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Preoperative Pulmonary Evaluation of the Thoracic Surgical Patient
Thorac Surg Clin 15 (2005) 297 – 304
Preoperative Pulmonary Evaluation of the Thoracic Surgical Patient Aditya K. Kaza, MD, John D. Mitchell, MD* Section of General Thoracic Surgery, Division of Cardiothoracic Surgery, University of Colorado Health Sciences Center, 4200 East 9th Avenue, C-310, Denver, CO 80262, USA
Surgery remains the mainstay of therapy for earlystage non – small lung cancer, with approximately 45,000 cases of early-stage disease (stages I, II, and select IIIA) diagnosed annually. Many of these patients have poor underlying pulmonary function, in large part resulting from long-term tobacco abuse. It is the responsibility of the thoracic surgeon to assess accurately the pulmonary function of a potentially operable patient at the time of the preoperative evaluation. This assessment provides an objective risk profile associated with the planned pulmonary resection for the patient and family, minimizes morbidity and mortality, and in some cases leads the surgeon to recommend alternative therapies.
General considerations Several questions should be asked in the general pulmonary assessment of a patient being considered for lung resection surgery. Careful appraisal of prior history and pertinent review of systems (Box 1) often can predict the objective results obtained in subsequent pulmonary function testing. Is the patient currently smoking? Active use of tobacco at the time of surgery predisposes patients to a variety of postoperative pulmonary complications [1,2], usually through increased production and reduced clearance of sputum in the perioperative
* Corresponding author. E-mail address: [email protected] (J.D. Mitchell).
period. Significant atelectasis, pneumonia, or respiratory insufficiency requiring intubation may result. Patients should be counseled regarding the benefits of abstinence from smoking as early as possible before the procedure. A long prior smoking history may suggest significant occult parenchymal disease (chronic obstructive pulmonary disease), but is associated with increased risk even in the absence of such findings [3]. Does the patient have an occupational or travel history that would predispose him or her to certain pulmonary disorders? A variety of industrial and environmental exposures, both organic and inorganic, can lead to the insidious development of interstitial lung disease and reduced pulmonary function [4]. Common environmental agents include silica, asbestos, beryllium, and animal/bird products (farmer’s lung or variants). A history of travel to areas endemic to certain fungal infections (Coccidioides or Histoplasma) also may be relevant. What is the activity level of the patient? Patients with suboptimal performance on objective exercise testing are at increased risk for perioperative cardiopulmonary complications [5 – 8]. In addition, selfreported poor exercise tolerance has been shown to be associated reliably with increased postoperative risk [9]. Pulmonary rehabilitation, although not always practical, may improve exercise tolerance dramatically and is strongly advocated before lung transplantation or lung volume reduction surgery [10,11]. Does the patient have a history of prior or active pulmonary infection? A history of recurrent pulmonary infections may suggest impaired mucociliary clearance, airway obstruction, or localized bronchiec-
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Box 1. General considerations in the pulmonary resection candidate Smoking history Occupational and travel history Exercise tolerance Prior history of: Recurrent pulmonary infections Recognized pulmonary airway/parenchymal disease Cardiac disease Pulmonary or cardiac surgery
tasis. Successful treatment of active infection before surgical resection is advised, but not always feasible in the setting of a postobstructive infectious process. Is an underlying pulmonary parenchymal disorder present? The concomitant presence of significant obstructive, interstitial, or infectious lung disease can have a major impact on the patient’s functional status and the conduct of the proposed operation. In addition, certain pulmonary disorders (particularly interstitial lung disease) may be associated with a poor prognosis, which may influence the degree of risk a patient may wish to assume in the perioperative period. Is cardiac disease present? Many cardiac and pulmonary disorders have common etiologic factors. The presence of significant ischemic or valvular heart disease can have an impact on postoperative pulmonary complications. Preexisting right ventricular dysfunction has been shown to be a risk factor for complications after pulmonary resection [12]. Has the patient had prior thoracic surgery? A prior history of pulmonary resection or significant intrathoracic procedure can have a significant impact on the risk profile at the time of subsequent surgery.
