Preoperative Evaluation of Patients Undergoing Lung Resection Surgery

doi:10.1378/chest.123.6.2096

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Volume 123, Issue 6, June 2003, Pages 2096-2103

https://doi.org/10.1378/chest.123.6.2096 Get rights and content

Lung cancer continues to be the leading case of cancer deaths in the United States. In patients with resectable non-small cell lung cancer, surgical resection is the treatment of choice. An accurate preoperative general and pulmonary-specific evaluation is essential as postoperative complications and morbidity of lung resection surgery are significant. After confirming anatomic resectability, patients must undergo a thorough evaluation to determine their ability to withstand the surgery and the loss of the resected lung. The measurement of spirometric indexes (ie, FEV₁) and diffusing capacity of the lung for carbon monoxide (Dlco) should be performed first. If FEV₁ and Dlco are > 60% of predicted, patients are at low risk for complications and can undergo pulmonary resection, including pneumonectomy, without further testing. However, if FEV₁ and Dlco are < 60% of predicted, further evaluation by means of a quantitative lung scan is required. If lung scan reveals a predicted postoperative (ppo) values for FEV₁ and Dlco of > 40%, the patient can undergo lung resection. If the ppo FEV₁ and ppo Dlco are < 40%, exercise testing is necessary. If this reveals a maximal oxygen uptake ( $\dot{V}$ o₂max) of > 15 mL/kg, surgery can be undertaken. If the $\dot{V}$ o₂max is < 15 mL/kg, surgery is not an option. This review discusses the existing modalities for preoperative evaluation prior to lung resection surgery.

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

$\dot{V}$ o₂ in the lungs is representative of $\dot{V}$ o₂ at the cellular level. With an increase in the cellular respiration from exercise, there is a predictable increase in $\dot{V}$ o₂. $\dot{V}$ o₂ is related to age, sex, weight, and type of work performed. A formula for estimating $\dot{V}$ o₂ reported by Wasserman and Whipp³⁰is as follows: $predicted \dot{V} o_{2} = 5.8 \times weight in kg + 151 + 10.1 (W of workload)$

The rate of $\dot{V}$ 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 $\dot{V}$ o₂max earlier in the assessment. Patients with either FEV₁ or Dlco values < 80% of predicted underwent exercise testing to determine $\dot{V}$

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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ReviewsPreoperative Evaluation of Patients Undergoing Lung Resection Surgerya

Section snippets

Preoperative Evaluation of Patients With Operable Lung Cancer

Initial Evaluation

Pulmonary-Specific Evaluation

Stages of Pulmonary-Specific Evaluation

Stage I Assessment

Stage II Assessment

Stage III Assessment

Principles of Exercise Testing

Types of Exercise Testing

An Alternative Approach to Preoperative Evaluation Prior To Lung Resection Surgery

Conclusion

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Preoperative Evaluation of Patients Undergoing Lung Resection Surgery^a