Regional Versus General Anesthesia in Surgical Patients With Chronic Obstructive Pulmonary Disease: Does Avoiding General Anesthesia Reduce The Risk of Postoperative Complications?

Regional Anesthesia
Section Editor: Terese T. Horlocker
Regional Versus General Anesthesia in Surgical

Patients with Chronic Obstructive Pulmonary Disease:
Does Avoiding General Anesthesia Reduce the Risk of
Postoperative Complications?
Mark S. Hausman, Jr., MD, Elizabeth S. Jewell, MS, and Milo Engoren, MD
BACKGROUND: Surgical patients with chronic obstructive pulmonary disease (COPD) are at
increased risk of perioperative complications. In this study, we sought to quantify the benefit of
avoiding general anesthesia in this patient population.
METHODS: Data from the National Surgical Quality Improvement Program database (2005–
2010) were used for this review. Patients who met the National Surgical Quality Improvement
Program definition for COPD and underwent surgery under general, spinal, epidural, or periph-
eral nerve block anesthesia were included in this study. For each primary current procedural
terminology code with ≥1 general and ≥1 regional (spinal, epidural, or peripheral nerve block)
anesthetic, regional patients were propensity score--matched to general anesthetic patients.
Propensity scoring was calculated using all available demographic and comorbidity data. This
match yielded 2644 patients who received regional anesthesia and 2644 matched general
anesthetic patients. These groups were compared for morbidity and mortality.
RESULTS: Groups were well matched on demographics, comorbidities, and type of surgery.
Compared with matched patients who received regional anesthesia, patients who received gen-
eral anesthesia had a higher incidence of postoperative pneumonia (3.3% vs 2.3%, P = 0.0384,
absolute difference with 95% confidence interval = 1.0% [0.09, 1.88]), prolonged ventilator
dependence (2.1% vs 0.9%, P = 0.0008, difference = 1.2% [0.51, 1.84]), and unplanned post-
operative intubation (2.6% vs 1.8%, P = 0.0487, difference = 0.8% [0.04, 1.62]). Composite
morbidity was 15.4% in the general group versus 12.6% (P = 0.0038, difference = 2.8% [0.93,
4.67]). Composite morbidity not including pulmonary complications was 13.0% in the general
group versus 11.1% (P = 0.0312, difference = 1.9% [0.21, 3.72]). Thirty-day mortality was
similar (2.7% vs 3.0%, P = 0.6788, difference = 0.3% [−1.12, 0.67]). As a test for validity, we
found a positive association between pulmonary end points because patients with 1 pulmonary
complication were significantly more likely to have additional pulmonary complications.
CONCLUSIONS: The use of regional anesthesia in patients with COPD is associated with
lower incidences of composite morbidity, pneumonia, prolonged ventilator dependence, and
unplanned postoperative intubation. (Anesth Analg 2015;120:1405–12)
S
urgical patients with chronic obstructive pulmonary pulmonary function,4 reduced the risk of postoperative
disease (COPD) are at increased risk of perioperative pulmonary infection,5 and improved 30-day mortality5 in
complications.1–3 These patients are more likely to patients with COPD. A review of 141 prospective, random-
require unplanned postoperative intubation,1 have a higher ized trials comparing neuraxial versus general anesthesia
incidence of postoperative pulmonary infection,2,3 and have demonstrated decreased mortality and decreased incidence
increased length of hospital stay2 compared with patients of postoperative pulmonary and cardiac complications,
without COPD. renal failure, and deep venous thrombosis in the patients
Postoperative epidural analgesia for patients with COPD receiving neuraxial anesthesia.6 However, 3 more recent tri-
undergoing major abdominal surgery under general anes- als found modest to no benefit to epidural anesthesia and
thesia has been shown to be beneficial in some patient popu- analgesia,7–9 and a very recent post hoc subgroup analysis
lations.4,5 Epidural analgesia promoted better postoperative of a large prospective trial of β-blockers found that neur-
axial anesthesia was associated with increased adverse car-
From the Department of Anesthesiology, Division of Critical Care Medicine, diovascular outcomes.10 These studies were not specific to
University of Michigan Health Systems, Ann Arbor, Michigan.
patients with COPD, and the benefits or harms associated
Accepted for publication October 22, 2014.
with neuraxial/regional anesthesia may be related to non-
Funding: Funding in the form of salary support for authors was provided by
the University of Michigan, Department of Anesthesiology. COPD patients who comprised the majority of subjects in
The authors declare no conflicts of interest. these studies. Therefore, whether using regional (spinal,
Reprints will not be available from the authors. epidural, or peripheral nerve block) anesthesia and thus
Address correspondence to Mark S. Hausman, Jr., MD, Department of Anes- avoiding operative endotracheal intubation and mechani-
thesiology, University of Michigan Health Systems, 1H247 University Hos- cal ventilation improves outcomes in surgical patients with
pital, 1500 E Medical Center Dr., SPC 5048, Ann Arbor, MI 48109. Address
e-mail to mhausman@umich.edu. COPD remains unknown. We hypothesized that avoid-
Copyright © 2014 International Anesthesia Research Society ing general anesthesia in patients with COPD would sig-
DOI: 10.1213/ANE.0000000000000574 nificantly reduce the incidence of postoperative pulmonary
June 2015 • Volume 120 • Number 6 www.anesthesia-analgesia.org 1405

