|Year : 2019 | Volume
| Issue : 1 | Page : 47-51
Evaluation of risk factors for postoperative pulmonary complications after elective open upper abdominal surgery in chronic obstructive pulmonary diseases patients
Mukesh Kumar Prasad1, Sanjay Sahay2, Rohit Kumar Varshney1, Gurdeep Singh Jheetay1
1 Department of Anaesthesiology, Teerthankar Mahaveer Medical College, Moradabad, Uttar Pradesh, India
2 Department of TB and Respiratory Diseases, Teerthankar Mahaveer Medical College, Moradabad, Uttar Pradesh, India
|Date of Web Publication||14-Oct-2019|
Department of TB and Respiratory Diseases, Teerthankar Mahaveer Medical College, Moradabad - 244 001, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
Background: Postoperative pulmonary complications (PPCs) range from 9% to 40% in various nonthoracic surgeries. Various risk factors are attributed for these complications. The aim of this study was to determine the risk factors for PPC in chronic obstructive pulmonary disease (COPD) patients submitted to elective open upper abdominal surgery.
Materials and Methods: This was a prospective cohort study conducted in a tertiary care center after obtaining ethical committee clearance. Two hundred and twenty-nine of 427 patients planned for elective abdominal surgeries were labeled as COPD based on spirometry test. PPC and various factors affecting it were analyzed. Pre- and intra-operative data were collected and their association with the occurrence of PPC was analyzed. Relationship between PPC and other variables was tested by linear and logistic regression. Multivariate logistic regression was performed using a backward stepwise approach and accepting statistical significance at P < 0.05.
Results: Of 229 COPD patients, 34 (14.84%) suffered PPC. The mean age was 55.76 ± 8.40 years with 78.6% being male. Patients having age >50 years and the American society of anesthesiologists IV status were more prone to developing PPC. The multivariate analysis revealed body mass index (BMI) >30 kg/m2, duration of surgery >150 min, and pCO2>45 mmHg in arterial blood gas as independent predictors of PPC.
Conclusions: The present study concluded that increased pCO2, BMI, and longer duration of surgery increase PPC in COPD patients. Hence, preoperative optimization of pCO2, BMI, and a proper plan to shorten the duration surgery may reduce PPC in COPD patients undergoing open upper abdominal surgeries.
Keywords: Chronic obstructive pulmonary diseases, complications, postoperative, pulmonary
|How to cite this article:|
Prasad MK, Sahay S, Varshney RK, Jheetay GS. Evaluation of risk factors for postoperative pulmonary complications after elective open upper abdominal surgery in chronic obstructive pulmonary diseases patients. J Med Soc 2019;33:47-51
|How to cite this URL:|
Prasad MK, Sahay S, Varshney RK, Jheetay GS. Evaluation of risk factors for postoperative pulmonary complications after elective open upper abdominal surgery in chronic obstructive pulmonary diseases patients. J Med Soc [serial online] 2019 [cited 2019 Nov 12];33:47-51. Available from: http://www.jmedsoc.org/text.asp?2019/33/1/47/269110
| Introduction|| |
With the increase in life expectancy, increasing number of chronic obstructive pulmonary disease (COPD) patients and increase in need for diagnostic and surgical procedures anesthesiologists, chest physicians, and surgeons every day often encounter high-risk respiratory patients. Postoperative pulmonary complications (PPCs) range from 9% to 40% in various studies may be because of methodological discrepancies. In noncardiac surgery, pulmonary complications occur more frequently than cardiac complications. These complications prolong the hospital stay or are responsible for increased morbidity and mortality., Complications may arise from pneumonia, atelectasis, respiratory failure, bronchospasm, and exacerbation of underlying chronic lung disease. Risk of developing PPC is increased in COPD patients. Patients with severe COPD undergoing abdominal surgeries are six times more prone to postoperative complications. Data suggest that COPD will be the third leading cause of death in the world by 2020. It is characterized by persistent airways obstruction, resulting from inflammatory response to noxious agents like cigarette smoke, and can be treated if intervened. The benefits of surgery must be weighed against these complications. High-risk COPD patients can be easily identified by a vigilant and careful preoperative evaluation. Clinical spirometry can easily detect pulmonary diseases and its severity among symptomatic and asymptomatic patients. These high-risk patients can be optimized by treatment before surgery. The aim of this study was to determine the risk factors for PPC in COPD patients submitted to elective open upper abdominal surgery.
