1. Pre existing respiratory conditions.
Amber Woodcock

2. Contents Respiratory system Post operative pulmonary complications
Conditions/risk factors which predispose
OSA
COPD
Asthma
Pre op optimisation

3. Respiratory system Main functions: Oxygenation of blood
Removal of carbon dioxide
Produce a cough
Adjust respiratory rate to accommodate for problems, eg acidosis, pyrexia etc.
Image from clipart

4. Post operative pulmonary complications (PPC’S)
Various but some include:
Pneumonia
Aspiration pneumonitis
Pleural effusion
Re-intubation
Bronchospasm
Pneumothorax
And others…..
Image from clipart

5. Pre existing risk factors for PPC’s
Age
Smoker
Obesity
Current respiratory problem
Current respiratory symptoms
Resting saturations on air <92 %
Co-morbidities
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6. Obstructive sleep apnoea (OSA)
Apnoeas – no breathing for 10 secs
Hypopnoeas – 50% > airflow reduction for 10 secs.
More common in obese men
Due to peripheral and central factors (not fully understood).
Large number of people undiagnosed
Associated problems – pulmonary hypertension, polycythaemia, Hypertension, hypercarbia and hypoxia.
Image from clipart

7. OSA - screening
Stop bang criteria - Image from clipart

8. OSA – Risks and recomendations for anaesthesia
Recommendations
Increased mortality and morbidity
Poor laryngoscopy views
Difficult to ventilate
Loss of airway completely
Sleep studies to confirm diagnosis – overnight saturations
Weight loss
Avoid benzodiazepenes
Ask patient to bring CPAP machine with them to hospital
Extubate fully upright and avoid supine position
Avoid LMA
Local/regional blocks preferable over GA.

9. Chronic obstructive pulmonary disease (COPD)
Progressive inflammation/parenchymal destruction and partial reversibility.
Often due to smoking
Dyspnoea/productive cough/wheeze
Reduced ability to do ADL’s
Co-morbidities/complications- Cor pulmonale, polycythaemia etc.

10. COPD assessment - Spirometry

11. COPD Risks Recommendations
Bronchospasm – often at induction/maintenance
Pneumothorax (bullae)
V/Qmismatch
Sputum plugging/lobar collapse
Ongoing support needed
Breath stacking
Increased salbutamol prior to operation
CXR prior to operation
Supplemental oxygen during procedure
Positive pressure ventilation
Saline nebulisers
Suctioning/Chest physiotherapy
Adequate analgesia to enable cough
Low respiratory rate on ventilator to allow for expiration
Regular ABG
Consider HDU bed post op

12. Pre-operative optimisation
Arrange appropriate investigations – overnight oximetry, CXR, spirometry, stair climbing etc.
Smoking cessation – ideally done at least 8 weeks in advance, as causes increased mucus production initially.
Lose weight – reduces risk of sleep apnoea and improves airway management.
Treat infections and ensure adequate recovery time
Optimise diagnosed conditions – Inhalers, steroids etc

13. Asthma Reversible airway obstruction and inflammation
Various triggers/allergies
Dry cough, wheeze, atopy. Diurnal variation in symptoms.
Look at peak flow diary (if has one)
Exercise tolerance?
Smoker?

14. Asthma Risks Recommendations Induction bronchospasm
High peak airway pressures/Bronchospasm
Breath stacking
Extubation bronchospasm
Avoid atracurium – causes histamine release ++
Deepen anaesthesia – Isoflurane is a bronchodilator
Consider Salbutamol before and during surgery
Make expiratory time longer
Consider smaller tidal volumes
Adequate suctioning
Anti secretory agents – eg Glycopyyrolate
Adequate analgesia

15. References 1. http://www.sleepmd.us/sleep-apnea.html
2. Apnoea-and-anaesthesia1.pdf
3. COPD.pdf
4. e%20patient%20with%20respiratory%20disease.pdf
5. Preoperative evaluation and risk management. Parsons, David P. 6.