Preoperative Pulmonary Evaluation in Thoracic Surgeries

Prof. Dr. Metin ÖZKAN

No Conflict of interest

Post operative pulmonary complications (POPC): Importance

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• More common and serious than cardiac complications

• Longer hospital stay (1-2 weeks)

• Increased morbidity and mortality

• Frequency 2-70%;

• patient selection,

• risk factors due to operation,

• defination of complication

Pulmonary pathophysiology during surgery under general anesthesia

Thorax and upper abdominal surgery:

FRC

Vital Capacity

30%

50-60%

Diaphragmatic dysfunction MultifactorialPain, incision

Upper abdomen, lung, esophagus, cardiac surgery

Cough suppression and decrease in mucus clerence Inhaled analgesics, opiates, pain

Atelectasis FRC,

Diaphragmatic dysfunction

Cough

Mucociliary clearance

Impairment of gas exchange Shunt due to atelectasis

Ventilation/perfusion disturbances due to hypoventilation and vasoconstriction

Respiratory depression Opiates

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Up to 1 week

Postoperative pulmonary complicationsGeneral ComplicationsAtelectasisInfections Bronchitis

Pneumonia

Respiratory depression/hypoxemiaPulmonary embolismGastric aspirationAcute Lung Injury (ALI)/ARDS)BronchospasmExacerbation of underlying diseaseOSA

Specific to Thoracic Surgery Nerve injuries

Phrenic

Recurrent laryngeal

Pleural effusion Bronchopleural fistula Empyema Postpneumonectomy pulmonary

edema Sternal wound infection Postpneumonectomy syndrome Pulmonary torsion

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Factors associated with the development of postoperative pulmonary complications

Preoperative (patient related) Chronic lung disease + +  Smoking + + General health status + + (ASA> class 2) Age + / - Obesity + / - Nutritional / metabolic status + (albumin <30 g / L and urea> 30 mg / dL) Concomitant infection of the respiratory system

Intraoperative (Operation related)  Type of anesthesia  Duration of anesthesia  Site of surgery Type of incision

Postoperative İmmobilization Poor pain control

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+ +, strong determinant; +, moderate; + / - weak evidence of increased risk

Factors associated with the development of postoperative pulmonary complications

The presence of COPD is a significant risk POPC (2.7-6.0) Complication rates of 25-100% POPC rate and severity correlates with Preop. PFT

(FEV1 <65%: POPK> 50%) Intensive bronchodilator therapy smoking cessation Short-term corticosteroid therapy In the case of an acute attack elective surgery must be postponed

Although COPD is a serious risk, there is not a lower limit of PFT where the surgery is absolute contraindicated (other than resection)

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Preoperative (patient related) Chronic lung disease + +  Smoking + + General health status + + (ASA> class 2) Age + / - Obesity + / - Nutritional / metabolic status + (albumin <30 g / L and urea> 30 mg / dL) Concomitant infection of the respiratory system

COPDPulmonary Complications COPD ( - )

( % )

COPD ( + )

( % )

p

Prolonged air leak, px 3.6 15.4 0.001**

Atelectasis 5.4 15.4 0.01*

Prolonged O2 support 8.4 28.2 <0.001**

Pneumonia 3.0 11.5 0.008**

Bronchopleural fistula, empyema 1.2 3.8 0.174

ARDS 1.8 5.1 0.147

Prolonged mechanical ventilation 4.2 16.7 <0.001**

Toraks 2012 Sekine Y.Lung Cancer 37:95-101,2002Sekine Y.Lung Cancer 37:95-101,2002

Complications after lung cancer surgery in patients with NSCLC

This slide is taken from Prof. Dr. Ertürk Erdinç’s speech in Winter School of Turkish Thoracic Society.

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89 severe COPD (FEV1 <50%), 107 surgical procedures

RESULTS: POPC 29% Significantly associated with the Type and duration of surgery and ASA classification

Coronary artery bypass grafting (60%)Major abdominal surgery (56%)Other general surgical procedures (27%)Spinal anesthesia was applied (16%)

Duration of the Operations; < 1h (4%), 1-2 h (23%), 2-4 h (38%) > 4h (73%)

ASA; class II (10%), Class III (28%), Class IV (46%)

6 deaths and 2 non-fatal respiratory failure. 5 of 10 bypass (50%) and 1 of 97 non-coronary bypass operations (1%) died.

