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Anesthesia for the Patient with Pulmonary Disease
TEXTCoexisting Disease · 9 min read
COPD, asthma, OSA, ILD, recent URI. Postop pulmonary complications rival cardiac in morbidity — most are preventable.
After this lesson you can
2 min read6 sections- Optimize COPD/asthma before surgery.
- Plan ventilator settings to avoid auto-PEEP.
- Choose regional when possible.
- Recognize + treat bronchospasm.
COPD
Severity by FEV1 %predicted.
Periop optimization: smoking cessation ≥8 weeks ideal (4-8 weeks may worsen secretions; <24 hr improves COHb).
Bronchodilators continued/optimized.
Steroid burst for active flare.
Anesthetic: regional > general where feasible.
- low tidal volume (6-8 mL/kg IBW)
- PEEP titration
- longer expiratory time (I:E 1:3-1:5) to prevent breath-stacking
- watch for auto-PEEP
Avoid N₂O (bullae).
Volatile agents are bronchodilators.
Extubate awake; consider postop NIV for chronic CO₂ retainers.
Asthma
- peak flow within personal best
- no recent exacerbation
- no URI in past 4 weeks
Steroid burst if active wheeze.
Pre-induction albuterol.
Volatile agents bronchodilate (avoid desflurane — pungent, can trigger).
Propofol > ketamine > etomidate > thiopental (thiopental can histamine-release).
Lidocaine 1.5 mg/kg IV pre-intubation blunts airway reflexes.
LMA over ETT if appropriate.
- deepen anesthesia
- inhaled albuterol
- IV epinephrine
10-100 mcg - IV magnesium
- IV hydrocortisone
Obstructive sleep apnea
Bring CPAP machine to hospital.
Difficult mask + difficult intubation — ramp position, video laryngoscopy first-line for severe.
Multimodal opioid-sparing analgesia critical.
- continuous SpO₂ minimum
- capnography if monitored bed available
- CPAP in PACU + on floor
Avoid full µ-opioids for outpatient surgery — discharge home risk of overdose.
Regional anesthesia preferred where possible.
Restrictive lung disease (ILD, kyphoscoliosis, obesity)
Anesthetic: low tidal volume, higher rate, accept higher peak pressures (lung disease) or plateau pressures (chest wall disease — these patients tolerate high airway pressures because elastic load is chest wall not lung).
Pulm HTN often present — manage as above.
Postop ventilatory failure risk — plan extubation criteria carefully.
Recent URI
Postpone elective for active fever, purulent secretions, productive cough, wheeze.
Mild URI in adults often OK to proceed.
Peds with URI: higher complication risk; specific risk factors include age <1, ETT (vs mask/LMA), copious secretions, parental smoking.
Plan with smaller ETT, LMA when possible, atropine pre-induction, IV lidocaine.
Postop pulmonary complications
- age
- surgery site (thoracic + upper abdo highest)
- duration >3 hr
- GA vs regional
- COPD
- smoking
- OSA
- incentive spirometry
- early mobilization
- multimodal opioid-sparing analgesia
- neuraxial for thoracic/upper abdo
- head-of-bed up
- oral hygiene/CHG for vent patients
⚠ Common pitfalls
- Forgetting that COPD patients benefit from LONGER expiratory time.
- Standard ventilator settings causing auto-PEEP — drops venous return + worsens hypotension.
- Aborting bronchospasm with one albuterol nebulizer — escalate quickly.
- Volatile alone for severe bronchospasm — IV epinephrine + magnesium adjuncts.
💎 Clinical pearls
- Pre-op optimization: bronchodilator + steroid + treat infection 2 weeks pre-op.
- Sevoflurane is the most bronchodilatory volatile.
- Auto-PEEP recognition: expiratory flow doesn't return to zero; treat by increasing E-time.
- Severe bronchospasm in OR: epi 10-20 mcg IV bolus, then drip; magnesium 2 g IV over 20 min.
Recap
- Pre-op optimization: bronchodilator + steroid + treat infection 2 weeks pre-op.
- Sevoflurane is the most bronchodilatory volatile.
- Auto-PEEP recognition: expiratory flow doesn't return to zero; treat by increasing E-time.
- Severe bronchospasm in OR: epi 10-20 mcg IV bolus, then drip; magnesium 2 g IV over 20 min.
Mark each section done to complete the module.