Anesthesia for patients with severe chronic obstructive pulmonary disease

The safety of early discharge following transfemoral transcatheter aortic valve replacement under general anesthesia

Background

There is growing evidence of the safety of same-day discharge for low-risk conscious sedated TAVR patients. However, the evidence supporting the safety of early discharge following GA-TAVR with routine transesophageal echocardiography (TEE) is limited.

Aims

To assess the safety of early discharge following transcatheter aortic valve replacement (TAVR) using General Anesthesia (GA-TAVR) and identify predictors for patient selection.

Materials and methods

We used data from 2,447 TEE-guided GA-TAVR patients performed at Cedars-Sinai between 2016 and 2021. Patients were categorized into three groups based on the discharge time from admission: 24 h, 24–48 h, and >48 h. Predictors for 30-day outcomes (cumulative adverse events and death) were validated on a matched cohort of 24 h vs. >24 h using the bootstrap model.

Results

The >48 h group had significantly worse baseline cardiovascular profile, higher surgical risk, low functional status, and higher procedural complications than the 24 h and the 24–48 h groups. The rate of 30-day outcomes was significantly lower in the 24 h than the >48 h but did not differ from the 24–48 h (11.3 vs. 15.5 vs. 11.7%, p = 0.003 and p = 0.71, respectively). Independent poor prognostic factors of 30-day outcomes had a high STS risk of ≥8 (OR 1.90, 95% CI 1.30–2.77, E-value = 3.2, P < 0.001), low left ventricle ejection fraction of <30% (OR 6.0, 95% CI 3.96–9.10, E-value = 11.5, P < 0.001), and life-threatening procedural complications (OR 2.65, 95% CI 1.20–5.89, E-value = 4.7, P = 0.04). Our formulated predictors showed a good discrimination ability for patient selection (AUC: 0.78, 95% CI 0.75–0.81).

Conclusion

Discharge within 24 h following GA-TAVR using TEE is safe for selected patients using our proposed validated predictors.

Ambulatory Anesthesia for a Case of Idiopathic Bronchiolitis Obliterans

Bronchiolitis obliterans is rarely described in the nonlung transplant anesthesia literature. This case report describes a 27-year-old female patient with idiopathic bronchiolitis obliterans and dental anxiety who safely received intravenous deep sedation using diphenhydramine, dexmedetomidine, and ketamine in an ambulatory community dental clinic. This report outlines the anesthetic plan developed following a thorough preoperative assessment and review of the key anesthetic considerations of idiopathic bronchiolitis obliterans (eg, potential respiratory complications and appropriateness for the ambulatory dental environment) and discusses the careful anesthetic management of this patient using deep sedation to facilitate comprehensive restorative dentistry.

Effects of salbutamol on the kinetics of sevoflurane and the occurrence of early postoperative pulmonary complications in patients with mild-to-moderate chronic obstructive pulmonary disease: A randomized controlled study

Bronchodilators dilate the bronchi and increase lung volumes, thereby improving respiratory physiology in patients with chronic obstructive pulmonary disease (COPD). However, their effects on sevoflurane kinetics remain unknown. We aimed to determine whether inhaled salbutamol affected the wash-in and wash-out kinetics of sevoflurane and the occurrence of early postoperative pulmonary complications (PPCs) in patients with COPD undergoing elective surgery. This randomized, placebo-controlled study included 63 consecutive patients with COPD allocated to the salbutamol (n = 30) and control groups (n = 33). The salbutamol group received salbutamol aerosol (2 puffs of ~200 μg) 30 min before anesthesia induction and 30 min before surgery completion. The control group received a placebo. Sevoflurane kinetics were determined by collecting end-tidal samples from the first breaths at 1, 2, 3, 4, 5, 7, 10, and 15 min before the surgery (wash-in) and after closing the vaporizer (wash-out). PPCs were recorded for 7 days. The salbutamol group had higher end-tidal to inhaled sevoflurane ratios (p<0.05, p<0.01) than the control group, from 3 to 10 min during the wash-in period, but no significant differences were observed during the wash-out period. The arterial partial pressure of oxygen to the fraction of inhaled oxygen was significantly higher in the salbutamol group at 30 (320.3±17.6 vs. 291.5±29.6 mmHg; p = 0.033) and 60 min (327.8±32.3 vs. 309.2±30.5 mmHg; p = 0.003). The dead space to tidal volume ratios at 30 (20.5±6.4% vs. 26.3±6.0%, p = 0.042) and 60 min (19.6±5.1% vs. 24.8±5.5%, p = 0.007) and the incidence of bronchospasm (odds ratio [OR] 0.45, 95% confidence interval [CI] 0.23–0.67, p = 0.023) and respiratory infiltration (OR 0.52, 95% CI, 0.40–0.65, p = 0.017) were lower in the salbutamol group. In patients with COPD, salbutamol accelerates the wash-in rate of sevoflurane and decreases the occurrence of postoperative bronchospasm and pulmonary infiltration within the first 7 days.

