How are respiratory risk factors assessed during dermatologic preoperative evaluation and management?

Updated: Mar 16, 2020
  • Author: Robert A Schwartz, MD, MPH; Chief Editor: Dirk M Elston, MD  more...
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Respiratory complications occur in 2 major patient groups: (1) patients with normal lungs who develop respiratory abnormalities secondary to anesthetic agents and (2) patients with overt chronic lung disease in whom the problems of anesthesia and the operation are superimposed on intrinsically diseased pulmonary tissue.

The preoperative risk factors for pulmonary complications include the following:

  • Thoracic and upper abdominal surgery

  • Preoperative history of chronic obstructive pulmonary disease

  • Preoperative purulent productive cough

  • Anesthesia time greater than 3 hours

  • History of cigarette smoking

  • Age older than 60 years

  • Obesity

  • Poor preoperative state of nutrition

  • Symptoms of respiratory disease

  • Abnormal findings upon physical examination

  • Abnormal findings on chest radiographs

The distinction between obstructive pulmonary emphysema and nonobstructive pulmonary emphysema can be made with the standard pulmonary function tests. Although several specific tests delineate minimal acceptable function, careful evaluations by both the surgeon and the pulmonologist are often indicated. A simple, useful test is having the patient take a brisk walk up a flight of stairs and observing his or her tolerance. A split pulmonary ventilation-perfusion scan can be helpful in determining which portions of the lungs are most likely to be involved in functional gas exchange to predict postoperative pulmonary function. Arterial blood gas levels should be obtained as a baseline in patients who are symptomatic and who undergo major surgery, especially thoracic procedures.

Preoperative preparatory maneuvers aimed at preventing postoperative respiratory complications include cessation of smoking, use of bronchodilators, chest physical therapy, education, and, occasionally, antibiotics (if sputum is purulent). All the maneuvers cited are important for patients with chronic obstructive pulmonary disease. Vigorous pulmonary physical therapy in the form of nasotracheal suction and even bronchoscopy can be used to maintain alveolar patency postoperatively and to minimize atelectasis and its associated risk of pneumonia.

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