Scientific paper“Prohibitive” lung function and major surgical procedures☆
Abstract
Sixteen patients with preoperative pulmonary function testing data placing them in the “prohibitive” range underwent major surgical procedures with one mortality (6 per cent) and three major pulmonary complications (19 per cent). All complications were after pulmonary resections in patients with marked muscular weakness. Patients should not be denied necessary operative procedures on the basis of pulmonary function testing placing them in the “prohibitive” range of the Miller quadrant diagram alone. This term should be changed to “increased risk.”
References (7)
- JR Schwaber
Evaluation of respiratory status in surgical patients
Surg Clin North Am
(1970) - EA Gaensler et al.
The role of pulmonary insufficiency in mortality and invalidism following surgery for pulmonary tuberculosis
J Thorac Surg
(1955) - WF Miller et al.
Convenient method of evaluating pulmonary ventilatory function with a single breath test
Anesthesiology
(1956)
Cited by (34)
Impact of COPD on pulmonary complications and on long-term survival of patients undergoing surgery for NSCLC
2002, Lung CancerPurpose: The purpose of our study was to determine the incidence of various types of postoperative pulmonary complications and to evaluate the impact of chronic obstructive pulmonary disease (COPD) on the long-term survival of patients with non-small cell lung cancer (NSCLC) undergoing pulmonary resection. Methods: We performed a retrospective chart review of 244 patients who had undergone lung resection for NSCLC at Indiana University. COPD, defined as predicted forced expiratory volume in 1 s (FEV1)⩽70% and FEV1/FVC⩽70%, was determined based on preoperative pulmonary function testing in 78 of 244 patients (COPD group). The remaining 166 patients were classified as non-COPD. The incidence of postoperative complications, which included air leak of ⩾10 days, atelectasis, pneumothorax, pneumonia, bronchopleural fistula, empyema, acute respiratory distress syndrome, mechanical ventilation of ⩾7 days, and outpatient oxygen supplementation were compared between the two groups. Long-term survival and mortality due to respiratory failure were analyzed between the two groups using the Kaplan–Meier method and log rank test. Results: All of the above-stated postoperative pulmonary complications occurred more frequently in the COPD than in the non-COPD patients (all P<0.01). The overall 5-year survival rate was 36.2% in the COPD and 41.2% in the non-COPD patients (P=0.1023). Five-year cancer related survival was 43.2% in the COPD and 47.7% in the non-COPD patients (P=0.357). There was no significant difference in survival among patients with different stages of lung cancer. However, the intercurrent survival, which is associated with non-cancer related death, was 60.1% in patients with COPD and 86.2% in patients without COPD at 5 years (P<0.0001). The major cause of non-cancer related death in the COPD group was respiratory failure (P=0.0008). Conclusion: The presence of COPD is an acceptable predictor of postoperative pulmonary complications in patients with NSCLC. COPD is also a significant risk factor for development of respiratory-related complications, which may explain the poor long-term survival in these patients.
Postoperative lung complications and mortality in patients with mild-to-moderate COPD undergoing elective general surgery
2001, Archivos de BronconeumologiaVerificar la incidencia de complicaciones pul-monares postoperatorias (CPP) y mortalidad en enfermos con enfermedad pulmonar obstructiva crónica (EPOC) de grado leve y moderado sometidos a cirugía general electiva, y correlacionarlas con sexo, edad, anestesia, incisión quirúr-gica, tiempo quirúrgico, tabaquismo, síntomas respiratorios, otras enfermedades clínicas, estado nutricional, examen pul-monar, electrocardiograma anormal, valores de PaO2, PaCO2, FEV1 y FEV1 /FVC.
Prospectivo y abierto.
Se evaluó e incluyó a 59 portadores de EPOC (FEV1 /FVC por debajo del 88% de lo previsto para mujeres y por debajo del 89% para varones), en un hospital universitario de nivel terciario, acompañados en los períodos pre y postoperatorio, hasta su alta hospitalaria o su fallecimiento.
