Assessment of suitability for lung

resection
Gerard Gould FRCA
Adrian Pearce FRCA

Approximately 2400 lobectomies and 500 Table 1 Cardiovascular recommendations before lung
resection Key points
pneumonectomies are undertaken in the UK
annually, the majority for malignancy. For Cardiac risk should be stratified Co-morbidity is common in
All patients should have a preoperative ECG
this group of patients, in-hospital mortality All patients with a cardiac murmur should undergo
patients with lung cancer.
rates are 2–4% and 6–8%, respectively in the echocardiography A preoperative FEV1 of
Patients should wait 6 weeks after myocardial infarction
UK, although world mortality rates as high
before lung resection
>1.5 litre for lobectomy
as 11% have been cited for pneumonectomy. A cardiology opinion should be sought for all patients and >2.0 litre for
For lung cancer surgery, there are three pre- considered for lung surgery within 6 months of pneumonectomy generally
requisites before pulmonary resection is even myocardial infarction indicates suitability. Values
considered. The tumour type should be non- less than this should prompt
small cell (the majority are squamous cell or further investigation of
adenocarcinoma), the tumour is considered Table 2 Major risk factors for increased perioperative respiratory function.
cardiac morbidity
surgically resectable and the patient consents A thorough assessment of
to surgery. Surgical resectability depends on Unstable coronary syndromes cardiorespiratory reserve
 acute or recent myocordial infarction (MI) with includes calculation of
the absence of significant mediastinal or dis- evidence of important ischaemic risk by clinical
tant spread as judged by computerised tomo- symptoms or noninvasive study
predicted postoperative
 unstable or severe angina pulmonary function.
graphy (CT), positron emission tomography
Decompensated heart failure
(PET), bronchoscopy or mediastinoscopy. CPET should be available in
Significant arrhythmia
Guidelines1 on the selection of patients  high-grade atrioventricular block centres providing a thoracic
with lung cancer for surgery, published by a  symptomatic ventricular arrhythmias in the surgical service.
presence of underlying heart disease
joint working party of the British Thoracic  supraventricular arrhythmias with uncontrolled
A multidisciplinary approach
Society (BTS) and Society of Cardiothoracic ventricular rate is essential and should include
Surgeons of Great Britain and Ireland advise Severe valvular disease anaesthetist, chest physician,
that fitness for surgery is based on assessment thoracic surgeon and
radiologist.
of age, cardiovascular fitness, nutrition and
performance status and respiratory function. Tests of pulmonary function
Perioperative morbidity increases with age;
a careful assessment of co-morbidity should
Lung function tests pre-surgery
be made in elderly patients. However, age Basic spirometry will measure the forced
alone is not a contraindication to lobectomy expiratory volume in 1 s (FEV1) and forced
or wedge resection in early disease, although it vital capacity (FVC) and the best value after
is a factor to be considered before undertaking optimal bronchodilator therapy is used. The
pneumonectomy. Weight loss >10%, a low measured value in litres may also be compared
BMI or serum albumin may indicate more with the predicted value for a ‘normal’ person
advanced disease or an increased risk of post- derived from population studies and vary-
operative complications. Recommendations ing with age, gender, race and height, giving
Gerard Gould FRCA
appropriate to the cardiovascular system are a percentage of the predicted normal value.
SpR 5
summarized in Table 1. The guidelines2 from The ratio of FEV1/FVC is commonly deter- Thoracic Anaesthesia
the American College of Cardiology and the mined. More sophisticated testing allows mea- Guy’s and St Thomas’ Hospital
American Heart Association should be used London
surement of the peak, mid- and end-expiratory
to stratify perioperative cardiovascular risk. flow rates and residual volume. Flow-volume Adrian Pearce FRCA
Those at major risk (Table 2) should undergo loops may be constructed in which flow rates Consultant Anaesthetist
a cardiology assessment and be considered for during inspiration and expiration are recorded Department of Anaesthesia
Guy’s and St Thomas’ Hospital
coronary angiography. Generally, patients in continuously from residual volume to vital London SE1 9RT
intermediate and minor risk categories should capacity and back to residual volume. UK
be assessed for functional capacity and con- Diffusion capacity is calculated by mea- Tel: 020 7188 0644
Fax: 020 8468 7466
tinue with surgery. surement of the amount of carbon monoxide E-mail: adrian.pearce@gstt.nhs.uk
(for correspondence)

doi:10.1093/bjaceaccp/mkl016
Continuing Education in Anaesthesia, Critical Care & Pain | Volume 6 Number 3 2006 97
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Assessment of suitability for lung resection
(CO) taken up by the patient in unit time (DLCO). The units
are amount of CO per unit of alveolar concentration per unit
time—mmol kPa1 min1. The test provides a gross estimate of
alveolar/capillary function and is not (as commonly supposed)
just a test of the diffusion of oxygen across the alveolar
capillary membrane. The diffusion capacity may be referenced
to alveolar volume (transfer coefficient, KCO) with units mmol
kPa1 min1 litre1. Both DLCO and KCO may be described as
the actual value or as a percentage of the predicted ‘normal’
values for a particular patient.