CONCLUSION: Severe COPD is an acceptable risk factor for non-cardiac surgery.

Kroenke K et al. Operative risk in patients with severe obstructive pulmonary disease. Arch Intern Med. 1992;152(5):967-71.

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Presence of asthma

Even high probability of POPC expected, there is no data on this subject.

706 patients with asthma, various general surgical procedures; pulmonary complications: Bronchospasm 1.7% Respiratory failure, 0.1% 0.3% of laryngospasm. No Death

Warner DO, et al. Perioperative respiratory complications in patients with asthma. Anesthesiology 1996; 85:460–467.

In patients under control wheezing, (-) PEF> 80% do not have an additional risk

In the perioperative period Short-term Corticosteroid

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Preoperative (patient related) Chronic lung disease + +  Smoking + + General health status + + (ASA> class 2) Age + / - Obesity + / - Nutritional / metabolic status + (albumin <30 g / L and urea> 30 mg / dL) Concomitant infection of the respiratory system

Smoking

A prospective study of 200 patients underwent coronary by-pass surgery. Eight weeks

ago for those who quit smoking POPC, significantly lower than those who continue to

smoke (14.5% vs. 57.1%).

In those who quit smoking before 6 months the complication rates were determined at

the same level of never smokers (11.9% to 11.1%)

Warner MA et al. Mayo Clin Proc. 1989 Jun;64(6):609-16.

Although most of the smokers have normal PFT;increased secretion,mucociliary dysfunction,increased pain,opiates,impaired cough,retained secretions due to atelectasis,infection andhypoxemia. Toraks 2012

Preoperative (patient related) Chronic lung disease + +

  Smoking + + General health status + + (ASA> class 2) Age + / - Obesity + / - Nutritional / metabolic status + (albumin <30 g / L and urea> 30 mg / dL) Concomitant infection of the respiratory system

“American Society of Anesthesiologists” (ASA) classificationASA Class

Systemic disorders POPK (%)

Mortalite (%)

1 Healthy, except for surgical intervention 1.2 <0.03

2 Patients with mild to moderate systemic disease under control 5.4 0.2

3 Patients with severe systemic disease that limits but not stops activity

11.4 1.2

4 Patients with severe systemic disease that is a constant threat to life

10.9 8

5 Moribund patients who are not expected to survive without the operation

?? %34

6 A declared brain-dead patient whose organs are being removed for donor purposes

?? ??

ASA-E Emergency operation of any variety Artmış ArtmışToraks 2012

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Pulmonary Risk IndexRİSK FACTORS POINT

Obesity (BMI >27 kg/m2) 1

Smoking in past 8 weeks 1

Productive cough in past 5 days 1

Last 5 days, widespread rhonchi

1

FEV1/FVC < 70% Emergency operation

1

PaCO2 > 45 mmHg 1

Cardiopulmonary risk index Cardiopulmonary risk index

score: score: ( 1 - 4 ) + ( 0 - 6 )( 1 - 4 ) + ( 0 - 6 )

KPRIS >KPRIS >4; 22 times more higher

complication

< 2 low complication2 low complication

Complication Age 60-69 70 p

Pneumonia %3.3 %3.38 0.977

Atelectasis %8.8 %3.38 0.320

Acute respiratory distress %2.2 %3.38 0.650

Pneumothorax %3.2 %3.38 0.280

arrhythmia – Myocardial Infarction %9.9 %15.2 0.320

Re-operation %2.2 %0 0.520

Wound infection %4.4 %0 0.130

Excess fluid in the chest tube %0 %2 0.150Stolz A. Ind CardVasc 2;623-630,2003Stolz A. Ind CardVasc 2;623-630,2003

AGE

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Preoperative (patient related) Chronic lung disease + +  Smoking + + General health status + + (ASA> class 2) Age + / - Obesity + / - Nutritional / metabolic status + (albumin <30 g / L and urea> 30 mg / dL) Concomitant infection of the respiratory system

This slide is taken from Prof. Dr. Ertürk Erdinç’s speech in Winter School of Turkish Thoracic Society.

Obesity

Chest wall, diaphragm and abdominal fat accumulation reduces total respiratory compliance in 60%.

This change will increase in the supine position .

