THORACIC ANAESTHESIA
Tests of pulmonary function
before thoracic surgery
Andrew N Davies
Palanikumar Saravanan
Abstract
Respiratory complications contribute significantly to perioperative
morbidity and mortality after surgery. There are evidence-based guide-
lines that support the use of pulmonary function tests (PFTs) and cardio-
pulmonary exercise testing (CPET) in the preoperative assessment of
patients undergoing lung resection surgery to determine whether patients
can tolerate the resection. Spirometry, lung volumes and flowevolume
analysis provide information on the respiratory mechanics of the patient
while transfer factor and arterial blood gas analysis help to evaluate the
ability of lung parenchyma in gas exchange. CPET evaluates the dynamic
response of the cardiac and pulmonary function to exercise. The forced
expiratory volume at 1 second (FEV1) and predicted postoperative FEV1
(ppoFEV1) are useful indicators of postoperative respiratory complica-
tions following thoracic surgery. CPET measures VO2Max and can help in
the selection patients for lung resection.
Keywords Cardiopulmonary exercise test; lung function tests; preoper-
ative assessment; spirometry; thoracic surgery
Royal College of Anaesthetists CPD matrix: 3G00
Pulmonary function tests are used to evaluate the patients before
lung resection surgery. Patient’s general clinical state including
their co-morbities such as any cardiac or other systemic diseases,
anaemia, and nutritional status are important in the preoperative
evaluation of these patients. Weight loss greater than 10% and
low serum albumin are markers of advanced disease and indicate
increased risk during surgery. Pulmonary function tests (PFTs)
are used in conjunction with these findings to evaluate the risk of
resection and risk of postoperative complications.
Reasons for PFTs before thoracic surgery
The most common problem after thoracic surgery is atelectasis,
which reduces lung compliance and functional residual capacity.
In addition, lung resection surgery is associated with marked
changes in respiratory function, both as a consequence of lung
resection and as a result of altered chest wall dynamics due to
thoracotomy incision. These changes include significant re-
ductions in maximal expiratory force, vital capacity (VC), forced
expiratory volume in 1 second (FEV1), and peak expiratory flow
rate (PEFR). The decrease in VC often exceeds the volume of lung
Andrew N Davies FRCA is an ST6 in Anaesthesia in the North West
Deanery, UK. Conflicts of interest: none declared.
Palanikumar Saravanan FRCA is a Consultant Cardiothoracic Anaesthetist
at Lancashire Cardiac Centre, Blackpool, UK. Conflicts of interest: none
declared.
ANAESTHESIA AND INTENSIVE CARE MEDICINE 15:11
Learning objectives
After reading this article, you should be able to discuss:
C when pulmonary function testing should be considered
C the available tests of pulmonary function
C the difference between static and dynamic tests of pulmonary
function
C how these tests contribute to the pre operative assessment of
patients
removed during surgery. Patients with lung cancer may also have
abnormal pulmonary function prior to surgery, most often due to
smoking. These patients are at risk of both immediate perioper-
ative pulmonary complications and long-term disability
following curative intent surgery while suboptimal lung resection
decreases the survival benefit. PFTs are used to stratify the risk of
lung resection and predict the risk of postoperative
complications.
To minimize postoperative respiratory complications, medical
therapy can be instituted in patients with pre-existing respiratory
problems to optimize the pulmonary function before surgery.
PFTs help in identifying patients with preexisting respiratory
problems and evaluating their response to such optimization
therapy. This concept has been expanded into ‘preoperative
pulmonary rehabilitation’ where patients are given a 2-week
period of intense breathing exercises including incentive
spirometry and regular nebulized bronchodilators. The evidence
for this is still limited.
Tests of pulmonary function
Pulmonary function is measured in a three-legged approach, with
tests for respiratory mechanics, lung parenchymal function and
cardiorespiratory reserve comprising the three legs of the
assessment. There are other tests such as imaging which provide
additional information and are used along with the conventional
tests in risk stratification and perioperative management of pa-
tients for lung resection.
Tests for respiratory mechanics
Spirometry and flowevolume analysis
The most commonly used test to assess suitability for lung
resection surgery is spirometry. Spirometry with flowevolume
loops assesses the mechanical properties of the respiratory sys-
tem by measuring expiratory volumes and flow rates. It is a
versatile test of pulmonary physiology. The patient breathes
through the mouth into the spirometer with nose clipped. At the
end of a normal tidal volume expiration, the patient breathes in
up to the total lung capacity and performs a forced vital capacity
(FVC) manoeuvre and a volumeetime curve is recorded
(Figure 1). A flowevolume loop is recorded when the patient
breathes in, after complete expiration to residual volume, to
reach the total lung capacity and forcefully breathes out back to
residual volume (Figure 2).
FEV1 and FVC, which is the largest volume expired from the
total lung capacity, are measured from these tests. Results are
495 Ó 2014 Elsevier Ltd. All rights reserved.
 THORACIC ANAESTHESIA

expiratory flow and FVC can be derived from the loop. It is also
useful to evaluate the nature of lung disease (restrictive or
obstructive) and, in addition, presence of any major airway
obstruction.
Spirometry and flowevolume analysis are performed whilst
the patient is at rest and so they do not reflect the way the whole
cardiorespiratory system responds to increasing workload.