Predicted postoperative respiratory function
The predicted or estimated postoperative (ppo or epo) values of
FEV1, FVC and diffusion capacity can be obtained by consid-
eration of the lung volume removed at surgery. For lobectomy,
the simple calculation uses the number of bronchopulmonary
segments removed compared with the total number (19) in both
lungs. For right upper lobectomy (3 segments) in a patient with a
preoperative FEV1 of 1.6 litre which is 80% of predicted normal,
the ppo-FEV will be 1.6·16/19 ¼ 1.35 litre, and the ppo-FEV1%
will be 80%·16/19 ¼ 67%. The same form of ppo calculation may
be applied to the measured DLCO or the DLCO as a percentage
of the predicted normal value. Of course, this gross calculation
assumes that all bronchopulmonary segments contribute equally
to the overall lung function and this may not be so. Ventilation
scans will provide a more accurate calculation of ppo lung
volumes.
Ventilation/perfusion scanning
Quantitative ventilation–perfusion scanning calculates the per-
centage function of each lung. This is achieved by the inhalation
of radioactive xenon and the i.v. administration of technetium
labelled macroaggregates. A gamma camera and computer cal-
culate the uptake of radioactive ions by the lung or the perfusion
of technetium. The percentage of radioactivity taken up by each
lung correlates with the contribution of that lung to overall func-
tion. Using the measured radioactive uptake of the lung that
will not be operated on, the predicted FEV1 of the residual
lung after pneumonectomy can be calculated by the following
simple equation:
Postop FEV1 ¼
Preop FEV1 · % radioactivity of non-operated lung
A further calculation has been developed for predicting post-
lobectomy pulmonary function using V/Q scanning.
Expected loss of function
¼ pre-op FEV1 · % function of affected lung
number of segments in lobe to be resected
·
total number of segments in whole lung
98 Continuing Education in Anaesthesia, Critical Care & Pain | Volume 6 Number 3 2006
Exercise capability
Exercise testing stresses the cardiopulmonary and oxygen delivery
systems and provides a good indication of cardiopulmonary
reserve. The simplest test assesses the number of flights of stairs
that may be climbed without stopping. This may be undertaken in
the outpatient department or ward and is a good screening test.
Two more standardized tests may be used. The 6-min walk
involves walking as far as possible in 6 min. The test should be
performed indoors along a long, flat, straight, enclosed corridor.
Most studies quote a course of 30 m in length with cones at
either end to act as turnaround points. Rest is allowed during
the test. In the shuttle walk test, the patient walks back and forth
around two markers at increasing speed timed by an audible
signal. The markers are usually cones with their centres 9 m
apart making the course 10 m in length. The subject aims to walk
around the 10 m course and turn around the first marker cone
when the first audio signal is given, and so on. Progression to the
next level of difficulty is indicated by a triple bleep which lets
the subject know that an increase in walking speed is required.
The test stops when the patient is too breathless to maintain the
speed required or after 12 min, and the number of cones reached is
recorded.
Cardiopulmonary exercise testing
Formal testing of cardiopulmonary exercise capability appears
to give the most accurate indication of postoperative complica-
tions. Cardiopulmonary exercise testing (CPET) is a non-invasive
technique that involves submaximal and maximal treadmill or
bicycle exercise (Fig. 1) with continuous ECG monitoring and
breath-by-breath determination of oxygen uptake and carbon
dioxide output, and spirometry. Maximal oxygen consumption
(V_ O2 max), peak heart rate, exercise capacity, anaerobic thresh-
old and respiratory gas exchange ratio can be calculated. V_ O2
max is the highest oxygen consumption achieved at maximal
work before stopping the test (Fig. 2), and is usually given in
the units ml kg1 min1. The predicted normal V_ O2 max for a
patient may be derived from charts, allowing derivation of V_ O2
max as a % of predicted normal (% V_ O2 max predicted).
Arterial blood gases
Arterial PaCO2 > 6 kPa (45 mm Hg) does not appear to be
an independent predictor of poor outcome but preoperative
hypoxaemia, oxygen saturations <90% and desaturation >4%
with exercise have all been associated with an increased risk
of complications.
Predictive power of preoperative tests
Data in >2000 patients from the 1970s indicate that a low mor-
tality can be achieved if the preoperative FEV1 is >1.5 litre

Fig. 1 Patient undergoing CPET.
for lobectomy and >2 litre for pneumonectomy. Using absolute
FEV1 values may be inappropriate in elderly, female or patients
of short stature. An FEV1 >80% predicted indicates suitability
for pneumonectomy. The relevance of DLCO was suggested in
1988 in a retrospective study 3 in 237 patients. The preoperative
DLCO, expressed as % predicted, had a higher correlation with
postoperative deaths than FEV1 measurements. A DLCO <60%
predicted was associated with increased mortality and <80% pre-
dicted with increased pulmonary complications. In a prospective
study,4 67 patients with preoperative FEV1 >80% and DLCO
>80% and no cardiac history underwent lung resection, including
pneumonectomy, without death.