Copyright © 2014 International Anesthesia Research Society. Unauthorized reproduction of this article is prohibited.
Regional Versus General Anesthesia in COPD
infection, as well as reduce the incidence of perioperative technique, and ≥1 qualifying patient who underwent gen-
and postoperative morbidity. eral anesthesia as the primary technique (with or without
adjunct regional analgesia), regional patients were matched
METHODS to general anesthetic patients on the basis of a calculated
The University of Michigan IRB approved this retrospective propensity score. Propensity scores were calculated using a
propensity-matched cohort study (IRB registration num- nonparsimonious binary logistic regression for demographic
ber HUM00052066). Data from the American College of and comorbidity variables (Table 1), with type of primary
Surgeons National Surgical Quality Improvement Program anesthetic (regional or general) as the dependent variable.
(NSQIP) participant use data file from 2005 to 2010 were Cases missing these data were excluded (Fig. 1). Within each
used for this study. A waiver for informed consent was identical surgical procedure (unique CPT code), patients
granted because we used an existing, deidentified data who received regional anesthesia as the primary anesthetic
set. NSQIP data were collected from 186 hospitals, across a technique were matched to those who received general anes-
wide variety of case types. The data were collected prospec- thesia as the primary technique using a caliper width that
tively and were subject to the accuracy and completeness of maximizes the number of matches while maintaining all
NSQIP data collection and reporting systems. They were standardized differences <10%. Area under the curve for the
collected by trained professionals using standardized defi- propensity score logistic regression was 0.66. In addition to
nitions, and data entry was audited. This process ensures exact matching by primary CPT code, patients underwent
standard interpretations of the definitions, and the meth- exact matching based on level of dyspnea (none, moderate,
odology, accuracy, and reproducibility of these data have or at rest; Appendix 1), as well as history of bleeding disor-
been documented in previous studies.11,12 The participant der. The result of this matching yielded 2644 patients who
use data file includes multispecialty NSQIP contributions, received regional anesthesia and 2644 patients who under-
so a wide range of case types are included in this study. went identical operations under general anesthesia. All sub-
group analyses retained the exact match on primary CPT
Inclusion/Exclusion Criteria code, level of dyspnea, and bleeding history.
Patients were included if they had an NSQIP preopera-
tive diagnosis of severe COPD (Appendix 1) and received Power Analysis
general or regional as the principal anesthetic technique. A power analysis for our primary outcome given our sam-
Patients were excluded if they required ventilator-assisted ple size, assuming that postoperative pulmonary infection
respiration within 48 hours before surgery or if they had occurs in 8% of patients receiving general anesthesia, 2644
a preoperative pulmonary infection (Appendix 1). Patients patients in each group would detect a difference of 2%, with
who did not meet the NSQIP definition of severe COPD 80% power at a significance level of α = 0.05.
were excluded, as were patients undergoing cardiac sur-
gery, solid organ transplant, emergency surgery, reopera- Statistical Analysis
tion within 30 days of initial operation, or were American Demographic and comorbidity data in the matched groups
Society of Anesthesiologists (ASA) classification 5 or 6. were compared using standardized differences. Relative
Finally, to ensure that we were analyzing only operations and absolute risk differences were calculated for out-
that were done under both general or regional anesthesia, comes of interest, and χ2 tests were used for comparison.
patients were excluded if their primary surgical current Multivariable logistic regressions were used to further
procedural terminology (CPT) code did not have ≥1 general examine the effects of prothrombin time, partial thrombo-
and ≥1 regional anesthetic case reported. plastin time, and platelet level on 30-day mortality and com-
posite morbidity by type of anesthesia. The regional group
Outcomes was divided into subsets by type of regional anesthesia (spi-
The primary outcome for this study was postoperative pul- nal, epidural, and peripheral nerve block), and relative and
monary infection reported in the postoperative inpatient absolute risk differences were used to compare each subset
setting (Appendix 1). Secondary outcomes included 30-day with its general anesthesia matches. In addition, matched
mortality, ventilator dependence for >48 hours postop- pairs were grouped by level of dyspnea (at rest, with mod-
eratively, unplanned postoperative intubation, and a com- erate activity, and no dyspnea; Appendix 1) and by ASA
posite morbidity consisting of any of these 3 respiratory status, and relative and absolute risk differences for the out-
complications or any of the following: new dialysis require- comes were calculated in those subsets. Whereas relative
ment, progressive renal failure, postoperative cardiac arrest, risk and absolute risk differences were calculated for our
postoperative myocardial infarction, sepsis, septic shock, outcomes of interest, we report the results as absolute risk
wound infection, stroke, urinary tract infection, signifi- in the forest plots and as absolute event rates elsewhere.14
cant postoperative bleeding, peripheral nerve injury, deep A total of 107 patients (4%) in the general anesthesia group
venous thrombosis, and pulmonary embolus. All outcomes and 64 (2%) in the regional anesthesia group were missing
are as defined by the American College of Surgeons NSQIP postoperative bleeding data. The relative and absolute risk
data sheet, updated April 1, 2009.13 differences for this outcome were calculated without these
subjects. SAS Software, version 9.2 (SAS Institute, Cary, NC)
Study Design and R version 2.15.2 (R Foundation, Vienna, Austria) were
From within each primary CPT code that had ≥1 qualifying used for the statistical analysis, and SAS gmatch macro was
patient who underwent regional anesthesia as the primary used for the propensity score matching.
1406
www.anesthesia-analgesia.org anesthesia & analgesia

