Pulmonary Disease

The Big Asthma Lie

Treating  Asthma

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Bronchial asthma, chronic bronchitis, chronic obstructive pulmonary disease, obesity, history of smoking, and recent upper respiratory infection are the most common medical conditions which may influence pulmonary function in the perioperative period. An estimated 4.5 % of the population may suffer some form of reactive airway disease [116]. If these medical conditions are identified in the preoperative history, a thorough evaluation of the patient's pulmonary function should ensure. As with other medical conditions, a careful history may help separate patients with these medical conditions into low and high risk groups, especially since the degree of preoperative respiratory dyspnea closely correlates with postoperative mortality [117]. Using a simple grading scale, the patients' preoperative pulmonary function can be estimated (Table 2.4).

Patients with level 2 dyspnea or greater should be referred to a pulmonologist for more complete evalua-

Table 2.4. Grade of dyspnea while walking. (Adapted from Boushyet al. [117])

Level

Clinical response

G

No dyspnea

1

Dyspnea with fast walking only

2

Dyspnea with one or two blocks walking

3

Dyspnea with mild exertion (walking around the

house)

4

Dyspnea at rest

tion and possibly further medical stabilization. The benefits of elective surgery in patients with level 3 and 4 dyspnea should be carefully weighed against the increased risks. Certainly, this group of patients would not be considered good candidates for outpatient surgery.

Since upper respiratory infection (URI) may alter pulmonary function for up to 5 weeks [118], major surgery requiring general endotracheal anesthesia should be postponed, especially if the patient suffers residual systems, such as fevers, chills, coughing and sputum production, until the patient is completely asymptomatic.

While many studies confirm that patients who smoke more than one to two packs of cigarettes daily have a higher risk of perioperative respiratory complications than non-smokers, cessation of smoking in the immediate preoperative period may not improve patients' outcome. In fact, patients' risk of perioperative complications may actually increase if smoking is stopped immediately prior to surgery. A full 8 weeks may be required to successfully reduce perioperative pulmonary risk [119].

If the physical examination of asthmatic patients reveals expiratory wheezing, conventional wisdom dictates that potentially reversible bronchospasm should be optimally treated prior to surgery. Therapeutic agents include inhaled or systemic, selective beta-ad-renergic receptor type-2 agonists (albuterol) as a sole agent or in combination with anticholinergic (ipratro-pium) and locally active corticosteroid (beclomethaso-ne dipropronate) medications [120]. Continuing the asthmatic medications up to the time of surgery [121] and postoperative use ofincentive spirometry [122] has been shown to reduce postoperative pulmonary complications.

With regard to treated stable pulmonary disease, there are no conclusive, prospective, randomized studies to indicate which anesthesia technique or medications would improve patient outcome.

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