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criteria for safe pulmonary resection, including an FEV1 greater than 1.5 L for a proposed lobectomy and greater than 2 L for a pneumonectomy [13 – 15]. These criteria have been adopted as guidelines by at least one major thoracic society, with no further testing needed to ensure operability [16]. The difficulty with these absolute values is that they do not take into account size or gender of the particular patient, producing bias against resection in smaller individuals. For this reason, most practitioners use or express measured FEV1 as a percentage of the predicted value for the patient’s gender, height, and weight. In this fashion, investigators have suggested an FEV1 greater than 80% of the predicted value is associated with a low risk of perioperative complications after major lung resection, and no further testing is needed (Fig. 1) [17]. Other parameters investigated include maximum voluntary ventilation (MVV) and FEV25 – 75%, with a MVV less than 40% predicted or a FEV25 – 75% of 0.6 to 1 L indicative of a marginal candidate for lobar resection [18].
Diffusion capacity The diffusion capacity in the lung for carbon monoxide (Dlco) was found to be the most important predictor of mortality and was the sole predictor of postoperative pulmonary complications in a retrospective review of 237 patients published by Ferguson et al [19] in 1988. In this study, a Dlco less than 60% of predicted was associated with increased mortality. The importance of Dlco in risk assessment before lung resection has been substantiated by further reports, with little interplay between Dlco and either FEV1 or maximum oxygen con˙ o2max) [20,21]. sumption (V
Arterial blood gas analysis Spirometry Spirometry is a simple, inexpensive, readily available test and remains the starting point in the evaluation of a patient for proposed pulmonary resection. Spirometry should be performed with the patient in stable condition, with and without the use of inhaled bronchodilators. A bronchodilator response greater than 15% is considered significant and indicates a component of reactive airways disease. The forced expiratory volume in 1 second (FEV1) is the most commonly used parameter from spirometric testing for pulmonary risk assessment. Several large studies in the past have suggested FEV1
The presence of resting hypercapnea, defined as a Pco2 greater than 45 mm Hg on room air, has long been described as a relative contraindication to lung resection [14,18]. Other reports dispute this assertion, however, and show equivalent outcomes above and below this value [22 – 24].
Prediction of postoperative function Most patients presenting for lung surgery are likely to have reduced lung function, and it is the responsibility of the surgeon to ensure adequate
preoperative pulmonary evaluation
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Fig. 1. (A) CT scan of a patient with severe environmental mycobacterial disease involving the left lung. Pneumonectomy was suggested, with a preoperative FEV1 1.1 L or 53% predicted. (B) Quantitative lung perfusion scan of the same patient, with 5% of total lung perfusion to the affected lung. Postoperative FEV1 values corresponded to calculated values of 1.05 L, or 50% predicted. See text. (Courtesy of Marvin Pomerantz, MD.)
pulmonary function will remain after the proposed resection. If preoperative pulmonary function testing reveals suboptimal function (FEV1 and Dlco < 80% predicted), additional testing is indicated to estimate the predicted postoperative (ppo) values. The most commonly used methods include nuclear medicine ventilation-perfusion (V/Q) scanning [15,25 – 28], quantitative CT [29,30], and segment counting [31,32]. These methods may be applied to the actual and the percent predicted spirometry/Dlco values, although the latter is more common. Nuclear medicine V/Q scanning provides the relative contribution of each lung to overall pulmonary function (Fig. 2). For a pneumonectomy, calculation of the ppoFEV1 (or % predicted ppoFEV1) can be accomplished easily using the data
from the perfusion scan and the preoperative spirometry results: ppoFEV1 ¼ preoperative FEV1 ð1 % perfusion to affected lungÞ Although discrepancies may occur when there is significant V/Q mismatching, numerous studies have shown good correlation between predicted and actual measured FEV1 using this formula, with several studies noting a slight underestimation of the actual measured postoperative value, providing an element of safety for a marginal patient [15,25,33]. Use of the perfusion scintigraphy data also may be applied ˙ o2max [26]. Some to predict ppoDlco and ppoV investigators have suggested that dynamic perfusion
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Proposed Lung Resection
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Spirometry DLCO
FEV1 > 80% predicted DLCO > 80% predicted
FEV1 < 80% predicted DLCO < 80% predicted
Estimation of Postoperative Function (ppo)*
ppoFEV1 >40% predicted ppoDLCO >40-50% predicted
ppoFEV1 <40% predicted ppoDLCO <40-50% predicted
Exercise Study
VO2max >15 ml/kg/min
VO2max <15 ml/kg/min ppoVO2max >10 ml/kg/min
ppoVO2max <10 ml/kg/min
Defer Surgery
Offer Surgery
Fig. 2. Algorithm for preoperative pulmonary evaluation. *Estimated with quantitative perfusion scan, CT scan, or segment counting.