Table 1. Demographic and Clinical Characteristics for the Matched Study Population
General anesthesia Regional anesthesia Standardized
Clinical variable (N = 2644) (N = 2644) difference
N % N % %
Male gendera 1591 60 1563 59 2.2
IDDMa 400 17 347 15 5.9
DM requiring oral medicationsa 235 11 273 12 4.2
Smokera 998 37 943 36 4.3
Ascites within 30 da 7 0.3 8 0.3 0.7
Esophageal varicesa 8 0.3 5 0.2 2.3
CHF within 30 da 98 3.7 120 4.5 4.2
MI within 6 moa 49 1.9 44 1.7 1.4
Previous heart surgerya 514 19 506 19 0.8
Angina within 30 da 70 2.6 67 2.5 0.7
Hypertensiona 2123 80 2064 78 5.5
Peripheral revasc/ampa 658 25 595 23 5.6
Rest pain/gangrenea 434 16 401 15 3.4
ARF (Cr > 3)a 26 1.0 30 1.1 1.5
Dialysis dependenta 129 4.9 127 4.8 0.4
TIAa 243 9.2 248 9.4 0.7
Strokea 394 15 344 13 4.9
Impaired sensoriuma 22 0.8 27 1.0 2.0
Para-/quadriplegiaa 23 0.9 16 0.6 3.1
Disseminated cancera 22 0.8 29 1.1 2.7
Steroid therapya 214 8.1 269 10 7.2
>10% body weight lossa 37 1.4 64 2.4 7.5
Bleeding disordera 236 8.9 236 8.9 0
Preoperative bleedinga 18 0.7 11 0.4 3.6
Chemotherapy within 30 da 13 0.5 12 0.5 0.6
Radiation within 30 da 3 0.1 5 0.2 1.9
Sepsis within 48 ha 48 1.8 42 1.6 1.8
Mean SD Mean SD
Age (y)a 71 ± 10 72 ± 10 6.9
HCT (%)a 38 ± 5.6 38 ± 5.6 1.5
Platelets (K/μL)a 251 ± 90 255 ± 92 4.6
Protime (s) 13 ± 3.3 13 ± 3.3 9.9
PTT (s) 32 ± 11 31 ± 7.9 17.5
Creatinine (mg/dL)a 1.3 ± 1.2 1.3 ± 1.2 0.1
American Society of Anesthesiologists statusa 3.2 ± 0.5 3.2 ± 0.5 4.3
Operation time (min) 115 ± 81 106 ± 72 11.8
Body mass indexa 28 ± 7.4 28 ± 7.6 4.7
Definitions for all clinical variables are per American College of Surgeons National Surgical Quality Improvement Program data sheet, chapter 4, updated April
1, 2009.
IDDM = insulin-dependent diabetes mellitus; DM = diabetes mellitus; CHF = congestive heart failure; MI = myocardial infarction; revasc/amp = revascularization/
amputation; ARF = acute renal failure; TIA = transient ischemic attack; Cr = creatinine; HCT = hematocrit; PTT = partial thromboplastin time.
a
Variables used in propensity scoring and matching analysis. Functional capacity was also included in the propensity scoring.
RESULTS 133% higher risk of prolonged ventilator dependence (2.1%

