Preoperative evaluation (Pulmonary function testing and evaluation for
lung respectability)
• Goals in performing pulmonary function tests in a patient scheduled for lung resection
include
1) Identification of the patient at risk of increased postoperative morbidity and
mortality,
2) Identification of the patient who will need short- or long-term postoperative
ventilatory support, and
3) evaluation of the beneficial effect and reversibility of airway obstruction with the use
of bronchodilators.
ASSESSMENT OF RESPIRATORY FUNCTION
• Respiratory function can be divided into three related but somewhat
independent areas:
1. Respiratory mechanics,
2. Gas exchange, and
3. Cardiorespiratory interaction.
Contraindications
• Recent eye surgery
• Thoracic , abdominal and cerebral aneurysms
• Active hemoptysis
• Pneumothorax
• Aneurysm
• Acute disorders affecting test performance, such as nausea or vomiting
• Recent thoracic or abdominal surgical procedures
• Pleural Effusion
• Pulmonary embolus
Respiratory mechanics
• Many tests of respiratory mechanics and volumes show correlation
with post-thoracotomy outcome
• expiratory volume in one second (FEV1),
• forced vital capacity (FVC),
• maximal voluntary ventilation (MVV),
• residual volume/total lung capacity ratio (RV/TLC),
Expiratory volume in one second (FEV1),
Respiratory mechanics
• FEV1 : the volume exhaled during the first second of the FVC maneuver.
• Measures the general severity of the airway obstruction
• Normal is 3‐4.5 L
• FEV1 – Decreased in both obstructive & restrictive lung
• Mortality and morbidity are significantly increased if postoperative
FEV1 is less than 30% to 40% of normative FEV1
Risk stratification
• In the past, an FEV1 of less than 800 mL in a 70-kg man had been
considered an absolute contraindication to lung resection.
• However, with the advent of thoracoscopic surgery and improved
postoperative pain management, patients with smaller lung volumes are
now successfully undergoing surgery
Risk stratification
• It is preferable to indicate the percentage of predicted value, rather than
just using the actual results in liters.
• The percentage of predicted value takes into account the age and size of
the patient, and the same number may have a different implication in
another patient.
Respiratory mechanics
• FEV1 = Race x 1.08 x [(0.0395 x Height) - (0.025 x Age) - 2.6]
• Where Race variables are: 0.93 for Asian, 0.87 for Black or African
American and 1 for White Caucasian.
Respiratory mechanics
• The most valid single test for post-thoracotomy respiratory complications is the
predicted postoperative FEV1 (ppoFEV1 %), which is calculated as:
ppoFEV1 %= preoperative FEV1 %× (1 −% functional lung tissue removed/100)
OR
PpoFEV 1 = preoperative FEV 1% X No of Segments left after Resection
19
Risk stratification
Calculating the predicted postoperative FEV1 (ppoFEV1) and
TLCO (ppoTLCO):
• A 60-year-old man is scheduled for lung resection. His
chest CT showed a big RLL mass confirmed as carcinoma.
His preoperative FEV1 was 50% of the predicted value.
Calculate ppoFEV1? What is your suggest?
Lobes & segments of the lungs
Subsegments of each lobe
Forced vital capacity (FVC)/VC
• The FVC is the maximum volume of air that can be breathed out as
forcefully and rapidly as possible following a maximum inspiration. (VC 4 to
6 L), and this is the difference between TLC and RV.
• Spirometric value is normally related to height, sex and age, and equations
derived from clinical series are used to predict individualized normal data.
• Indirectly reflects flow resistance property of airways.
• VC is reduced in both restrictive and obstructive lung disease.
FVC
• An abnormal preoperative vital capacity can be identified in 30% to
40% of postoperative deaths.
