Treatment Complications
H.2 Surgical Procedures

The decision regarding surgery in the COPD patient must weigh the necessity of the proposed procedure against the potential risk to the patient. Any patient with moderate to severe COPD is at increased risk for postoperative complications, particularly respiratory complications. Patients having thoracic or abdominal surgery are at highest risk, while the risk associated with operations on the extremities is relatively low. With appropriate preparation and good anesthetic technique, most operations can be completed successfully and the risk of postoperative complications reduced.

If a given surgery does not involve lung resection and is clearly lifesaving, there is no absolute contraindication to surgery based on pulmonary function. In fact, no level of pulmonary function is an absolute contra-indication to elective nonthoracic surgery that may result in a marked improvement in quality of life. However, a clearly elective procedure with minor implications for improving nonpulmonary function may not be justified in a patient with very severe airflow obstruction.

Preoperative Assessment

A preoperative assessment of the respiratory system in the patient with COPD should include spirometry and arterial blood gas measurements to quantitate the degree of abnormality and to document reversibility. Patients with very severe disease (FEV1 of approximately 1 liter or less) and those being considered for thoracic surgery, especially if resection of the lung is involved, require more extensive pulmonary function testing. Referral to a pulmonary specialist for this purpose is recommended. Evaluation for lung resection should generally follow the algorithm shown in Figure 6.

Preoperative Management

Long-range preparation (beginning several weeks before the operation) should include smoking cessation, if this has not already been achieved. Bronchodilator therapy should be optimized as described in Section G. This should include a short trial of oral prednisone in patients with severe disease (FEV1 <50% of predicted). Secretion clearance should also be optimized by order-ing a trial of chest physiotherapy and teaching the patient the proper technique for coughing after the inhalation of bronchodilators. Any measures that might be required postoperatively, including the use of incen-tive spirometry, should be introduced preoperatively.

Perioperative Management

The anesthesiologist should be alerted that the patient is a high-risk patient and should plan the anesthesia accordingly. Usually the procedure should be scheduled later in the day to allow the patient sufficient time to clear the night's accumulated secretions before being given preoperative medications. Intravenous corticosteroids are indicated perioperatively if the patient has been receiving corticosteroids preoperatively; 50 to 100 mg of prednisolone or an equivalent delivered intravenously is a common loading dose prior to surgery.

Postoperative Managment

Attention to postoperative analgesia is extremely important to allow effective coughing. Epidural analgesia and patient-controlled analgesia are particularly useful techniques. Extubation of the patient as soon as possible is recommended to restore the patient's ability to cough. Frequent deep breathing to counteract atelectasis and coughing to clear secretions should be encouraged.

Incentive spirometry is a convenient technique to encourage deep breathing. Early ambulation and mobilization following surgery are especially helpful to patients whose compromised respiratory function predisposes them to pulmonary complications. If immobilization is unavoidable, efforts should be made to turn the patient often and the use of a rotating bed should be considered.

Recently, resection of the lung to improve the functioning of the remaining lung (possibly by eliminating excessive volume and partially restoring elastic recoil aimed at a more effective position of the diaphragm) has been proposed to improve dyspnea in patients with severe COPD. Further experience with this procedure is warranted before it can be recommended for routine use and particularly before patients can be appropriately selected.

Lung Volume Reduction Surgery

The history of lung volume reduction surgery, (LVRS), is interesting. In the late 1950's, an operation to improve pulmonary function by resecting areas of severest damage from emphysema, was introduced by Brantigan. Although clinical benefit occurred in some patients, operative and postoperative complications caused surgeons to abandon this somewhat heroic operation in that era. Joel Cooper, who was one of the main pioneers in lung transplantation, reopened the issue of clinical and physiological improvements in the modern era and showed substantial benefits in selected patients. Since most of the candidates for lvrs were elderly Medicare patients, the Health Care Finance Administration in conjunction with the National Heart, Lung, and Blood Institute have mandated a randomized controlled clinical trial comparing pulmonary rehabilitation with initial pulmonary rehabilitation following by lvrs. The purpose of this study is to identify the candidates most likely to benefit physiologically, to determine whether or not the surgery has an acceptable perioperative morbidity and mortality, and if survival is altered by this technique. This study is know as the National Emphysema Therapy Trial, (NETT). It will be perhaps five to ten years before the results of the nett are completed.

Lung Transplantation

Lung transplantation is clearly established as beneficial for advanced stages of COPD. The limitation of organ availability, makes this dramatic surgery available to only a small minority of patients with advanced COPD, mostly of the emphysema type.

References

Bartlett RH. Respiratory therapy to prevent pulmonary complications of surgery. Respir Care 1984;29:667-679. This article is one of several published in two issues of Respiratory Care (May and June, 1984) from a symposium that dealt with perioperative respiratory care.

Boysen PG. Perioperative management of the thora-cotomy patient. Clin Chest Med 1993;14:321-333. This article is included in a highly recommended issue of Clinics in Chest Medicine dedicated to perioperative care. This particular article focuses on preoperative and intraoperative management aimed at improving pulmonary function during the postoperative period.

Brantigan OC, Kress M, Mueller E. The surgical approach to pulmonary emphysema. Dis Chest 1961;39:485-499. The description of Brantigan’s operative procedure designed to improve the elastic recoil in the lungs of patients with advanced emphysema.

Cooper JD, Patterson GA, Sundaresan RS, et al. Results of 150 consecutive bilateral lung volume reduction procedures in patients with severe emphysema. J Thorac Cardiovasc Surg 1996;112:1319-1333. Limited results of the lung volume reduction surgery series from the St. Louis group.

Cooper JD, Trulock EP, Triantafillou AN, et al. Bilateral pneumectomy (volume reduction) for chronic obstructive pulmonary disease. J Thorac Cardiovasc Surg 1995;109:106-119. The first report from the St. Louis group on the modern approach to lung volume reduction surgery.

Davis RD, Jr., Trulock EP, Manley J, et al. Differences in early results after single-lung transplantation. Ann Thorac Surg 1994;58:1327-1334. Report of 43 COPD patients of 83 single lung transplantations for all causes in the St. Louis series.

Hudson LD, Pierson DJ, Pavlin EG. Evaluation and management of the patient with lung disease who requires surgery. in Kelley W (ed). Textbook of Internal Medicine, Second Edition. Philadelphia: JB Lippincott Company, 1992, pp 1865-1870. This chapter is a succinct review of how to evaluate (in order to establish their increased risk for postoperative complications) and subsequently manage the patient with lung disease who requires surgery.

Luce JM. Clinical risk factors for postoperative pulmonary complications. Respir Care 1984;29:484- 495. A review of the variables that predispose a patient to an increased risk of developing postoperative pulmonary complications.

Marshall MC, Olsen GN. The physiologic evaluation of the lung resection candidate. Clin Chest Med 1993;14:305-320. A thorough review of the evaluation procedures and techniques designed to predict postoperative morbidity and mortality.

Yeager MP, Glass DD, Neff RK, et al. Epidural anesthesia and analgesia in high risk surgical patients. Anesthesiology 1987;66:729-736. A report of a randomized controlled clinical trial that demonstrated beneficial effects of epidural anesthesia and postoperative analgesia (eaa), on postoperative morbidity in a group of high-risk surgical patients.

Zibrak JD, O'Donnell CR. Indications for preoperative pulmonary function testing. Clin Chest Med 1993; 14:227-236. This article discusses the controversies surrounding the use of preoperative pulmonary function testing to identify high-risk surgical candidates.