More than 1.3 million patients were screened for inclusion vs 0.9%, P = 0.0008, difference = 1.2% [0.51, 1.83]) and an
in this study and reflect the branch points for our ultimate approximately 44% higher risk of unplanned postopera-
yield of 2644 patients in each group (Fig. 1). The 2644 pairs tive intubation (2.6% vs 1.8%, P = 0.0487, difference = 0.8%
of patients were well matched on all factors, with similar [0.04, 1.62]) (Fig. 2). Furthermore, patients undergoing
age, comorbidities, and laboratory values (Table 1) and general anesthesia had a higher composite morbidity, both
exactly matched on primary CPT code. The most common when including pulmonary complications (15.4% vs 12.6%,
operations were carotid endarterectomy (12%), total knee P = 0.0038, difference = 2.8% [0.93, 4.67]) and when exclud-
arthroplasty (8.9%), total hip arthroplasty (5.3%), and open ing pulmonary complications (13.0% vs 11.1%, P = 0.0312,
inguinal hernia repair (4.7%). All primary CPT codes asso- difference = 1.9% [0.21, 3.72]). Both groups had similar
ciated with matches that occurred at a frequency of >1% odds of individual nonpulmonary complications, includ-
appear in Table 2. ing renal failure, deep venous thrombosis, and bleeding
The use of general anesthesia in COPD patients was asso- (Fig. 2). Patients with ≥1 pulmonary complication had sig-
ciated with an approximately 43% higher risk of pulmonary nificantly higher mortality (24.0% vs 1.8%, P < 0.0001, differ-
infection (3.3% vs 2.3%, P = 0.0384, absolute difference with ence = 22.1% [16.8, 27.5]). Furthermore, associations among
95% confidence interval = 1.0% [0.09, 1.88]) but no differ- pulmonary end points were tested to assess for validity, and
ence in 30-day mortality (2.7% general vs 3.0% regional, Tables 3, 4, and 5 demonstrate that patients who had 1 pul-
P = 0.6788, difference = 0.3% [−1.12, 0.67]) (Fig. 2). In addition, monary complication were significantly more likely to have
general anesthesia was associated with an approximately additional pulmonary complications.

