Adult patient with COPD and wheezing - cancel case?

[jd1572]

60 year old Female with recent diagnosis of COPD (but 1ppd x 30 years history) comes in for a shoulder replacement. Patient in preop area has a mild wheeze, but o2 sat is normal and otherwise feels fine.

Is there any evidence that proceeding with this case (given the wheeze) is dangerous? What if the patient had asthma rather than COPD? I imagine that some people would cancel this case because it is elective and bronchospasm could be catastrophic, but I was wondering if there were any studies or any personal stories anyone had about this.

Thanks!

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[2ndyear]

Any studies? I didn't look, but even if there were a great randomized controlled trial about elective surgery and wheezing you have to apply it to the patient in front of you right now. You probably have more of the story, how was COPD diagnosed (ie PFT's), is she treated, if so with what, was a CXR done, if so what does it look like, what is her exercise tolerance?

Wheezing on physical exam is only one part of the picture here. If the whole story says not optimized in terms of COPD, then probably not a good day to have a total shoulder. But I have seen those patients and typically they come in on home O2, can't walk more than a few feet, are maxed out on bronchodilators and anticholinergics, etc. Those patients need a careful analysis of risk vs. benefit for elective surgery. I think your patient will be fairly straightforward.

 

[Jeff05]

if her COPD is severe enough (PFTS/functional status) i would stay away from an ISB. pts. with COPD are at a much higher risk for postop pulmonary complications, especially with longer procedures.

this is an elective procedure - this patient's COPD is not optimized. i would send her back to her pulmonologist so he can address any reversible components of her disease.

in PP land, i would throw in an interscalene with 20mL of mepiv 1.5% - 3-4 hours just to get her through the procedure. albuterol/ipratropium nebs prior to induction. LMA with PSVPro (nice TV and some PEEP). have the surgeon suture in a Q-ball for postop pain.

 

[IceDoc]

So let's do a "what if"?

What if this patient (or any patient with "COPD" for that matter) gets treated on some form of bronchodilator, steroid, whatever, and is still wheezing. Are you going to proceed? Probably. So for this patient, who appears asymptomatic (given the OP post), is there any real benefit to delaying the case and having her started on medications? Probably not. You can take a history yourself and determine how bad the COPD is i.e. on home O2, in the hospital recently, do they get exacerbations, and are any symptoms that they have now any different from normal? And if there's no evidence of something like acute bronchitis, then you're probably good to go. Or, you could have her worked up for non-respiratory causes of wheezing like CHF, mediastinal masses, or malingering by the 8yo kid who can actually make himself wheeze on command. But I digress.


To be fair, I haven't answered the actual question of "is there any data to suggest..." because most such data will end up not applying to the patient in front of you. This is because "good data" needs umteen variables controlled, and it's more likely than not that your patient would miss inclusion criteria for that study.

So if you have an asymptomatic patient and cannot identify any acutely worsening condition (bronchitis, chf, etc) I would suggest that you would not be providing the patient any benefit by canceling them.

 

[proman]

Some COPDers wheeze at baseline. Warn about the possibility of post op ventilation and do the case.

 

[IceDoc]

. have the surgeon suture in a Q-ball for postop pain.

I haven't worked anywhere that uses this, so I haven't paid much attention. But aren't there concerns with these in the shoulder?

Also, agree with caution on ISB. The only patient I regretted putting one in was because she did not tolerate the hemidiaphragmatic paresis with her COPD. Worked out well though.

 

[Planktonmd]

GETA + Interscalene block.

 

[Bertelman]

Some COPDers wheeze at baseline. Warn about the possibility of post op ventilation and do the case.

Exactly. I'm not terribly impressed when I hear wheezing in a Pt. with known COPD. If they don't need O2 at baseline, the COPD isn't that bad.

 

[aredoubleyou]

Exactly. I'm not terribly impressed when I hear wheezing in a Pt. with known COPD. If they don't need O2 at baseline, the COPD isn't that bad.

Agree. Wheezing, imho, is not a useful way to risk stratify COPD. The big categories in my mind is functionality, CO2 retention and O2 dependence. If there is wheezing and no evidence of exacerbated COPD, then do the case. I would be concerned about interscalene block, but wheezing would not be a reason that I would choose not to. Also, seems like people over-state the liklihood of post-op vent support. Thats certainly where the big time CO2 retainers can get into trouble, but 99% of those carying the diagnosis are no where near that level, especially the ones we see for elective surgery.

 

[djipopo]

60 year old Female with recent diagnosis of COPD (but 1ppd x 30 years history) comes in for a shoulder replacement. Patient in preop area has a mild wheeze, but o2 sat is normal and otherwise feels fine.

Is there any evidence that proceeding with this case (given the wheeze) is dangerous? What if the patient had asthma rather than COPD? I imagine that some people would cancel this case because it is elective and bronchospasm could be catastrophic, but I was wondering if there were any studies or any personal stories anyone had about this.

Thanks!

Ok, so here's my pseudo oral board answer: I would perform a thorough focused H&P and PE on this patient with particular attention paid to her current functional status, need for home O2, medication regimen, WOB, accessory m. use and characteristic of lung sounds. I would try to find any recent medical records looking particularly for any CXR's, ABG's or PFT's to give me an idea as to how severe her COPD is. Considering the fact that her O2 sat is stable on room air and assuming that she isn't breathless or desatting while talking to me during this process, I would most likely proceed with the case without delay after pretreatment with a bronchodilator and would place an interscalene block preop and proceed with GA after extensive discussion with her about the risks of pulmonary complications with these interventions. I would prefer to use an LMA in this case (precluding any contraindications) in order to avoid precipitating bronchospasm with instrumentation of her airway. If it were necessary to place an ETT, I would then do so with the patient in a deep state of GA, after tracheal instillation of lidocaine and maintain her at a deep level of GA.

