Pre-operative Medication Management for COPD Patients Undergoing Elective Surgery
Continue all baseline inhaled therapies (including inhaled corticosteroids and long-acting bronchodilators) through the morning of surgery, and provide stress-dose intravenous hydrocortisone (100 mg every 8 hours) during the perioperative period for patients on chronic oral steroids. 1, 2
Baseline Inhaled Therapy Management
Continue All Maintenance Inhalers
All regular inhaled medications—including inhaled corticosteroids (ICS), long-acting muscarinic antagonists (LAMA), and long-acting β2-agonists (LABA)—must be continued without interruption through the morning of surgery. 2 Modern inhaled corticosteroids at recommended doses do not cause clinically significant hypothalamic-pituitary-adrenal axis suppression and are safe to continue perioperatively. 2
Maintaining baseline ICS therapy is superior to rescue treatment for preventing inflammatory airway edema from direct airway injury during intubation and anesthesia. 2
Patients should take their usual morning dose of all inhalers on the day of surgery with a small sip of water. 2
Pre-operative Bronchodilator Administration
Administer a short-acting β2-agonist (e.g., albuterol 2.5–5 mg) via nebulizer or metered-dose inhaler with spacer 30–60 minutes before induction of anesthesia. 3, 2 This pre-medication reduces bronchospasm risk during airway manipulation. 2
For patients with moderate-to-severe COPD (FEV₁ <60% predicted), consider adding ipratropium bromide 0.25–0.5 mg to the pre-operative bronchodilator regimen for superior bronchodilation. 3
Systemic Corticosteroid Management
Stress-Dose Steroid Protocol for Chronic Oral Steroid Users
Any patient who has received oral corticosteroids for more than 4 weeks within the past 6 months requires stress-dose intravenous hydrocortisone: 100 mg IV at induction, then 100 mg IV every 8 hours during the perioperative period until oral intake resumes. 1, 2 This prevents adrenal crisis from hypothalamic-pituitary-adrenal axis suppression. 1
Once the patient can tolerate oral intake, rapidly taper to their baseline oral prednisone dose within 24 hours post-operatively. 1 There is no value in prolonging supraphysiologic steroid doses beyond the immediate perioperative period. 1
Oral prednisolone 5 mg is equivalent to intravenous hydrocortisone 20 mg; adjust dosing accordingly when transitioning. 1
Pre-operative Steroid Optimization
For elective surgery, attempt to reduce oral prednisone to the lowest possible dose (ideally <20 mg daily) in the weeks before surgery, as doses ≥20 mg are associated with increased risk of postoperative infectious complications, venous thromboembolism, and anastomotic leak. 1
If the patient is on ≥40 mg prednisone daily, strongly consider delaying elective surgery until the dose can be reduced, unless the surgical indication is urgent. 1
Do not abruptly stop chronic oral steroids pre-operatively—this risks adrenal crisis and disease flare. 1
Short-Term Pre-operative Inhaled Therapy Optimization
For Patients Not on Optimal Maintenance Therapy
If the patient is not already on dual or triple inhaled therapy, initiate a LAMA/LABA combination (e.g., umeclidinium/vilanterol or tiotropium/olodaterol) at least 2–4 weeks before elective surgery to optimize lung function. 4 Short-term pre-operative LAMA/LABA therapy for approximately 1 month significantly improves FEV₁ (mean increase 129 mL) and reduces post-operative pulmonary complications. 4
For patients with moderate-to-severe COPD (FEV₁ <60% predicted) and blood eosinophils ≥150–200 cells/µL, consider adding ICS to LAMA/LABA therapy 2–4 weeks pre-operatively. 5, 6 Adequate ICS treatment in eosinophilic COPD reduces postoperative pulmonary complications. 6
Risk Stratification and Additional Considerations
High-Risk Features Requiring Intensified Pre-operative Management
Age >75 years, FEV₁ <50% predicted, smoking within 8 weeks of surgery, upper abdominal or thoracic surgery, and operation time ≥5 hours are independent risk factors for postoperative pulmonary complications. 6
Smoking cessation must be strongly encouraged at every pre-operative visit; ideally, patients should stop smoking ≥8 weeks before elective surgery. 5 Even shorter periods of abstinence reduce complications. 5
For patients with smoking index ≥20 pack-years or severe COPD (GOLD stage 3–4), obtain pre-operative spirometry and arterial blood gas if SpO₂ <92% on room air. 2
Medications to Avoid Pre-operatively
Beta-blocking agents (including ophthalmic formulations) must be avoided in all COPD patients, as they can precipitate bronchospasm. 5
Discontinue theophylline 24–48 hours before surgery (depending on formulation) to reduce perioperative arrhythmia risk, but this is rarely relevant as theophylline has limited role in modern COPD management. 1, 5
Inhaler Technique Verification
Directly observe and correct inhaler technique at the pre-operative visit, as 76% of COPD patients make critical errors with metered-dose inhalers. 5, 7 Incorrect technique renders pre-operative optimization ineffective. 7
If the patient cannot demonstrate proper MDI technique despite instruction, switch to a breath-actuated MDI (e.g., Respimat) or dry powder inhaler, or plan for nebulized delivery perioperatively. 7
Common Pitfalls to Avoid
Never discontinue inhaled corticosteroids pre-operatively—unlike oral steroids, ICS do not require tapering and should be continued to prevent airway inflammation. 2
Do not give "stress-dose" steroids to patients on ICS alone—only those on chronic oral steroids (or high-dose ICS >1000 µg fluticasone-equivalent daily for >6 months) require supplemental IV hydrocortisone. 1, 2
Avoid delaying surgery to achieve "perfect" pulmonary function—if FEV₁ remains <50% predicted despite 2–4 weeks of optimized inhaled therapy, proceed with surgery using appropriate anesthetic techniques (regional anesthesia when feasible) rather than indefinitely postponing. 2
Do not use oral corticosteroids routinely for pre-operative optimization in stable COPD—short-term high-dose oral steroids (≥30 mg prednisone) improve FEV₁ modestly but increase perioperative complications and are not recommended unless the patient is experiencing an acute exacerbation. 8