Preoperative Evaluation for Thoracic Surgery

Abstract

The goal of the preoperative evaluation for thoracic surgery is to assess and implement measures to decrease perioperative complications and prepare high-risk patients for surgery. Major respiratory complications, such as atelectasis, pneumonia, and respiratory failure, occur in 15% to 20% of patients and account for most of the 3% to 4% mortality rate. Development of pulmonary complications has been associated with higher postoperative mortality rates. Strategies aimed at preventing postoperative difficulties have the potential to reduce morbidity and mortality, decrease hospital stay, and improve resource use. One lung ventilation leads to a significant derangement of gas exchange, and hypoxemia can develop due to increased intrapulmonary shunting. Recent advances in anesthetic management, monitoring devices, improved lung isolation techniques, and improved critical care management have increased the number of patients who were previously considered inoperable. In addition, there is a growing tendency to offer surgery to patients with significant lung function impairment; hence a higher incidence of intraoperative gas-exchange abnormalities can be expected. The anesthesiologist must also consider the risks of denying or postponing a potentially curative operation in patients with lung cancer. Detailed consideration of the information provided by preoperative testing is essential to successful outcomes following thoracic surgery.

Practical anesthetic considerations in patients undergoing tracheobronchial surgeries: a clinical review of current literature

“…Pulmonary function tests might be helpful in predicting the likelihood of post-operative ventilatory dependence in the setting of pulmonary dysfunction and in monitoring the progress of obstruction after treatment (14)(15)(16). The clinical relevance of flow volume loops is questionable.…”

“…This procedure involves removal of a circular sleeve in the main bronchus leaving lung parenchyma intact, and is considered for patients with insufficient cardiopulmonary reserve indicated for pneumonectomies. As previously mentioned, pulmonary function tests might predict postoperative ventilatory dependence (14). Double lumen tubes or bronchial blockers are the common devices used for lung isolation.…”

Anesthesia for Tracheobronchial Surgery

“…PFTs may be used early to differentiate airway pathology from primary lung pathology; however, direct examination by flexible bronchoscopy and possible rigid bronchoscopy provides the definitive surgical information. A complete review on PFT utilization in lung resection surgery was recently presented in this journal by Bernstein and Deshpande 3 and serves as a complete review for both airway lesions and thoracic lung masses requiring resection. Additionally, the review by Blasberg and Wright that accompanies this article provides the surgical approach and discussion of airway lesions, including methods in preoperative planning for tracheal resection.…”

“…Because these lesions may involve lung resection and need for 1-lung ventilation, PFT testing serves as a useful predictive tool and has been described in detail previously. 3 The procedure is intrathoracic, usually approached from a thoracotomy or median sternotomy, and the lungs cannot be treated as a single entity. As in all thoracotomies, arterial monitoring is prudent, and methods of postoperative analgesia, such as thoracic epidural catheters, are indicated (Please see section on postthoracotomy pain below).…”

Pulmonary function testing

“…Advances in anesthetic management with improved lung isolation techniques and better critical care management have increased the number of patients previously considered inoperable [1]. Pulmonary function testing (PFT) can aid in identifying those patients at risk with the hope of decreasing perioperative complications and shortening hospital stay.…”