Postępowanie okołooperacyjne u chorych z przewlekłą obturacyjną chorobą płuc poddanych zabiegom pozapłucnym

*Katarzyna Rutkowska, Hanna Misiołek, Hanna Kucia, Piotr Knapik

Summary
Chronic obstructive pulmonary disease (COPD) is characterized by airflow limitation and peripheral airway inflammation, occurring mostly in smokers. The intraoperative effect of COPD can be significantly influenced by the choice of anaesthetic technique and anaesthetic agent. The perioperative anaesthetic risk will be determined by the severity of the chronic obstructive pulmonary disease (COPD) and the degree of bronchial hyperreactivity. This risk has to be assessed by a careful preoperative evaluation and will provide the rationale for deciding on the appropriate anaesthetic technique.
Spirometry is regarded as a standard test required for risk assessment in COPD patients. Lung function parameters such as forced expiration volume in 1 second (FEV₁) compared to predicted FEV₁ and FEV₁/FVC (forced vital capacity) are used to classify the severity of the disease. COPD is recognized when the FEV₁/FVC ratio is below 70% of the normal value. The treatment of COPD is mostly symptomatic, and is based on the use of bronchodilators, mucolytics, and in severe exacerbations, oxygen.
COPD patients present a definite risk of postoperative complications, prolonged mechanical ventilation and tracheotomy. The risk is markedly increased by the severity of operation, with the highest morbidity and mortality being observed in patients undergoing cardiac operations.
COPD patients should stop smoking at least 8 weeks prior to the planned surgery. Premedication should be given cautiously and opioids are to be avoided. H₂ antagonists are contraindicated because of the high risk of bronchoconstriction. Regional analgesia should be used whenever possible, with epidural analgesia appearing to be superior because of the lower risk of high motor block. Propofol is recommended for intravenous induction, while for maintenance, volatile anaesthesia appears be safer than TIVA. Remifentanil is the opioid of choice for these patients due to its rapid elimination and fast recovery. Muscle relaxants should be used sparingly, with atracurium and mivacurium being relatively contraindicated. Low inspired oxygen mixtures and permissive hypercapnia are recommended for ventilation during anaesthesia and surgery. Careful observation is required after surgery and opioids should be avoided. Regional anaesthesia remains as the preferred method for postoperative pain treatment in these patients.

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