• A patient with an abnormal vital capacity has a 33% likelihood of
complications and a 10% risk of postoperative mortality
• A vital capacity of at least three times the VT is necessary for an
effective cough
Spirometry: Normal and COPD
0
FEV1 FVC FEV1/ FVC
Normal 4.150 5.200 80 %
1 COPD 2.350 3.900 60 %
2
FEV1
Liter
3
COPD
4 FVC
FEV1
5 Normal
FVC
1 2 3 4 5 6 Seconds
FVC
• FVC = Race x 1.15 x [(0.0443 x Height) - (0.026 x Age) - 2.89]
Interpretation of % predicted:
• 80-120% Normal
• 70-79% Mild reduction
• 50%-69% Moderate reduction
• <50% Severe reduction
VC(ml)= (27.63-o.112*age)Ht cm in Male
VC(ml)= (21.78-0.101*age)Ht cm in female
Case scenario
• A 40-year-old white caucasian female patient scheduled for left upper
lobe resection due to confirmed large cell carcinoma. Her height was
165cm, preoperative FEV1 of 1300ml, FVC of1900. Calculate predicted
% of FEV1,predicted % FVC and Predicted post operative FEV1
percentage. How do stratify the risk of surgery of this patient?
FEV1= Race x 1.08 x [(0.0395 x Height) - (0.025 x Age) - 2.6]
FVC = Race x 1.15 x [(0.0443 x Height) - (0.026 x Age) - 2.89]
VC(ml)= (27.63-o.112*age)Ht cm in Male
VC(ml)= (21.78-0.101*age)Ht cm in female
Maximum Voluntary Ventilation (MVV) or maximum breathing
capacity (MBC)
• Measures ‐ speed and efficiency of filling & emptying of the lungs during
increased respiratory effort.
• Maximum volume of air that can be breathed in and out of the lungs in 1
minute by maximum voluntary effort.
• It reflects peak ventilation in physiological demands.
• Normal : 150 ‐175 l/min. It is FEV1 * 35 <80% ‐ gross impairment.
MBC
• The subject is asked to breathe as quickly and
as deeply as possible for 12 secs and the
measured is extrapolated to 1min.
• Periods longer than 15 seconds should not be allowed
• MVV is markedly decreased in patients with
A. Emphysema
B. Airway obstruction
C. Poor respiratory muscle strength
FEV1/FVC ratio
• Reduced in obstructive disorders.
Interpretation of % predicted:
- >75% Normal
- 60%‐75% Mild obstruction
- 50‐59% Moderate obstruction
- <49% Severe obstruction
• It is normal in restrictive disease
LUNG PARENCHYMAL FUNCTION (GAS‐ EXCHANGE TESTS)
• Is a test that detect the ability of the lung to exchange oxygen and
carbon dioxide between the pulmonary vascular bed and the alveoli
• Also known as transfer factor for carbon monoxide or TLCO
• The most useful test of the gas exchange capacity of the lung is the
diffusing capacity for carbon monoxide (DLco).
LUNG PARENCHYMAL FUNCTION (GAS‐ EXCHANGE TESTS)
• The DLco correlates with the total functioning surface area of
alveolar-capillary interface.
• A ppoDLco less than 40% predicted correlates with both increased
respiratory and cardiac complications and is usually independent of
the FEV1.
• Why Co ???
FACTORS EFFECTING DLCO
GAS EXCHANGE TEST
Tests for cardiopulmonary reserve (cardiopulmonary
interaction)
• Formal laboratory exercise testing is currently the gold standard for assessment of
cardiopulmonary function, and the maximal oxygen consumption (VO2max) is the
most useful predictor of post-thoracotomy outcome.
• VO2 max, or maximal oxygen consumption, refers to the maximum amount of oxygen
that an individual can utilize during intense or maximal exercise.
Low risk = Vo2max > 20 mL/kg/min is consumed.
Moderate risk = Vo2max 15 to 20 mL/kg/min is consumed.
High risk = Vo2max < 15 mL/kg/min is consumed.
VO2 max
Tests for cardiopulmonary reserve (cardiopulmonary interaction)
• Stair climbing and 6‐minute walk test
Ventilation-Perfusion
Scintigraphy
• Prediction of post-resection pulmonary function can be further refined by
assessment of the preoperative contribution of the lung or lobe to be
resected using ventilation perfusion V˙ /Q˙ lung scanning.
• If the lung region to be resected is nonfunctioning or minimally functioning,
the prediction of postoperative function can be modified accordingly.
