The patient with lung disease (asthma, COPD, OSA)

What it is

Lung disease raises the risk of postoperative pulmonary complications: bronchospasm, atelectasis, pneumonia, respiratory failure and unplanned ventilation. In asthma the airways are hyperreactive; instrumenting them, especially tracheal intubation under light anaesthesia, can trigger severe bronchospasm, so the plan is good control before surgery, a bronchodilator beforehand, regional anaesthesia or a supraglottic airway where suitable, deep anaesthesia before the airway is touched, bronchodilating agents such as propofol, ketamine and volatile anaesthetics, and a ventilation pattern with a long expiratory time to avoid gas trapping. In chronic obstructive pulmonary disease the same principles apply, with extra attention to smoking, sputum, poor reserve and, in some patients, chronic carbon dioxide retention. Obstructive sleep apnoea, which is common and often undiagnosed, predicts difficult mask ventilation and intubation, great sensitivity to opioids and sedatives, and airway obstruction after surgery; it is screened for with a simple questionnaire, managed with opioid-sparing analgesia, extubation fully awake and sitting up, the patient's own positive airway pressure device after surgery, and monitored recovery.

What changes in this patient

• Asthma: hyperreactive airways that narrow with airway instrumentation, cold dry gases, light anaesthesia and some drugs.
• COPD: fixed airflow limitation, gas trapping, sputum, possible pulmonary hypertension and, in some, chronic carbon dioxide retention.
• Gas trapping (intrinsic positive end-expiratory pressure) raises intrathoracic pressure, lowers venous return and can cause hypotension.
• Sleep apnoea: upper airway collapse in sleep, made worse by sedatives, opioids, residual neuromuscular block and lying flat.
• Sleep apnoea is linked to obesity, hypertension, atrial fibrillation and pulmonary hypertension, and is often undiagnosed.
• Upper abdominal and thoracic surgery, smoking, poor exercise tolerance and long operations raise the risk of pulmonary complications.

Anaesthetic plan (and why)

1. Assess control: symptoms, reliever use, recent attacks, steroid courses, admissions, and sputum or infection — postpone if uncontrolled.
2. Screen for sleep apnoea with a questionnaire on snoring, tiredness, observed apnoeas, pressure, weight, age, neck and sex — it changes the airway plan.
3. Continue inhalers and give a short-acting bronchodilator before surgery — this lowers airway reactivity at induction.
4. Prefer regional anaesthesia or a supraglottic airway where suitable — avoiding the trachea avoids the strongest bronchospasm trigger.
5. If intubation is needed, deepen anaesthesia first and use bronchodilating agents — light anaesthesia plus laryngoscopy provokes bronchospasm.
6. Ventilate with a slower rate and a long expiratory time — this lets trapped gas escape and prevents rising pressure and hypotension.
7. Use opioid-sparing multimodal analgesia and regional blocks — opioids and sedatives cause airway obstruction in sleep apnoea.
8. Reverse neuromuscular block fully, extubate awake and semi-upright, and restart the patient's positive airway pressure device — this keeps the airway open.
9. In COPD with carbon dioxide retention give controlled oxygen to a target range — high oxygen can worsen hypercapnia.
10. Encourage deep breathing, early mobilisation and good analgesia after surgery — they reduce atelectasis and pneumonia.

Three lung patients, three main worries

Risks and complications

• Bronchospasm at induction or intubation: wheeze, high airway pressure and a sloping capnography trace, sometimes a silent chest.
• Gas trapping with hypotension and high airway pressures in severe asthma or COPD.
• Difficult mask ventilation and intubation, and desaturation at induction, in sleep apnoea and obesity.
• Postoperative airway obstruction and respiratory arrest in sleep apnoea, especially after opioids at night.
• Atelectasis, pneumonia and respiratory failure after surgery; pneumothorax with high pressures in bullous disease.
• Hypercapnia and drowsiness when high-flow oxygen is given to patients who retain carbon dioxide.

Next step

• Postpone elective surgery until asthma or COPD is controlled and any chest infection has cleared.
• Refer suspected severe untreated sleep apnoea for a sleep study before major elective surgery when time allows.
• Call a senior for severe bronchospasm, an expected difficult airway or a patient who may need ventilation after surgery.
• Plan monitored recovery, with continuous oximetry, for sleep apnoea patients who receive opioids.
• Ask the patient to bring inhalers and the positive airway pressure device, and resume both after surgery.

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Elsewhere in DurgiPedia

• Airway resistance
• Lung volumes, capacities and spirometry
• Reading spirometry: obstructive or restrictive?
• Starting non-invasive ventilation
• Obstructive vs restrictive lung disease: the comparison table

Connections

← All of anaesthesia

Educational content; it does not replace supervised training, your institution's protocols or the anaesthetist's or intensivist's decision. It contains no doses and no ventilator or infusion settings.

Sources: Anesthesia Management in Patients with Asthma (StatPearls (NCBI Bookshelf), 2025); Obstructive Sleep Apnea (StatPearls (NCBI Bookshelf), 2025); Chronic Obstructive Pulmonary Disease (COPD) (StatPearls (NCBI Bookshelf), 2026).

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Representative model, for educational purposes only.