Hypercapnia in COPD Patients Undergoing Endobronchial Ultrasound under Local Anaesthesia and Analgosedation: A Prospective Controlled Study Using Continuous Transcutaneous Capnometry

BACKGROUND

Flexible bronchoscopy (FB) in analgosedation causes alveolar hypoventilation and hypercapnia, the more so if patients suffer from COPD. Nonetheless, neither is capnometry part of standard monitoring nor is there evidence on how long patients should be monitored after sedation.

OBJECTIVES

We investigated the impact of COPD on hypercapnia during FB with endobronchial ultrasound (EBUS) in sedation and how the periprocedural monitoring should be adapted.

METHODS

Two cohorts of consecutive patients - with advanced and without COPD - with the indication for FB with EBUS-guided transbronchial needle aspiration in analgosedation received continuous transcutaneous capnometry (ptcCO2) before, during, and for 60 min after the sedation with midazolam and alfentanil.

MAIN RESULTS

Forty-six patients with advanced COPD and 44 without COPD were included. The mean examination time was 26 ± 9 min. Patients with advanced COPD had a higher peak ptcCO2 (53.7 ± 7.1 vs. 46.8 ± 4.8 mm Hg, p < 0.001) and mean ptcCO2 (49.5 ± 6.8 vs. 44.0 ± 4.4 mm Hg, p < 0.001). Thirty-six percent of all patients reached the maximum hypercapnia after FB in the recovery room (8 ± 11 min). Patients with COPD needed more time to recover to normocapnia (22 ± 24 vs. 7 ± 11 min, p < 0.001). They needed a nasopharyngeal tube more often (28 vs. 11%, p < 0.001). All patients recovered from hypercapnia within 60 min after FB. No intermittent ventilation manoeuvres were needed.

CONCLUSION

A relevant proportion of patients reached their peak-pCO2 after the end of intervention. We recommend using capnometry at least for patients with known COPD. Flexible EBUS in analgosedation can be safely performed in patients with advanced COPD. For patients with advanced COPD, a postprocedural observation time of 60 min was sufficient.

Benefit of Physiologically Variable Over Pressure-Controlled Ventilation in a Model of Chronic Obstructive Pulmonary Disease: A Randomized Study

Introduction

The advantages of physiologically variable ventilation (PVV) based on a spontaneous breathing pattern have been demonstrated in several respiratory conditions. However, its potential benefits in chronic obstructive pulmonary disease (COPD) have not yet been characterized. We used an experimental model of COPD to compare respiratory function outcomes after 6 h of PVV versus conventional pressure-controlled ventilation (PCV).

Materials and Methods

Rabbits received nebulized elastase and lipopolysaccharide throughout 4 weeks. After 30 days, animals were anesthetized, tracheotomized, and randomized to receive 6 h of physiologically variable (n = 8) or conventional PCV (n = 7). Blood gases, respiratory mechanics, and chest fluoroscopy were assessed hourly.

Results

After 6 h of ventilation, animals receiving variable ventilation demonstrated significantly higher oxygenation index (PaO₂/FiO₂ 441 ± 37 (mean ± standard deviation) versus 354 ± 61 mmHg, p < 0.001) and lower respiratory elastance (359 ± 36 versus 463 ± 81 cmH₂O/L, p < 0.01) than animals receiving PCV. Animals ventilated with the variable mode also presented less lung derecruitment (decrease in lung aerated area, –3.4 ± 9.9 versus –17.9 ± 6.7%, p < 0.01) and intrapulmonary shunt fraction (9.6 ± 4.1 versus 17.0 ± 5.8%, p < 0.01).

