A. Does Patient Require Emergency Surgery? - In-hospital respiratory specialist or intensivist should be notified for perioperative care, but emergency surgeries, including repair femoral neckhip fractures, should not be held up pending consultation.

B. Contact Intensivist and Switch to IV Steroids if Patient is on Systemic Steroids - In-house respiratory specialist or intensivists should be notified for perioperative care. If patient is on systemic steroids, switch to IV steroids using hydrocortisone 300 mg/day or an equivalent.

C. Refer to Pulmonary Specialist - Client should be referred to a respiratory or thoracic specialist prior to scheduling of a lung resection. In some cases, for example in patients with mild COPD and a solitary pulmonary nodule, the patients can be referred directly to a thoracic surgeon.

D. Minor Surgery Requiring Local Anesthesia - Administration of local anesthesia presents a very low risk, even in the presence of severe COPD. In clinically stable patients with mild or moderate COPD, a phone evaluation to inquire about exacerbation might suffice. Pulmonary Function Test (PFT) is not required.

E. Obtain Pulmonary Function Test - There is no universal opinion on the value of pulmonary function testing preoperatively. A common opinion is that "When a preoperative evaluation of a patient about to undergo elective CABG surgery suggests lung disease, simple spirometry can better characterize the nature of the patient's pulmonary problems and aid in the decision about appropriate preoperative medical therapy" (Zibrak et al. 1993). One study (Wong 1995) showed that low FEV₁ predicted postoperative complications such as prolonged ICU stay, prolonged hospital stay, prolonged mechanical ventilation, and pneumonias, but this study looked only at patients with severe COPD (FEV₁ < 1.2L), with mixed surgical sites. On the other hand, other studies (Kroenke 1993) have shown pulmonary function testing does not predict perioperative complications.

F. Obtain Chest X-Ray - Chest x-ray should be done preoperatively in patients with an established diagnosis of COPD who may potentially require general anesthesia, since an abnormal chest x-ray is a predictor of perioperative complications in thoracic and major abdominal surgery.

"A preoperative chest x-ray in patients for noncardiothoracic surgery is sensible, because patients with COPD are at increased risk of pulmonary neoplasm." (ATS Guidelines 1995).

H. Is Surgery on Upper Abdomen or Thorax? - The guidelines for the American Thoracic Society (1995) state that "Upper abdominal surgery poses a risk of postoperative pulmonary complications for all patients.. Upper abdominal surgery shifts the respiratory pump from the diaphragm to the accessory muscles, due to a non-pain-related reflex. Non-imperative upper abdominal surgery such as cholecystectomy should be avoided in patients with moderate to severe COPD. If surgery is necessary, attempts should be made to provide careful anesthesia. Another potential way to decrease operative risk may be to perform the procedure laparoscopically."

I. Is PaCO₂ > 45? - Hypercapnia is an independent risk factor for patients with moderate to severe COPD who are having upper abdominal or thoracic surgery.

K. Administer Postoperative Subcutaneous Heparin - Postoperative subcutaneous heparin is useful for prophylaxis versus pulmonary emboli, and should be strongly considered in patients who start with limited pulmonary reserve.

L. Arrange for Postoperative Incentive Spirometry or Controlled Deep Breathing and Cough - Deep breathing and controlled cough with or without incentive spirometry should be done postoperatively.