Table 2. Most Common Surgical Procedures for the

Matched Study Population
Matched
patients (%)
CPT code Surgical procedure (n = 2644)
35301 Carotid/vertebral endarterectomy 12.2
27447 Total knee arthroplasty 8.9
27130 Total hip arthroplasty 5.3
49505 Inguinal hernia repair 4.7
27590 Above knee amputation 3.9
27880 Below knee amputation 3.9
34802 Endovascular AAA repair with 1 docking limb 3.9
35656 Lower extremity arterial bypass 3.7
34803 Endovascular AAA repair with 2 docking limbs 3.1
52601 Transurethral resection of prostate 2.9
35371 Lower extremity arterial thrombectomy 2.0
52648 Laser transurethral prostate ablation 1.6
27236 ORIF thigh fracture 1.3
52235 Cystoscopy 1.2
28805 Transmetatarsal amputation 1.1
35583 Lower extremity vein bypass 1.1
27245 ORIF thigh fracture 1.0
AAA = abdominal aortic aneurysm; CPT = current procedural terminology;
ORIF = open reduction and internal fixation.
However, general anesthesia patients with moderate dys-

pnea were found to have an increased incidence of pro-
longed ventilator requirement (1.9% vs 0.8%, P = 0.0300,
difference = 0.8% [0.19, 2.10]) and a higher composite
morbidity [15.5% vs 12.0%, P = 0.0174, difference = 3.5%
[0.70, 6.37]) compared with matched regional patients. Of
the 1311 matched patients with no dyspnea, general anes-
thetic patients were more likely to have prolonged ventila-
Figure 1. Flow diagram showing >1.3 million patients screened tor requirement (1.9% vs 0.8%, P = 0.0172, difference = 0.8%
from the National Surgical Quality Improvement Program (NSQIP)
[0.27, 2.02]), require unplanned postoperative intubation
database and branch points for exclusion for this study, resulting
in 2644 matched pairs of chronic obstructive pulmonary disease (2.5% vs 1.4%, P = 0.0477, difference = 1.1% [0.09, 2.20]),
patients. COPD = chronic obstructive pulmonary disease. and have a higher composite morbidity (15.0% vs 11.7%,
P = 0.0186, difference = 3.3% [0.60, 5.80]).
Subgroup analysis by type of regional anesthesia yielded When we analyzed by ASA subgroup, ASA-3 patients
341 epidural, 1713 spinal, and 590 peripheral nerve block who received general anesthesia had a higher composite
patients (Fig. 3). Compared with matched epidural patients, morbidity (14.1% vs 11.4%, P = 0.0195, difference = 2.7%
patients receiving general anesthesia did not have a higher [0.05, 4.86]) than ASA-3 patients who had regional anesthe-
incidence of pulmonary complications, composite morbid- sia (Fig. 5). ASA-4 patients had similar composite morbidity
ity, or 30-day mortality. However, compared with patients with either general or regional anesthesia (Fig. 6).
receiving spinal anesthesia, general anesthetic patients had
a higher composite morbidity (15.7% vs 11.8%, P = 0.0011, DISCUSSION
difference = 3.9% [1.61, 6.21]) and higher incidence of pro- Our findings suggest that, compared with general anesthe-
longed ventilator dependence (2.2% vs 0.8%, P = 0.0013, sia, the use of regional anesthesia in patients with severe
difference = 1.4% [0.58, 2.22]). Patients undergoing general COPD is associated with a lower incidence of postoperative
anesthesia had a higher incidence of unplanned postopera- pulmonary complications. Our findings are novel, in that
tive intubation compared with patients receiving peripheral the improved outcomes are only present in patients receiv-
nerve block anesthetics (3.1% vs 1.2%, P = 0.0432, differ- ing spinal or peripheral nerve block and not in epidural
ence = 1.9% [0.23, 3.50]). anesthetics. Furthermore, the improved outcomes were not
An additional subgroup analysis was performed in present in patients with dyspnea at rest.
which patients were stratified by level of dyspnea (defined Although composite morbidity, as well as nonpulmonary
in Appendix 1), yielding 201 pairs of patients with dys- composite morbidity, was lower in patients not receiving
pnea at rest, 1132 pairs with moderate, and 1131 pairs with general anesthesia, this advantage did not extend to mor-
none (Fig. 4). In patients with dyspnea at rest, there were tality, which was similar between groups. This differs from
no differences in any of the outcomes by type of anesthetic. a meta-analysis of older studies comparing 9559 patients
1408