MR imaging techniques may be a feasible alternative to V/Q scintigraphy [34]. The perfusion study also may be used to predict function after lobectomy, as described by Wernly et al [15]: ppoFEV1 ¼ preoperative FEV1 preoperative FEV1 % perfusion to affected lung # resected segments # segments in affected lung An alternative method of calculating ppoFEV1 without the use of a quantitative perfusion study involves simply accounting for the number of resected segments as a percentage of the total number of segments in both lungs, as described by Juhl and Frost [31].
With 19 lung segments, each segment accounts for roughly 5.26% of the overall lung function: ppoFEV1 ¼ preoperative FEV1 ð1 ½# segments resected 5:26=100Þ Simple segment counting obviates the need for expensive nuclear medicine testing and has been adopted as the preferred method of calculating postoperative spirometry values after lobectomy by at least one major thoracic society [16]. Although segment counting has been suggested to be as accurate as V/Q scintigraphy [35], it does not take into account the functional differences between varying segments, which may prove important in mar-
preoperative pulmonary evaluation
ginal patients with heterogeneous patterns of lung disease, such as emphysema. Perhaps to account for this factor, one group suggested adding 250 mL of volume to the ppoFEV1 calculated by segment counting, to obtain a more reliable estimation of postoperative function [32]. At least one study has compared scintigraphy, segment counting, and quantitative CT in predicting postoperative pulmonary function [36]. In this study, four parameters were assessed: FEV1, FVC, Dlco, ˙ o2max. Although scintigraphy and CT were and V found to be useful, perfusion scintigraphy was noted to be the most accurate. Numerous studies have shown ppoFEV1 to be a predictor of perioperative risk. Historically a cutoff of ppoFEV1 less than 800 mL was used as a determinant of unresectability [37]. More recent studies suggest that morbidity and mortality are significantly increased if the ppoFEV1 is less 40% [22,38 – 40]. Similarly, ppoDlco has been shown to be strongly predictive of complications and death when the value is less than 40% [18,21]. At least one group has suggested the product of ppoFEV1 and ppoDlco (predicted postoperative product) less than 1650 may be an even more sensitive indicator of postoperative mortality [33].
