Preoperative evaluation for lung resection
- Steven E Weinberger, MD
Steven E Weinberger, MD
- Adjunct Professor of Medicine
- University of Pennsylvania School of Medicine
- Executive Vice President and CEO
- American College of Physicians
Lung cancer is currently the leading cause of cancer death in the United States . Surgical resection remains the only potentially curative therapy for patients with localized non–small cell lung cancer (NSCLC). Due to the shared risk factor from tobacco smoking for both lung cancer and chronic obstructive pulmonary disease (COPD), however, the clinician is often faced with contemplating surgical resection in patients with impaired pulmonary function and an increased risk for lung resection.
Ever since Graham and Singer's report in 1933 of the first successful pneumonectomy for the treatment of lung cancer , the search has been ongoing for the ideal preoperative test to identify those patients at greatest risk for postoperative complications. Based on the assumption that a level of pulmonary impairment exists beyond which the risk of surgical intervention is prohibitive, efforts have been wide-ranging to identify the best predictive tests and to define the threshold values necessary for minimizing surgical risk [3,4].
Suggested tests have included measurement of preoperative pulmonary function, calculation of predicted postoperative (postresectional) pulmonary function, measures of gas exchange, and exercise testing . The utility of each of these tests and a recommended approach will be presented here.
General concepts regarding preoperative pulmonary assessment and factors that estimate the risk of postoperative pulmonary complications are discussed separately. (See "Evaluation of preoperative pulmonary risk" and "Evaluation of preoperative pulmonary risk", section on 'Assessment of postoperative pulmonary risk'.)
Preoperative pulmonary function — We agree with both the American College of Chest Physicians (ACCP) and the British Thoracic Society (BTS)that the forced expiratory volume in one second (FEV1) and the diffusing capacity for carbon monoxide (DLCO) be measured in all patients with lung cancer in whom resectional surgery is being considered [6,7].
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- PULMONARY FUNCTION
- Preoperative pulmonary function
- - Spirometry
- - Diffusing capacity
- - Current guidelines
- - Predicted postoperative pulmonary function
- Current guidelines
- MEASUREMENT OF GAS EXCHANGE
- Arterial PO2
- Arterial PCO2
- EXERCISE TESTING
- Stair climbing
- Incremental shuttle walk test
- Integrated cardiopulmonary exercise testing
- CONCOMITANT VOLUME REDUCTION SURGERY
- CARDIOVASCULAR RISK
- SUMMARY AND RECOMMENDATIONS