Veinte pacientes (33,9%) presentaron CPP y 6 fallecieron (dos por causa pulmonar [3,4%]). Ocurrieron 35 CPP (neumonía, 37,2%); broncospasmo, 22,9%; atelect-tasia, 11,4%; insuficiencia respiratoria aguda, 11,4; ventila-ción mecánica prolongada, 11,4%; infección bronquial, 5,7%. Los factores de riesgo para CPP fueron el sexo mas-culino, tiempo quirúrgico mayor de 210 min, relación FEV1 /FVC disminuida (71,9 ± 10,9%) e incisión quirúrgica en el tórax o la región abdominal superior. No hubo diferen-cia entre el grupo con y sin CPP cuando analizamos las va-riables edad, presencia de síntomas respiratorios, enferme-dad clínica asociada, examen pulmonar alterado, estado nutricional, tabaquismo, electrocardiograma anormal, PaO2, PaCO2, FEV1 y tiempo de hospitalización preoperato-ria. El uso de la mediana del consumo de cigarrillos de 40 paquetes/año ha demostrado que los pacientes con consumo por encima de este valor presentaron un número más gran-de de CPP. Los pacientes con CPP permanecieron interna-dos más días (16,6 ± 15,0 frente a 7,5 ± 5,7) y en unidades de terapia intensiva (7,0 ± 5,9 frente a 1,7 ± 0,7) que los que no tuvieron complicaciones (p < 0,05).
La incidencia de CPP fue del 33,9%, y la mortalidad por causa pulmonar del 3,4%. Se consideraron factores de riesgo el sexo masculino, intensidad del tabaqui-mo, tiempo quirúrgico mayor de 210 min, relación FEV1 /FVC disminuida e incisión quirúrgica en tórax o re-gión abodminal alta. No hubo ningún factor de riesgo que pronosticase la mortalidad en este grupo.
To verify the incidence of postoperative pul-monary complications (PPC) and mortality in patients with mild-to-moderate chronic obstructive pulmonary disease (COPD) who undergo elective general surgery. Incidence of PPC and mortality were studied in relation to sex, age, anesthesia, surgical incision, duration of surgery, smoking, respiratory symptoms, comorbidity, nutritional status, lung examination, abnormal electrocardiogram, and PaO2, PaCO2, FEV1 and FEV1 /FVC.
Prospective, open study.
Fifty-nine COPD patients were enrolled (FEV1 /FVC < 88% of reference for women and < 89% for men) and studied at a tertiary care univer-sity hospital. The patients were examined during the pre-operative period and followed until discharge.
Twenty patients (33.9%) experienced PPC and 6 died, two (3.4%) from lung-related causes. Thirty-five PPC events occurred: pneumonia (37.2%), bronchospasm (22.9%), atelectasis (11.4%), acute respiratory insufficiency (11.4%), prolonged mechanical ventilation (11.4%) and bron-chial infection (5.7%). Risk factors for PPC were male gen-der, duration of surgery over 270 minutes, low FEV1 /FVC (71.9 ± 10.9%) and surgical incision in the chest or upper ab-domen. No significant difference between patients with or without PPC were found for age, presence of respiratory symptoms, comorbidity, abnormal lung examination, nutri-tional status, smoking, abnormal electrocardiogram, PaO2, PaCO2, FEV1 or duration of pre-operative hospitalization. The rate of PPC was higher in patients smoking more than a mean 40 packs of cigarettes per year. Patients with PPC had longer hospital stays (16.6 ± 15.0 vs. 7.5 ± 5.7 days) and sta-yed longer in intensive care units (7.0 ± 5.9 vs. 1.7 ± 0.7 days) than did those with no complications (p < 0.05).
The incidence of PPC was 33.9% and lung-related mortality was 3.4%. Risk factors were male gender, amount of smoking, duration of surgery over 270 minutes, low FEV1 /FVC, and chest or upper abdominal incision. No risk factor was found to predict mortality in this group.
Oxygen-dependent chronic obstructive pulmonary disease does not prohibit aortic aneurysm repair
1999, American Journal of SurgeryBackground: Severe oxygen-dependent chronic obstructive pulmonary disease (COPD) is considered by many to be a contraindication to open abdominal aortic aneurysm (AAA) repair. We reviewed our own experience with this patient population.
Methods: From July 1995 to March 1999, 14 consecutive patients limited by home oxygen-dependent COPD underwent elective open infrarenal AAA repair. Their medical records were reviewed.
