Prospective Evaluation of an Algorithm for the Functional Assessment of Lung Resection Candidates

Abstract

Patients with impaired pulmonary function are at increased risk for the development of postoperative complications. Recently exercise testing and predicted postoperative (ppo) function have gained increasing importance in the evaluation of lung resection candidates. We prospectively evaluated an algorithm for the preoperative functional evaluation that was developed at our institution. This algorithm incorporated the cardiac history including an electrocardiogram (ECG), and the three parameters FEV 1 , diffusing capacity of the lungs for carbon monoxide (D L CO ), and maximal oxygen uptake ( O 2 max), as well as their respective ppo values (FEV 1 -ppo, D L CO -ppo, and O 2 max-ppo) calculated based on radionuclide perfusion scans. A consecutive group of 137 patients (mean age 62 yr; range 23 to 81; 102 males, 35 females) with clinically resectable lesions underwent assessment according to our algorithm. Five patients were deemed functionally inoperable, 132 passed the algorithm and underwent pulmonary resections with standard thoracotomy: 9 segmental or wedge resections, 85 lobectomies (inclusive 3 bilobectomies), and 38 pneumonectomies. All patients were extubated within 24 h. The mean stay in the ICU was 1.4 ( Ϯ 1.8) d, and the mean hospital stay was 14.6 ( Ϯ 5) d. Postoperative complications (within 30 d) occurred in 15 patients (11%), of whom two died (overall mortality rate 1.5%). In comparison to our previous series this meant a 50% reduction in complications whereas the percentage of inoperable patients remained unchanged (4% now, 5% before). We conclude that adherence to our algorithm resulted in a very low complication rate (morbidity and mortality), and excluded more rigorous patient selection as a bias for the improved results. . V . VPatients with lung cancer who undergo evaluation for lung resection are usually smokers and therefore often have concomitant heart and lung disease. This puts them at increased risk for the development of postoperative complications, including permanent respiratory disability and death. Therefore, the functional assessment of their cardiorespiratory reserves is very important. This assessment has recently undergone major changes; apart from preoperative measurement of pulmonary function (FEV 1 , diffusing capacity of the lungs for carbon monoxide [D L CO ]), exercise testing with the determination of maximal oxygen uptake ( O 2 max) has gained increasing importance. Recently the emphasis has shifted to the prediction of postoperative function (predicted postoperative = ppo). The parameter, most firmly established, is the FEV 1 -ppo, but also D L CO -ppo (1-3), and most recently O 2 max-ppo (3) have been suggested.Despite increasing enthusiasm for exercise testing and split function studies, one has to remember that many patients undergoing lung resections up to pneumonectomy do not need extensive tests for the assessment of their cardiorespiratory reserves. We therefore developed an algorithm for the preoperative functional evaluation (Figure 1) incorporating the cardiac...

Exercise capacity and extent of resection as predictors of surgical risk in lung cancer

“…Nevertheless, in the absence of a real therapeutic alternative, informed older patients may be in favour of an operation even in the light of a higher operative risk given the reasonable life expectancy at 70 yrs of age, 10.3 yrs for males and 14.7 yrs for females in Switzerland [29,30]. The present 0% (0/42) mortality rate in patients of >70 yrs of age, the low mortality rate found in the literature and the fact that the 2-yr survival of such patients is reported to be independent of age [28] encourage an aggressive approach in this population subgroup. Therefore, chronological age alone should not be a reason for excluding patients from sur-gery.…”

“…A limitation of the present study is the lack of measurement of the diffusing capacity of the lung for carbon monoxide (DL,CO), which has recently gained in importance [27] and also been integrated into an algorithm for functional evaluation by BOLLIGER and coworkers [24,28]. At the time the study was planned, the importance of measuring DL,CO in such patients had not been firmly established and, therefore, this lung function parameter was not used in the present patients.…”

Prediction of Postoperative Lung Function

“…Algorithmic approaches for the candidate selection have been developed in an effort to improve decision making (Colice, et al 2007;Wyser, et al 1999). Wyser et al showed that algorithmic decision reduced the complications in half compared with the author's prior series.…”

Perioperative Pulmonary Functional Assessment

“…In the algorithms used for the functional assessment of candidates for lung resection, the value of postoperative FEV1 (ppo-FEV1) plays an important role in the alternative to perform further tests or exclude patients from surgery without performing these tests (Wyser et al, 1999) (figure 1). In this sense, a value of ppo-FEV1 less than 40% of predicted increases the risk of perioperative complications and mortality by 16-50% (Pierce et al, 1994), being higher (60%) when ppo-FEV1 is less than 30% (Nakahara et al, 1985).…”