IM25.10-11 | Geriatric COPD and Surgical Care — Summary & Reflection

KEY TAKEAWAYS

COPD in the elderly:
- GOLD spirometric grading: FEV₁/FVC <0.70 + FEV₁ % predicted: GOLD 1 ≥80%, 2 50-79%, 3 30-49%, 4 <30%
- ABE classification adds symptom burden and exacerbation history → guides treatment intensity
- Indian risk factors: tobacco + biomass burning (wood fire, rural women)
- Management: LABA + LAMA (Group B); LABA + LAMA ± ICS (Group E, especially eosinophils ≥300); LTOT ≥15 hours/day if PaO₂ ≤55 mmHg; pulmonary rehabilitation from GOLD 2
- Exacerbation: controlled O₂ target 88–92%; nebulised SABA + SAMA; prednisolone 40 mg × 5 days; antibiotics if purulent; NIV for type 2 respiratory failure (pH <7.35 + PaCO₂ elevated)

Elderly surgical care:
- Pre-op risk: ASA classification, RCRI (cardiac), spirometry (pulmonary), CFS frailty, nutritional status, medication review
- Frailty (CFS ≥5 or Fried ≥3/5): disclose in consent, plan prehabilitation, intense post-op monitoring
- Medication perioperative management: stress-dose corticosteroids (do NOT stop), warfarin bridging, aspirin continue in IHD, stop ACE/ARB morning of surgery, stop metformin 24–48 hours pre-op
- Post-op: delirium prevention (HELP bundle), respiratory physiotherapy, LMWH thromboprophylaxis, pain control (avoid systemic opioids in CO₂ retainers), early mobilisation, ERAS protocol

REFLECT

Subramaniam from the opening hook has COPD that reached its current severity over 40 years — from his first cigarette at 18 to his factory years and eventual hospital admission. His smoking cessation at 65 slowed the decline but could not restore lost alveolar tissue. Consider the trajectory: what opportunities existed at ages 30, 40, 50, and 60 to change his course — earlier spirometry, smoking cessation counselling, optimal maintenance therapy, pulmonary rehabilitation? Now, facing major surgery, his reduced reserve makes every decision — the oxygen target, the anaesthetic technique, the post-operative monitoring intensity — consequential in a way it would not be for a 45-year-old with healthy lungs. What does this case teach you about the relationship between preventive medicine earlier in life and surgical risk later? And for the elderly patient facing major surgery who says 'just do whatever you need, doctor' — how do you ensure that a goals-of-care conversation happens before the operation, not in the ICU afterward?