Tests for lung parenchymal function

Figure 1
typically reported in both absolute values and as predicted per-
centages of normal. Normal values vary, depending on gender,
race, age and height, and can be used to determine the pattern of
lung disease as well as to establish any reversibility with bron-
chodilators. The results obtained from the volumeetime curves
are effort dependent and can be underestimated. In normal in-
dividuals, the FEV1 and FVC should be more than 80% of pre-
dicted values for their height and weight. These values and the
FEV1/FVC ratio are used to determine the nature of the lung
disease. The flowevolume loop is used to measure the flow
pattern during inspiration and expiration (Figure 2). Peak
Diffusion capacity of lung
Diffusion capacity of the lung is the ability of the alveolar
capillary membrane to transfer gas across it. Diffusion capacity of
lung for carbon monoxide (DLCO) is used to assess alveolar
membrane efficiency. Carbon monoxide (CO) is 400 times more
avid to haemoglobin than oxygen and hence is rapidly taken up
by haemoglobin with its transfer limited mainly by diffusion. The
patient takes a VC inspiration from the residual volume and in-
hales a mixture of 0.3% carbon monoxide and 10% helium. The
gas mixture exhaled following 10 seconds breath-holding is
analysed and DLCO is calculated using a formula. DLCO is the
volume of CO transferred across the alveoli per minute per unit
alveolar partial pressure and is reduced with increased alveolar
membrane thickness as in pulmonary fibrosis. It will also be
reduced following pneumonectomy as a result of reduced total
alveolar membrane area. DLCO is also expressed in absolute
values and in percentage predicted values. The predicted values
are reference values generated from a healthy population. The
normal values vary depending on age, sex, height, exercise, body
position and altitude and it should be interpreted taking these
factors into consideration. DLCO is identified as one of the in-
dependent predictors of major complications following
pneumonectomy.

Figure 2 A, normal lung. Normal PEF is achieved during forced expiration. B, obstructive lung pathology. Flow rate is low during expiration and the
prolonged expiration causes the typical concave pattern of the waveform. Less PEF is achieved during expiration. C, restrictive lung pathology, lung
volumes and PEF are less. D, variable extra thoracic airway obstruction. Flow is normal during expiration and decreased during inspiration. E, variable
intrathoracic airway obstruction. Flow is normal during inspiration and decreased during expiration.

