The risk of post-operative pulmonary complications in lung resection candidates with normal forced expiratory volume in 1 s and diffusing capacity of the lung for carbon monoxide: a prospective multicentre study

Abstract

IntroductionAccording to the guidelines for preoperative assessment of lung resection candidates, patients with normal forced expiratory volume in the first second (FEV1) and diffusing capacity for carbon monoxide (DLCO) are at low risk for postoperative pulmonary complications (PPC). However, PPC affect hospital length of stay and related health care costs. We aimed to assess risk of PPC for lung resection candidates with normal FEV1and DLCO(>80% predicted) and identify factors associated with PPC.MethodsThree hundred and ninety-eight patients were prospectively studied at 2 centers between 2017 and 2021. PPC were recorded from the first 30 post-operative days. Subgroups of patients with and without PPC were compared and factors with significant difference were analyzed by uni- and multivariate logistic regression.ResultsOne hundred and eighty-eight subjects had normal FEV1and DLCO. Of these, 17 patients (9%) developed PPC. Patients with PPC had significantly lower pressure of end-tidal carbon dioxide (PETCO2) at rest (27.7versus29.9; p=0.033) and higher ventilatory efficiency (VE/VCO2) slope (31.1versus28; p=0.016) compared to those without PPC. Multivariate models showed association between rest PETCO2(OR 0.872; p=0.035) and VE/VCO2slope (OR 1.116; p=0.03) and PPC. In both models, thoracotomy was strongly associated with PPC (OR 6.419; p=0.005 and OR 5.884; p=0.007, respectively). Peak oxygen consumption failed to predict PPC (p=0.917).ConclusionsRest PETCO2adds incremental information for risk prediction of PPC in patients with normal FEV1and DLCO. We propose rest PETCO2be an additional parameter to FEV1and DLCOfor preoperative risk stratification.

New Models for Prediction of Post-Operative Pulmonary Complications in Lung Resection Candidates

“…An important question is, what extent of calculated risk should be perceived as acceptable, increased or prohibitive for lung resection. In a recent study, the risk of PPC in patients with preserved lung function was 9% [29], while 14.5-17% or even 25% in less selected populations [3,4,12]. In view of these data, we suggest that acceptable risk of PPC shouldn´t exceed 30%, while >50% risk be prohibitive for surgical treatment.…”

“…The current ERS/ACCP guidelines recommend FEV 1 and DL CO measurements as part of routine pre-operative evaluation [8,9]. While spirometry and DL CO assessment have a reasonable negative predictive value in patients with preserved lung function [29], patients with a predicted post-operative (ppo) FEV 1 of ˂40% or ˂30% were observed with 16-50% [30,31] and approaching 60% rates of post-operative mortality [32], respectively. FVC wasn´t significantly different between groups with and without PPC.…”

Early outcomes of “low-risk” patients undergoing lung resection assessed by cardiopulmonary exercise testing: Single-institution experience

“…According to ESTS/ERS guidelines ( 3 ), patients with both FEV1 and DLCO >80% predicted do not have to be further investigated by CPET and can undergo any extent of surgical resection with low risk for perioperative cardiopulmonary complications and deaths, whose incidence rates are about 13% and 0%, respectively ( 15 ). Nevertheless, recently, Cundrle and colleagues ( 22 ) have selectively analyzed surgical outcomes of this group of patients assessed by CPET, reporting 9% cardiopulmonary morbidity rate, mainly affecting those with lower end-tidal carbon dioxide pressure (P ET CO 2 ) and increased VE/VCO 2 slope, and suggesting to perform routinary CPET to identify these patients. Our matched control patients have experienced 5% cardiopulmonary morbidity rate and 0% mortality rate, slightly better but grossly comparable to previous results.…”