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Preoperative Pulmonary FunctionEvaluation in Lung Resection

Ri/

CR

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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

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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)

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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, 2096-2103Resp Med (2004) 98, 598-605

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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, 2096-2103Resp Med (2004) 98, 598-605

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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, 2096-2103Resp Med (2004) 98, 598-605

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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

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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

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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

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Postoperative Lung Function

Pulmonary function is affected by lung

resection, extent varies:

pneumonectomy:

FEV1: 34~36%

FVC: 36~40%

VO2max: 20~28%

lobectomy:

FEV1: 9~17%

FVC: 7~11%

VO2max: 0~13%

Am J of Med (2005) 118, 578583

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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

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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

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Prediction of Post-op Lung Function

Methods to predict postoperative

pulmonary function:

segment method

radionuclide scanning techniques

quantitative computed tomography

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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

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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

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Quantitative Computed Tomography

-500~-910 Hounsfield unit is used to

estimate functional lung volume

correlates better than radionuclide

scanning method

AJ R (2002) 178, 667672

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Lung Resection

3rd phase (mimic post-op condition): temporary balloon occlusion (with or without

exercise) skill-demanding, rarely performed

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

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Testing Phases

Chapter 49, Millers Anesthesiology, 6th Edition

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Pulmonary Function Test

Chapter 49, Millers Anesthesiology, 6th Edition

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Pre-op Predicted Post-op

FVC (L) 3.20 2.69

FEV1 (L) 1.66 (>1.2~1.0) 1.40 (>1)

FEV1/FVC (%) 51.9 (>40)RV/TLC (%) 55.0

MVV (L/min)

% predicted (%)

53.3 (>40)

69.9 (>40)

VO2 max (L/min)

VO2 max (ml/kg/min)

0.944 (15,

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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, 333-

339

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

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Thank you for your attention!

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