title: Regional versus general anesthesia in surgical patients with chronic obstructive pulmonary disease: does avoiding general anesthesia reduce the risk of postoperative complications?
abstract: 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 peripheral 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 general 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 postoperative 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.
authors.affiliation: From the Department of Anesthesiology, Division of Critical Care Medicine, University of Michigan Health Systems, Ann Arbor, Michigan.
authors.forename: Mark S
authors.initials: MS
authors.lastname: Hausman
authors.forename: Elizabeth S
authors.initials: ES
authors.lastname: Jewell
authors.forename: Milo
authors.initials: M
authors.lastname: Engoren
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000765:Anesthesia, Conduction / Q000009:adverse effects / Q000401:mortality; D000768:Anesthesia, General / Q000009:adverse effects* / Q000401:mortality; D016009:Chi-Square Distribution; D015897:Comorbidity; D016208:Databases, Factual; D005260:Female; D006801:Humans; D015994:Incidence; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D011183:Postoperative Complications / Q000401:mortality / Q000517:prevention & control*; D057216:Propensity Score; D029424:Pulmonary Disease, Chronic Obstructive / Q000150:complications* / Q000401:mortality; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D013514:Surgical Procedures, Operative / Q000009:adverse effects* / Q000401:mortality; D016896:Treatment Outcome; D014481:United States / Q000453:epidemiology