Results: The mean aortic aneurysm size was 6.3 cm. The mean PaO2 = 70 mm Hg, PaCO2 = 45 mm Hg, forced expiratory volume in 1 second (FEV1) = 34% of predicted, and forced vital capacity (FVC) = 67% of predicted. All 14 patients were extubated within 24 hours, mean length of hospital stay was 5.9 days, and there were no perioperative deaths.
Conclusions: Severe home oxygen-dependent COPD is not a contraindication to safe elective open AAA repair.
50 years of general surgery at the Southwestern Surgical Congress
1998, American Journal of SurgeryPreoperative prediction of postoperative respiratory outcome: Coronary artery bypass grafting
1996, ChestThe hypothesis that traditionally defined preoperative risk factors predict prolonged mechanical ventilation after coronary artery bypass graft surgery (CABG) was tested in our cohort. The predictive power of these factors was quantified, and specific patient subsets destined for prolonged mechanical ventilation after CABG surgery were defined.
Five hundred thirteen consecutive patients undergoing CABG were prospectively evaluated. Preoperative pulmonary evaluation included clinical historic data, standard spirometry, and arterial blood gas. Preoperative cardiac parameters included clinical parameters and left ventricular function assessment. Nonthoracic organ (renal, endocrine, pancreas, liver) function was assessed.
University-based, tertiary referral center.
None (observational only).
Duration of mechanical ventilation, duration of surgical ICU stay, and mortality.
Multivariate regression analyses revealed that for the patient undergoing routine elective surgery and the patient undergoing urgent surgery, prolonged mechanical ventilation and death were rare events (8.3% and 2.0%, respectively). The combination of reduced left ventricular ejection fraction and the presence of selected preexisting comorbid conditions (clinical congestive heart failure, angina, current smoking, diabetes) served as modest risk factors for prolonged mechanical ventilation; their absence strongly predicted an uncomplicated postoperative respiratory course. No pulmonary diagnosis, mechanical lung function, or blood gas parameter substantially contributed to predicting adverse outcome. Classification and regression tree subgroup analysis refined specific factors important in specific subgroups.
With the exception of left ventricular ejection fraction, no preoperative factors emerge as good predictors across all subgroups. This series suggests that pulmonary diagnosis, lung mechanics, and blood gas parameters do not offer the clinician global rules in predicting postoperative respiratory outcome, nor should they be used as exclusion criteria for CABG surgery.
To determine the risk of thoracic and major abdominal surgery in patients with chronic obstructive pulmonary disease (COPD).
Retrospective cohort study with controls.
A 692-bed teaching hospital.
A cohort of 26 patients with severe COPD (FEV1 <50 percent predicted) undergoing thoracic and major abdominal surgery was matched by age and type of operation to 52 patients with mild-moderate COPD and 52 patients with no COPD.
The 26 patients with severe COPD had rates of cardiac, vascular, and minor pulmonary complications similar to patients with mild-moderate COPD and without COPD, but experienced higher rates of serious pulmonary complications (23 percent vs 10 percent vs 4 percent, p = 0.03) and death (19 percent vs 4 percent vs 2 percent, p = 0.02). All deaths and instances of ventilatory failure in the patients with severe COPD occurred in the subset undergoing coronary artery bypass surgery. Logistic regression revealed that increased age, higher American Society of Anesthesiologists class, an abnormal chest radiograph, and perioperative bronchodilator administration were associated with higher cardiac or serious pulmonary complication rates. Spirometry was not an independent predictor of postoperative complications.
Clinical variables appear better than preoperative spirometry in predicting postoperative cardiopulmonary complications. The utility of preoperative spirometry as well as the benefits of perioperative bronchodilators in patients in stable condition remain to be determined.
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Presented at the Twenty-Eighth Annual Meeting of the Southwestern Surgical Congress, Houston, Texas, May 3–6, 1976.
- 1
From the Department of Surgery, John Peter Smith Hospital, Fort Worth, Texas.
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Present address: Department of Surgery, University of New Mexico Medical Center, 2211 Lomas Boulevard, NE, Albuquerque, New Mexico 87106.