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術前の肺リスク評価法の手引き
Evaluation of preoperative pulmonary risk　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　
参考：UpToDate Evaluation of preoperative pulmonary risk

問診の重要性

確実なリスクファクター
１.　年齢＞50歳
2.　COPD
3.　うっ血性心不全
4.　全身状態不良：ASA　class　＞2
5.　要介護
6.　上腹部、胸部、大動脈、頭頸部、脳神経外科、AAAの手術
7.　3時間以上の手術時間
8.　緊急手術
9.　pancuronium（ミオブロック）の使用
ほぼ確実なリスクファクター
1.　睡眠時無呼吸
2.　全身麻酔（脊髄麻酔、硬膜外麻酔との比較で）
3.　PaCO2＞45mmHg
4.　胸部異常影
5.　8週間以内の喫煙歴
6.　上気道感染の存在

American Society of Anesthesiologists classification of preoperative risk
ASA class Systemic disturbance Mortality
1 Healthy patient with no disease outside of the surgical process <0.03 ％
2 Mild to moderate systemic disease caused by the surgical condition or by other pathological processes, medically well-controlled 0.2 ％
3 Severe disease process which limits activity but is not incapacitating 1.2 ％
4 Severe incapacitating disease process that is a constant threat to life 8 ％
5 Moribund patient not expected to survive 24 hours with or without an operation 34 ％
E Suffix to indicate emergency surgery for any class Increased -
Adapted from Cohen, MM, Duncan, PG, Tate, RB, JAMA 1988; 260:2859.
Arozullah respiratory failure index

Preoperative predictor Point value
Type of surgery -
　Abdominal aortic aneurysm 27
　Thoracic 21
　Neurosurgery, upper abdominal, peripheral vascular 14
　Neck 11
Emergency surgery 11
Albumin <3.0 g/dL 9
BUN >30 mg/dL 8
Partially or fully dependent functional status 7
History of COPD 6
Age -
　> 70 years 6
　60-69 4
Arozullah, AM, Daley, J, Henderson, WG, Khuri, SF, Ann Surg 2000; 232:242.

Performance of the Arozullah respiratory failure index

Class Point total Percent respiratory failure
1 ≦10 0.5%
2 11-19 1.8%
3 20-27 4.2%
4 28-40 10.1%
5 >40 26.6%
Arozullah, AM, Daley, J, Henderson, WG, Khuri, SF, Ann Surg 2000; 232:242.
Strategies to reduce postoperative pulmonary complication

Preoperative — The following preoperative interventions are definitely beneficial:
  • Smoking cessation for eight weeks
  • Inhaled ipratropium or tiotropium for all patients with clinically significant COPD
  • Inhaled beta-agonists for patients with COPD or asthma who have wheezes or dyspnea
  • Preoperative corticosteroids for patients with COPD or asthma who are not optimized and whose airway obstruction has not been maximally reduced
  • Delay elective surgery if respiratory infection present
  • Antibiotics for patients with infected sputum
  • Patient education regarding lung expansion maneuvers
Intraoperative — The following intraoperative interventions are definitely beneficial:

  • Choose alternative procedure lasting less than three to four hours when possible
  • Minimize duration of anesthesia
  • Surgery other than upper abdominal or thoracic when possible
  • Regional anesthesia (nerve block) in very high-risk patients
  • Epidural or spinal anesthesia in lieu of general anesthesia in high risk patients
  • Avoid use of pancuronium as a muscle relaxant in high-risk patients
Choosing laparoscopic rather than open abdominal surgery when possible may be beneficial. However, perioperative pulmonary artery catheterization is not beneficial.
Postoperative — The following postoperative interventions are definitely beneficial:
  • Deep breathing exercises or incentive spirometry in high risk patients
  • Epidural analgesia in lieu of parenteral opioids
Continuous positive airway pressure (CPAP), intercostal nerve blocks, and selective use of nasogastric tubes after abdominal surgery for symptoms only are probably beneficial postoperative interventions. Postoperative doxapram might be beneficial.
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