Chest
The Physiologic Evaluation of Patients With Lung Cancer Being Considered for Resectional Surgery*
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 ( 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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