Exercise testing Patients considered at high risk for perioperative complications on the basis of standard spirometry testing and calculation of postoperative function should undergo exercise testing. The purpose of exercise testing is to identify some patients deemed high risk but still able to tolerate resection with acceptable morbidity and mortality. The easiest form of exercise testing is stair climbing, with the height climbed inversely related to the frequency of postoperative complications [41,42]. Investigators have found increased morbidity and mortality when less than 2 flights [43,44], 3 flights [45,46], 12 m [47], or 44 steps [48] are climbed. One study found the height climbed to be the sole predictor of morbidity through multivariate analysis [47]. Others have shown correlation with the ˙ o2max [49]. patient’s V The 6-minute walk test was modified from the original 12-minute test and provides objective evidence of the patient’s exercise function [50]. The test, usually performed in a hallway over a preset distance, measures the distance a patient can walk quickly on a hard, flat surface in 6 minutes. The test is self-paced
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and does not reflect maximal exercise capacity. Some investigators believe that because most activities of daily living are performed in a submaximal exercise environment, the test is a better assessment of the patient’s general exercise tolerance. Holden et al [48] found an achieved distance of greater than 1000 feet to be associated with improved surgical outcomes after lung resection. The 6-minute walk test is commonly used in lung transplantation evaluations and was used to exclude patients with severely reduced exercise capacity after pulmonary rehabilitation in the National Emphysema Treatment Trial [10]. A variation of the 6-minute walk test is the shuttle walk, in which patients ambulate between two cones placed 10 m apart. The walking speed, paced by an audio signal, is increased each minute until the patient is unable to continue. The shuttle walk more ˙ o2max, with one study closely correlates with V showing that inability to complete 25 shuttles (250 m ˙ o2max less than 10 mL/ [about 820 ft]) suggested a V kg/min [51]. Where available, formal cardiopulmonary exercise testing should be pursued when preliminary spirometry and split function studies suggest the patient is at increased risk of perioperative complications. The test usually is performed with incremental work performed on a treadmill or bicycle ergometer, measuring oxygen saturation and exhaled ˙ o2max, carbon dioxide gases to determine Vo2, V output, and minute ventilation. The most commonly used parameter measured with cardiopulmonary ˙ o2max, which denotes a plateau exercise testing is V above which further increases in work do not result in greater oxygen consumption. This parameter differs slightly from Vo2peak, which describes the highest oxygen consumption achieved before symptoms (fatigue, dyspnea) forced the patient to stop the test. Such limitations are common in patients with advanced lung disease. Several studies have shown patients to be at low risk for perioperative complications if the preopera˙ o2max is greater than 20 mL/kg/min [52 – 54], tive V ˙ o2max greater than 15 mL/kg/min whereas others use V ˙ o2max less than as a cutoff for resection [55,56]. A V 10 mL/kg/min is associated with prohibitive morbidity and mortality [17,52,57,58]. Bolliger et al [58] ˙ o2max less than 10 mL/kg/min to corfound a ppoV relate with a 100% postoperative mortality. Exercise oximetry has been suggested to be helpful in predicting postoperative complications by some authors [16,59,60] and not by others [61]. Ninan et al [59] found desaturation with exercise greater than 4% highly predictive of longer ICU stays and major morbidity.
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Effect of lung volume reduction surgery Occasionally a patient with a lung mass and poor pulmonary function may present with functional and anatomic factors favorable for lung volume reduction surgery [10]. Because successful lung volume reduction surgery results in an improvement in FEV1 and other pulmonary parameters, a combined operation has been proposed as a strategy to allow safe resection. The pulmonary mass may reside in the severely emphysematous part of the lung or may be resected separately from the lung volume resection. Several small studies have validated this approach in selected patients [62,63].
Summary Fig. 2 is an algorithm for the preoperative pulmonary evaluation of the lung resection candidate. Patients should undergo routine spirometry and diffusion capacity testing. If the FEV1 and Dlco are greater than 80% predicted, no further study is needed. When these parameters are less than 80%, some estimation of postoperative function is likely needed, taking into account the proposed resection. Patients with ppoFEV1 or ppoDlco less than 40% are at increased risk of perioperative complications or death and should undergo formal exercise testing. A ˙ o2max or ppoV ˙ o2max less than 10 mL/kg/min is V associated with prohibitive risk for anatomic lung resection, and alternative treatment modalities should be considered.
