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Ann Thorac Surg 2007;84:683-685
© 2007 The Society of Thoracic Surgeons

How To Do It

Nurse-Led Preoperative Screening and Targeted Optimization of Pulmonary Dysfunction in Patients Undergoing Cardiac Surgery

Sivakumar Sivalingam, MB, FRCS(CTh), Sridhar Rathinam, MB, FRCSEd(CTh), Adam Ajis, MB, BCh, Christopher M.R. Satur, MD, FRCS(CTh)*

Department of Cardiothoracic Surgery, University Hospital of North Staffordshire, Stoke-on-Trent, United Kingdom

Accepted for publication November 9, 2006.

* Address correspondence to Dr Satur, University Hospital of North Staffordshire, Princes Road, Stoke-on-Trent, ST4 7LN United Kingdom (Email: christopher.satur{at}uhns.nhs.uk).


   Abstract
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 Abstract
Introduction
 Technique
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 References
 
Postoperative pulmonary dysfunction prolonging intensive care treatment after cardiac surgery most commonly occurs in patients with a background of pre-existing pulmonary dysfunction. However, many patients have occult dysfunction and present primarily after surgery. We describe and discuss the results of a respiratory optimization program utilizing a peak expiratory flow rate below 400 L/min as a screening test to identify patients in a nurse-directed preoperative clinic.


   Introduction
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 Abstract
 Introduction
Technique
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Chronic obstructive airway disease is a risk factor for early mortality in patients undergoing coronary artery bypass grafting [1]. While being responsible for devastating postoperative complications, pulmonary dysfunction commonly remains untreated or undetected, or both, before surgery.

We have undertaken a pilot clinical study in which patients undergoing elective cardiac surgical procedures were screened to identify those at risk of postoperative respiratory difficulties. Peak expiratory flow rate (PEFR) measurements (used as part of a nurse directed pre-admission clinic protocol) were used to detect these patients. Subsequently these patients were admitted to a program of pulmonary optimization prior to surgery. We share the positive impact of this novel approach on our practice in preventing postoperative respiratory morbidity.


   Technique
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 Abstract
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At our institution patients are reviewed in a nurse-led preoperative assessment clinic in which a protocol of tests including those for respiratory functions is undertaken. The protocol was devised by the consultant surgeons of the department and are reviewed and updated regularly. Patients of a single surgeon (CMRS) with a PEFR value below 400 L/min were admitted approximately 5 days before surgery for pulmonary optimization therapy with nebulized salbutamol (5 mg) four times a day and nebulized budesonide (1 mg) twice a day. An essential part of the program is the use of inhaled high-dose steroids, as it is important to provide stabilization of the reactive airways. The nurse looking after these patients performed the PEFR twice a day with the same peak flow meter and the response to the nebulized bronchodilator and steroid therapy was charted twice a day. A pre-therapy PEFR and another one performed an hour after therapy were recorded. The improvement was evaluated until the rise in values reached a plateau and resolution of the reversible component was identified. It was at this point that surgery was undertaken. Patients were continued on this program after surgery, but were converted to a standard metered dose inhaler administration prior to discharge from the hospital.

Methods
A retrospective review of the prospectively collected data of patients who underwent the optimization therapy was analyzed. This study was discussed with the local ethics committee and was deemed not requiring ethical approval as it was seen as an outcome audit of the unit. Individual patient consent was not obtained as no patient is identified. The study was performed with departmental approval.

Patients entered into the pulmonary optimization program between July 2003 and October 2004 were identified, and outcome measures such as the length of postoperative ventilation, the period of intensive care unit management, occurrence of chest infection, and prolonged hospital stay were analyzed. The data was collected from individual patient notes and charts and the surgical database.

Outcomes
Of a total of 258 patients receiving coronary artery bypass grafting or valve surgery by a single surgeon (CMRS) during the period of the study, 14 patients (5.4%) were identified for targeted pulmonary optimization. The median age was 73 years (range, 53 to 79 years) with 9 males (64%).

Ten of the 14 patients were ex-smokers, 3 were smoking at the time of admission and 1 was a lifelong nonsmoker. They were admitted at a median of 6 days prior to surgery. The median preoperative PEFR was 300 L/min (range, 157 to 340 L/min), which a median 67% predicted for age, height, and sex (38% to 79%). After optimization the PEFR rose by 40% to a median value of 420 L/min (range, 400 to 520 L/min), which improved the values to 89% of predicted values (range, 68% to 108%) (Fig 1).


Figure 1
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  		Fig 1. Change in peak expiratory flow rates (PEFRs) after pulmonary optimization. The improvement of PEFR values of individual patients undergoing optimization therapy (p < 0.001).

 
The median ventilation time was 8 hours (range, 4 to 72 hours) with the median intensive care unit stay of 10.5 hours (range, 5 to 80 hours), and the median postoperative hospital stay was 7 days with 2 patients staying over 10 days (range, 6 to 17 days). One patient who had associated carotid artery and peripheral vascular disease was reintubated and ventilated due to mental agitation rather than respiratory failure. No other patients suffered significant respiratory compromise or chest infection. Five patients had postoperative atrial fibrillation. There were no postoperative deaths.


