Pulmonary Risk Assessment

Pulmonary Risk Assessment - Lung Alert!

• Postoperative Pulmonary Complications (PPCs): Include atelectasis, pneumonia, respiratory failure, exacerbation of underlying lung disease (e.g., COPD, asthma).
• Goals of Preoperative Assessment: Identify at-risk patients, guide risk-reduction strategies, and optimize patient's preoperative condition.
• Incidence & Impact: PPCs occur in 5-10% of major non-cardiac surgeries; they significantly ↑morbidity, mortality, and length of hospital stay.

⭐ PPCs are a significant cause of perioperative morbidity and mortality, often comparable to cardiac complications.

Key Risk Factors - Danger Zones

Clinical Evaluation - Breath Checks

• Focused History:
  • Dyspnea: severity, character.
  • Cough, sputum production.
  • Exercise tolerance: METs, stair climbing.
    • ⭐ > An inability to climb 2 flights of stairs (approximately 4 METs) is a simple clinical indicator of poor functional capacity and increased PPC risk.
  • History of previous Postoperative Pulmonary Complications (PPCs).
  • Recent respiratory infection (<1 month).
• Physical Examination Findings:
  • Auscultation: wheezing, rhonchi, crackles.
  • Observation: prolonged expiratory phase, use of accessory muscles.
  • Signs of Heart Failure (HF): e.g., elevated JVP, peripheral edema. ## Clinical Evaluation - Breath Checks
• Focused History:
  • Dyspnea: severity, character.
  • Cough, sputum production.
  • Exercise tolerance: METs, stair climbing.
    • ⭐ > An inability to climb 2 flights of stairs (approximately 4 METs) is a simple clinical indicator of poor functional capacity and increased PPC risk.
  • History of previous Postoperative Pulmonary Complications (PPCs).
  • Recent respiratory infection (<1 month).
• Physical Examination Findings:
  • Auscultation: wheezing, rhonchi, crackles.
  • Observation: prolonged expiratory phase, use of accessory muscles.
  • Signs of Heart Failure (HF): e.g., elevated JVP, peripheral edema. (image)[ef11ccda-7e8f-4a20-907b-13f9a20b4735]

Preoperative Testing - Lung Scans & Puffs

• CXR: New/worsening cardiopulmonary signs/symptoms.
• PFTs/Spirometry:
  • Indications: Unexplained dyspnea/exercise intolerance; planned lung resection; assess known lung disease.
  • Key: FEV1, FVC, FEV1/FVC ratio.
  • Critical: FEV1 < 1.5L or < 50% pred.; ppoFEV1 < 30-40% (lung resection).
• ABG: Baseline in severe COPD / suspected hypoxemia.
• CPET: High-risk non-lung resection or lung resection candidates.

⭐ Routine preoperative PFTs are NOT recommended for all patients; they are selectively used, especially for patients undergoing lung resection or those with undiagnosed respiratory symptoms.

Risk Indices & Strategies - Predict & Protect

• Risk Indices:

  • ARISCAT Score:
    • Components: Age, SpO2 (<90%), resp. infection (recent), anemia (<10Hb), site (thoracic/upper abdo), duration (>2h), emergency.
    • Interpretation:

      Risk Level	Score Range	PPC Risk (%)
      Low	< 26	1.6
      Intermediate	26-44	13.3
      High	> 44	42.1

  • Gupta Resp. Failure Calculator.

• Risk Reduction Strategies:

  • Smoking cessation: >4-8 weeks prior.
  • Optimize lung disease (Asthma/COPD): Bronchodilators, steroids.
  • Treat infections.
  • Lung expansion: Deep breathing, incentive spirometry, CPAP/BiPAP, early mobilization.
  • Anesthesia: Regional preferred; avoid long-acting neuromuscular blockers.
  • 📌 CAN SCARE LUNGS: (COPD/CHF, Age, Nutrition, Site, Cough/Capacity, Anesthesia, Routine PFTs, Emergency, Lung Expansion, General health, Smoking).

⭐ The ARISCAT score is a widely validated and recommended tool for predicting postoperative pulmonary complications (PPCs).

High‑Yield Points - ⚡ Biggest Takeaways

• Major PPC risk factors: COPD, smoking, OSA, age >60, thoracic/upper abdominal surgery, long surgery duration.
• Smoking cessation: Advise at least 4-8 weeks preoperatively to ↓ PPCs.
• PFTs: Not routine; consider for unexplained dyspnea or lung resection.
• ARISCAT score: Widely used to predict postoperative pulmonary complications (PPCs).
• Prevention: Lung expansion maneuvers (incentive spirometry), pain control, early mobilization.
• OSA: Screen with STOP-BANG; continue CPAP perioperatively if used.