Psychosomatics 49:208-211, May-June 2008
doi: 10.1176/appi.psy.49.3.208
© 2008 Academy of Psychosomatic Medicine
The Safety of ECT in Patients With Chronic Obstructive Pulmonary Disease
Kathryn M. Schak, M.D.,
Paul S. Mueller, M.D.,
Roxann D. Barnes, M.D., and
Keith G. Rasmussen, M.D.
Received January 20, 2006; revised July 6, 2006; accepted July 12, 2006. From the Dept. of Psychiatry and Psychology; Dept. of Internal Medicine; Dept. of Anesthesiology, Division of Cardiovascular Anesthesiology, Mayo Clinic, Rochester, MN. Send correspondence and reprint requests to Keith G. Rasmussen, M.D. Mayo Clinic Dept. of Psychiatry and Psychology, 200 First St. SW, Rochester, MN 55905. e-mail: rasmussen.keith{at}mayo.edu
© 2008 The Academy of Psychosomatic Medicine
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ABSTRACT
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BACKGROUND: Electroconvulsive therapy (ECT) involves the administration of general anesthesia and assisted ventilation while the patient is apneic. OBJECTIVE: Care must be taken to screen for significant pulmonary dysfunction before treatment. Very little has been written about the safety and management strategy of ECT patients with chronic obstructive pulmonary disease (COPD). METHOD: In this retrospective chart review, authors describe their experience with patients in recent years who had this disorder and were treated with ECT. RESULTS: Authors list recommendations for the pre-ECT work up and anesthetic management during and after the treatments. CONCLUSION: Recent guidelines recommend administration of patients’ prescribed inhalers on the morning of ECT treatment. Also, caution is recommended when using ECT in patients taking theophylline because this drug has been associated with prolonged seizures and status epilepticus in these patients.
Key Words: Electroconvulsive Therapy • COPD
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INTRODUCTION
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Electroconvulsive therapy (ECT) is an extremely safe procedure, with low morbidity and mortality.1 Nonetheless, complications do occur, usually in the setting of preexisting medical conditions.2 Because the procedure involves the administration of general anesthesia and the need for assisted ventilation, one might speculate that patients with preexisting pulmonary conditions such as chronic obstructive pulmonary disease (COPD) might be at heightened risk of complications. However, surprisingly little has been written about the safety of ECT in these patients. Herein, we review the case files of COPD patients receiving ECT at our facility and present recommendations for clinical practice.
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METHOD
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This project was conducted with Institutional Review Board approval. We reviewed our ECT database, utilizing diagnostic codes from 2001 until mid-2006 for any patients treated who had COPD listed as one of their diagnoses on their medical chart. We reviewed the medical charts for any information relating to the pulmonary diagnosis, including pulmonary-function tests, radiologic findings, and concomitant medications. We also reviewed their ECT records and noted any complications recorded on the chart.
The ECT course at our institution generally begins with examination by an internist and a medical work-up tailored to the needs of the patient. Anesthesia is induced most commonly with thiopental, which is followed by succinylcholine for neuromuscular paralysis. Glycopyrrolate is administered intravenously before anesthesia as an antisialogogue and to prevent vagally-induced arrhythmias; 100% oxygen is administered with positive pressure ventilation at the beginning of apnea until the resumption of spontaneous respirations after seizure termination. Continuous pulse oximetry and ECG, as well as frequent blood pressure measurements, are also conducted and monitored during the treatment. In the post-anesthesia recovery room, 100% oxygen is administered by mask until the patient is capable of fully sustaining his or her own airway, and ECG and pulse-oximetry monitoring are continued until discharge from the unit.
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RESULTS
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Table 1 presents the results of our chart review. We found 34 patients diagnosed with COPD. Their Mayo Clinic medical records were thoroughly reviewed by a board-certified internist (PSM) in order to find documentation supporting a diagnosis of COPD, namely, pulmonary-function test results or an evaluation by a Mayo pulmonologist confirming the diagnosis of COPD or by whom medications were prescribed. In seven patients carrying a chart diagnosis of COPD, no further documentation could be found, and these patients are not included in the table. In the sample of 27 "confirmed" COPD patients, there were 11 women (age range: 55–93) and 16 men (age range: 50–83). Generally, if patients were receiving prescribed inhalers, these were administered just before the treatments if these were daily medications. If the inhalers were used on an as-needed basis and the patient did not currently have wheezing or a history of anesthesia-induced wheezing, they were usually not administered before ECT. None of the patients was taking theophylline or oral corticosteroids. All patients were treated for a severe depressive syndrome. Some patients only had an acute course of two- or three-times-weekly treatments, whereas some patients had continuation series, in which treatments were administered every 1 to 4 weeks to prevent depressive relapse. In some patients receiving maintenance ECT, the treatments were continued for an extended period of time because of a history of a highly recurrent depressive illness; thus, there were a large number of treatments in those cases. In the cases where there was only one treatment, the course was not stopped because of adverse respiratory events. None of the patients in our series (including the seven in whom a diagnosis of COPD could not be confirmed) suffered complications, specifically, exacerbations of COPD or upper respiratory infections, during their treatment with ECT.
Special mention should be made of one patient who died in our series. She was a 79-year-old woman with a history of restrictive airway disease with bronchial reactivity who was chronically depressed and refractory to several antidepressant medication trials. An initial course of ECT was highly effective early in 1999; however, she relapsed into depression several months later on antidepressant medication, and a second course of treatments was undertaken, again with high efficacy, which was followed by maintenance ECT. The latter was continued, ultimately at 3- to 4-week intervals, for approximately 6 years, until her death in 2005. She was using inhalers daily and was on supplemental oxygen. In spite of her frail health, she obtained continuing antidepressant benefits from these treatments and tolerated them without complications. Her death occurred approximately 2 weeks after her last treatment and was related to her wish, with corroboration of her legally authorized surrogate decision-maker, to increase narcotic pain medication for her severe pain related to longstanding thoracic compression fractures (which predated her course of ECT), and she was placed on hospice-type care, then stopped eating. She notably did not experience any pulmonary complications due to ECT. Thus, her death was unrelated to ECT.