Decreased compliance:increased work of breathing;Increase in minute ventilation,An increase in oxygen consumptionIncreased production of CO2

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Preoperative (patient related) Chronic lung disease + +  Smoking + + General health status + + (ASA> class 2) Age + / - Obesity + / - Nutritional / metabolic status + (albumin <30 g / L and urea> 30 mg / dL) Concomitant infection of the respiratory system

Obesity

A prospective study of 272 non-thoracic surgeryhypercapnia (45 mm Hg or more) (odds ratio, 61.0),FVC <1.5 L / min (odds ratio, 11.1),maximal laryngeal height: 4 cm or less (odds ratio, 6.9),Forced expiratory time> 9 seconds (odds ratio, 5.7),More than 40 pack-years or more smoking (odds ratio, 5.7),Body mass index: 30 or higher (odds ratio, 4.1).

McAlister FA, et al. Accuracy of the preoperative assessment in predicting pulmonary risk after nonthoracic surgery.J Respir Crit Care Med. 2003;167(5):741-4.

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OSA172 patients with evidence of OSA (snoring,

daytime sleepiness, witnessed apnea) undergone elective surgeryPatients were followed up with oximetry and for at least 4%

desaturation index (ODI4%) had been established.Cardiac complications (4% - 1%) and POPC (8%-1%) were

determined higher in patients with ODI4%> 5. Pulmonary complications; pneumonia, atelectasis, and hypoxemia

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Hwang D, Shakir N, Limann B, Sison C, Kalra S, Shulman L, Souza Ade C, Greenberg H Association of sleep-disordered breathing with postoperative complications. Chest. 2008;133(5):1128-34.

OSA (postoperative follow-up )Pain control: Systemic opioids should be avoided; regional

aneljezi or nonsteroidal antiinflammatory drugs .O2 support: postoperative oxygen supplementation should be provided for

all patients with OSA.CPAP: Should be continued postoperatively.  CPAP training should be given

preoperatively to the patients with untreated OSA. SaO2 monitoring: Monitoring with Pulse oximetry should be continuously,

not intermittent, done after leaving intensive care unitBody Position: Turn the person on the lateral position or upright position

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Metabolic disorder

Malnutrition (albumin <30g / l, odds ratio =2.5) By reducing the work of breathing  causes of hypoxia and

hypercapnia.

Contribute to respiratory muscle dysfunction and reduces lung

elasticity.

Elevated urea (BUN>30mg/dl) odds ratio=2.3.

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Preoperative (patient related) Chronic lung disease + +  Smoking + + General health status + + (ASA> class 2) Age + / - Obesity + / - Nutritional / metabolic status + (albumin <30 g / L and urea> 30 mg / dL) Concomitant infection of the respiratory system

İntraoperative risk factors

Operation site: thoracic and upper abdominal

  Emergency interventions

  Prolonged anesthesia (> 3 h)

  General anesthesia

  long-

acting neuromuscular blockers (eg, pancuroni

um)

  Excessive blood transfusion during the

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Aortic aneursymThoracic SurgeryUpper abdominal surgeryBrain surgeryProlonged surgeryHead and neck surgeryEmergency surgeryVascular surgery

Anesthesia-Analgesia FRK

Tidal volume V / Q imbalance

Deterioration in oxygenation and CO2 excretion

An epidural anesthesia at T4 level does not cause a significant change in FRC, VC, FEV1, alveolar-arterial oxygen gradient, shunt ratio or in cardiac output.

duration of anesthesia 3-4 hours anesthesia may cause serious complications. Risk of pneumonia is 5 times greater in a-4 hours operation when compared with a-2 hours

one.

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Pancuronium does the residual NM blockade. The incidence of POPC increases 3-fold.

Postoperative epidural analgesia prevents respiratory muscle dysfunction and pain induced hypoventilation

Surgical Site

Complication rates (except for thromboembolism) : non-thoracoabdominal surgery  <1%

Lower abdominal surgery <5%

Upper abdominal surgery > 5% (there are reports of 7-76%)

Some factors influencing the complication rates of lung resectional surgery (1) the presence of underlying disease

(2)  the amount of resection of the functional lung Toraks 2012

Type of surgical incision

In abdominal surgeries vertical incision is more risky than horizontal incision.

