Answer:

Preoperative evaluation of patients with asthma and COPD focuses on the assessment of disease severity, the effectiveness of current medical management, and the potential need for additional therapy before surgery. The history should include assessment of exercise tolerance, recent or current respiratory infections, sputum quantity and quality, known triggers of attacks, most recent exacerbations, current medications and time of last use, smoking history, and prior surgical and anesthetic history.

A focused cardiopulmonary exam should occur, which should focus on detecting signs of acute bronchospasm, active lung infection, and right heart failure. Note the patient’s general appearance and observe the patient’s breathing. Look for use of accessory muscles, pursed-lip exhalation, or cyanosis. Auscultation of the lungs can reveal wheezing, adventitious lung sounds, and hyperinflation. Auscultation of the heart may reveal a split second heart sound typical of cor pulmonale or the murmur of tricuspid or pulmonary regurgitation present in some patients with long-standing pulmonary hypertension. Additionally, jugular venous distension, peripheral edema, and hepatic enlargement may be present. Cachexia may also be seen.

Laboratory testing is guided by the history and physical examination. For major surgery, it is reasonable to obtain a complete blood count, serum electrolytes, electrocardiogram, and chest radiograph. Additionally, these patients should have a room air SpO₂. It is not recommended to routinely perform pulmonary function tests. However, if the worsening of disease severity is elicited from the history and physical examination, additional diagnostic tests may include a computed tomography scan of the chest, echocardiogram, detailed lung volume testing, and a room air ABG.

• Hines RL, Marschall KE, eds. Stoelting’s Anesthesia and Co-existing Disease. 7th ed. Philadelphia, PA: Elsevier; 2018:15-32.
• Lakshminarasimhachar A, Smetana GW. Preoperative evaluation: estimation of pulmonary risk. Anesthesiol Clin. 2016;34:71-88.
• Woods BD, Sladen RN. Perioperative considerations for the patient with asthma and bronchospasm. Br J Anaesth. 2009;103(suppl 1):i57-i65.