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DISCUSSION
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There is very little in the literature informing clinicians about the management of patients with COPD undergoing ECT. Recent guidelines on the care of medically ill ECT patients recommend administration of patients’ prescribed inhalers the morning of ECT treatments.2,3 Also, caution is recommended in the use of ECT in patients taking theo-phylline, which has been associated with prolonged seizures and status epilepticus in ECT treatment.4–7
On the basis of our experience, we offer the following clinical recommendations: A history and physical should be performed before anesthetizing a patient with COPD and should provide guidance as to further management before anesthesia. The patient should be queried regarding frequency of COPD exacerbations, the usual intensity of the treatment required for exacerbations (emergency room visits, hospitalization, or intensive-care unit treatment, etc.), current medication regimen (type, dose, frequency), past and current use of corticosteroids (both oral and inhaled), smoking history, current symptoms, and recent history of upper-respiratory infections. If, on the basis of these inquiries, the internist feels the patient’s COPD is not optimally managed, then ECT should be postponed until such result is achieved.
Pulmonary-function testing, particularly measures of obstruction (e.g., peak expiratory flow, forced expiratory volume in 1 sec.), are useful in the general management of COPD but are not specifically indicated before ECT. A chest X-ray should be done to screen for infections. Concomitant psychotropic medications should be minimized, but most of the patients in our series were prescribed one or more psychotropics (usually antidepressants, but benzodiazepines and atypical antipsychotics, as well, to help with anxiety or agitation), and no untoward reactions were noted.
In the surgical setting, smokers who meet the criteria for moderate-to-severe airway obstruction on preoperative pulmonary-function testing have more bronchospasm intraoperatively and postoperatively.8 It is not clear whether this applies to patients receiving ECT treatment, which is an extremely brief procedure. Although, empirically, it seems reasonable to administer inhalers before ECT treatments prophylactically, there is no evidence in the literature to support this practice. Patients who are wheezing should receive inhaled beta2 agonists and parenteral corticosteroids.9 Unless the psychiatric indication for ECT is life-threatening, significant COPD exacerbations should be treated first before administering ECT.
For COPD patients on oxygen therapy, few data are available regarding how to manage these patients post-procedurally. It is known that anesthetics blunt the ventilatory responses both to elevated CO2 and hypoxemia,10 which is exacerbated in patients with COPD. We are careful not to blunt the respiratory drive of COPD patients by administering excessive oxygen, because these patients often depend on their relative hypoxemia as a drive to breathe.
The main weakness of our data-set is a possible lack of generalizability to COPD patients given ECT with a different anticholinergic agent from glycopyrrolate (or no anticholinergic), a different anesthetic from thiopental, or with a different pattern of concomitant psychotropic medication use. We feel that these issues, however, are unlikely to be of clinical significance. Also, we made every attempt to review the chart of every COPD patient in our ECT practice for the time-period in question, but it is possible that some COPD patients were missed. However, we feel that if a patient had substantial evidence of COPD, it would have been unlikely not to have been coded in on their chart and therefore would be discoverable by our database review. Furthermore, for the seven patients in whom a chart listing of COPD as a diagnosis could not be substantiated by pulmonary-function tests or pulmonologist review, there were still no complications during ECT. In summary, our experience is that with careful pretreatment assessment and vigilant intraprocedural management, COPD patients can safely be given ECT.
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REFERENCES
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- Nuttall GA, Bowersox MR, Douglass SB, et al: Morbidity and mortality in the use of electroconvulsive therapy. J ECT 2004; 20:237–241[CrossRef][Medline]
- Rasmussen KG, Rummans TA, Tsang TSM, et al: ECT in the medically ill, in American Psychiatric Publishing Textbook of Psychosomatic Medicine. Edited by Levenson J. Washington, DC, American Psychiatric Publishing, 2004
- American Psychiatric Association Committee on ECT. The Practice of Electroconvulsive Therapy: Recommendations for Treatment, Training, and Privileging, 2nd Edition. Washington, DC, American Psychiatric Press, 2001
- Peters S, Wochos D, Peterson G: Status epilepticus as a complication of concurrent electroconvulsive and theophylline therapy. Mayo Clin Proc 1984; 59:568–579[Medline]
- Devanand DP, Sackeim HA, Decina P, et al: Status epilepticus following ECT in a patient taking theophylline. J Clin Psychopharmacol 1988; 8:153[CrossRef][Medline]
- Abrams R: Electroconvulsive Therapy, 3rd Edition. New York, Oxford University Press, 1997, pp 97-111
- Rasmussen KG, Zorumski CF: Electroconvulsive therapy in patients taking theophylline. J Clin Psychiatry 1993; 54:427–431[Medline]
- Warner DO, Warner MA, Offord KP, et al: Airway obstruction and perioperative complications in smokers undergoing abdominal surgery. Anesthesiology 1999; 90:372–379[CrossRef][Medline]
- Rock P, Passannante A: Preoperative assessment: pulmonary. Anesth Clin N Am 2004; 22:77–91[CrossRef]
- Knill RL, Clement JL: Variable effects of anaesthetics on the ventilatory response to hypoxaemia in man. Can Anaesthet Soc J 1982; 29:93–99
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ABSTRACT
INTRODUCTION