Laparoscopic and thoracoscopic surgery are more reliable: Short hospital stay,Quick return to everyday lifeLess incisional pain

Laparoscopic cholecystectomy lung volumes are preserved,Less PO pain,use of less anelgesicHigher SaO2

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POSTOPERATIVE RISK FACTORS  Inappropriate Postoperative Analgesia

During PO period effective pain control is very important. Pain; blocks cough, deep breathe and early mobilization.

Barriers to better PO pain control: Hiding the pain by the patient Not to use narcotic analgesics when needed

Immobilization Prolonged bed rest and inactivity increases POPC‘s: FRC, 500-1000 ml reduced in the supine position

Atelectasis Short duration of hospitalization increases the mobilization and excretion of secretions. PO inactivity is a high risk for deep venous thrombosis and pulmonary thromboembolism 

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Pulmonary evaluationAnamnesis Deatiled history and physical exam

Undiagnosed chronic lung disease Decreased exercise tolerance unexplained dyspnea Sputum, cough

Symptoms of sleep apnea Pre-existing lung diseases Existing respiratory infections or exacerbations Smoking signs of COPD

Decreased breath sounds prolongation of expirium wheezing

Signs of deep vein thrombosis

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Pulmonary function testing: To which patientAll candidates for lungPatients with asthma or

COPDOthers:

Patients undergoing coronary bypass or upper abdominal surgery with a history of smoking or dyspnea.

Patients undergoing head and neck, orthopedic, or lower abdominal surgery with unexplained dyspnea or pulmonary symptoms

PFTs (cont.)PFTs should not be used as the primary factor to

deny surgerythe results from PFT should be interpreted in

context of clinical situation and should not be the sole reason to withhold necessary surgery

Two reasonable goals to use of preoperative PFTsIdentification of a group of patients for whom the risk of the

proposed surgery is not justified by the benefitIdentification of a subset of patients at higher risk for whom

aggressive perioperative management is warranted

PFTs (cont.)Spirometry

performed when the patient is clinically stable and receiving maximal bronchodilator therapy

Risky for Pneumonectomy FEV1< 60% of the predicted value or < 2 liters DLCO< 60% of the predicted value MVV< 50% of the predicted value

Safe lower limit for Pneumonectomy FEV1> 80% of the predicted value or > 2 liters

Safe lower limit for Lobectomy FEV1 > 60% of the predicted value or >1.5 litres

PFTs (cont.)Blood gas analysis

Current data do not support the use of preoperative arterial blood gas analyses to stratify risk for postoperative pulmonary complications

Hypoxemia: SaO2 < 90%Hypercapnia: PaCO2 > 45mmHg

not necessarily an absolute contraindication for surgery lead to a reassessment of the indication for the proposed

procedure and aggressive preoperative preparation

Split PFTPredicting post-resection pulmonary functionPredicted postoperative FEV1 (ppoFEV1) is the most

valid single test availableppoFEV1 = preoperative FEV1 × (1– %functional tissue

removed/100)lung function can be calculated by counting the number of

segments removed The lungs contain 19 segments (3 right upper lobes, 2 right middle lobes,

5 right lower lobes, 3 left upper lobes, 4 left lower lobes, 2 left lingula)

Split PFT (cont.)Ventilation-perfusion(V/Q) scan

allows detailed assessment of the functional capacity of the lung and accurate determination of which lobes or segments contribute proportionally to ventilation and perfusion before their resection

Allows the calculation of the functional remaining parenchyma after surgery and the predicted post-resection FEV1 value

Quantitatve CT

Split PFT (cont.)ppoFEV1 > 40%, ppo DLco > 40%

Widely accepted as a predictor of average risk for complications

ppoFEV1 < 40%, ppo DLco < 40%High risk of perioperative complications including

deathFEV1ppo <1L → sputum retentionFEV1ppo <0.8L → preclude resection , dependent

on a ventilator

Cardiopulmonary exercise testMaximal oxygen uptake (VO2max)

VO2max > 20mL/kg/min are not at increased risk for complications or death

VO2max < 15 mL/kg/min an increased risk of peri-operative complications

VO2max < 10 mL/kg/min a very high risk for post-operative complications or death

Chest x-rayLow contribution in healthy subjectsPathologies that affect the operation were detected in only 1-3 % patients

with routine preoperative chest X-ray The possibility of an abnormal X-ray increases with ageRoutine application:

Known cardiopulmonary disease Risky surgery > 50 years

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Blood gases Not necessary routinely Neither hypercapnia nor hypoksemia is an independant factorHowever, ACP (American College of Physicians) recommends the following

cases: Coronary artery bypass Upper abdominal surgery Pulmonary resection

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PaO2 >60 mmHg , PaCO2 < 45 mmHg Low risk

PaCO2 > 45 mmHg (aggressive preoperative evaluation)(PFT, exercise testing)

POPC assessmentNon pulmonary resection

Careful physical exam, historyAny risk factor for pulmonary

Complications ? NO: Low riskNo need for other tests

YES:•COPD•Unexplained dyspnea or dyspnea on exertionThe story of smoking in last 8 weeks•Poor general health status> ASA2•Pathologic examination of lung•Upper abdominal, abdominal aortic aneurysm or thoracic surgery•Operation will take longer than 3 hours•Emergency surgery

Chest x-ray PFT

Abnormal or multiple risk factors

High Risk:Re-evaluation of surgical indication Perioperative treatmentChoose a short-term procedureEpidural or spinal anesthesia

Normal

Medium risk: Peroperative treatment to decrease the risk

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Preoperative evaluation for lung resection

Lung resection surgery The initial PFT assessment should include:

FEV1 FVC DLCO

FEV1 > 2.0 L or > %80 pneumonectomy DLCO >%80 pneumonectomy FEV1 > 1.5 Lobectomy

VO2max>20/ml/kg or > 75% of predicted pneumonectomy

VO2max>15ml/kg/dak lobectomy

<10ml/kg/dak or <%40: major risk for POPC

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Estimated FEV1 after resection

For Pneumonectomy:

Estimated

PO FEV1 = Preoperative FEV1 X The percentage of remaining lung perfusion

For Lobectomy:

Estimated

PO FEV1 = Preoperative FEV1 X Number of segments after resection The total number of segments in both lungs

Further investigations must be planned to measure the contribution of lung to be resected:

Anatomical calculation Quantitative CT Split perfusion scintigraphy

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ppoFEV1 (% predicted) Interpretation> 40 Minor complication< 40 Perioperative mortality high*< 30 Alternatives other than surgery

ppoDLCO (% predicted) Interpretation> 40, ppoFEV1 >%40 and SaO2 > %90

Minor complication, no need to other tests

< 40 and ppoFEV1 <%40 High risk; CPET* < 30 Alternatives other than surgery

Interpretation of postoperative predicted (ppo) FEV1 and DLCO after resection

* CPET should be done

FEV1

FEV1>2lt veya > beklenen normalin %80’i

Pnömonektomi yapılabilir

FEV1< 2lt veya < beklenen normalin %80’i

PPO FEV1

Pnömonektomi içinPPO FEV1>%40

Pnömonektomi yapılabilir

Pnömonektomi içinPPO FEV1=%30-40

Pnömonektomi içinPPO FEV1<%30

Sınırda Pnömonektomi Yüksek riskli

Pnömonektomi içinPPO DLCO

Pnömonektomi için PPO DLCO > %40

Pnömonektomi yapılabilir

Pnömonektomi için PPO DLCO < % 40

Pnömonektomi Yüksek riskli

Lobektomi içinPPO FEV ve DLCO

Beklenen post lobektomi FEV1ve DLCO >%40

Lobektomi yapılabilir

Beklenen post lobektomi FEV1veya DLCO < %40

Lobektomi yüksek riskli

Akciğer rezeksiyonu için Preoperatif değerlendirme

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Case1

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A 57-year-old man is booked for right thoracotomy and lung resection. His pulmonary function tests show that his spirometry values are near normal, but that his TLCO is significantly reduced:

The surgeon plans to perform a right upper lobectomy, but may consider upper and middle bi-lobectomy or pneumonectomy depending on his findings at thoracotomy

Actual Predicted % predicted

FEV1 2.76 3.04 91

FVC 3.74 3.80 98

DLCO 55.5

Which resection rate is suitable for this case ?

a. Only right upper lobectomy

b.Right upper + middle lobe

c. Pneumonectomy

d.Not suitable for operation

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Actual Predicted % predicted

FEV1 2.76 3.04 91

FVC 3.74 3.80 98

DLCO 55.5

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Case 1The calculations show that his predicted postoperative DLCO after pneumonectomy mean that adequate oxygenation will not be achievable without oxygen therapy.

