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3: Pulmonary Physiology, Function Tests, and Bronchoscopic Techniques

Lonny Yarmus; David J. Feller-Kopman

Key Concepts

  • Epidemiology

    • Pulmonary complications occur in 5 to 10 percent of all surgical patients and have been shown to prolong hospital stay by 1 to 2 weeks. Approximately 25 percent of deaths within the first week after surgery are due to pulmonary complications.

  • Pathophysiology

    • Pneumonia occurs in 10 to 40 percent of patients after major surgery and is associated with a mortality rate of 30 to 45 percent. General anesthesia can decrease lung volumes by 30 to 40 percent, and this decrease may persist for 1 to 2 weeks postoperatively.

  • Clinical features

    • Cardiothoracic surgery is associated with the highest frequency of pulmonary complications. Risk factors include the type of surgery, general anesthesia, length of surgery and general anesthesia, smoking, chronic obstructive pulmonary disease, age, obesity, functional status, and a history of dyspnea.

  • Diagnostics

    • Preoperative evaluation should include a directed history and physical examination to identify those patients at particular risk for pulmonary complications. Pulmonary function tests with spirometry and arterial blood gases (ABGs) should be obtained for any patient undergoing lung resection. For further risk stratification, cardiopulmonary exercise testing (CPET) is indicated in high-risk patients who do not have adequate predicted postoperative lung function. Alternatives to CPET include the shuttle-walk or stair-climb test.

    • Bronchoscopy is an essential tool in the preoperative work for diagnosis, staging, and surgical planning.

  • Treatment

    • Inhaled bronchodilators may successfully reverse some cases of obstructive pulmonary disease.

  • Outcomes

    • Preoperative pulmonary function evaluation can stratify patients for risk, thus identifying those who can safely undergo major cardiothoracic surgery and minimizing the risk of significant morbidity and mortality.

    • Appropriate nodal staging is essential in the workup of lung cancer patients and essential for surgical planning.

Introduction

Pulmonary complications in the perioperative period remain a significant cause of morbidity and mortality and occur in 5 to 10 percent of all surgical patients. Not only have these complications been shown to prolong hospital stay by an average of 1 to 2 weeks but 25 percent of deaths within the first week after surgery are reportedly due to pulmonary complications.1–4 One way to minimize these complications is with the appropriate use of preoperative testing. Both noninvasive preoperative testing such as pulmonary function testing and minimally invasive testing such as bronchoscopy can add valuable information to the workup of the preoperative cardiothoracic patient. In this chapter, we will review the burden of postoperative complications, basic pulmonary physiology, the preoperative pulmonary workup for the cardiothoracic surgical patient, and the role of bronchoscopy for the diagnosis and staging of lung cancer.

Perioperative Pulmonary Complications

In the postoperative period, there are a wide range of pulmonary complications (Table 3-1) that can occur in patients with underlying lung disease. Postoperative pneumonia can occur in 10 to 40 percent of patients and is associated with a mortality rate of 30 to 45 percent after major surgical procedures. The ...

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