The ppo values of FEV1 and DLCO may be used and generally
a threshold ppo-FEV1 of 0.7–0.8 litre is advisable after lung
resection. The ppo value of FEV1 or DLCO as a percentage of
the ‘predicted normal’ value appears to be particularly valuable.
Several studies indicate that mortality increases when ppo-FEV1
or ppo-DLCO is <40% predicted. The product of ppo-FEV1%
and ppo-DLCO% may be useful and a threshold of 1650 has been
used. There are few prospective studies evaluating outcome in
patients with ppo-FEV1 or DLCO <40% but in one study5 of
65 patients with poor lung function and undergoing either
lobectomy or pneumonectomy the mortality rate was only 6.2%.
Continuing Education in Anaesthesia, Critical Care & Pain | Volume 6 Number 3 2006
Assessment of suitability for lung resection
2.5
1.5
VO2
0.5 VCO2
0
00:00 02:24 04:48 07:12 09:36 12:00 14:24
Fig. 2 Oxygen consumption plotted against increasing work. The
V_ O2 max is the highest oxygen consumption (ml kg1 min1) at
maximal work.
Historically patients were considered suitable for lobectomy
if able to climb three flights of stairs and for pneumonectomy
if able to climb five flights. This was found to correlate with
lung function, three flights indicating an FEV1 >1.7 litre and
five flights an FEV1 > 2 litre. Limited work suggests that
patients who can climb five flights of stairs have a V_ O2 max
>20 ml kg1 min1 and those unable to climb one flight one
of <10 ml kg1 min1. An inability to complete 25 shuttles
(250 m) in 5 min on two occasions suggests a V_ O2 max
<10 ml kg1 min1 and a high risk for surgery.
The usefulness of V_ O2 max was indicated by a study of 19
patients in 1982. Patients with a V_ O2 max >1 litre min1 survived
and those < 1 litre min1 died. Numerous further studies indicate
that V_ O2 max may be used to stratify risk of postoperative com-
plications and mortality. V_ O2 max >20 ml kg1 min1 indicates
no increased risk of complications or death, <15 ml kg1 min1
indicates an increased risk of complications and < 10 ml kg1
min1 indicates mortality rates of 40–50%. Satisfactory VO2
max may allow selection of patients deemed unsuitable by
lung volume measurements. In 37 patients6 with poor respiratory
function (FEV1 <40%, ppo-FEV1 <33% or PaCO2 >6 kPa),
8 patients with VO2 max >15 ml kg1 min1 survived lobectomy.
The use of the preoperative V_ O2 max % predicted has been
analysed. In 80 patients7 undergoing lung resection, V_ O2 max %
predicted was more sensitive than absolute V_ O2 max. V_ O2 max %
predicted >75% indicated a low risk of complications, <43% a
99
Assessment of suitability for lung resection
Routine Lung Function Tests
FEV1 < 1.5 litre (Lobectomy)
< 2.0 litre (pneumonectomy)
Quantitative Lung Scan
% ppo FEV1 < 40%
% ppo TLCO< 40%
VO2 max < 15ml kg–1 min–1
Fig. 3 Preoperative evaluation before lung resection.
high risk of complications and <60% appeared to be the
threshold value for resections of more than one lobe.
A number of studies support the finding that patients with
a preoperative V_ O2 max of >20 ml kg1 min1 are not at
increased risk of complications or death and those with a V_ O2
max <10 ml kg1 min1 have a very high risk for postoperative
complications.
If CPET is unavailable then other less sophisticated tests
can be used.
Algorithms
Both the BTS and American College of Chest Physicians
(ACCP)8 9 have produced management algorithms which are
similar. The flow chart shown in Figure 3 is an amalgamation
of the BTS and ACCP guidelines.
The initial screening tool is of preoperative measured FEV1
with >2 litre required for pneumonectomy and >1.5 litre for
lobectomy. If there is no diffuse lung disease and no co-
morbidity, achievement of the appropriate lung volume is suffi-
cient. When these threshold lung volumes are not present, full
respiratory function testing allows calculation of the predicted
postoperative FEV1 and DLCO. If both are >40% and the
oxygen saturation is >90% on air the patient is in an average
risk group. If either (or both) the predicted postoperative
FEV1 or DLCO are <40%, the patient should undergo formal
CPET, if necessary through referral to a unit with this expertise.
The threshold V_ O2 max of 15 ml kg1 min1 delineates between
high and medium risk patients.
100 Continuing Education in Anaesthesia, Critical Care & Pain | Volume 6 Number 3 2006
FEV1 > 1.5 litre suitable for lobectomy
FEV1 > 2.0 litre suitable for pneumonectomy
SURGERY
% ppo FEV1 > 40%
% ppo TLCO> 40%
Exercise Testing VO2 max > 15ml kg–1 min–1
Consider other
options
References
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perioperative cardiovascular evaluation for noncardiac surgery 2002.
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Please see multiple choice questions 1–5.