ANAESTHESIA AND INTENSIVE CARE MEDICINE 15:11 496 Ó 2014 Elsevier Ltd. All rights reserved.
 THORACIC ANAESTHESIA
Arterial blood gases
Arterial blood gas values can also indicate abnormal gas ex-
change in presence of unexplained hypoxaemia or hyper-
capnoea. A baseline blood gas value is obtained by taking an
arterial blood sample in a heparinized syringe and measuring pH,
partial pressure of oxygen (PaO2) and carbon dioxide (PaCO2) in
a blood gas analyser using glass pH electrode, polarographic
oxygen electrode and Severinghaus carbon dioxide electrodes
respectively. Many blood gas analysers also calculate the actual
and standard bicarbonate values and base excess using Siggaard-
Andersen nomogram. The PaO2 and PaCO2 values on room air
will provide some guidance on fitness of the individual when the
results from the standard tests are inadequate for decision
making. PaCO2 levels of more than 45 mmHg/6 kPa and satu-
ration of arterial oxygen (SaO2) less than 90% while spontane-
ously breathing room air are considered to be associated with
increased risk of postoperative complications. However there is
no evidence for using any absolute values on deciding the fitness
for surgery.
Tests for cardiopulmonary reserve
Cardiopulmonary exercise testing
Cardiopulmonary exercise testing (CPET) is a non-invasive,
objective method of assessing the response of the heart, lungs
and musculoskeletal and circulatory systems to incremental ex-
ercise. It relies on breath-by-breath analysis of carbon dioxide
production and oxygen consumption (VO2) at rest and at graded
exercise. The exercise ECG and the heart rate response to exer-
cise are also recorded. A computer programme is used to increase
workload according to a set protocol. The test can be stopped by
the patient at any time because of exhaustion, breathlessness or
chest pain and by the technician if significant ST changes in the
ECG or dysrhythmias are noted. A computer software package is
used to calculate the maximal oxygen consumption (VO2Max) and
the anaerobic threshold (AT). VO2Max is the maximum amount of
oxygen in millilitres the individual can use in 1 minute/kg body
weight and this usually is the value of VO2 at the termination of
the test. AT is the point of VO2 at which the oxygen demand
exceeds the supply and the individual moves from aerobic to
anaerobic metabolism. While VO2Max may vary with patient
motivation, AT will not vary and it provides a reliable and pa-
tient-specific measurement of cardiorespiratory reserve. The
higher the values of AT and VO2Max, the fitter is the individual.
The test requires complex equipment and trained personnel and
is contraindicated in patients with significant heart disease.
Other exercise tests
The 6-minute walk test (6MWT), shuttle walk test (SWT) and
stair-climbing test are used as surrogates for CPET. In the 6MWT,
patients are asked to walk on level ground without stopping at
their own pace. The oxygen saturation is measured continuously
and recorded. The total distance the patient is able to cover in 6
minutes is recorded and if this is more than 600 m, it indicates
good cardiorespiratory reserve. In the SWT two cones are placed
10 m apart on level ground. A pre-recorded series of tones set the
pace the patient is required to walk at between the cones. When
the patient can no longer keep up with the required walking pace
because of breathlessness, the test is stopped. The ability to
ANAESTHESIA AND INTENSIVE CARE MEDICINE 15:11
complete 25 shuttles is considered to indicate a good cardiore-
spiratory reserve.
The ability of the patient to climb stairs is used more often as
it is easy to perform. The number of flights climbed is correlated
to how fit the individual is. Ability to climb three flights corre-
lates with an FEV1 of more than 1.7 litres while five flights of
stairs with an FEV1 of over 2 litres. The drawbacks with these
tests are lack of standardization of how they are performed and
inability of patients with neurological diseases, musculoskeletal
diseases and peripheral vascular diseases to perform these tests.
Failure to complete 6 minutes of walking, inability to walk 600 m
in 6MWT, inability to complete 25 shuttles in SWT and inability
to climb a flight of stairs or severe oxygen desaturation during
any of these tests (>4% from the baseline) indicates a higher risk
for postoperative complications.
Other tests
Ventilationeperfusion (V/Q) scanning and CT scanning are also
used to assess lung function before thoracic surgery when the
results from the other tests are inadequate for decision-making.
These scans provide additional information on the extent and
nature of the disease and are useful in predicting the post-
operative function. They may also be more sensitive indicators of
any diffuse parenchymal lung disease.
Predicted postoperative (ppo) lung function can be calculated
by estimating the amount of functioning lung tissue that would
be lost with surgical resection. The methods available for this are
V/Q scan, quantitative CT scans and anatomic estimation. The
anatomic estimation is based on counting the number of seg-
ments to be resected and reducing the lung volumes propor-
tionately. The advantage of quantitative CT scans is that it is
routinely performed for staging purposes and allows calculation
of postoperative lung function without the need for further
scanning. The ventilationeperfusion scan is used to measure the
postoperative lung function by taking into account the contri-
bution of the lung segments to be resected to the overall venti-
lation and perfusion. This helps in predicting the impact of
resection on postoperative lung function. Various formulae are
used to predict the postoperative FEV1 and DLCO.
ppoFEV1 post-resection ¼ preoperative FEV1  ð1  y=zÞ
where y is the number of functional segments resected and z is
the total number of functional segments. ppoDLCO can be
calculated using a similar formula. These values can be con-
verted to percentage values using standard calculations and can
be used for decision-making.
Role of PFTs in thoracic surgery
The American College of Chest Physicians, the British Thoracic
Society, the European Respiratory and European Thoracic Sur-
gery Societies and NICE have produced evidence-based guide-
lines on the selection of patients for lung cancer surgery
(Table 1). Prior to lung resection surgery, if the FEV1 is greater
than 80% predicted or over 2 litres and there is no evidence of
either undue dyspnoea on exertion or interstitial lung disease,
the patient is suitable for resection including pneumonectomy
without further evaluation. If there is evidence of undue
497 Ó 2014 Elsevier Ltd. All rights reserved.
 THORACIC ANAESTHESIA