| Materials and Methods|| |
This was a prospective cohort study. The target population was composed of adults undergoing elective open upper abdominal surgery in the tertiary center at Moradabad, India, from August 2017 to April 2018. The protocol was approved by the local Ethics Research Committee. Written informed consent was obtained in all cases. In this study, 427 patients referred from various surgical departments such as general surgery, urosurgery, obstetrics, and gynecology scheduled for open upper abdominal surgery were allocated for preanesthetic checkup in the Department of Anesthesia. Demographic and medical information including age, gender, weight, height, smoking habits, history of a cough, and shortness of breath were collected. Patients were categorized as per the American Society of Anesthesiologists (ASA) classification by anesthesiologist in preanesthetic checkup. All the patients were sent to the Department of Pulmonary Medicine for further evaluation for fitness of surgery. All patients were subjected to spirometry test. Of 427 patients referred, those patients who fulfilled GOLD's criteria for COPD, i.e., having postbronchodilator (forced expiratory volume in 1 s/forced volume capacity) <0.7 were labeled as COPD and taken for further evaluation. The following variables were tested, based on previous research results and the authors' clinical judgment: age (≤50 years vs. >50 years), gender, body mass index (BMI) (BMI ≤30 vs. >30 kg/m2), smoking status, arterial blood gas (ABG) analysis (pCO2≤45 mmHg vs. Pco2>45 mmHg), 6-min walk distance test (6MWD) as 0 (≥350 m), +1 (250–349 m), and +2 (150–249 m), modified medical research council dyspnea scale as per symptom severity (0, +1, +2, +3, and +4), duration of surgery (≤150 min vs. >150 min), and type of anesthesia given (general anesthesia or regional anesthesia).
Patients >40 years of age of both sexes who were chronic smokers or having exposure to the second-hand smoke in home or workplaces having cough and SOB were referred to the Department of Pulmonary Medicine, for fitness for general surgery, were included in the study.
Patients who failed to give consent, those who were not fit for spirometry and those with recent myocardial infarction or unstable angina, recent cerebrovascular accidents, individuals with the previous diagnosis of neuromuscular disease, recent chest injuries, pneumothorax, active hemoptysis, active pulmonary tuberculosis, and pregnancy were excluded from the study.
PPC was recorded as primary outcomes which included – pneumonia, atelectasis, pleural effusion, and acute respiratory failure requiring mechanical ventilation.
In our study, categorical variables were expressed as actual numbers (n) and percentages (%), whereas continuous variables were presented as the mean ± standard deviation. Relationship between PPC and other variables was tested by linear and logistic regression. Odds ratios and 95% (95% confidence intervals) were used to estimate the association between PPC and variables. Multivariate logistic regression was performed using a backward stepwise approach and accepting statistical significance at P < 0.05. PPC was used as the dependent variable. Statistical significance was considered at the level of P ≤ 0.05. Statistical Package for the Social Sciences (SPSS®) for Windows version 21.0 (IBM Corp, Armonk, NY, USA) was used to analyze the data.
| Results|| |
We evaluated a total of 427 patients during preoperative evaluation for open upper abdominal surgery. Of 427 patients, 229 were labeled as COPD depending on spirometry test. Thirty-four (14.84%) patients out of 229 suffered PPC in the form of pneumonia, atelectasis, pleural effusion, and respiratory failure [Table 1].
|Table 1: Chronic obstructive pulmonary disease patients with grades of severity based on spirometry|
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PPC increased with increasing of ASA class level. The ASA class 4 or 3 m suffered maximum PPC, respectively [Table 2].
|Table 2: Postoperative pulmonary complications according to the level American Society of Anesthesiologist class of the patients|
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PPC increased with the decrease in 6MWD in COPD patients [Table 3].
|Table 3: Postoperative pulmonary complications according to 6-min walk distance|
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Most of COPD patients who stopped for breath after walking for 91 m suffered PPC [Table 4].
|Table 4: Postoperative pulmonary complications according to the Modified Medical Research Council Dyspnea Scale|
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[Table 5] shows association between the preoperative history, physical examination, investigations, anesthetic techniques, duration of surgery, and occurrence of PPC.
|Table 5: The association between the preoperative history, physical examination, investigations, anesthetic techniques, duration of surgery, and occurrence of postoperative pulmonary complications|
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The multivariate analysis revealed BMI >30 kg/m2, duration of surgery >150 min, and pCO2>45 mmHg in ABG as independent predictors of PPC [Table 6].
|Table 6: Logistic regression - independent risk factors for pulmonary complications following elective open upper abdominal surgery (n=229)|
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| Discussion|| |
In this study, multiple risk factors have been identified which help in predicting PPC.