30 day mortality
Composite morbidity
Pulmonary infection
Ventilator dependence
Unplanned intubation
Non−pulmonary
composite morbidity
Cardiac arrest
Myocardial infarction
Progressive renal failure
Figure 2. The effect of regional versus gen- Dialysis requirement (new)

eral anesthesia on postoperative morbidity
and 30-day mortality for patients with chronic Sepsis
obstructive pulmonary disease. All outcomes Septic shock
are as defined by the National Surgical Quality
Improvement Program data sheet, chapter 4, Stroke
updated April 1, 2009. Deep venous thrombosis
Pulmonary embolism
Superficial skin infection
Deep incisional infection
Wound disruption
Peripheral nerve injury
Urinary tract infection
Bleeding
−5 −4 −3 −2 −1 0 1 2
Favors Regional Favors General
Absolute Risk Difference
randomized to regional or general anesthesia that found a (25% vs 23%) and mortality (7.5% vs 9.6%), further study
one-third reduction in mortality with regional anesthesia.6 is needed to determine how best to provide anesthesia to
However, more recent studies have found no mortality COPD patients with dyspnea at rest. Additional subgroup
benefit for regional over general anesthesia,7–9 and 1 very analysis of ASA-3 and ASA-4 patients found that only in
recent study showed potential harm as a result of increased ASA-3 patients was receiving general anesthesia found to be
cardiovascular morbidity.10 These recent studies, as well as associated with a higher composite morbidity than regional
our findings, challenge previous data that avoiding general patients. This further suggests that the beneficial effects of
anesthesia provides a mortality benefit. However, those regional anesthesia may be muted in the sickest patients.
studies6–10 included non-COPD patients whereas, our study COPD patients with moderate or no reported dyspnea
is limited to patients with COPD. did benefit from avoiding general anesthesia. They were less
We also found that although patients who received spi- likely to require prolonged mechanical ventilation and had
nal anesthetics had fewer composite morbidities, there was a lower composite morbidity if they received regional anes-
no difference between those who received epidural and thesia. There are several mechanisms by which general anes-
general anesthesia. Our study was not designed or powered thesia may result in pulmonary complications in patients
to find a difference among the different types of regional with COPD. Residual effect of neuromuscular blocking
anesthetics, and therefore, this lack of difference may sim- drugs increases the incidence of hypoxia and unplanned
ply be loss of power from the smaller sample size. intubation in the postoperative care unit.15 COPD patients
We found better outcomes in the regional anesthesia may be particularly sensitive to this effect. General anes-
group only in the subgroups with moderate dyspnea or thesia and positive pressure ventilation disturb pulmonary
none but not in those with dyspnea at rest. Although this physiology, causing atelectasis, gas exchange abnormalities,
lack of effect may have been attributable to lack of statis- and ventilation/perfusion mismatch.16 These disturbances
tical power or hidden confounders, such as the spectrum are less likely to be tolerated by patients with COPD.
of COPD severity in patients with dyspnea at rest, it may There were several limitations to this study. COPD was
also have reflected physiological differences. In severely clinically defined, not defined on the basis of pulmonary func-
symptomatic COPD patients, the adverse effects of regional tion tests. Although the clinical definitions were standardized,
anesthesia, including loss of accessory muscles of respira- we cannot exclude the possibility that anesthesiologists had
tion, phrenic nerve paralysis, and poor tolerance for supine other clinical information that may have influenced their deci-
positioning, tend to negate the potential benefits of avoid- sion on the type of anesthetic to provide. We attempted to mit-
ing operative endotracheal intubation and mechanical ven- igate this using exact matching for level of dyspnea to control
tilation.15,16 Given the high rate of composite morbidities for varying clinical severities of COPD. Although propensity