 

[Bertelman]

Ok, so here's my pseudo oral board answer: I would perform a thorough focused H&P and PE on this patient with particular attention paid to her current functional status, need for home O2, medication regimen, WOB, accessory m. use and characteristic of lung sounds. I would try to find any recent medical records looking particularly for any CXR's, ABG's or PFT's to give me an idea as to how severe her COPD is. Considering the fact that her O2 sat is stable on room air and assuming that she isn't breathless or desatting while talking to me during this process, I would most likely proceed with the case without delay after pretreatment with a bronchodilator and would place an interscalene block preop and proceed with GA after extensive discussion with her about the risks of pulmonary complications with these interventions. I would prefer to use an LMA in this case (precluding any contraindications) in order to avoid precipitating bronchospasm with instrumentation of her airway. If it were necessary to place an ETT, I would then do so with the patient in a deep state of GA, after tracheal instillation of lidocaine and maintain her at a deep level of GA.

Do you instill tracheal lidocaine every time you tube a COPDer? Which do you think carries more risk: possible bronchospasm from intubation or hypoventilation/difficult ventilation using an airway device which relies on ventilatory drive in a patient with impaired CO2 response? What do you do when the LMA Pt. starts desatting during shoulder surgery? What if your surgeon asks for some relaxation?

 

[Versed0101]

Exactly. I'm not terribly impressed when I hear wheezing in a Pt. with known COPD. If they don't need O2 at baseline, the COPD isn't that bad.

Seems like a pretty incomplete history. Hope he's not using this forum to make clinical decisions. 🙂

 

[Bertelman]

Seems like a pretty incomplete history. Hope he's not using this forum to make clinical decisions. 🙂

😉

 

[Octagonecology]

Given the depth of knowledge and experience required to answer these questions I will never understand how this sort of responsibility could be turned over to a nurse (CRNA). Some things I will never get....

 

[djipopo]

Do you instill tracheal lidocaine every time you tube a COPDer? Which do you think carries more risk: possible bronchospasm from intubation or hypoventilation/difficult ventilation using an airway device which relies on ventilatory drive in a patient with impaired CO2 response? What do you do when the LMA Pt. starts desatting during shoulder surgery? What if your surgeon asks for some relaxation?

Here we go....🙄

No, but since this pt came in actively wheezing, I'm concerned about her degree of airway irritation, so to mitigate that risk, I'll instill the lidocaine before I intubate her. As for which option carries more risk - who can say? I've had COPD'ers go into bronchospasm during intubation, during the procedure, after extubation, etc. I've also had COPDers who did well with LMA's too. Do you have any data to support one option or the other? What do you do when any pt desat's with an LMA? Lastly, hopefully the pt has a good block which will provide some m. relaxation in and of itself. If the surgeon asks for more relaxation, depending on where we are in the case I can dial up the agent, give a little propofol or give a small dose of a NMBD and put the pt on pressure controlled ventilation well below the pressure where the leak was noted initially while still maintaining adequate tidal volumes.

 

[Bertelman]

Here we go....🙄

No, but since this pt came in actively wheezing, I'm concerned about her degree of airway irritation, so to mitigate that risk, I'll instill the lidocaine before I intubate her. As for which option carries more risk - who can say? I've had COPD'ers go into bronchospasm during intubation, during the procedure, after extubation, etc. I've also had COPDers who did well with LMA's too. Do you have any data to support one option or the other? What do you do when any pt desat's with an LMA? Lastly, hopefully the pt has a good block which will provide some m. relaxation in and of itself. If the surgeon asks for more relaxation, depending on where we are in the case I can dial up the agent, give a little propofol or give a small dose of a NMBD and put the pt on pressure controlled ventilation well below the pressure where the leak was noted initially while still maintaining adequate tidal volumes.

No eye roll needed. You offered your oral board answer, I'm offering my oral board examiner follow-up questions. In this particular situation, I would think long and hard before throwing an LMA down a patient that (at my institution) would be undergoing surgery in a beach-chair position, when I have ANY doubts about their ability to ventilate. I don't usually use LMAs (except for very low invasive procedures) if I suspect I may not have instant access to the airway, especially not in someone with known pulmonary disease. I imagine your ABA examiner would tell you the COPD Pt. just desatted, or suffered bronchospasm, and would then ask how you intend to intubate this patient under the drapes in a beach-chair position.

 

[djipopo]

Well, here we do them supine with slight lateral tilt, so the difficulty with positioning isn't an issue but... even if it was, at that point you would need to communicate with the surgeon, flatten the patient out as much as possible, push a little propofol and intubate.

 

[urge]

Pent, sux, tube...

 

[jd1572]

Thank you for your thoughts on this.

For the most part, your average person with COPD or Asthma should not be wheezing. If they have end stage or poorly controlled COPD or Asthma, then perhaps they will be wheezing at baseline. Does anyone know (actual studies) or think that the wheeze is a sign that this patient may be at higher risk of going into bronchospasm? What if the patient was an asthmatic child (NOT an adult) with a wheeze, but otherwise asymptomatic?

I've seen people cancel cases when an adult asthmatic patient has a wheeze but is otherwise asymptomatic. Again, I don't know if this is the best thing to do, but people argue that this may be the "safe" option given that the case was elective.

I hear people talking about checking PFT's, but how many of your pre-op patients have a copy of these in their chart? And how would PFT's help you now anyway?

I think you have to be careful about doing an interscalene block in a COPD patient given the 100% incidence of hemidiaphragm paresis.