A 56-year-old man is evaluated in the preoperative clinic 4 weeks prior to an elective right knee replacement for severe osteoarthritis. Medical history is notable for hypertension and chronic obstructive pulmonary disease. The patient uses inhaled bronchodilators, inhaled corticosteroids, and amlodipine. He has never required hospitalization for respiratory-related issues. The patient is able to perform all basic activities of daily living without dyspnea and was playing golf once a week prior to the knee pain limiting his activity. He previously smoked a pack of cigarettes daily beginning at age of 21 but has cut down to 3 or 4 cigarettes per day over the last 2 years. Vital signs are within normal limits. Oxygen saturation is 92% on room air. Lung auscultation shows slightly diminished breath sounds with prolonged expiration but no wheezes or crackles. Heart sounds are normal. The abdomen is soft and nontender with no organomegaly. There is no extremity edema. The right knee has crepitus and decreased range of motion. Blood cell counts and serum chemistry studies are within normal limits. Which of the following interventions is most appropriate to decrease the risk of postoperative pulmonary complications in this patient?

Question

A 56-year-old man is evaluated in the preoperative clinic 4 weeks prior to an elective right knee replacement for severe osteoarthritis.  Medical history is notable for hypertension and chronic obstructive pulmonary disease.  The patient uses inhaled bronchodilators, inhaled corticosteroids, and amlodipine.  He has never required hospitalization for respiratory-related issues.  The patient is able to perform all basic activities of daily living without dyspnea and was playing golf once a week prior to the knee pain limiting his activity.  He previously smoked a pack of cigarettes daily beginning at age of 21 but has cut down to 3 or 4 cigarettes per day over the last 2 years.  Vital signs are within normal limits.  Oxygen saturation is 92% on room air.  Lung auscultation shows slightly diminished breath sounds with prolonged expiration but no wheezes or crackles.  Heart sounds are normal.  The abdomen is soft and nontender with no organomegaly.  There is no extremity edema.  The right knee has crepitus and decreased range of motion.  Blood cell counts and serum chemistry studies are within normal limits.  Which of the following interventions is most appropriate to decrease the risk of postoperative pulmonary complications in this patient?

Quizplus · Accepted Answer

This patient with chronic obstructive pulmonary disease (COPD) is at increased risk for postoperative pulmonary complications, including pneumonia and respiratory failure requiring mechanical ventilation. Medical optimization of COPD symptoms (eg, dyspnea, wheezing) prior to surgery helps reduce this risk. Active smoking is also an independent risk factor for postoperative pulmonary complications, and this effect is amplified in patients with underlying lung disease. Even a small amount of active smoking (eg, 3 or 4 cigarettes per day) is associated with increased postoperative pulmonary risk. In all patients anticipating elective surgery, immediate smoking cessation is recommended as those who quit smoking >4-8 weeks prior to surgery substantially decrease their postoperative pulmonary risk. Lesser durations of preoperative smoking cessation do not reduce the risk, likely because the airway inflammation and increased bronchial mucus production induced by smoking requires some time to improve. (Choice B) Long-term oxygen therapy improves mortality in patients with COPD and significant chronic hypoxemia (ie, resting arterial oxygen saturation ≤88%); however, it has not been shown to benefit patients with lesser degrees of hypoxemia. (Choice C) There is no evidence that preoperative antibiotics active against respiratory pathogens (eg, moxifloxacin) decrease the risk of pneumonia, COPD exacerbation, or other postoperative pulmonary complications. (Choice D) Systemic glucocorticoids are indicated in an acute exacerbation of COPD, but preoperative use has not been shown to decrease the risk of postoperative pulmonary complications. (Choice E) Theophylline is sometimes used as an additional therapy in patients with COPD who have persistent symptoms despite smoking cessation and optimal usage of inhaled bronchodilators and corticosteroids. However, it is not indicated in this patient whose symptoms are controlled by his current therapy. Educational objective: Active smoking increases the risk of postoperative pulmonary complications (eg, pneumonia, respiratory failure requiring mechanical ventilation), especially in patients with underlying lung disease (eg, chronic obstructive pulmonary disease). Smoking cessation is recommended >4-8 weeks prior to elective surgery as it has been shown to reduce the risk of postoperative pulmonary complications. References: A prospective survey of the incidence of postoperative pulmonary complications. (http://www.ncbi.nlm.nih.gov/pubmed/5635926) Impact of smoking on perioperative outcomes after major surgery. (http://www.ncbi.nlm.nih.gov/pubmed/25980408)

A 56-Year-Old Man Is Evaluated in the Preoperative Clinic 4