Chest
Volume 123, Issue 1, Supplement, January 2003, Pages 105S-114S
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The Physiologic Evaluation of Patients With Lung Cancer Being Considered for Resectional Surgery*

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The preoperative physiologic assessment of a patient being considered for surgical resection of lung cancer must consider the immediate perioperative risks from comorbid cardiopulmonary disease, the long-term risks of pulmonary disability, and the threat to survival due to inadequately treated lung cancer. As with any planned major operation, especially in a population predisposed to atherosclerotic cardiovascular disease by cigarette smoking, a cardiovascular evaluation is an important component in assessing perioperative risks. Measuring the FEV1 and the diffusing capacity of the lung for carbon monoxide (Dlco) measurements should be viewed as complementary physiologic tests for assessing risk related to pulmonary function. If there is evidence of interstitial lung disease on radiographic studies or undue dyspnea on exertion, even though the FEV1 may be adequate, a Dlco should be obtained. In patients with abnormalities in FEV1 or Dlco identified preoperatively, it is essential to estimate the likely postresection pulmonary reserve. The amount of lung function lost in lung cancer resection can be estimated by using either a perfusion scan or the number of segments removed. A predicted postoperative FEV1 or Dlco < 40% indicates an increased risk for perioperative complications, including death, from lung cancer resection. Exercise testing should be performed in these patients to further define the perioperative risks prior to surgery. Formal cardiopulmonary exercise testing is a sophisticated physiologic testing technique that includes recording the exercise ECG, heart rate response to exercise, minute ventilation, and oxygen uptake per minute, and allows calculation of maximal oxygen consumption ( V˙o2max). Risk for perioperative complications can generally be stratified by V˙o2max. Patients with preoperative V˙o2max > 20 mL/kg/min are not at increased risk of complications or death; V˙o2max < 15 mL/kg/min indicates an increased risk of perioperative complications; and patients with V˙o2max < 10 mL/kg/min have a very high risk for postoperative complications. Alternative types of exercise testing include stair climbing, the shuttle walk, and the 6-min walk. Although often not performed in a standardized manner, stair climbing can predict V˙o2max. In general terms, patients who can climb five flights of stairs have V˙o2max > 20 mL/kg/min. Conversely, patients who cannot climb one flight of stairs have V˙o2max < 10 mL/kg/min. Data on the shuttle walk and 6-min walk are limited, but patients who cannot complete 25 shuttles on two occasions will have V˙o2max < 10 mL/kg/min. Desaturation during an exercise test has been associated with an increased risk for perioperative complications. Lung volume reduction surgery (LVRS) for patients with severe emphysema is a controversial procedure. Some reports document substantial improvements in lung function, exercise capability, and quality of life in highly selected patients with emphysema following LVRS. Case series of patients referred for LVRS indicate that perhaps 3 to 6% of these patients may have coexisting lung cancer. Anecdotal experience from these case series suggest that patients with extremely poor lung function can tolerate combined LVRS and resection of the lung cancer with an acceptable mortality rate and good postoperative outcomes. Combining LVRS and lung cancer resection should probably be limited to those patients with heterogeneous emphysema, particularly emphysema limited to the lobe containing the tumor.

Section snippets

General Issues for Lung Cancer Surgery

All patients with lung cancer should be seen by a physician interested in the management of this disease. Patients seen by specialists will have higher rates of diagnosis, referral to surgeons and oncologists, and treatment with better outcomes.78 A multidisciplinary team approach is essential in the assessment of these patients. The proposed procedure should be discussed with the patient and relatives.

Age should not be a reason to deny patients with lung cancer access to lung cancer services.9

Spirometry and Diffusing Capacity

The FEV1 obtained by spirometry is the most commonly used test to assess suitability of patients with lung cancer for surgery. Spirometry should be performed when the patient is in clinically stable condition and receiving maximal bronchodilator therapy. The FEV1 can be expressed in either absolute values or as a percentage of predicted.

There have been several studies looking at the minimum absolute values of FEV1 that, as a single measurement, will predict whether a patient will survive a

Predicted Postoperative Values of Lung Function

The extent of further evaluation in patients with diminished pulmonary reserve depends on the extent of planned pulmonary resection: pneumonectomy, lobectomy, wedge resection, or segmentectomy. In patients with compromised lung function preoperatively, it is therefore essential to estimate the likely pulmonary reserve postresection. Approaches to obtaining the predicted postoperative (ppo) lung function have relied on several different methods to estimate the amount of functioning lung tissue

Cardiopulmonary Exercise Testing

Formal cardiopulmonary exercise testing (CPET) is a sophisticated physiologic testing technique that includes recording the exercise ECG, heart rate response to exercise, minute ventilation, and oxygen uptake per minute. Maximal oxygen consumption ( V˙o2max) is calculated from this type of exercise test. Algorithms for the preoperative physiologic assessment of patients being considered for lung cancer resection have incorporated use of CPET as an adjunct to estimating the %ppo FEV1 and D

Arterial Blood Gas Tensions

Historically, hypercapnea (Paco2 > 45 mm Hg) has been quoted as an exclusion criterion for lung resection.165354 This recommendation was made on the basis of the association of hypercapnea with poor ventilatory function.55 The few studies that address this issue, however, suggest that preoperative hypercapnea is not an independent risk factor for increased perioperative complications. Stein et al56 showed hypercapnea was associated with serious postoperative respiratory difficulties in five

LVRS

LVRS for patients with severe emphysema is a controversial procedure. Some reports document substantial improvements in lung function, exercise capability, and quality of life in highly selected patients with emphysema following LVRS.59 However, recently published results from a larger prospective, randomized, controlled trial indicate an increased mortality rate after LVRS in patients with either homogenous emphysema or a low Dlco.60 Case series of patients referred for LVRS indicate that

Summary

Patients with lung cancer often have concomitant obstructive lung disease and/or atherosclerotic cardiovascular disease as a consequence of their smoking habit. These diseases may place these patients at increased risk for perioperative complications, including death, after lung cancer resection. A careful preoperative physiologic assessment will be useful to identify those patients at increased risk and to enable an informed decision by the patient about the appropriate therapeutic approach to

Summary of Recommendations

  • 1.

    Patients with lung cancer should be seen by physicians interested in the management of this disease. Level of evidence, fair; benefit, substantial; grade of recommendation, B

  • 2.

    Patients with lung cancer should be assessed by a multidisciplinary team for their suitability for surgery; there should be liaison between the chest physician, thoracic surgical team, and oncologist in all cases prior to surgery. Level of evidence, poor; benefit, substantial; grade of recommendation, C

  • 3.

    Patients with lung

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