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Post-operative breathlessness 

Post-operative breathlessness
Chapter:
Post-operative breathlessness
Author(s):

Stephen Chapman

, Grace Robinson

, John Stradling

, Sophie West

, and John Wrightson

DOI:
10.1093/med/9780198703860.003.0009
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date: 26 October 2021

Introduction

The respiratory physician is often asked to see patients post-operatively who have become dyspnoeic following an operative procedure. The risk of pulmonary complications is greatest with thoracic or upper abdominal surgery, when a degree of pulmonary dysfunction and consequent breathlessness due to atelectasis is inevitable. Always rule out upper airway obstruction. See Table 9.1 for possible causes and management.

Table 9.1 Management of post-operative dyspnoea

Possible cause of dyspnoea

Management options

Basal atelectasis (commoner in smokers and following abdominal or trans-thoracic procedures. Mucus in bronchial tree causes small airway obstruction, subsequent alveolar air reabsorption, and collapse of lung segments); collapsed lobe—mucus plugging

Adequate analgesia to encourage expectoration, nebulized saline, chest physiotherapy, deep breathing. If lung does not reinflate, consider bronchoscopy to suction out secretions

Pneumonia—follows atelectasis and collapse. Possible aspiration also

If fever and chest signs, give antibiotics for hospital-acquired pneumonia (see Post-operative breathlessness pp. [link][link]), adequate analgesia to encourage expectoration, chest physiotherapy

Thromboembolic disease

O2 as required. Measure A–a gradient on blood gas. Start treatment dose of unfractionated heparin (if not contraindicated by the operation); arrange V/Q scan or CTPA; check D-dimers (although unhelpful unless negative). If in extremis, consider urgent CT or echo and thrombolysis (see Post-operative breathlessness pp. [link][link])

Respiratory failure

Opiate overdose or anaesthetic agents causing neuromuscular block not reversed. Undiagnosed respiratory muscle weakness

Metabolic acidosis

Check U&E; look for underlying problem such as renal failure or sepsis

Myocardial ischaemia

O2, check 12h troponin. Sublingual or IV glyceryl trinitrate, if required for pain. Start prophylactic heparin (if not contraindicated by the operation)

MI or acute coronary syndrome

Thrombolysis likely to be contraindicated by recent surgery, so consider referral for 1° angioplasty. Consider aspirin, clopidogrel, low molecular weight heparin (LMWH)

Cardiac failure/fluid overload

O2, IV furosemide, central line, and inotropes if required. Echo to assess LV

ARDS

Supportive, likely to need mechanical ventilatory assistance (see Post-operative breathlessness pp. [link][link])

Phrenic nerve damage causing diaphragmatic paralysis. May occur with thoracic operations such as CABG

Diagnose on lung function tests, CXR, and clinically decreased diaphragm movement. Advise to tilt whole bed (head up) when sleeping. Phrenics may recover but can take 2+ years

Fat embolism following long bone fracture, especially with reaming and manipulation

O2, IV fluids, supportive care

Laryngeal spasm

Reassurance, O2 if required

Anaemia

Cross-match and transfuse. Identify if ongoing bleeding source

Myasthenia gravis crisis precipitated by anaesthetic agents

May need intubation and ventilation. Stop all anticholinesterases. Consider plasma exchange and IV immunoglobulin. Urgent neurology input

The four most likely common causes are:

  • Infection/atelectasis

  • PE

  • LVF (fluid overload)

  • Exacerbation of underlying lung disease such as COPD or UIP.

Initial assessment

  • Is the patient acutely unwell, needing immediate resuscitation and ventilatory support?

  • Comorbid disease and past medical history, especially pulmonary, cardiac, or thromboembolic disease

  • Type of surgery:

    • Thoracic surgery Consider lobar gangrene (torsion of the remaining lobe causing vascular occlusion) leading to pulmonary infarction with fever and haemoptysis, bronchopleural fistula, often associated with an infected pleural space, leading to sepsis and failure of the underlying lung to re-expand

  • Time since surgery:

    • Early complications (hours) related to residual anaesthetic effect not adequately reversed, atelectasis, respiratory failure, hypovolaemic shock, infection, PE, fat embolism, air embolism, LVF and fluid overload, myocardial ischaemia

    • Later complications (hours to days) related to PE, ARDS, infection, myocardial ischaemia.

Initial investigations

  • O2 saturations and ABG breathing room air and on O2

  • ECG

  • CXR—compare with preoperative CXR, if available

  • FBC and clotting screen

  • U&E and bicarbonate

  • See if they had preoperative oximetry and spirometry performed. There should be a record of the O2 saturation in the anaesthetic room.

A D-dimer level is unhelpful, as it will be raised by many different intra- and post-operative mechanisms.

CRP and WCC are also largely unhelpful, as these are frequently raised post-operatively.