Conclusion

PVV applied to a model of COPD improved oxygenation, respiratory mechanics, lung aeration, and intrapulmonary shunt fraction compared to conventional ventilation. A reduction in alveolar derecruitment and lung tissue stress leading to better aeration and gas exchange may explain the benefits of PVV.

Anesthetic management of patients with chronic obstructive pulmonary disease

Chronic obstructive pulmonary disease (COPD) is the third most common cause of death worldwide. It has a prevalence of 14% among Koreans aged above 40 years and a prevalence of 31% among those aged above 65 years. However, only 6% of the COPD patients receive treatment. Most of the patients do not seek medical attention, as they think that dyspnea, cough, and productive sputum, which are the common symptoms of COPD, are normal aging phenomena. Smoking is a major risk factor for COPD, but environmental hazards and genetic susceptibility are also involved. With aging, lung injuries due to these risk factors accumulate, leading to increased prevalence of COPD. The major concerns regarding perioperative management of COPD patients include preoperative evaluation of cardiopulmonary risks, optimization of lung function, and evaluation of COPD-related physiological functions that are easily aggravated during anesthesia. These include respiratory muscle dysfunction, dynamic hyperinflation and auto-positive end-expiratory pressure, hypoxia-hypercarbia, and pulmonary hypertension-associated heart failure. Therefore, anesthesia for COPD patients should focus on preoperative evaluation, risk reduction measures, and prevention of postoperative pulmonary complications.

Preoperative Pulmonary Evaluation

The preanesthesia evaluation is an opportunity to elucidate a patient's underlying medical disease, determine if the patient is optimized, treat modifiable conditions, screen for potentially unrecognized disorders, and present the clear picture of the patient's overall risk for perioperative complications. This article presents the preoperative assessment of pulmonary patients in 2 sections. First, the components of a thorough assessment of patients presenting for preanesthesia evaluation, which should occur for all patients, regardless of the presence of pulmonary pathology, are discussed. Then, the considerations unique to patients with pulmonary diseases commonly encountered are described.

Joint consensus on anesthesia in urologic and gynecologic robotic surgery: specific issues in management from a task force of the SIAARTI, SIGO, and SIU

INTRODUCTION

Proper management of patients undergoing robotic-assisted urologic and gynecologic surgery must consider a series of peculiarities in the procedures for anesthesiology, critical care medicine, respiratory care, and pain management. Although the indications for robotic-assisted urogynecologic surgeries have increased in recent years, specific guidance documents are still lacking.

EVIDENCE ACQUISITION

A multidisciplinary group including anesthesiologists, gynecologists, urologists, and a clinical epidemiologist systematically reviewed the relevant literature and provided a set of recommendations and unmet needs on peculiar aspects of anesthesia in this field.

EVIDENCE SYNTHESIS

Nine core contents were identified, according to their requirements in urogynecologic robotic-assisted surgery: patient position, pneumoperitoneum and ventilation strategies, hemodynamic variations and fluid therapy, neuromuscular block, renal surgery and prevention of acute kidney injury, monitoring the Department of anesthesia, postoperative delirium and cognitive dysfunction, prevention of postoperative nausea and vomiting, and pain management in endometriosis.

CONCLUSIONS

This consensus document provides guidance for the management of urologic and gynecologic patients scheduled for robotic-assisted surgery. Moreover, the identified unmet needs highlight the requirement for further prospective randomized studies.

Office-Based Sedation/General Anesthesia for COPD Patients, Part II

The safe treatment of patients with chronic obstructive pulmonary disease (COPD) in dental office office-based settings can be quite complex without a current understanding of the etiology, course, severity, and current treatment modalities of the disease. The additional concerns of providing sedation and/or general anesthesia to patients with COPD in settings outside of a hospital demand thorough investigation of individual patient presentation and realistic development of planned treatment that patients suffering from this respiratory condition can tolerate. Along with other co-morbidities, such as advanced age and potential significant cardiovascular compromise, the dental practitioner providing sedation or general anesthesia must tailor any treatment plan to address multiple organ systems and mitigate risks of precipitating acute respiratory failure from inadequate pain and/or anxiety control. Part I of this article covered the epidemiology, etiology, and pathophysiology of COPD. Patient considerations in the preoperative period were also reviewed. Part II will cover which patients are acceptable for sedation/general anesthesia in the dental office-based setting as well as sedation/general anesthesia techniques that may be considered. Postoperative care will also be reviewed.

