Should a 32-year-old female with a history of vaping and a body mass index (BMI) of 45 be referred to pulmonology (lung specialty) and cardiology (heart specialty) for clearance?

Referral Recommendations for 32-Year-Old Female with Vaping History and BMI of 45

Yes, this patient should be referred to both pulmonology and cardiology for preoperative clearance due to her significant risk factors of vaping history and severe obesity.

Risk Assessment

Pulmonary Risk Factors

• Vaping history: Vaping is associated with significant pulmonary complications including E-cigarette or Vaping Product-Associated Lung Injury (EVALI), which can present with pulmonary infiltrates and respiratory symptoms 1, 2.
• Severe obesity (BMI 45): Obesity can make diaphragm placement difficult and may be associated with respiratory complications 3.
• Combined risk: The combination of vaping history and severe obesity creates a compounded risk for respiratory complications that warrants specialist evaluation.

Cardiovascular Risk Factors

• Severe obesity (BMI 45): Obesity is a known risk factor for cardiovascular disease and can complicate perioperative management 3.
• Vaping history: Vaping has been associated with cardiovascular effects, though less well-characterized than pulmonary effects 2.

Guideline-Based Recommendations

The American College of Chest Physicians evidence-based clinical practice guidelines recommend:

1. Multidisciplinary assessment: Patients with significant risk factors should be assessed by a multidisciplinary team, which includes specialists in relevant areas 3.

2. Pulmonary function evaluation: Both FEV1 and diffusing capacity for carbon monoxide (DLCO) should be measured in patients with significant pulmonary risk factors 3.

3. Preoperative cardiac evaluation: Patients with increased perioperative cardiovascular risk should undergo preoperative cardiac evaluation 3.

Specific Evaluation Recommendations

Pulmonology Referral Should Include:

• Comprehensive pulmonary function testing (PFTs) including:

  • FEV1 and DLCO measurements
  • Calculation of predicted postoperative (PPO) values
  • Exercise capacity testing if PPO FEV1 or PPO DLCO are <60% predicted

• Specific evaluation for vaping-related lung injury:

  • Assessment for respiratory symptoms (cough, shortness of breath)
  • Evaluation for pulmonary infiltrates
  • Exclusion of other causes of respiratory symptoms 2, 4

Cardiology Referral Should Include:

• Cardiovascular risk assessment using validated tools (e.g., revised cardiac risk index)
• Evaluation of exercise capacity
• Assessment for signs of right ventricular dysfunction or pulmonary hypertension
• Recommendations for perioperative cardiovascular management

Additional Recommendations

Smoking/Vaping Cessation

• Immediate cessation of vaping is strongly recommended 5
• Consider combination therapy with varenicline plus nicotine replacement therapy for smoking/vaping cessation 5
• Provide counseling and behavioral support for cessation efforts

Weight Management

• Consider referral to weight management program
• Discuss potential benefits of weight reduction before surgery if time permits
• Evaluate for obesity-related comorbidities that may affect surgical risk 6

Potential Pitfalls to Avoid

1. Underestimating vaping risks: Do not assume vaping is safer than traditional smoking; it carries significant pulmonary risks 1, 2.

2. Focusing only on BMI: While BMI indicates severe obesity, also assess for functional limitations and specific obesity-related complications 6.

3. Delaying referrals: Early specialist consultation allows time for optimization before surgery and may reduce perioperative complications.

4. Missing the opportunity for intervention: The preoperative period represents an excellent opportunity to address both vaping cessation and weight management strategies 5.

By obtaining both pulmonology and cardiology clearance, you will ensure comprehensive risk assessment and optimization for this patient with multiple significant risk factors for perioperative complications.