From the Guidelines
A comprehensive pre-operative pulmonary consultation should begin with a thorough history and physical examination, focusing on respiratory symptoms, exercise tolerance, smoking history, and previous pulmonary complications, as recommended by the American College of Physicians 1.
Key Components of the Consultation
- Review the patient's medical records for existing pulmonary conditions such as COPD, asthma, or sleep apnea
- Perform pulmonary function tests including spirometry, lung volumes, and diffusion capacity, with arterial blood gases if indicated by history or spirometry results, as suggested by the American College of Chest Physicians 1
- A chest X-ray should be obtained, with chest CT considered for patients with abnormal findings or high-risk procedures
- Risk stratification tools like the ARISCAT score can help identify patients at higher risk for postoperative pulmonary complications
- Laboratory tests should include complete blood count and basic metabolic panel
Management of Existing Pulmonary Conditions
- For patients with existing pulmonary conditions, ensure optimal management before surgery - this may include bronchodilators (albuterol 2-4 puffs every 4-6 hours as needed, tiotropium 18mcg daily), inhaled corticosteroids (fluticasone 100-500mcg twice daily), and antibiotics if infection is present
- Smoking cessation should be strongly encouraged at least 8 weeks before surgery, with nicotine replacement therapy or medications like varenicline (0.5mg daily for 3 days, then 0.5mg twice daily for 4 days, then 1mg twice daily) offered as appropriate
- Preoperative pulmonary rehabilitation may benefit high-risk patients, as recommended by the American College of Chest Physicians 1
Documentation and Communication
- Document recommendations clearly, including risk assessment, optimization strategies, and specific perioperative management plans for existing conditions
- Communicate effectively with the patient, surgeon, and anesthesiologist to ensure a comprehensive and coordinated approach to perioperative care.
From the Research
Comprehensive Pre-Operative Pulmonary Consultation
To perform a comprehensive pre-operative pulmonary consultation, several key steps and considerations must be taken into account:
- Patient History and Physical Examination: A thorough patient history and physical examination are essential in assessing the patient's respiratory system and identifying potential risk factors for postoperative pulmonary complications (PPCs) 2, 3.
- Risk Factors Identification: Identifying patients who are at risk for the development of PPCs is crucial, and managing their underlying modifiable risk factors aggressively prior to surgery is essential 4, 2.
- Preoperative Evaluation: The preoperative evaluation of patients undergoing general surgery is predominantly based on medical history and physical examination, with additional tests such as chest radiographs and pulmonary function tests indicated in high-risk patient groups 2.
- Preoperative Optimization: Optimizing the patient's medical ailments before surgery is critical, and collaborative efforts and adequate communication between the medical and surgical teams are necessary to ensure appropriate patient management before surgery 5.
- Prevention of Postoperative Pulmonary Complications: Prevention of PPCs should begin with discontinuation of smoking at least 8 weeks prior to surgery, and preoperative chest physiotherapy, including incentive spirometry, may be beneficial in high-risk patients 2.
- Assessment of Pulmonary Function: Assessing pulmonary function is critical in patients with pulmonary diseases, and considerations unique to patients with pulmonary diseases commonly encountered must be taken into account 6.
Key Components of Preoperative Pulmonary Evaluation
The key components of a preoperative pulmonary evaluation include:
- Medical History: A thorough medical history to identify underlying medical disease and determine if the patient is optimized 6.
- Physical Examination: A physical examination to assess the patient's respiratory system and identify potential risk factors for PPCs 3.
- Chest Radiograph: A chest radiograph may be indicated in high-risk patient groups or in patients undergoing lung resection surgery 2.
- Pulmonary Function Tests: Pulmonary function tests may be indicated in high-risk patient groups or in patients undergoing lung resection surgery 2.
- Quantitative Perfusion Scan and Exercise Testing: A quantitative perfusion scan and exercise testing may be useful for the assessment of operative risk in patients with severely compromised preoperative lung function 2.