Office-Based Sedation/General Anesthesia for COPD Patients, Part I

The safe treatment of patients with chronic obstructive pulmonary disease (COPD) in dental office-based settings can be quite complex without a current understanding of the etiology, course, severity, and treatment modalities of the disease. The additional concerns of providing sedation and/or general anesthesia to patients with COPD in settings outside of a hospital demand thorough investigation of individual patient presentation and realistic development of planned treatment that patients suffering from this respiratory condition can tolerate. Along with other comorbidities, such as advanced age and potential significant cardiovascular compromise, the dental practitioner providing sedation or general anesthesia must tailor any treatment plan to address multiple organ systems and mitigate risks of precipitating acute respiratory failure from inadequate pain and/or anxiety control. Part I of this article will cover the epidemiology, etiology, and pathophysiology of COPD. Patient evaluation in the preoperative period will also be reviewed. Part II will cover which patients are acceptable for sedation/general anesthesia in the dental office-based setting as well as sedation/general anesthesia techniques that may be considered.

Transcatheter Aortic Valve Implantation Versus Surgical Aortic Valve Replacement in Lower-Surgical-Risk Patients With Chronic Obstructive Pulmonary Disease

Respiratory complications are a major factor contributing to postoperative morbidity and mortality, especially in patients with chronic obstructive pulmonary disease (COPD). Our objective was to compare the rate of respiratory complications in patients with COPD with severe aortic stenosis who underwent transcatheter aortic valve implantation (TAVI) versus surgical aortic valve replacement (SAVR). Low-to-intermediate surgical-risk patients with moderate or severe COPD who underwent TAVI or SAVR at 2 tertiary centers were included in this study. COPD was defined by the Global Initiative for Chronic Lung Disease classification. The primary end point was the 30-day composite of respiratory mortality, prolonged ventilation (>24 hours), the need for reintubation for respiratory causes, tracheostomy, acute respiratory distress syndrome, pneumonia, or pneumothorax. The inverse probability of treatment weighting was determined to reduce baseline imbalance between the 2 groups. A total of 321 patients (mean age 72.4 ± 9.3 years old, 74.5% male, mean Society of Thoracic Surgeons predicted risk of mortality 3.8 ± 1.9%, mean forced expiratory volume 1: 59 ± 13%) were included in the analysis. TAVI was performed in 122 patients, whereas 199 underwent SAVR. There were no differences between the 2 groups regarding the composite respiratory primary end point (SAVR 10.6%, TAVR 7.4%, adjusted odds ratio 0.57, 95% confidence interval 0.20 to 1.65, p = 0.30). Transfemoral TAVI without general anesthesia (28 patients) was associated with the lowest rate of respiratory complications (3.6%). Among patients with moderate or severe COPD at low-to-intermediate surgical risk, TAVI patients had a similar rate of 30-day major pulmonary complications compared with SAVR patients despite a higher baseline risk profile. Future studies should further investigate whether TAVI is associated with reduced respiratory complications, comparing transfemoral TAVI recipients treated with local anesthesia with their SAVR counterparts.

Anesthetic Management of the Adult Patient with Concomitant Cardiac and Pulmonary Disease

Several common diseases of the cardiac and pulmonary systems and the interactions of the two in disease and anesthetic management are discussed. Management of these disease processes in isolation is reviewed and how the management of one organ system impacts another is then explored. For example, in a patient with acute lung injury and right heart failure, lung-protective ventilation may directly conflict with strategies to minimize right heart afterload. Such challenging clinical scenarios require appreciation of each disease entity, their appropriate management, and the balance between competing priorities.

Perioperative Evaluation of Patients with Pulmonary Conditions Undergoing Non-Cardiothoracic Surgery

This review describes the perioperative management of patients with suspected or established pulmonary conditions undergoing non-cardiothoracic surgery, with a focus on common pulmonary conditions such as obstructive airway disease, pulmonary hypertension, obstructive sleep apnea, and chronic hypoxic respiratory conditions. Considering that postoperative pulmonary complications are common and given the increasing number of surgical procedures and the size of the aging population, familiarity with current guidelines for preoperative risk assessment and intra- and postoperative patient management is recommended to decrease the morbidity and mortality. In particular, smoking cessation and pulmonary rehabilitation are perioperative strategies for improving patients’ short- and long-term outcomes. Understanding the potential risk for pulmonary complications allows the medical team to appropriately plan the intra- and postoperative care of each patient.