It is generally accepted that a ppoFEV1 of 0.8 litres is the lower

Suggested lung function criteria for lung resection limit for allowing patients to undergo surgical resection. A
surgery ppoFEV1 or ppoDLCO of less than 40% indicates an increased
For pneumonectomy FEV1 2 litres or 80% predicted risk of perioperative death and cardiopulmonary complications.
DLCO 80% of predicted It is recommended that these patients undergo exercise testing
VO2Max >75% or >20 ml/kg/minute preoperatively. Lung cancer patients with a ppoFEV1 under 30%
ppoFEV1 40% or >800 ml should be counselled about non-standard surgery and non-
ppoDLCO 40% operative treatment options. Arterial PaCO2 of more than 45
For lobectomy FEV1 1e1.5 litres or >40e50% mmHg/6 kPa is considered to indicate a ppoFEV1 of less than 800
predicted ml though this is not an independent predictor for postoperative
For wedge resection FEV1 0.6e0.8 litres respiratory complications. Patients with greater than 20% ppo-
For lung volume reduction ppoFEV1 >20% FEV1 and ppoDLCO can undergo lung volume reduction surgery
surgery ppoDLCO >20% for emphysema.
Unsafe for resection surgery FEV1 <1 litre Recently it has been shown that ppoFEV1 is not a reliable
VO2Max <35% or <10 ml/kg/minute predictor of complications in patients with chronic obstructive
ppoFEV1 <30% or <800 ml pulmonary disease (COPD). Often the early postoperative func-
ppoDLCO <30% tion is underestimated. Patients are worse than predicted and in
Arterial PaCO2 >45 mmHg patients with a ppoFEV1 less than 40% the mortality is not as bad
SaO2 <90% on room air as it was thought to be. This is especially true in COPD patients
and it has been postulated that this is due to the ‘lung volume
FEV1, forced expiratory volume in 1 sec; DLCO, diffusion capacity for carbon reduction effect’ in patients with obstructive airflow disease. A
monoxide; VO2Max, maximal oxygen consumption; ppo, predicted postopera-
tive; PaCO2, partial pressure of arterial carbon dioxide; SaO2, arterial oxygen
saturation.
FURTHER READING
Aubrey W, Saravanan P. Tests of pulmonary function before surgery.
Table 1
Anaesth Intensive Care Med 2011; 12: 539e41.
British Thoracic Society and Society of Cardiothoracic Surgeons of Great
dyspnoea on exertion or interstitial lung disease, measurement of Britain and Ireland Working Party. Guidelines on the selection of pa-
DLCO is recommended even if FEV1 appears adequate. If either tients with lung cancer for surgery. Thorax 2001; 56: 89e108.
FEV1 or DLCO is less than 80% predicted, it is recommended that Brunelli A, Charloux A, Bolliger CT, et al. ERS/ESTS clinical guidelines on
postoperative lung function should be predicted through addi- fitness for radical therapy in lung cancer patients. Eur Respir J 2009;
tional testing or calculation and the patient should undergo some 34: 17e41.
form of CPET to stratify the risk of postoperative complications Colice GL, Shafazand S, Griffin JP, et al. Physiologic evaluation of the
and the risk of long-term disability from surgical resection. This patient with lung cancer being considered for resectional surgery.
allows the patient to make the most informed decision about ACCP Evidenced based clinical practice guidelines. Chest 2007;
undergoing surgery. 132(suppl 3): 161Se77.
Patients with a preoperative VO2Max of 15e20 ml/kg/minute NICE Guidance. Lung Cancer. The diagnosis and treatment of lung cancer.
can undergo curative lung resection surgery with a low risk of April 2011, http://www.nice.org.uk/nicemedia/live/13465/54202/
mortality. Patients with a VO2Max of less than 10 ml/kg/minute 54202.pdf (accessed 5 Jun 2014).
have a very high risk of perioperative mortality and are consid- Powell ES, Pearce AC, Cook D, et al. UK pneumonectomy outcome study
ered unsuitable for any form of resection. Inability to climb one (UKPOS): a prospective observational study of pneumonectomy
flight of stairs is associated with a VO2Max of less than 10 ml/kg/ outcome. J Cardiothorac Surg 2009; 4: 41.
minute while inability to walk 600 m in 6MWT or to complete 25 Slinger PD, Johnston MR. Preoperative assessment for pulmonary resec-
shuttles on two occasions in SWT is associated with less than 15 tion. 2005. Available at: http://www.thoracic-anesthesia.com.
ml/kg/minute. Patients with a VO2Max under 10 ml/kg/minute Tho VYS, Mackay J. Tests of pulmonary function before thoracic surgery.
are at high risk for all forms of surgery. The American and Eu- Anaesth Intensive Care Med 2008; 9: 523e6.
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ANAESTHESIA AND INTENSIVE CARE MEDICINE 15:11 498 Ó 2014 Elsevier Ltd. All rights reserved.