Preoperative assessment of the high-risk patient for lung resection

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Background.

We wanted to determine if cardiopulmonary exercise testing could better identify the threshold where physiologic function is irreparably impaired for patients with borderline pulmonary function who are being considered for lung cancer resection.

Methods.

We performed an open, prospective preoperative trial and a postoperative outcome evaluation with a combined medical, surgical, and exercise physiology evaluation at three university hospitals. All eligible patients had spirometry, lung volume determination, and quantitative perfusion scanning and performed a cardiopulmonary stress test, stair climbing, and a 12-minute walk for distance. Functional status was determined with an Eastern Cooperative Oncology Group score, a dyspnea score, and a cardiopulmonary risk index.

Results.

We identified 12 patients who met strict criteria for borderline pulmonary function during a 1-year study period. The mean forced expiratory volume in 1 second (FEV1) was 1.38 L (48% of predicted). The mean predicted postoperative FEV1 based on pneumonectomy was 700 mL. Eleven of the patients did the stair climb and 10 passed. All 12 patients achieved a maximum oxygen consumption greater than or equal to 10 mL · kg−1 · min−1 (mean value, 13.8 mL · kg−1 · min−1). Thirteen operations were performed on the 12 patients. Nine complications occurred in 7 patients.

Conclusions.

Patients with borderline pulmonary function can undergo resection safely if they have an FEV1 equal to or greater than 1.6 L or 40% of its predicted value, a predicted postoperative FEV1 of 700 mL or more, a maximum oxygen consumption of 10 mL · kg−1 · min−1 or greater, or stair climbing of three flights or more. Cardiopulmonary stress testing and stair climbing add valuable clinical information for patients with an FEV1 of less than 1.6 L.

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    A total of 24 different CPET variables were associated with one or more types of complications after surgery. Fifteen studies (Smith et al., 1984; Miyazaki et al., 2018; Brutsche et al., 2000; Nagamatsu et al., 2004; Richter Larsen et al., 1997; Pate et al., 1996; Shafiek et al., 2016; Rodrigues et al., 2016; Licker et al., 2011; Brunelli et al., 2009b; Villani and Busia, 2004; Villani et al., 2003; Bechard and Wetstein, 1987; Epstein et al., 1993) reported that VO2peak (both absolute values and values normalized for body mass) was associated with cardiac and pulmonary complications or mortality after surgery, whereas two studies merely reported an association with postoperative pulmonary complications (Fang et al., 2013; Villani et al., 2003). Predicted VO2peak was associated with postoperative cardiac and pulmonary complications (Smith et al., 1984; Brutsche et al., 2000; Fang et al., 2013; Rodrigues et al., 2016; Licker et al., 2011; Villani and Busia, 2004; Villani et al., 2003), pulmonary complications (Brunelli et al., 2009b), and postoperative mortality (Richter Larsen et al., 1997; Brunelli et al., 2009b).

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