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[52] Bechard D, Wetstein L. Assessment of exercise oxygen consumption as preoperative criterion for lung resection. Ann Thorac Surg 1987;44:344 – 9. [53] Smith T, Kinasewitz G, Tucker W, et al. Exercise capacity as a predictor of post-thoracotomy morbidity. Am Rev Respir Dis 1984;129:730 – 4. [54] Bolliger C, Jordan P, Soler M, et al. Exercise capacity as a predictor of postoperative complications in lung resection candidates. Am J Respir Crit Care Med 1995; 151:1472 – 80. [55] Walsh G, Morice R, Putnam Jr J, et al. Resection of lung cancer is justified in high-risk patients selected by exercise oxygen consumption. Ann Thorac Surg 1994; 58:704 – 10. [56] Morice R, Peters E, Ryan M, Putnam J, Ali M, Roth J. Exercise testing in the evaluation of patients at high risk for complications from lung resection. Chest 1992;101:356 – 61. [57] Olsen GN, Weiman DS, Bolton JW, et al. Submaximal invasive exercise testing and quantitative lung scanning in the evaluation for tolerance of lung resection. Chest 1989;95:267 – 73. [58] Bolliger C, Wyser C, Roser H, Soler M, Perruchoud A.
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Preoperative Pulmonary Evaluation of the Thoracic Surgical Patient Aditya K. Kaza, MD, John D. Mitchell, MD* Section of General Thoracic Surgery, Division of Cardiothoracic Surgery, University of Colorado Health Sciences Center, 4200 East 9th Avenue, C-310, Denver, CO 80262, USA
Surgery remains the mainstay of therapy for earlystage non – small lung cancer, with approximately 45,000 cases of early-stage disease (stages I, II, and select IIIA) diagnosed annually. Many of these patients have poor underlying pulmonary function, in large part resulting from long-term tobacco abuse. It is the responsibility of the thoracic surgeon to assess accurately the pulmonary function of a potentially operable patient at the time of the preoperative evaluation. This assessment provides an objective risk profile associated with the planned pulmonary resection for the patient and family, minimizes morbidity and mortality, and in some cases leads the surgeon to recommend alternative therapies.
General considerations Several questions should be asked in the general pulmonary assessment of a patient being considered for lung resection surgery. Careful appraisal of prior history and pertinent review of systems (Box 1) often can predict the objective results obtained in subsequent pulmonary function testing. Is the patient currently smoking? Active use of tobacco at the time of surgery predisposes patients to a variety of postoperative pulmonary complications [1,2], usually through increased production and reduced clearance of sputum in the perioperative
* Corresponding author. E-mail address: [email protected] (J.D. Mitchell).
period. Significant atelectasis, pneumonia, or respiratory insufficiency requiring intubation may result. Patients should be counseled regarding the benefits of abstinence from smoking as early as possible before the procedure. A long prior smoking history may suggest significant occult parenchymal disease (chronic obstructive pulmonary disease), but is associated with increased risk even in the absence of such findings [3]. Does the patient have an occupational or travel history that would predispose him or her to certain pulmonary disorders? A variety of industrial and environmental exposures, both organic and inorganic, can lead to the insidious development of interstitial lung disease and reduced pulmonary function [4]. Common environmental agents include silica, asbestos, beryllium, and animal/bird products (farmer’s lung or variants). A history of travel to areas endemic to certain fungal infections (Coccidioides or Histoplasma) also may be relevant. What is the activity level of the patient? Patients with suboptimal performance on objective exercise testing are at increased risk for perioperative cardiopulmonary complications [5 – 8]. In addition, selfreported poor exercise tolerance has been shown to be associated reliably with increased postoperative risk [9]. Pulmonary rehabilitation, although not always practical, may improve exercise tolerance dramatically and is strongly advocated before lung transplantation or lung volume reduction surgery [10,11]. Does the patient have a history of prior or active pulmonary infection? A history of recurrent pulmonary infections may suggest impaired mucociliary clearance, airway obstruction, or localized bronchiec-
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Box 1. General considerations in the pulmonary resection candidate Smoking history Occupational and travel history Exercise tolerance Prior history of: Recurrent pulmonary infections Recognized pulmonary airway/parenchymal disease Cardiac disease Pulmonary or cardiac surgery
tasis. Successful treatment of active infection before surgical resection is advised, but not always feasible in the setting of a postobstructive infectious process. Is an underlying pulmonary parenchymal disorder present? The concomitant presence of significant obstructive, interstitial, or infectious lung disease can have a major impact on the patient’s functional status and the conduct of the proposed operation. In addition, certain pulmonary disorders (particularly interstitial lung disease) may be associated with a poor prognosis, which may influence the degree of risk a patient may wish to assume in the perioperative period. Is cardiac disease present? Many cardiac and pulmonary disorders have common etiologic factors. The presence of significant ischemic or valvular heart disease can have an impact on postoperative pulmonary complications. Preexisting right ventricular dysfunction has been shown to be a risk factor for complications after pulmonary resection [12]. Has the patient had prior thoracic surgery? A prior history of pulmonary resection or significant intrathoracic procedure can have a significant impact on the risk profile at the time of subsequent surgery.
