Preoperative Pulmonary Function Evaluation in Lung Resection

Ri / CR

Pulmonary Function Test

Preoperative pulmonary evaluation of patients with lung cancer concerns both resectability and operability. resectability: TNM staging operability: how much tissue can be safely removed

Commonly Used Parameters

FEV1 (Forced Expiratory Volume in 1 second)
FVC (Functional Vital Capacity) FEV1/FVC

MVV (Maximum Voluntary Ventilation)

= MBC (Maximum Breathing Capacity)

DLCO (Diffusing Capacity of Carbon Monoxide) VO2 max (Maximum Oxygen Consumption)

FEV1
best parameter to predict risk of post-op complications (including death) ppoFEV1 (predicted postoperative FEV1)

Am J of Med (2005) 118, 578583 Chest (2003) 123, 2096-2103 Resp Med (2004) 98, 598-605

MVV (MBC)
largest volume breathed voluntarily in 1 min an estimate of the peak ventilation available to meet physiological demands represents respiratory muscle strength and correlates with post-op morbidity

Am J of Med (2005) 118, 578583 Chest (2003) 123, 2096-2103 Resp Med (2004) 98, 598-605

DLCO
independent predictor for risk of post-op complications (including death) reflects alveolar membrane integrity and pulmonary capillary blood flow low DLCO implies significant emphysema, and reduced pulmonary capillary vascular bed

Am J of Med (2005) 118, 578583 Chest (2003) 123, 2096-2103 Resp Med (2004) 98, 598-605

VO2 max (Exercise Test)

exercise capacity (measured as VO2 max) predictor of post-op complications (including death)
exercise oximetry stair climbing shuttle walking 6-minute walk test

helps to identify high-risk patients who can safely undergo lung resection
Am J of Med (2005) 118, 578583

VO2 max
Eugene et al VO2 max > 1 L/min little complications

Smith et al
VO2 max > 20 ml/kg/min post-op complications 10% VO2 max = 15~20 ml/kg/min post-op complications 66% VO2 max < 15 ml/kg/min post-op complications 100% Markos et al oxygen desaturation during a 12-min walk, ppoDLCO and ppoFEV1 were more reliable predictors of post-op mortality

Chest (2003) 123, 2096-2103

Other Parameters
FEF25-75%: highly variable ABG: hypercapnia (>45 mmHg) PPP (predicted postoperative product)
product of ppoFEV1 and ppoDLCO

Am J of Med (2005) 118, 578583

Postoperative Lung Function

Pulmonary function is affected by lung resection, extent varies: pneumonectomy:
FEV1: 34~36% FVC: 36~40% VO2 max: 20~28%

lobectomy:
FEV1: 9~17% FVC: 7~11% VO2 max: 0~13%
Am J of Med (2005) 118, 578583

Lung Resection
may undergoes up to 3 testing phases:

1st phase (whole-lung tests):

room-air ABG, simple spirometry, lung volume, (DLCO, exercise test)
i. PaCO2 > 45 mmHg ii. FEV1 or MVV < 50% predicted iii. RV/TLC > 50%

if any combination of the above exists proceed to 2nd phase

Chapter 49, Millers Anesthesiology, 6th Edition

Lung Resection
2nd phase (single-lung tests):
ventilation/perfusion of each lung quantitative CT scanning
i. ppoFEV1 < 0.85 L ii. > 70% blood flow to the diseased lung

if any of the above exists proceed to 3rd phase

Chapter 49, Millers Anesthesiology, 6th Edition

Prediction of Post-op Lung Function

Methods to predict postoperative pulmonary function: segment method radionuclide scanning techniques quantitative computed tomography

Segment Method
19 total segments (right 10, left 9) estimated post-op pulmonary function = (pre-op pulmonary function) * (post-op remaining segments) / 19 subsegments also being used (total of 42 subsegments)

Am J of Med (2005) 118, 578583

Radionuclide Scanning Techniques

inhaled 133Xe or intravenous 99Tc-labeled macroaggregates estimation by quantifying the perfusion to a specific area:
ppoFEV1 = preoperative FEV1 * % of radioactivity contributed by nonoperated lung

Am J of Med (2005) 118, 578583

Quantitative Computed Tomography

-500~-910 Hounsfield unit is used to estimate functional lung volume correlates better than radionuclide scanning method

AJR (2002) 178, 667672

Lung Resection
3rd phase (mimic post-op condition):
temporary balloon occlusion (with or without exercise) skill-demanding, rarely performed

Chapter 49, Millers Anesthesiology, 6th Edition Ann Thorac Cardiovasc Surg (2004) 10, 333-339

Testing Phases

Chapter 49, Millers Anesthesiology, 6th Edition

Pulmonary Function Test

Chapter 49, Millers Anesthesiology, 6th Edition

Case
Pre-op FVC (L) FEV1 (L) FEV1/FVC (%) RV/TLC (%) MVV (L/min) % predicted (%) VO2 max (L/min) VO2 max (ml/kg/min) 3.20 1.66 (>1.2~1.0) 51.9 (>40) 55.0 53.3 (>40) 69.9 (>40) 0.944 (<1) 15.9 (>15, <20) Predicted Post-op 2.69 1.40 (>1)

Oxy-Hb drop in exercise (%) None (<5%)

The patient should therefore be safe to undergo RUL lobectomy.

Reference
1. Anesthesia for thoracic surgery, Miller: Millers Anesthesiology (2005) 6th Edition, chapter 49 2. Pulmonary function testing, Miller: Millers Anesthesiology (2005) 6th Edition, chapter 26

3. Mazzone et al., Lung cancer: preoperative pulmonary evaluation of the lung resection candidate. Am J of Med (2005) 118, 578583
4. Datta et al., Preoperative evaluation of patients undergoing lung resection surgery. Chest (2003) 123, 2096-2103 5. Wang et al., Pulmonary function tests in preoperative pulmonary evaluation. Resp Med (2004) 98, 598-605 6. Tanita et al., Review of preoperative functional evaluation for lung resection using the right ventricular hemodynamic functions. Ann Thorac Cardiovasc Surg (2004) 10, 333339 7. Wu et al., Prediction of postoperative lung function in patients with lung cancer: comparison of quantitative CT with perfusion scintigraphy. AJR (2002) 178, 667-672

Thank you for your attention!

predicted VO2 = 5.8 * weight in kg + 151 + 10.1 (W of workload)