Anaesthesia for patient with chronic obstructive pulmonary disease

The chronic obstructive pulmonary disease has become a disease of public health importance. Among the various risk factors, smoking remains the main culprit. In addition to airway obstruction, the presence of intrinsic positive end expiratory pressure, respiratory muscle dysfunction contributes to the symptoms of the patient. Perioperative management of these patients includes identification of modifiable risk factors and their optimisation. Use of regional anaesthesia alone or in combination with general anaesthesia improves pulmonary functions and reduces the incidence of post-operative pulmonary complications.

Patients with chronic pulmonary disease

Chronic pulmonary disease is common among the surgical population and the importance of a thorough and detailed preoperative assessment is monumental for minimizing morbidity and mortality and reducing the risk of perioperative pulmonary complications. These comorbidities contribute to pulmonary postoperative complications, including atelectasis, pneumonia, and respiratory failure, and can predict long-term mortality. The important aspects of the preoperative assessment for patients with chronic pulmonary disease, and the value of preoperative testing and smoking cessation, are discussed. Specifically discussed are preoperative pulmonary assessment and management of patients with chronic obstructive pulmonary disease, asthma, restrictive lung disease, obstructive sleep apnea, and obesity.

Perioperative lung protection strategies in cardiothoracic anesthesia: are they useful?

Patients are at risk for several types of lung injury in the perioperative period. These injuries include atelectasis, pneumonia, pneumothorax, bronchopleural fistula, acute lung injury, and acute respiratory distress syndrome. Anesthetic management can cause, exacerbate, or ameliorate most of these injuries. Lung-protective ventilation strategies using more physiologic tidal volumes and appropriate levels of positive end-expiratory pressure can decrease the extent of this injury. This review discusses the effects of mechanical ventilation and its role in ventilator-induced lung injury with specific reference to cardiothoracic anesthesia.

Lung transplantation in patients with prior cardiothoracic surgical procedures

The full spectrum of prior cardiothoracic procedures in lung transplant candidates and the impact of prior procedures on outcomes after lung transplantation (LTx) remain unknown, though the impact is considered to be large. Patients transplanted at our institution from 2004 to 2009 were identified (n = 554) and divided into two groups: patients who had undergone cardiothoracic surgical (CTS) procedures prior to LTx (n = 238) and patients who had not (non-CTS: n = 316). Our primary endpoint was survival. Secondary endpoints included allograft function and the incidence of major complications including reexploration due to bleeding, prolonged ventilation, renal insufficiency and primary graft dysfunction. Long-term survival was not significantly different between the groups whereas postoperative bleeding, nerve injury, respiratory and renal complications were higher in the CTS group. Posttransplant peak FEV1 was lower in the CTS group (73.4% vs. 86.9%, p < 0.05). In multivariate analysis, performance of a chemical pleurodesis procedure and prolonged cardiopulmonary bypass were significantly associated with mortality (OR, 1.7; CI, 1.5-2.0; p < 0.005). Our results suggest that patients with LTx and prior CTS remain technically challenging and experience worse outcomes than patients without prior CTS. A surgical strategy to minimize cardiopulmonary bypass time is critical for these challenging LTx patients.

[Preoperative evaluation and risk estimation in thoracic surgery]

Preoperative evaluation of patients undergoing lung resection remains an interdisciplinary challenge. Despite substantial progress in anesthesiology, intensive care medicine and surgery, mortality of patients undergoing pneumonectomy remains high at 5-9%. Guidelines were developed to identify patients with an increased perioperative risk for morbidity and mortality. These guidelines are focused around the forced expiratory capacity (FEV) measured by spirometry, following further investigations in patients with limited FEV(1). Extended testing includes measurement of the diffusion capacity, calculation of postoperative predicted values of lung function and spiroergometry to determine maximal oxygen uptake. In this article the methods to measure parameters of lung function and gas exchange are described and evaluated in the context of the current guidelines.