Rate of PPC increased with increasing age, and incidences were more in patients above 50 years of age. These findings are consistent with studies conducted by Staehr-Rye and Eikermannand Canet et al.,, Males were relatively more prone to PPCs probably with a possible explanation documented by Serejo LG et al. that men tend to breathe more with their diaphragm and women more with their thorax – thus when the movements of the diaphragm are restricted after upper abdominal operations, the males suffer more from lack of expansion of the lungs.
Patients having the ASA physical status (ASA PS) >2 were associated with more PPC in our study which corroborates with findings of various studies.,,
The subjective nature of the ASA score (ASA PS) and the lack of inclusion of functional status in its calculation have been noted,, but ASA PS >2 remains a risk factor for the development of PPC.,,
Most of the COPD patients found to have hyperinflated lungs. However, Scholes et al. demonstrated that a baseline chest X-ray is not usually a useful tool in assessing the risk of PPC.
Smoking status of patient correlates well with PPC. Smoking cessation as early as 3–4 weeks before surgery decreases the risk of respiratory complications.
Patients classified in GOLD's criteria Grades 3 and 4 during preoperative pulmonary evaluation suffered more PPCs. In a study conducted by McAlister et al. found that patients who had undergone preoperative pulmonary evaluation had PPC of 6.9% as compared to 9.4% who had not undergone preoperative pulmonary function testing., Earlier studies by Arozullah et al. correlated with these findings.
6 MWD proves to be a good indicator to assess the functional status of COPD patients. It is less expensive and easy to perform regardless of patient age and education., Patients in Grades +1 and +2 were found to have more PPCs. Lower levels of exercise capacity during preoperative evaluation increase the risk for both cardiac and pulmonary complications.
This study showed BMI >30 kg/m2 had significantly higher incidence of PPCs. Serejo LG et al. found that advanced age, abnormal BMI (<21 kg/m2 or ≥30 kg/m2), upper or upper/lower incision, and multiple procedures were associated with increased risk for PPC in patients undergoing emergency open upper abdominal surgery.
We found a significant correlation between PPCs and pCO2>45 mmHg in ABG findings in preoperative evaluation. Gerald WM found PaCO2 value >45 mmHg as strong risk factor for PPCs.
PPC was more common in patients who were administered general anesthesia rather than in those who were given regional anesthesia in our study. It is accepted the fact that general anesthesia, especially with tracheal intubation and intermittent positive pressure ventilation, is associated with adverse outcomes in patients with COPD. These patients are prone to laryngospasm, bronchospasm, cardiovascular instability, barotraumas, and hypoxemia, and have increased the rates of PPC. There is increasing evidence to support the use of regional techniques in COPD cases which lead to decrease in PPC., Another study suggests that the use of general anesthesia and long-acting muscle relaxant is associated with increased PPC in high-risk populations.
In this study, PPC was more in patients where the duration of surgery lasted >2.5 h. These findings are similar to the findings of Kodra et al. However, percentage of patients having PPC were relatively less as compared to the study of Kodra et al. which may be because they included nonoptimized emergency patients.
| Conclusions|| |
Our study concluded that risk factors such as increased pCO2, BMI, and longer duration of surgery increase PPC in COPD patients. Hence, preoperative optimization of pCO2, BMI, and a proper plan to shorten the duration surgery may reduce PPC in COPD patients undergoing open upper abdominal surgeries.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Halbert RJ, Natoli JL, Gano A, Badamgarav E, Buist AS, Mannino DM, et al.
Global burden of COPD: Systematic review and meta-analysis. Eur Respir J 2006;28:523-32.
Dilworth JP, Warley AR, Dawe C, White RJ. The effect of nebulized salbutamol therapy on the incidence of postoperative chest infection in high risk patients. Respir Med 1994;88:665-8.
Lawrence VA, Hilsenbeck SG, Mulrow CD, Dhanda R, Sapp J, Page CP, et al.
Incidence and hospital stay for cardiac and pulmonary complications after abdominal surgery. J Gen Intern Med 1995;10:671-8.
Weissman C. Pulmonary complications after cardiac surgery. Semin Cardiothorac Vasc Anesth 2004;8:185-211.
Kinugasa S, Tachibana M, Yoshimura H, Ueda S, Fujii T, Dhar DK, et al.
Postoperative pulmonary complications are associated with worse short- and long-term outcomes after extended esophagectomy. J Surg Oncol 2004;88:71-7.
