Anesthesia and Analgesia for High-Risk Pulmonary Patients

Dear Colleagues,

Chronic obstructive pulmonary disease (COPD) is a common disease with a prevalence of 10.1% worldwide. According to the WHO, it has become the third leading cause of mortality in the world. Using the National Surgical Quality Improvement Program database (2007-8, N = 468,795), a study by the BOLD collaboration group revealed that patients with COPD (n = 22,576) who underwent surgery were found to have a higher morbidity (25.8%), 30-day mortality (6.7%), and longer length of stay (4 days) than patients without COPD (10.2%, 1.4%, and 1 day, respectively; p < 0.0001). Surgical patients with COPD were found to have an increased risk of postoperative pneumonia, sepsis, respiratory failure, myocardial infarction, cardiac arrest, and renal failure.

It is widely known that general anesthesia in patients with COPD is associated with adverse outcomes, particularly when administered with an endotracheal tube and intermittent positive pressure ventilation. COPD patients under general anesthesia are more likely to have postoperative pulmonary complications and are prone to laryngospasm, bronchospasm, barotrauma, and hypoxemia. For these reasons, with increasing supportive evidence in the literature, it is recommended to use regional anesthesia instead of general anesthesia. However, the interscalene brachial plexus block remains a relative contraindication since it is associated with phrenic nerve palsy and diminished respiratory function.

Shoulder pain is a common pathology that carries a prevalence of up to 26%. Major shoulder surgery is known to cause moderate to severe postoperative pain. Peripheral nerve blocks have become the mainstay and proven effective modality for treating postoperative shoulder pain. The interscalene block is still considered the gold standard in providing surgical anesthesia as well as analgesia for most shoulder surgery. However, the inherent risk of blocking the phrenic nerve when performing the interscalene block has prohibited its use among high-risk patients with severe pulmonary disease.

Recent advances in regional anesthesia have widened the usability of peripheral nerve blocks, even to certain high-risk patients that were once precluded due to the frailty of their respiratory condition. Compromised pulmonary patients would be subjected to general anesthesia and higher opioid usage, leading to an increased risk of postoperative pulmonary complications. Due to the innovations of ultrasonography, regional blocks have recently been refined to target select nerves supplying the shoulder that do not lead to adverse events, such as the suprascapular and axillary nerves. These novel phrenic-sparing blocks may be effective alternatives to the interscalene block and provide anesthesia and analgesia to these high-risk patients.

This Special Issue will identify the gaps in the novel regional techniques that are diaphragm sparing based on original research and review papers.

Topics will include:

• The use of novel regional techniques that are diaphragm sparing
• Comparison between novel techniques to the interscalene block
• Postoperative complications of patients with pulmonary disease
• Regional versus general anesthesia in patients with pulmonary disease

Dr. David H. Kim
Guest Editor

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• diaphragm-sparing
• phrenic nerve sparing
• shoulder surgery
• COPD
• brachial plexus block