   Comment
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The patients with chronic obstructive pulmonary disease undergoing coronary artery bypass grafting have been noted to have higher mortality and morbidity when compared with a group without chronic obstructive airway disease matched for age, sex, and ejection fraction. These patients with chronic obstructive pulmonary disease have shown to have prolonged duration of intubation, reintubation, increased stay in intensive care, and hospital [2]. Therefore we believed we needed to preoperatively optimize the lung function to the maximum so they would have a better postoperative outcome.

The PEFR test was chosen to be readily reproducible at a busy a nurse-led clinic, and measurements were calculated and compared with predicted values according to the manufacturer’s guidelines [3]. The cut off value of 400 L/min was selected from normogram of normal reference values for age and sex as documented in the British Thoracic Society guidelines [4]. The value of 400 L/min was selected because it is significantly below all male normal values; thus it is an extreme by which patients could be judged requiring intervention. However, female values do overlap the value of 400 L/min in advancing ages. As this was a pilot study to identify a strategic mechanism to identify patients at risk of airway complications, the lowest level of the British Thoracic Society chart was chosen that was applicable in advanced ages. The reservation regarding the value of the numerator was that of women who have lower PEFR values, and there is potentially a broad spread of values around the norm. However, in support of this value was that most patients with lower values produced PEFR results that were significantly below, and subsequently demonstrated marked improvement. Second, the aim of the protocol management of this problem was to provide readily usable guidelines, which provide a simple trigger to commence medical intervention, which has proven to be such. However, this article can not prove whether patients with higher PEFR values would have also benefited from this therapy.

Nurse-directed preoperative assessment clinics have improved the cardiac services in the changing environment of the reduction in the working hours of the junior doctors due to implementation of the European working time directive [5]. The value of nurse-directed preoperative assessment clinics has reduced the cancellations and delays in surgical services [6]. However, the supporting role of nurses to the doctors in these areas requires comprehensive but not complicated protocols that provide guidance when working with the patients. Thus a simple measurement provides an addition to existing protocols that allows rapid evaluation of patients who require further assessment of respiratory function.

The main aim of preoperative optimization was to improve pulmonary function prior to surgery as we believed this would help the patients during the postoperative period by improving their pulmonary reserves. Cardiac surgery causes a significant decrease in the lung function with forced expiratory volume in 1 second dropping as much as 30% [7]. We have forestalled a composite of this decline and pulmonary compromise already experienced by patients. An integral component of the protocol is the utilization of inhaled high-dose steroids to provide stabilization of the reactive airways. Optimization requires a period of few days as the positive response of the PEFR to bronchodilators is temporary returning to baseline between the doses. Addition of inhaled steroids has a number of effects (ie, it prevents the recurrent decline after use of bronchodilators, it reduces the degree of decline, and it causes a steady improvement in maximum PEFR). The optimized pulmonary function reaches a plateau after surgery is undertaken.

The level of care required during preoperative optimization is significantly lower than that required in the intensive care unit [8]. Thus in spite of the increased preoperative stay, early discharge from the intensive care unit, avoidance of respiratory complications, and earlier discharge from the hospital may provide financial benefits.

In conclusion, our experience has demonstrated that a PEFR of 400 L/min is a useful trigger for admission of patients from a nurse directed pre-admission clinic for optimization of pulmonary function. These patients also experienced an improved pattern of recovery including a short period of ventilation, intensive care unit admission, and hospital stay after surgery.


   References
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 Abstract
 Introduction
 Technique
 Comment
 References
 

  1. Medalion B, Katz MG, Cohen AJ, Hauptman E, Sasson L, Schachner A. Long-term beneficial effect of coronary artery bypass grafting in patients with COPD Chest 2004;125:56-62.[Medline]
  2. Cohen A, Katz M, Katz R, Hauptman E, Schachner A. Chronic obstructive pulmonary disease in patients undergoing coronary artery bypass grafting J Thorac Cardiovasc Surg 1995;109:574-581.[Abstract/Free Full Text]
  3. Mini-Wright Peak Flow MeterPeak Expiratory Flow Rate. 2006Available at: http://www.peakflow.com/top_nav/normal_values/PEFNorms.html. Accessed October 20.
  4. British guideline on the management of asthma Thorax 2003;58(Suppl):I5.
  5. United Kingdom Department of Health. European Working Time Directive. Available at http://www.dh.gov.uk/policyandguidance/humanresourcesandtraining/workingdifferently/europeanworkingtimedirective/fs/en. Accessed October 20, 2006.
  6. Rai MR, Pandit JJ. Day of surgery cancellations after nurse-led pre-assessment in an elective surgical centre: the first 2 years Anaesthesia 2003;58:692-699.[Medline]
  7. Nicholson DJ, Kowalski SE, Hamilton GA, Meyers MP, Serrette C, Duke PC. Postoperative pulmonary function in coronary artery bypass graft surgery patients undergoing early tracheal extubation: a comparison between short-term mechanical ventilation and early extubation J Cardiothorac Vasc Anesth 2002;16:27-31.[Medline]
  8. Rajakaruna C, Rogers CA, Angelini GD, Ascione R. Risk factors for and economic implications of prolonged ventilation after cardiac surgery J Thorac Cardiovasc Surg 2005;130:1270-1277.[Abstract/Free Full Text]



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