Kroenke K, Lawrence VA, Theroux JF, Tuley MR, Hilsenbeck S. Postoperative complications after thoracic and major abdominal surgery in patients with and without obstructive lung disease. Chest 1993;104:1445-51.
Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global Strategy for the Diagnosis, Management and Prevention of chronic obstructive pulmonary disease: 2017 Report. Available from: www.goldcopd.org. [Last accessed on 2018 March 10].
Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global Strategy for the Diagnosis, Management and Prevention of chronic obstructive pulmonary disease: 2018 Report. Available from: www.goldcopd.org. [Last accessed on 2018 April 18].
Staehr-Rye AK, Eikermann M. Eliminate postoperative respiratory complications: Preoperative screening opens the door to clinical pathways that individualise perioperative treatment. Eur J Anaesthesiol 2015;32:455-7.
Canet J, Sabaté S, Mazo V, Gallart L, de Abreu MG, Belda J, et al.
Development and validation of a score to predict postoperative respiratory failure in a multicentre European cohort: A prospective, observational study. Eur J Anaesthesiol 2015;32:458-70.
Serejo LG, da Silva-Júnior FP, Bastos JP, de Bruin GS, Mota RM, de Bruin PF, et al.
Risk factors for pulmonary complications after emergency abdominal surgery. Respir Med 2007;101:808-13.
Roizen MF, Fleisher LA. Anesthetic implications of concurrent disease. In: Miller R, editor. Miller's Anesthesia. 7th
ed., Ch. 35. New York: Churchill Livingstone; 2010. p. 1103-11.
Qaseem A, Snow V, Fitterman N, Hornbake ER, Lawrence VA, Smetana GW, et al.
Risk assessment for and strategies to reduce perioperative pulmonary complications for patients undergoing noncardiothoracic surgery: A guideline from the American College of Physicians. Ann Intern Med 2006;144:575-80.
Owens WD, Felts JA, Spitznagel EL Jr. ASA physical status classifications: A study of consistency of ratings. Anesthesiology 1978;49:239-43.
Brull SJ, Barash PG. Is “Ol' reliable” still reliable? Anesth Analg 2015;121:1-3.
Scholes RL, Browning L, Sztendur EM, Denehy L. Duration of anaesthesia, type of surgery, respiratory co-morbidity, predicted VO2 max and smoking predict postoperative pulmonary complications after upper abdominal surgery: An observational study. Aust J Physiother 2009;55:191-8.
Wong J, Lam DP, Abrishami A, Chan MT, Chung F. Short-term preoperative smoking cessation and postoperative complications: A systematic review and meta-analysis. Can J Anaesth 2012;59:268-79.
McAlister FA, Khan NA, Straus SE, Papaioakim M, Fisher BW, Majumdar SR, et al.
Accuracy of the preoperative assessment in predicting pulmonary risk after nonthoracic surgery. Am J Respir Crit Care Med 2003;167:741-4.
Arozullah AM, Daley J, Henderson WG, Khuri SF. Multifactorial risk index for predicting postoperative respiratory failure in men after major noncardiac surgery. The National Veterans Administration Surgical Quality Improvement Program. Ann Surg 2000;232:242-53.
Guyatt GH, Sullivan MJ, Thompson PJ, Fallen EL, Pugsley SO, Taylor DW, et al.
The 6-minute walk: A new measure of exercise capacity in patients with chronic heart failure. Can Med Assoc J 1985;132:919-23.
Szekely LA, Oelberg DA, Wright C, Johnson DC, Wain J, Trotman-Dickenson B, et al.
Preoperative predictors of operative morbidity and mortality in COPD patients undergoing bilateral lung volume reduction surgery. Chest 1997;111:550-8.
Diaz-Fuentes G, Hashmi HR, Venkatram S. Perioperative evaluation of patients with pulmonary conditions undergoing non-cardiothoracic surgery. Health Serv Insights 2016;9:9-23.
Gerald WM. Current concepts. Preoperative pulmonary evaluation. N
Engl J Med 1999;340:937-44.
Lumb A, Biercamp C. Chronic obstructive pulmonary disease and anaesthesia. Contin Educ Anaesth Crit Care Pain 2014;14:1-5.
van Lier F, van der Geest PJ, Hoeks SE, van Gestel YR, Hol JW, Sin DD, et al.
Epidural analgesia is associated with improved health outcomes of surgical patients with chronic obstructive pulmonary disease. Anesthesiology 2011;115:315-21.
Kodra N, Shpata V, Ohri I. Risk factors for postoperative pulmonary complications after open upper abdominal surgery. Open Access Maced J Med Sci 2016;4:259-63.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]