• This is particularly useful in pneumonectomy patients and V˙ /Q˙ scanning
should be considered for any pneumonectomy patient who has a
preoperative FEV1 and/or DLco less than 80%.
Combination of Tests
• No single test of respiratory function has shown adequate validity as a sole
preoperative assessment
• Before surgery, an estimate of respiratory function in all three areas—lung
mechanics, parenchymal function, and cardiopulmonary interaction—should
be made for each patient
• These three aspects of pulmonary function form the “three legged stool”
that is the foundation of prethoracotomy respiratory assessment
Prethoracotomy respiratory assessment
Postthoracotomy management
Flow-volume loops
• Flow-volume loops display essentially the same information as a spirometer but
are more convenient for measurement of specific flow rates
• The flow-volume loop is a plot of inspiratory and expiratory flow (on the Y-axis) against
volume (on the X-axis) during the performance of maximally forced inspiratory and
expiratory maneuvers.
• Changes in the contour of the loop can aid in the diagnosis and localization of airway
obstruction
Normal flow volume loop
Flow volume of Asthmatic
Flow volume of emphysematous
RESTRICTIVE PATTERN‐flow
volume loop
Significance of Bronchodilator
Therapy
• Pulmonary function tests are usually performed before and after
bronchodilator therapy to assess the reversibility of the airways
obstruction.
• A 15% improvement in pulmonary function tests may be considered a
positive response to bronchodilator therapy and indicates that this therapy
should be initiated before surgery.
Split-lung Function Tests
• Regional lung function studies serve to predict the function of the lung tissue
that would remain after lung resection.
• methods have been described to try and simulate the postoperative respiratory
situation by unilateral exclusion of a lung or lobe with an endobronchial
tube/blocker or by pulmonary artery balloon occlusion of a lung or lobe artery
• A whole (two)-lung test may fail to estimate whether the amount of
postresection lung tissue will allow the patient to function at a reasonable level
of activity without disabling dyspnea or corpulmonale
Cardiac assessment
• All patients undergoing lung resection should have resting 12-lead electrocardiography
and echocardiography in the presence of cardiac murmur or known valvular or
structural heart disease.
• No patient should undergo surgery within 6 weeks of myocardial infarction (MI) and
all patients within 6 months of MI should have a cardiology opinion.
• Previous coronary artery bypass grafts should not limit surgery if the
patient has adequate functional capacity and is asymptomatic.
ASSESSMENT OF THE PATIENT WITH LUNG CANCER
• At the time of initial assessment, cancer patients should be assessed for the “4 Ms” associated
with malignancy
• Mass effects,( Obstructive pneumonia, lung abscess, SVC Superior venacava l syndrome ,
tracheobronchial distortion, Pancoast syndrome, recurrent laryngeal nerve or phrenic nerve
paresis, chest wall or mediastinal extension)
• Metabolic abnormalities, (: Lambert-Eaton syndrome)
• Metastases, and (Particularly to brain, bone, liver, adrenal)
• Medications. (Chemotherapy agents,
pulmonary toxicity (bleomycin, mitomycin),
cardiac toxicity (doxorubicin),
renal toxicity (cisplatin)
Effect of Anesthesia on Lung volume and
capacities
• The FRC is approximately 3000ml when upright but falls to around 2200ml in a
supine position due…. to upward pressure from abdominal contents.
• General anaesthesia relaxes the diaphragm and intercostal muscles, with a
further fall in FRC by 15-20% (approx 450ml)
• FRC is reduced by obesity, pregnancy, bowel distension or reduced alveolar
volume due to atelectasis, consolidation or oedema.
• Therefore, an obese, supine patient may have reduced the volume of their FRC
by 50%. This reduction in the store of oxygen will reduce the time taken to
become hypoxia after ventilation
Effect of Anesthesia on Lung volume and capacities
• CC = the lung volume at which small airways collapse, impeding flow of gas into
the alveoli
• Usually FRC exceeds CC and prevents collapse during normal expiration.
• However, during anaesthesia the CC approaches the FRC producing small
airway collapse in normal expiration with resultant atelectasis.
• This effect is also compounded in neonates, the elderly, smokers and patients
with respiratory disease.