Table 3. Validity Assessment: Relationship Among Pulmonary End Points: Association of Pneumonia with
Other Pulmonary Complications
Pneumonia No pneumonia Absolute 95% Confidence
N = 150 N = 5288 P value difference (%) interval
Interval n % n %
Unplanned intubation 41 27.3 75 1.5 <0.0001 25.9 18.7–33.0
Prolonged ventilation 35 23.3 46 0.9 <0.0001 22.4 15.7–29.2
Definitions for all clinical variables are per American College of Surgeons National Surgical Quality Improvement Program data sheet, chapter 4, updated April 1, 2009.
Absolute difference = absolute risk difference; unplanned intubation = unplanned postoperative intubation; prolonged ventilation = prolonged postoperative
mechanical ventilation.
Table 4. Validity Assessment: Relationship Among Pulmonary End Points: Association of Unplanned
Intubation with Other Pulmonary Complications
Unplanned No unplanned
intubation intubation Absolute 95% Confidence
Confidence N = 116 N = 5172 P value difference (%) interval
interval n % n %
Pneumonia 41 35.3 109 2.1 <0.0001 33.2 24.5–41.9
Prolonged ventilation 57 49.1 24 0.5 <0.0001 48.7 39.6–57.8
Table 5. Validity Assessment: Relationship Among Pulmonary End Points: Association of Prolonged
Ventilation with Other Pulmonary Complications
Prolonged No prolonged
ventilation ventilation Absolute 95% Confidence
N = 81 N = 5207 P value difference (%) interval
Confidence interval n % n %
35 43.2 115 2.2 <0.0001 41.0 30.2–51.8
Unplanned intubation 57 70.4 59 1.1 <0.0001 69.2 59.3–79.2
Epidural Spinal Nerve Block
30 day mortality
Composite morbidity
Pulmonary infection
−6 −3 0 3 6 −6 −3 0 3 6 −6 −3 0 3 6
Favors Epidural Favors General Favors Spinal Favors General Favors Nerve Block Favors General
Absolute Risk Difference Absolute Risk Difference Absolute Risk Difference
Figure 3. The effect of specific regional anesthetic technique (epidural, spinal, or peripheral nerve block) versus general anesthesia on 30-day
mortality, pulmonary morbidity, and composite morbidity in chronic obstructive pulmonary disease patients. All outcomes are as defined by
the National Surgical Quality Improvement Program data sheet, chapter 4, updated April 1, 2009.
matching is a well-accepted method for controlling for dif- Finally, postoperative patient management data, includ-
ferences in populations, it cannot control for hidden con- ing the type, dose, and duration of postoperative analge-
founders, and these may have introduced unknown biases sia used, are not reported in NSQIP nor are postoperative
into our analysis. In addition, because this was a retrospec- inflammatory biomarkers or core temperatures, which
tive observational study, we cannot determine causation but would have been interesting to correlate with our primary
only an association between type of anesthesia and outcomes. outcome. Postoperative epidural analgesia has been shown
Furthermore, the results of this study only apply to surgical to reduce the incidence of pulmonary complications in
procedures for which avoiding general anesthesia is feasible. patients with COPD,5 and therefore, any confounding effects
1410

At Rest Moderate None
30 day mortality
Composite morbidity
Pulmonary infection
−5 0 5 10 −5 0 5 10 −5 0 5 10
Favors Regional Favors General Favors Regional Favors General Favors Regional Favors General
Absolute Risk Difference Absolute Risk Difference Absolute Risk Difference
Figure 4. The effect of regional versus general anesthesia on postoperative morbidity and 30-day mortality for patients with chronic obstruc-
tive pulmonary disease with varying levels of dyspnea (at rest, moderate, and none). All outcomes are as defined by the National Surgical
Quality Improvement Program data sheet, chapter 4, updated April 1, 2009.
pulmonary complications, supporting our hypothesis that

