Emphysema is a type of chronic obstructive pulmonary disease with a prevalence in the United States reaching approximately 14 million 1. In the last few decades, the prevalence of emphysema and chronic obstructive pulmonary disease has increased in both the United States and globally due to an increasingly sedentary lifestyles, smoking, and longer life expectancy 2. Impaired lung function in patients with emphysema create additional considerations when undergoing surgery and anesthesia.
First, patients with emphysema require a comprehensive preoperative evaluation which should be carried out well in advance of the surgery, in case additional investigations and treatment are needed. A detailed history and routine preoperative blood tests are required. An electrocardiogram can help detect any evidence of right-sided heart disease or concomitant ischemic heart disease. Spirometry can help confirm a diagnosis and assess the severity of emphysema, while a baseline arterial blood gas measurement may be useful in predicting high-risk patients. In addition, all patients with emphysema should receive an examination just before anesthesia and the procedure, as patient condition on the day of surgery is one of the key considerations for the medical team. Decreased breath sounds, prolonged expiration, wheezing, and rhonchi may be predictive of postoperative pulmonary complications. Preoperative wheezing usually warrants aggressive preoperative treatment with bronchodilators and steroids.
A recent review identified that retrospective data observed from various studies and case reports showed regional anesthesia to be a valid and safe option in patients who are not ideal candidates of general anesthesia, such as patients with an obstructive pulmonary disease 3. It demonstrated better postoperative patient outcomes with respect to safety, efficacy, postoperative pulmonary complications, and analgesia, avoiding for example any risks linked to intubation or mechanical ventilation. As such, depending upon the disease severity, regional anesthesia may be considered 3.
Patients with emphysema may have difficulty breathing when lying flat or in certain positions. Careful positioning, such as raising the head of the bed or using pillows to support the chest and neck, may help with breathing during the procedure 3. Also, since patients with emphysema often have reduced oxygen levels in their blood, oxygen supplementation may be required during the procedure. This can be delivered via a face mask, a nasal cannula, or an endotracheal tube.
Close monitoring of the patient’s vital signs, including oxygen saturation, heart rate, blood pressure, and respiratory rate, is essential during the entire procedure. Continuous pulse oximetry should be used to assess oxygen saturation levels, and arterial blood gas analysis may be needed to monitor carbon dioxide levels. Following the procedure, patients with emphysema may require additional oxygen supplementation and close monitoring of their respiratory function. Lung expansion maneuvers such as deep breathing exercise, chest physiotherapy, incentive spirometry, and positive pressure breathing techniques are helpful to prevent postoperative pulmonary complications in high-risk patients. In addition, postoperative mechanical ventilation may be required 3. Eventually, early mobilization may help prevent post-operative complications. Finally, pain control should be carefully managed to avoid respiratory depression. Using a combination of different analgesic agents (opioids, paracetamol, and nonsteroidal anti-inflammatory drugs) can help manage pain while minimizing drug-related side-effects (sedation, respiratory depression, nausea, and vomiting) 4,5.
Much progress has been made in the clinical optimization of anesthesia management for patients with emphysema 6, and much applied clinical research remains to be carried out for further improvement 7. Patients with emphysema require special considerations for anesthesia and surgery due to impaired lung function, but modern techniques and technology allow for careful monitoring and support.
References
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