Preoperative Evaluation For Lung Resection

14/1/2016
Preoperative evaluation for lung resection
Official reprint from UpToDate

www.uptodate.com 2016 UpToDate

Author
Steven E Weinberger, MD
Section Editor
Talmadge E King, Jr, MD
Deputy Editor
Geraldine Finlay, MD
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Dec 2015. | This topic last updated: May 05, 2015.
INTRODUCTION Lung cancer is currently the leading cause of cancer death in the United States [1].
Surgical resection remains the only potentially curative therapy for patients with localized nonsmall 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 [2], 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 [5]. 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'.)
PULMONARY FUNCTION
Preoperative pulmonary function We agree with both the American College of Chest Physicians and the
British Thoracic Society 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].
The correlation between impaired respiratory functional status and surgical outcome following pulmonary
resection was first noted in 1955 [8]. Subsequent studies have confirmed the value of spirometry and diffusing
capacity (DLCO) in providing an accurate assessment of operative risk for lung resection via thoracotomy [9].
However, the predictive value of forced expiratory volume in one second (FEV1) and DLCO for pulmonary
complications is less clear when lobectomy is performed via thoracoscopy [9,10].
Maximal voluntary ventilation (MVV) represents an integrated test that takes into account both airflow and
muscle strength. However, its strong dependence on patient effort has led to its removal from most standard
pulmonary function testing, and it is now rarely used for preoperative evaluation. However, when requested by
the clinician, it may be valuable. In a study of patients undergoing lung resection and/or thoracoplasty for
pulmonary tuberculosis, patients with MVV (measured as the maximal amount a patient can inhale and exhale
over 12 seconds) less than 50 percent and a forced vital capacity (FVC) less than 70 percent of predicted had a
40 percent mortality following surgery [8]. Other studies have validated that a reduced preoperative MVV is
associated with an increased risk of operative complications, and a threshold value of 50 percent of predicted is
generally used to predict increased risk [11-13].
Spirometry The forced expiratory volume in one second (FEV1) has become the primary spirometric
value used for preoperative assessment. The FEV1 correlates well with the degree of respiratory impairment in
patients with COPD, and it provides an indirect measure of pulmonary reserve. In studies evaluating a variety of
preoperative spirometric values, a reduced preoperative FEV1 (<60 percent predicted) was the strongest
predictor of postoperative complications [14-19]. (See "Overview of pulmonary function testing in adults".)
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Diffusing capacity The usefulness of the diffusing capacity for carbon monoxide (DLCO) in predicting
postoperative complications following pulmonary resection has also been evaluated. Retrospective studies have
reported that actual DLCO (as a percent of the predicted value) and predicted postoperative DLCO are the most
important predictors of mortality and postoperative complications [20-22].
Current guidelines The American College of Chest Physician do not make recommendations for cut-off
values for spirometry or diffusion below which surgical resection should not be performed. Their focus is on
calculating the predicted post-operative values to facilitate the decision for surgical resection. (See 'Predicted
postoperative pulmonary function' below.)
British Thoracic Society (BTS) suggests that patients with a preoperative FEV1 in excess of 2 L (or >80 percent
predicted) generally tolerate pneumonectomy, whereas those with a preoperative FEV1 greater than 1.5 L
tolerate lobectomy [4,6]. However, it has been difficult to identify a single absolute value of preoperative FEV1
below which the risk of surgical intervention should be considered prohibitive for all patients [23]. Responsible
factors for this lack of a single value include the following:
Differences in the amount of lung tissue to be resected, as the extent of the planned resection will affect
the choice of an acceptable preoperative FEV1.
Differences in the severity of underlying lung disease and the contribution to total lung function of the
portion of lung to be resected.
Differences in size, age, gender, and race of patients undergoing lung resection.
In addition, most studies used for the BTS guidelines were published prior to 1990. Supportive care and
perioperative management have improved substantially since that time. Thus, strict use of these numbers could
result in an overly restrictive approach to surgical therapy. As an example, a retrospective analysis of 150
patients treated at a single center between 2001 and 2003 found that a cutoff preoperative FEV1 value of 47
percent resulted in the greatest diagnostic accuracy in predicting ability to survive pulmonary resection [24]. The
authors suggested that a lower threshold of predicted FEV1 (45 to 50 percent predicted) could be accepted
without increased mortality.
Predicted postoperative pulmonary function Patients who do not clearly fall into a low risk category
based upon the preoperative FEV1 and DLCO each being >80 percent predicted should undergo further testing
to allow calculation of predicted postoperative lung function [7,25]. Predicted postoperative values for FEV1 and
DLCO should take into account the preoperative values, the amount of lung tissue to be resected, and its
contribution to overall function (calculator 1 and calculator 2).
In one study that has been heavily cited, a predicted postpneumonectomy FEV1 greater than 0.8 L was chosen
as the threshold value [26]. Prediction of postoperative pulmonary function was based upon a combination of
spirometry and quantitative perfusion lung scanning to estimate the degree of functional loss following surgery.
Because it may be difficult to predict before the time of surgery whether the patient will need a pneumonectomy,
