Invasive exercise testing in the evaluation of patients at high-risk for lung resection

Abstract

Surgery alone or in combination with other strategies gives the best hope for lung survival in patients with resectable nonsmall-cell lung cancer [1]. Most patients with lung cancer are current smokers or exsmokers and often have associated chronic obstructive pulmonary disease (COPD) [2] and other comorbidity factors that increase the risk of postoperative complications and death. Pulmonary function tests (PFT) and split pulmonary function, as determined by quantitative macroaggregate lung scanning, are useful in identifying patients with impaired lung function who are at risk of postoperative complications [3]. To what extent further functional testing contributes to more accurate prediction of postoperative morbidity and mortality is unclear.Some authors have recommended exercise testing as a useful tool in the assessment of operative risk in thoracotomy candidates [4,5]. Impaired exercise capacity, as assessed by a low oxygen uptake (V 'O 2 ), has been proposed as a predictor of a poor postoperative outcome [4], but the usefulness of V 'O 2 imeasurements in patients with severely impaired pulmonary function at increased risk remains controversial. While some authors have shown that the V 'O 2 value is useful in the prediction of surgical outcome in high-risk candidates [6-9], others have not confirmed such results [10,11].Furthermore, since pulmonary hypertension is a poor prognostic factor in COPD [12] and a decreased arterial O 2 saturation on exertion has been proposed as a predictor of postoperative complications [13,14], it was hypothesized that among COPD patients who are at a high-risk for resectional lung surgery, those who develop gas exchange and/or haemodynamic abnormalities during exercise may be at greatest risk of morbidity and mortality after surgery. Accordingly, the present study was intended to evaluate the potential role of both gas exchange and pulmonary haemodynamic measurements during exercise in the prediction of early post-thoracotomy morbidity and mortality in patients with a high-risk for surgery as assessed by conventional PFT and lung scanning. Invasive exercise testing in the evaluation of patients at high-risk for lung resection. J. Ribas, O. Díaz, J.A. Barberà, M. Mateu, E. Canalís, L. Jover, J. Roca, R. Rodriguez-Roisin. ©ERS Journals Ltd 1998.ABSTRACT: The aim of this study was to investigate whether invasive exercise testing with gas exchange and pulmonary haemodynamic measurements could contribute to the preoperative assessment of patients with lung cancer at a high-risk for lung resection.Sixty-five patients scheduled for thoracotomy (aged 66±8 yrs (mean±SD), 64 males, forced expiratory volume in one second (FEV1) 54±13% predicted) were studied prospectively. High risk was defined on the basis of predicted postpneumonectomy (PPN) FEV1 and/or carbon monoxide diffusing capacity of the lung (DL,CO) <40% pred. Arterial blood gas measurements were performed in all patients at rest and during exercise. In 46 patients, pulmonary haemodynamic measurements were also performed at re...

ERS/ESTS clinical guidelines on fitness for radical therapy in lung cancer patients (surgery and chemo-radiotherapy)

“…However, others have reported better results in very small numbers of patients with lung function this poor [43][44][45][46].…”

Reduction of postoperative pulmonary complications after lung surgery using a fast track clinical pathway

“…As for the primary endpoint of our study, postoperative pulmonary complications (atelectasis, pneumonia, prolonged air leak and pleural effusion), we found a significant advantage for patients in the fast track group: 36% versus 7% ( p = 0.009); After thoracotomy due to lung cancer, pulmonary complications occur in up to 39% and continue to present a major source of morbidity and mortality [4,6]. Nosocomial pneumonia after thoracotomy represents an important risk factor for morbidity and mortality and its reported incidence ranges from 15 to 25% depending on preoperative pulmonary function and surgical procedure [6,23]. In our investigation pneumonia was confirmed in 11% in the conservative and in no patient in the fast track group.…”

Respiratory risk assessment prior to extrathoracic surgery

“…22 Based on a systematic review, a 2006 American College of Physicians' guideline recommended that clinicians should not use preoperative spirometry routinely to predict the risk of postoperative pulmonary complications. 21,23 A reasonable approach to patient selection for preoperative pulmonary function testing includes the following:…”