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criteria for safe pulmonary resection, including an FEV1 greater than 1.5 L for a proposed lobectomy and greater than 2 L for a pneumonectomy [13 – 15]. These criteria have been adopted as guidelines by at least one major thoracic society, with no further testing needed to ensure operability [16]. The difficulty with these absolute values is that they do not take into account size or gender of the particular patient, producing bias against resection in smaller individuals. For this reason, most practitioners use or express measured FEV1 as a percentage of the predicted value for the patient’s gender, height, and weight. In this fashion, investigators have suggested an FEV1 greater than 80% of the predicted value is associated with a low risk of perioperative complications after major lung resection, and no further testing is needed (Fig. 1) [17]. Other parameters investigated include maximum voluntary ventilation (MVV) and FEV25 – 75%, with a MVV less than 40% predicted or a FEV25 – 75% of 0.6 to 1 L indicative of a marginal candidate for lobar resection [18].
Diffusion capacity The diffusion capacity in the lung for carbon monoxide (Dlco) was found to be the most important predictor of mortality and was the sole predictor of postoperative pulmonary complications in a retrospective review of 237 patients published by Ferguson et al [19] in 1988. In this study, a Dlco less than 60% of predicted was associated with increased mortality. The importance of Dlco in risk assessment before lung resection has been substantiated by further reports, with little interplay between Dlco and either FEV1 or maximum oxygen con˙ o2max) [20,21]. sumption (V
Arterial blood gas analysis Spirometry Spirometry is a simple, inexpensive, readily available test and remains the starting point in the evaluation of a patient for proposed pulmonary resection. Spirometry should be performed with the patient in stable condition, with and without the use of inhaled bronchodilators. A bronchodilator response greater than 15% is considered significant and indicates a component of reactive airways disease. The forced expiratory volume in 1 second (FEV1) is the most commonly used parameter from spirometric testing for pulmonary risk assessment. Several large studies in the past have suggested FEV1
The presence of resting hypercapnea, defined as a Pco2 greater than 45 mm Hg on room air, has long been described as a relative contraindication to lung resection [14,18]. Other reports dispute this assertion, however, and show equivalent outcomes above and below this value [22 – 24].
Prediction of postoperative function Most patients presenting for lung surgery are likely to have reduced lung function, and it is the responsibility of the surgeon to ensure adequate
preoperative pulmonary evaluation
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Fig. 1. (A) CT scan of a patient with severe environmental mycobacterial disease involving the left lung. Pneumonectomy was suggested, with a preoperative FEV1 1.1 L or 53% predicted. (B) Quantitative lung perfusion scan of the same patient, with 5% of total lung perfusion to the affected lung. Postoperative FEV1 values corresponded to calculated values of 1.05 L, or 50% predicted. See text. (Courtesy of Marvin Pomerantz, MD.)
