airw ay manip ulation. May be provoked by histamine releasin g anaesthetic agents (avoid). Surgery Bod y cavity s u rgery is associated with significa nt morbid ity: Thoracic and upper abdom ina l > low er abd ominal. Prolonged su rgery in su p ine positi on. Diaph ragmatic exc ursion is im paired, restricted respi rato ry ex pansion d ue to pain.

Risk reduction
The key to risk reduction is the op timisation of the patient's peri opera tivc cond ition : Smo king. Cessa tion is d ifficult in patien ts w ith a lifelong habit, bu t redu ction in postoperative respiratory morbidity w ill resul t it it can be achieved 2 months prio r to surgery. Pharmacology. Optimise the regim en, particul arly if there is a reversible com po nent. Approp riate antib iotic treatment o f any intercurren t chest infection. Physiotherapy. Pre-emptive and w ith use of techn iqu es such as incentive sp irometry. Analgesia. Good postoperative ana lgesia (i.e. by epid u ral) w ill red u ce respiratory com plica tions incid en t upon di aphragmatic splin ting and basal atalectasis due to inhibition of d eep brea thi ng by pain. Regional an aesth esia. Use wherever feasible, b ut must bew are anaesthetising the intercosta l muscles with high neu raxial blocks, or using techniques which impair ph renic nerve fu n ction (in terscalene block ). Am b u lation. Encourage early mobilisation.

Marking points: Clinical exper ience and judgement is as impo rta nt as the

respiratory numbers in deciding whet he r or not these pati ents are going to require postoperative intensive care. You need to emphasise those clinical features as well as outlining an a naest hetic st rategy that will minimise th at risk. Good preoperative pre paration and optimal postoperative a nalgesia are crucial to that aim.