Chest
ReviewsPreoperative Evaluation of Patients Undergoing Lung Resection Surgerya
Section snippets
Preoperative Evaluation of Patients With Operable Lung Cancer
After determining the anatomic resectability of the disease, it needs to be decided whether the patient can withstand the planned procedure and can survive the loss of the resected lung. For this purpose, general and pulmonary-specific evaluations are necessary. Who should be evaluated? The general answer is as follows: all patients undergoing lung resection surgery, irrespective of age or extent of the lesion.
Initial Evaluation
Prior to taking the patient to surgery, a detailed medical history, including that of any coexisting disease should be sought to ensure the optimal treatment and control of that disease. History should include the patient’s functional capacity and the degree of limitation of activity. Since patients with lung cancer are usually smokers, a history of smoking and of symptoms suggestive of COPD should be elicited. This history may lead to preoperative therapeutic interventions such as therapy with
Pulmonary-Specific Evaluation
The pulmonary-specific evaluation (Fig 1) aims at assessing the patient’s physiologic pulmonary function. It helps to decide whether the patient is a candidate for surgery and the extent of resection that can be tolerated. Although a number of physiologic tests exist for this purpose, there is no single measure that is a “gold standard” in accurately predicting complications. However, certain criteria, when applied, have been shown to be predictive of outcome.
Stages of Pulmonary-Specific Evaluation
The pulmonary-specific evaluation can be divided into three stages of tests that are performed in a graded manner to meet the cited goals and help risk-stratify the patients prior to the anticipated surgery.
Stage I Assessment
The first stage of assessment consists of the following tests.
Stage II Assessment
The next stage of assessment consists of tests that measure individual lung function. These include the following.
Stage III Assessment
Patients with a low ppo FEV1 (ie, < 0.8 to 1 L or < 35 to 40% of predicted values) are considered to be at high risk for postoperative complications following lung resection surgery and need further workup. This can be done fairly accurately by means of exercise testing.
Exercise testing stresses the entire cardiopulmonary and oxygen delivery system, and provides a good estimate of cardiopulmonary reserve. Currently, exercise testing consists of having the patient perform an incremental amount
Principles of Exercise Testing
o2 in the lungs is representative of o2 at the cellular level. With an increase in the cellular respiration from exercise, there is a predictable increase in o2. o2 is related to age, sex, weight, and type of work performed. A formula for estimating o2 reported by Wasserman and Whipp30is as follows:
The rate of o2 increases with exercise until a point at which a plateau is reached and a further
Types of Exercise Testing
Two major types of exercise tests have been used in the preoperative evaluation of high-risk patients being considered for lung resection surgery.32These are: (1) fixed exercise challenge, in which a sustained level of work is performed, and (2) incremental exercise testing, in which the work rate is sequentially increased to a desired end point. These two types are further divided into maximal or submaximal, based on their end points. The maximal end point can be defined as an exercise,
An Alternative Approach to Preoperative Evaluation Prior To Lung Resection Surgery
An important study was performed by Wyser et al46in 1999. This study evaluated prospectively an algorithm for the functional assessment of lung resection candidates that was different from the approach traditionally used. Unlike earlier approaches to preoperative evaluation for lung resection surgery, this algorithm used exercise testing to determine o2max earlier in the assessment. Patients with either FEV1 or Dlco values < 80% of predicted underwent exercise testing to determine
Conclusion
Patients in whom anatomically resectable lung cancer is diagnosed should undergo evaluation for surgical resectability. This begins with routine pulmonary function testing. Patients whose PFT results show good lung function (ie, FEV1, > 2 L or > 60% of predicted; and Dlco, > 60%) can be referred for surgery without undergoing other tests for further assessing their pulmonary status.
Patients with preoperative FEV1 values < 60% of predicted and/or Dlco values < 60% of predicted need further
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