pulmonary function will remain after the proposed resection. If preoperative pulmonary function testing reveals suboptimal function (FEV1 and Dlco < 80% predicted), additional testing is indicated to estimate the predicted postoperative (ppo) values. The most commonly used methods include nuclear medicine ventilation-perfusion (V/Q) scanning [15,25 – 28], quantitative CT [29,30], and segment counting [31,32]. These methods may be applied to the actual and the percent predicted spirometry/Dlco values, although the latter is more common. Nuclear medicine V/Q scanning provides the relative contribution of each lung to overall pulmonary function (Fig. 2). For a pneumonectomy, calculation of the ppoFEV1 (or % predicted ppoFEV1) can be accomplished easily using the data
from the perfusion scan and the preoperative spirometry results: ppoFEV1 ¼ preoperative FEV1 ð1 % perfusion to affected lungÞ Although discrepancies may occur when there is significant V/Q mismatching, numerous studies have shown good correlation between predicted and actual measured FEV1 using this formula, with several studies noting a slight underestimation of the actual measured postoperative value, providing an element of safety for a marginal patient [15,25,33]. Use of the perfusion scintigraphy data also may be applied ˙ o2max [26]. Some to predict ppoDlco and ppoV investigators have suggested that dynamic perfusion
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Proposed Lung Resection
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Spirometry DLCO
FEV1 > 80% predicted DLCO > 80% predicted
FEV1 < 80% predicted DLCO < 80% predicted
Estimation of Postoperative Function (ppo)*
ppoFEV1 >40% predicted ppoDLCO >40-50% predicted
ppoFEV1 <40% predicted ppoDLCO <40-50% predicted
Exercise Study
VO2max >15 ml/kg/min
VO2max <15 ml/kg/min ppoVO2max >10 ml/kg/min
ppoVO2max <10 ml/kg/min
Defer Surgery
Offer Surgery
Fig. 2. Algorithm for preoperative pulmonary evaluation. *Estimated with quantitative perfusion scan, CT scan, or segment counting.
MR imaging techniques may be a feasible alternative to V/Q scintigraphy [34]. The perfusion study also may be used to predict function after lobectomy, as described by Wernly et al [15]: ppoFEV1 ¼ preoperative FEV1 preoperative FEV1 % perfusion to affected lung # resected segments # segments in affected lung An alternative method of calculating ppoFEV1 without the use of a quantitative perfusion study involves simply accounting for the number of resected segments as a percentage of the total number of segments in both lungs, as described by Juhl and Frost [31].
With 19 lung segments, each segment accounts for roughly 5.26% of the overall lung function: ppoFEV1 ¼ preoperative FEV1 ð1 ½# segments resected 5:26=100Þ Simple segment counting obviates the need for expensive nuclear medicine testing and has been adopted as the preferred method of calculating postoperative spirometry values after lobectomy by at least one major thoracic society [16]. Although segment counting has been suggested to be as accurate as V/Q scintigraphy [35], it does not take into account the functional differences between varying segments, which may prove important in mar-
preoperative pulmonary evaluation
ginal patients with heterogeneous patterns of lung disease, such as emphysema. Perhaps to account for this factor, one group suggested adding 250 mL of volume to the ppoFEV1 calculated by segment counting, to obtain a more reliable estimation of postoperative function [32]. At least one study has compared scintigraphy, segment counting, and quantitative CT in predicting postoperative pulmonary function [36]. In this study, four parameters were assessed: FEV1, FVC, Dlco, ˙ o2max. Although scintigraphy and CT were and V found to be useful, perfusion scintigraphy was noted to be the most accurate. Numerous studies have shown ppoFEV1 to be a predictor of perioperative risk. Historically a cutoff of ppoFEV1 less than 800 mL was used as a determinant of unresectability [37]. More recent studies suggest that morbidity and mortality are significantly increased if the ppoFEV1 is less 40% [22,38 – 40]. Similarly, ppoDlco has been shown to be strongly predictive of complications and death when the value is less than 40% [18,21]. At least one group has suggested the product of ppoFEV1 and ppoDlco (predicted postoperative product) less than 1650 may be an even more sensitive indicator of postoperative mortality [33].