30 day mortality the type of operative anesthetic is associated with outcome.
One strength of our study is that by using propensity
Composite morbidity scoring and exact matching, we were able to remove the
confounding effects of other factors, such as obstructive
Pulmonary infection sleep apnea, age, and obesity, which can contribute to post-
operative pulmonary complications. This allowed us to iso-
late the association between anesthetic type and outcome.
Another strength is that we used a national database with
>1.3 million patients from 186 hospitals to assess for our
end points of interest. Furthermore, our findings were sup-
−4 −2 0 2
ported by a validity assessment showing significant rela-
Absolute Risk Difference
tionships among pulmonary end points. This suggests that
our findings should be both credible and generalizable.
Figure 5. The effect of regional versus general anesthesia on post-
operative morbidity and 30-day mortality for American Society of In conclusion, our results suggest that in patients with
Anesthesiologists-3 patients with chronic obstructive pulmonary dis- severe COPD, the use of regional anesthesia is associated
ease. All outcomes are as defined by the National Surgical Quality with less composite morbidity, driven by fewer pulmonary
Improvement Program data sheet, chapter 4, updated April 1, 2009. complications, as well as less nonpulmonary composite
morbidity. This beneficial association was most notable
in COPD patients with moderate or no dyspnea and in
30 day mortality
patients receiving spinal anesthesia. E
Composite morbidity
DISCLOSURES
Name: Mark S. Hausman, Jr., MD.
Pulmonary infection Contribution: This author helped design the study, interpret
the results, and prepare the manuscript.
Ventilator dependence Attestation: Mark S. Hausman, Jr., has approved the final manu-
script, attests to the integrity of the original data and the analysis
Unplanned intubation reported in the manuscript, and is the designated archival author.
Name: Elizabeth S. Jewell, MS.
−8 −6 −4 −2 0 2 Contribution: This author helped design the study and statisti-
Absolute Risk Difference cal analysis, performed the statistical analysis, and helped pre-
Figure 6. The effect of regional versus general anesthesia on post- pare the manuscript.
operative morbidity and 30-day mortality for American Society of Attestation: Elizabeth S. Jewell has approved the final manu-
Anesthesiologists-4 patients with chronic obstructive pulmonary dis- script and attests to the integrity of the original data and the
ease. All outcomes are as defined by the National Surgical Quality analysis reported in the manuscript.
Improvement Program data sheet, chapter 4, updated April 1, 2009. Name: Milo Engoren, MD.
Contribution: This author helped design the study, interpret
of postoperative analgesia regimens cannot be determined. the results, and prepare the manuscript.
Although epidural and peripheral nerve block anesthesia Attestation: Milo Engoren has approved the final manuscript
can be converted to postoperative analgesia using the same and attests to the integrity of the original data and the analysis
catheter, spinal anesthesia cannot. Patients receiving spinal reported in the manuscript.
anesthesia showed significant reduction in postoperative This manuscript was handled by: Terese T. Horlocker, MD.

APPENDIX 1 are as follows: no dyspnea, dyspnea upon moderate exertion

From the National Surgical Quality Improvement Program (e.g., is unable to climb one flight of stairs without shortness of
manual (site.acsnsqip.org), definitions for severe chronic breath), and dyspnea at rest (e.g., cannot complete a sentence
obstructive pulmonary disease (COPD), pulmonary infec- without needing to take a breath). The time frame is at the
tion, and level of dyspnea are provided below. time the patient is being considered as a candidate for surgery
(which should be no longer than 30 days before surgery).
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Regional Versus General Anesthesia in Surgical Patients With Chronic Obstructive Pulmonary Disease: Does Avoiding General Anesthesia Reduce The Risk of Postoperative Complications?

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Regional Versus General Anesthesia in Surgical Patients With Chronic Obstructive Pulmonary Disease: Does Avoiding General Anesthesia Reduce The Risk of Postoperative Complications?

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Regional Anesthesia

Section Editor: Terese T. Horlocker

Regional Versus General Anesthesia in Surgical

June 2015 • Volume 120 • Number 6 www.anesthesia-analgesia.org 1405

RESULTS 133% higher risk of prolonged ventilator dependence (2.1%

June 2015 • Volume 120 • Number 6 www.anesthesia-analgesia.org 1407

Table 2. Most Common Surgical Procedures for the

However, general anesthesia patients with moderate dys-

Progressive renal failure

Figure 2. The effect of regional versus gen- Dialysis requirement (new)

Superficial skin infection

Deep incisional infection

Peripheral nerve injury

Urinary tract infection

June 2015 • Volume 120 • Number 6 www.anesthesia-analgesia.org 1409

Epidural Spinal Nerve Block

At Rest Moderate None

pulmonary complications, supporting our hypothesis that

June 2015 • Volume 120 • Number 6 www.anesthesia-analgesia.org 1411

APPENDIX 1 are as follows: no dyspnea, dyspnea upon moderate exertion

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