Extent of lung resection Lung remaining post resection

ppo DLCO

R U lobectomy 16/19 segments remaining 46.7%*

R U & M lobectomy 14/19 segments remaining 40.9%

R pneumonectomy 9/19 segments remaining 16.1%

* calculated as 16/19 x preoperative TLCO (55.5%).

Extent of lung resection Lung remaining post resection

ppo DLCO

R U lobectomy (and assume RU lobe

14/16 functional segments remaining

48.6%

R pneumonectomy (and assume RU

9/16 functional segments remaining

31.2%

If his right upper lobe is accepted as non fonctional new predicted post-pneumonectomy TLCO value is 31.2%. He is at high risk of preoperative complications, independent survival postpneumonectomy is possible.

Case 2

• A 65-year-old woman requires pneumonectomy for non-small cell carcinoma of the right lung. Her preoperative pulmonary function tests are:

• Can pneumonectomy be performed?

A. Yes

B. No

C. Ask to patient’s family

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Actual value

Predicted % predicted

ppo (9/19 segments remaining)

FEV1 1.48 2.28 65 % 30.8

FVC 1.96 2.70 72 34.1

DLCO 71 33.6

• FEV1 and TLCO are borderline

• However significant parts of her right lung may be non-functional.

• Ventilation scan, which demonstrates that the relative contribution

• On ventilation scan contribution of her right lung 36% and left lung 64%

• When her FEV1 and TLCO be calculated by multiplying the preresection values by 0.64 (64%), new values are:

• FEV1= 41.6% and DLCO= 45.4%

Pneumonectomy can be doneToraks 2012

Case 2

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Post-bronchodilator FEV1

<1.5 litres for lobectomy<2 litres for pneumonectomy

>1.5 litres for lobectomy>2 litres for pneumonectomy

Full pulmonary functiontests including DLCO withcalculation of ppo values

ppo FEV1 < %40ppo DLCO < %40

ppo FEV1 > %40ppo DLCO > %40

Proceedtosurgery

Exercisetesting

VO2 max > 15ml/kg/min

VO2 max < 15ml/kg/minor Shuttle walk < 250mor desaturation on >4% onstair climb

Consider alternative options(palliative therapy orchemotherapy)

Assessment of suitability for lung resection

Performance VO2Max equivalent Interpretation

>5 flights of stairs VO2 max > 20ml.kg-1.min-1

Correlates with, FEV1 > 2 L and low mortality after pneumonectomy

> 3 flights of stairs Correlates with FEV1 of 1.7l and low mortality after lobectomy

<2 flights of stairs

Correlates with high mortality

<1 flight of stairs

VO2 max < 10ml.kg-1.min-1

6min walk test < 600 meters

VO2 max <15ml.kg-1.min-1

Summary of stair-climbing assessment of performance

VO2 max Yorum

20ml.kg.-1min-1 or >15ml.kg.-1min-1 and FEV1 > 40% predicted

No increased risk of complications or mortality

< 15 ml/kg/min High risk

< 10 ml/kg/dak 40-50% mortality, considernon-surgical management

Interpreting the VO2 max

Summary: Preoperative pulmonary preparation

Respiratory function in patients with obstructive lung disease should be optimized bronchodilators;corticosteroids,antibiotics,If neded respiratory physiotherapy

Quiting smoking (ideally a minimum of 8 weeks ago)Weight controlPatient education (deep breathing exercises, cough, and pain control, and the

use of "incentive" spirometry) Preoperative pulmonary preparation reduces the complication rates 50%.

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SUMMARY: Intraoperative risk-reducing strategies

Duration of surgery < 3-4h

Spinal or epidural anesthesia in high risk patients

Regional anesthesia (nerve block) in high-risk patients, 

Refrain from using Pancuranium

Laparoscopic surgery is preferred if possible

If possible less aggressive methods should be used in upper abdominal or thoracic surgery 

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SUMMARY: Postoperative risk-reducing strategies Lung expansion techniques decrease the rate of lung complications. Insentif spirometry and chest physiotherapy significantly reduce POC’sNasal CPAP (10-15cmH2O)Pain control

Epidural analgesia Intercostal nerve blockade

Prophylaxis of venous thromboembolism

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