Exercise testing Patients considered at high risk for perioperative complications on the basis of standard spirometry testing and calculation of postoperative function should undergo exercise testing. The purpose of exercise testing is to identify some patients deemed high risk but still able to tolerate resection with acceptable morbidity and mortality. The easiest form of exercise testing is stair climbing, with the height climbed inversely related to the frequency of postoperative complications [41,42]. Investigators have found increased morbidity and mortality when less than 2 flights [43,44], 3 flights [45,46], 12 m [47], or 44 steps [48] are climbed. One study found the height climbed to be the sole predictor of morbidity through multivariate analysis [47]. Others have shown correlation with the ˙ o2max [49]. patient’s V The 6-minute walk test was modified from the original 12-minute test and provides objective evidence of the patient’s exercise function [50]. The test, usually performed in a hallway over a preset distance, measures the distance a patient can walk quickly on a hard, flat surface in 6 minutes. The test is self-paced
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and does not reflect maximal exercise capacity. Some investigators believe that because most activities of daily living are performed in a submaximal exercise environment, the test is a better assessment of the patient’s general exercise tolerance. Holden et al [48] found an achieved distance of greater than 1000 feet to be associated with improved surgical outcomes after lung resection. The 6-minute walk test is commonly used in lung transplantation evaluations and was used to exclude patients with severely reduced exercise capacity after pulmonary rehabilitation in the National Emphysema Treatment Trial [10]. A variation of the 6-minute walk test is the shuttle walk, in which patients ambulate between two cones placed 10 m apart. The walking speed, paced by an audio signal, is increased each minute until the patient is unable to continue. The shuttle walk more ˙ o2max, with one study closely correlates with V showing that inability to complete 25 shuttles (250 m ˙ o2max less than 10 mL/ [about 820 ft]) suggested a V kg/min [51]. Where available, formal cardiopulmonary exercise testing should be pursued when preliminary spirometry and split function studies suggest the patient is at increased risk of perioperative complications. The test usually is performed with incremental work performed on a treadmill or bicycle ergometer, measuring oxygen saturation and exhaled ˙ o2max, carbon dioxide gases to determine Vo2, V output, and minute ventilation. The most commonly used parameter measured with cardiopulmonary ˙ o2max, which denotes a plateau exercise testing is V above which further increases in work do not result in greater oxygen consumption. This parameter differs slightly from Vo2peak, which describes the highest oxygen consumption achieved before symptoms (fatigue, dyspnea) forced the patient to stop the test. Such limitations are common in patients with advanced lung disease. Several studies have shown patients to be at low risk for perioperative complications if the preopera˙ o2max is greater than 20 mL/kg/min [52 – 54], tive V ˙ o2max greater than 15 mL/kg/min whereas others use V ˙ o2max less than as a cutoff for resection [55,56]. A V 10 mL/kg/min is associated with prohibitive morbidity and mortality [17,52,57,58]. Bolliger et al [58] ˙ o2max less than 10 mL/kg/min to corfound a ppoV relate with a 100% postoperative mortality. Exercise oximetry has been suggested to be helpful in predicting postoperative complications by some authors [16,59,60] and not by others [61]. Ninan et al [59] found desaturation with exercise greater than 4% highly predictive of longer ICU stays and major morbidity.
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Effect of lung volume reduction surgery Occasionally a patient with a lung mass and poor pulmonary function may present with functional and anatomic factors favorable for lung volume reduction surgery [10]. Because successful lung volume reduction surgery results in an improvement in FEV1 and other pulmonary parameters, a combined operation has been proposed as a strategy to allow safe resection. The pulmonary mass may reside in the severely emphysematous part of the lung or may be resected separately from the lung volume resection. Several small studies have validated this approach in selected patients [62,63].
Summary Fig. 2 is an algorithm for the preoperative pulmonary evaluation of the lung resection candidate. Patients should undergo routine spirometry and diffusion capacity testing. If the FEV1 and Dlco are greater than 80% predicted, no further study is needed. When these parameters are less than 80%, some estimation of postoperative function is likely needed, taking into account the proposed resection. Patients with ppoFEV1 or ppoDlco less than 40% are at increased risk of perioperative complications or death and should undergo formal exercise testing. A ˙ o2max or ppoV ˙ o2max less than 10 mL/kg/min is V associated with prohibitive risk for anatomic lung resection, and alternative treatment modalities should be considered.
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