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ANAESTHESIA:

COPD, ASTHMA

Dr. Akanchaya Rana


Moderator: Dr Binod Gautam
POST OPERATIVE PULMONARY
COMPLICATIONS:

1. Hx of smoking ( current or >40pack-years)


2. ASA PS > II
3. Age> 70 yrs
4. COPD
5. Neck, upper abdominal , thoracic, aortic or
neurological surgery
6. Planned GA ( ETT)
7. Albumin <3gm/dl
8. Exercise capacity < 2 blocks or 1 flight of stairs
9. Prolonged procedure > 2hrs
10. BMI > 30
EFFECT OF ANAESTHESIA AND SURGERY
ON LUNG FUNCTIONS

 Site of incision

 Pre-existing respiratory dysfunction

 Type of anaesthesia
CLINICAL ENTITIES:

 Emphysema: alveolar wall destruction with


irreversible enlargement of the air spaces distal to the
terminal bronchioles and without evidence of fibrosis
 Chronic bronchitis: productive cough that is present
for a period of three months in each of two consecutive
years in the absence of another identifiable cause of
excessive sputum production

 Asthma: Disorder characterized by chronic airway


inflammation and increased airway responsiveness.
Wheeze, cough, chest tightness and dyspnea
DIAGNOSIS: ASTHMA

 Peak flow meters


 Pulmonary function test
 FEV1 = 15% (AND 200 ML) increase after administration
of a bronchodilator/ corticosteroids

 > 20% diurnal variation on 3 days a week for 2 weeks

 FEV1 = 15% decrease after 6 minutes of exercise


PAC
 History

 Previous hospitalization, ICU stay

 Cigarette consumption

 Cough? Sputum production

 Medical therapy

 Dyspnoea
ROIZEN’S CLASSIFICATION OF DYSPNOEA

Grade 0 No dyspnoea while walking at level in normal


pace
Grade I “ I am able to walk as far as I like provided I
take my time”
Grade II Specific street block limitation- “ I have to stop
for a while after one or two blocks”
Grade III Dyspnoea on mild exertion. “ I have to stop and
rest going from the kitchen to the bathroom”
Grade IV Dyspnoea at rest
PHYSICAL EXAMINATION
 Acute infections?

 Wheeze? Crepitations?

 Associated conditions

 Nutritional status

 Hydration status
INVESTIGATIONS:

 Hematocrit
 Total and differential count

 Renal function tests

 Random blood sugar

 ECG

 Chest X ray

 Echocardiography

 ABGs

 PFTs
PREOP OPTIMIZATION
 Stop smoking

 Treat infection

 physiotherapy (chest)

 Drug therapy
PREMEDICATION AND ADVICE:
 Atropine ?

 BZD?

 H2 blockers?

 H1 blockers: Diphenhydramine

 Continue all drugs

 Bring inhaler to OT
CONDUCT OF ANAESTHESIA
 RA where feasable

 GA:
 Analgesia: pethedine, fentanyl

 Induction: propofol, methohexital, ketamine

 Laryngoscopy only after adequate depth of


anaesthesia

o Maintainence: Halothane>enflurane> isoflurane>


sevoflurane
o Muscle relaxants: short acting. No histamine release

o Reversal of NM blockade?? Extubate deep vs awake?


INTRA-OPERATIVE BRONCHOSPASM: DIAGNOSIS OF
EXCLUSION

 Rule out the cause


 Mechanical obstruction to ETT: kinking, secretions, blood,
herniation, carinal stimulation
 Inadequate depth of anesthesia
 Endobronchial intubation
 Pulmonary edema/aspiration/ embolization
 Pneumothorax
 Acute asthmatic attack
 Anaphylaxis
 100% O2

 Increase concentraitn of volatile anaesthetics

 Salbutamol iv or via puff.

 Aminophylline

 Adrenaline, ketamine, magnesium

 hydrocortisone
POST OPERATIVE:
 Early mobilization and posture

 Regular clinical review

 Oxygen

 Fluid balance

 Pain management: avoid NSAID’S


RISK REDUCTION STRATEGIES
1. Preoperative:
- cessation of smoking
-treat infections, airflow obstruction
- pt education on lung volume manouvres
2. Intraoperative:
- minimally invasive technique
- RA
-avoid surgery > 3hrs
3. Postoperative:
- maximize analgesia
- lung volume manouvres