November FY23

[A Schutter]

This months Journal Club is presented by Dahlia Rouchon, CRNA  She chose an interesting article titled "Sarcoidosis: Perioperative Implications and Management. The article helps us understand sarcoidosis and its manifestations which are essential for providing a safe and effective preoperative experience.

Here is a link to the article.

Questions for discussion:
1. What airway and lung considerations would you have for a sarcoid patient and why?
2. How would you manage these concerns?

[sjsimmons]

1. As an intrinsic restrictive lung disease, sarcoidosis manifests as a reduction in lung volumes and lung compliance. Patients may present with dyspnea, persistent dry cough and, in more advanced disease, pulmonary hypertension. Sarcoidosis may affect any region of the lung, including upper respiratory tract, nasal passages, and lower respiratory tract, and may cause airway obstruction.

2. Depending on the severity of sarcoidosis, some patients should undergo radiologic imaging and pulmonary function tests to assess airway patency and functional capacity prior to surgery. Consider awake fiberoptic intubation in patients with known upper airway involvement. Due to their increased risk for post-operative pulmonary complications, patients with sarcoidosis should also avoid elective surgery with an active respiratory infection. Adequate preoxygenation with 100% oxygen and positioning are other important considerations for management of sarcoidosis to prolong the time to desaturation in the setting of reduced FRC.

[Anne McNulty]

1. I read this article a year ago and it is very interesting. We have many of Sarcoid patients at JHU. These patients need a thorough pre-op assessment of all body systems. The airway assessment needs to evaluate the presence of granulomas in the supraglottic and infraglottic region before surgery as well as distal airways. Bronchospasm is very common when distal airways are involved. (2) Awake fiberoptic intubation is the best choice if there is upper airway involvement. The patients that I have had ,responded well to Ketamine. Preoxygenate well due to reduced FRC. Use lung protective vent settings, and PEEP. Avoid hypercarbia, Hypoxia and acidosis. VQ mismatching hopefully will respond to increasing PEEP. Be ready for lots of suctioning due to mucus plugs. patients may also have granulomas in the brain. Ketamine is a good choice for headaches cause by brain granulomas.

[kels]

For the sarcoid patient I am considering all things that can optimize ventilation. I am also considering placing an ETT using the fiberoptic scope since these patients have a restrictive lung disease that can also have upper airway involvement. At minimum I would preoxygenate very well and use peep and suction if needed .

[Amy Swank]

Severity of sarcoidosis can vary greatly with with involvement of other organs and severity. Pulmonary hypertension occurs in end stage disease in about 25%, if present should be optimized before surgery. It's important to do a good airway assessment as the granulomas in upper respiratory tract predispose patient to airway obstruction and difficulty with ventilation and intubation. Also important to do a adequate preoxygenation, maybe even induce with patient in reverse Trendelenburg to optimize FRC. Vent strategies include avoiding nitrous, decreased tidal volumes, reduced FIO2 and use of PEEP.

[aileenm4]

airway and lung concerns: they can be a wide variety of severity in this disease
airway evaluation via nasal endoscopy preop to evaluate when patient has s/y hoarse or husky voice, cough, nose bleeds, airway obstruction etc.this will help guide your intubation needs
PFTs are not helpful for diagnosis but rather by primary care team to evaluate progression. Lung management is with ventilation with lung safe vent strategies, pulm HTN can be devistating
so avoid hypercarbia, hypoxia, acidosis or other things to cause crisis

[Belinda G]

1. What airway and lung considerations would you have for a sarcoid patient and why?
I would consider a thorough preoperative evaluation to include TTE/radiologic/FO evaluation of airways or studies as needed to evaluate extent of disease as well as to determine need for optimization preoperatively for all of the reasons stated above.
2. How would you manage these concerns?
Ensure studies are adequate, patient's symptoms are stable (no new or worsening SOB/Dyspnea/active URI), patient receives stress dose steroids when appropriate, preoxygenate well w/100% HOB up/ rev-Tburg, add PEEP/reduced TVs, avoid N20, fully reverse NMB, and suction airway well. Remember there may upper, glottic or lower airway involvement that may preclude the use of nasal airways etc and necessitate the use of FO intubation.

[Christine Velarde]

1. Pts with sarcoidosis may have restictive airways which may require preop prehab to help gain optimal intra and post-op recovery. The patient usually needs steroid therapy and may require a stress does. Potential pulmonary HTN and pulm fibrosis.
2. It is recommended to use smaller tidal volumes, lower oxygen therapy, steroid coverage and CPAP/ high flow post- procedure.