A 62-year-old woman comes to the office for a preoperative evaluation 3 days before undergoing elective cholecystectomy. Over the past few months, she has had transient episodes of postprandial abdominal pain after large meals. Abdominal ultrasound confirms multiple gallstones. The patient feels well overall but has had 3 days of cough productive of green sputum and worsened dyspnea. She has a history of chronic obstructive pulmonary disease, myocardial infarction with stenting of the right coronary artery, hypertension, and obesity. She currently takes aspirin, lisinopril, rosuvastatin, amlodipine, albuterol, and ipratropium. She has had no previous surgeries. The patient has smoked a pack of cigarettes daily for 35 years but does not use alcohol or illicit drugs. Vital signs are within normal limits. Physical examination reveals moist mucous membranes and normal jugular venous pressure. Pulmonary auscultation indicates wheezing over the bilateral lung fields and prolonged expiration. There are no heart murmurs. No edema is present, and the remainder of the examination is normal. Which of the following interventions is most likely to reduce the incidence of postoperative pulmonary complications in this patient?

Question

A 62-year-old woman comes to the office for a preoperative evaluation 3 days before undergoing elective cholecystectomy.  Over the past few months, she has had transient episodes of postprandial abdominal pain after large meals.  Abdominal ultrasound confirms multiple gallstones.  The patient feels well overall but has had 3 days of cough productive of green sputum and worsened dyspnea.  She has a history of chronic obstructive pulmonary disease, myocardial infarction with stenting of the right coronary artery, hypertension, and obesity.  She currently takes aspirin, lisinopril, rosuvastatin, amlodipine, albuterol, and ipratropium.  She has had no previous surgeries.  The patient has smoked a pack of cigarettes daily for 35 years but does not use alcohol or illicit drugs.  Vital signs are within normal limits.  Physical examination reveals moist mucous membranes and normal jugular venous pressure.  Pulmonary auscultation indicates wheezing over the bilateral lung fields and prolonged expiration.  There are no heart murmurs.  No edema is present, and the remainder of the examination is normal.  Which of the following interventions is most likely to reduce the incidence of postoperative pulmonary complications in this patient?

Quizplus · Accepted Answer

Explanation: This patient is scheduled for an elective cholecystectomy in 3 days but has clear symptoms (dyspnea, productive cough) and signs (wheezing, prolonged expiration) of a chronic obstructive pulmonary disease (COPD) exacerbation. To reduce her risk of postoperative pulmonary complications (PPCs), this elective procedure should be delayed until her respiratory status returns to a stable baseline. PPCs are most common after thoracic and upper abdominal surgery due to reduced lung volumes from diaphragmatic dysfunction and splinting (reduction in inspiration depth due to pain). Common PPCs include atelectasis, infection, hypoxia, and respiratory failure. Patients with the following underlying medical conditions are at the greatest risk for developing PPC: COPD Cigarette smoking Sleep apnea Heart failure Prior to undergoing an elective procedure, these conditions should be optimized. This typically includes smoking cessation (ideally >4 weeks prior to the procedure) and the treatment of any heart failure or COPD exacerbation. (Choice A) Nicotine patches can aid in smoking cessation. Patients who stop smoking >4 weeks prior to surgery have lower rates of PPCs and better wound healing. Three days of smoking cessation are unlikely to have a significant impact on the risk of PPCs. (Choices B and D) Incentive spirometry and deep breathing exercises are often prescribed postoperatively with the intent to increase lung volume and minimize atelectasis. However, meta-analysis shows that these therapies have little or no benefit. Incentive spirometry and breathing exercises are not typically prescribed preoperatively and would not likely improve this patient's COPD exacerbation. (Choice C) This patient with a COPD exacerbation will likely receive antibiotics and bronchodilators. However, proceeding with surgery in 3 days will put her at greater risk of PPC. This elective surgery should be delayed until her respiratory function returns to a stable baseline. Educational objective: Postoperative pulmonary complications occur most often in those undergoing thoracic or upper abdominal surgery. Risk is greatest when patients have a history of chronic obstructive pulmonary disease (COPD), cigarette smoking, congestive heart failure, or sleep apnea. Patients with a preoperative COPD or heart failure exacerbation should have surgery delayed until pulmonary and cardiac function is optimized. References: Pulmonary complications after major abdominal surgery: National Surgical Quality Improvement Program analysis. (http://www.ncbi.nlm.nih.gov/pubmed/25930169) Impact of COPD on postoperative outcomes: results from a national database. (http://www.ncbi.nlm.nih.gov/pubmed/23287892) Preoperative smoking status and postoperative complications: a systematic review and meta-analysis. (http://www.ncbi.nlm.nih.gov/pubmed/23799418)

A 62-Year-Old Woman Comes to the Office for a Preoperative