the authors used the calculated function in the entire noncancerous lung (ie, the lung that would remain if a
pneumonectomy needed to be performed) as a criterion for surgical candidacy.
Radionuclide perfusion lung scanning can help predict postoperative lung function following resection, taking into
account preoperative spirometry and the fractional predicted loss of lung function demonstrated by preoperative
scanning. In one study, the correlation between predicted postoperative lung function and observed
postoperative lung function was particularly good (and stable over time) following pneumonectomy [27]. However,
following lobectomy, there was a disproportionate early loss in observed function (compared to the predicted
loss), followed by significant functional improvement over time.
Numerical cutoffs for predicted postoperative lung function have also been based upon the percentage of
predicted value rather than the absolute level of predicted postoperative FEV1 [5,6,25,28]. Predicted
postoperative function is calculated using preoperative values of FEV1 or DLCO and measurement of lobar or
whole lung fractional contribution to function as determined by quantitative perfusion lung scanning, ventilation,
or CT lung scanning. Alternatively, the estimated postoperative (ePO) FEV1 is calculated by the formula: ePO
FEV1 = preop FEV1 x (number of segments remaining postoperatively/total number of lung segments [normally
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18]) [29]. The value obtained is then compared to the predicted value for FEV1 for that individuals height, age,
and gender to obtain the percent predicted postoperative FEV1. In one study, a predicted postoperative FEV1
that was 40 percent or more of the predicted normal value for that patient was associated with no postoperative
mortality (in 47 patients), whereas a value less than 40 percent was associated with 50 percent mortality (in six
patients) [28]. A subsequent study confirmed the correlation of predicted postoperative value of FEV1 with the
likelihood of postoperative complications in patients undergoing lung resection [30]. The odds ratio for
complications was 1.46 for each 0.2 L decrease in predicted postoperative FEV1.
Other reports have investigated the value of the predicted postoperative DLCO based upon the preoperative value
and an assessment of regional lung function by quantitative perfusion scanning [28,31]. In one such study, high
morbidity and mortality were associated with a predicted postoperative DLCO below 40 percent of the predicted
normal value [5,28].
Current guidelines Guidelines from the American College of Chest Physicians (ACCP) suggest
radionuclide perfusion lung scanning (the perfusion method) to calculate predicted postoperative FEV1 in a
patient undergoing pneumonectomy [7]. In this method, the formula for calculating predicted postoperative FEV1
(PPO FEV1) is as follows (calculator 2):
PPO FEV1 = preoperative FEV1 x (1 fraction of total perfusion in the resected lung)
where perfusion is measured with a quantitative radionuclide perfusion scan.
In a patient undergoing lobectomy, the anatomic method is used to calculate PPO FEV1 according to the
following formula (calculator 1):
PPO FEV1 = preoperative FEV1 x (1 y/z)
where y = number of functional or unobstructed lung segments to be removed, and z = total number of functional
segments (typically 19). Analogous formulas can also be used for calculating predicted postoperative DLCO
(PPO DLCO).
Based on the low risk of death and cardiopulmonary complications when both PPO FEV1 and PPO DLCO are
>60 percent, no further testing is necessary, if both values are >60 percent, and the patient is deemed to have
sufficient pulmonary function to undergo resectional surgery. (For a figure showing the ACCP algorithm, please
see Figure 2 in the guidelines at: http://journal.publications.chestnet.org/pdfaccess.ashx?
ResourceID=6566227&PDFSource=13) (algorithm 1) [7].
If either PPO FEV1 or PPO DLCO is <60 percent predicted, but both are >30 percent predicted, additional
evaluation with a low technology exercise test (either stair climb or a shuttle walk test) is indicated. If either
PPO FEV1 or PPO DLCO is <30 percent, a formal cardiopulmonary exercise test with measurement of maximal
oxygen consumption should be performed.
Guidelines from the European Respiratory Society and the European Society of Thoracic Surgery (ERS/ESTS)
similarly use a cutoff value for PPO FEV1 or DLCO of 30 percent (rather than the 40 percent used in several
studies), due to improvements in surgical technique and the belief that removal of hyperinflated, poorly
functioning lung tissue during surgery ameliorates the calculated loss in lung function through a lung volume
reduction effect [32]. However, evaluation with cardiopulmonary exercise testing is needed prior to making a
final decision on operability. (For a figure showing the ERS/ESTS algorithm, please see Figure 2 in the
guidelines at http://erj.ersjournals.com/content/34/3/782.full.pdf+html) [32]. (See 'Concomitant volume reduction
surgery' below and 'Integrated cardiopulmonary exercise testing' below.)
MEASUREMENT OF GAS EXCHANGE Although spirometric values, most notably the FEV1, correlate with
the severity of COPD, they do not provide direct information regarding the degree of gas exchange impairment
that is often present, which may be measured directly by arterial blood gases. However, arterial blood gases
have not proved to be as useful as measurement of FEV1 and DLCO in assessing suitability for lung resection.
Arterial PO2 Baseline (resting) arterial PO2 is probably not an important predictor of postoperative
complications or mortality following pulmonary resection. When there is partial or complete endobronchial
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obstruction in a region of lung that is to be resected, ventilation-perfusion matching and therefore resting arterial
PO2 may actually improve following pulmonary resection [33,34].
Arterial PCO2 Hypercapnia (arterial PCO2 greater than 45 mmHg) has traditionally been considered a
significant risk factor for pulmonary resection [34]. However, this hypothesis has never been proven, and a 1994
study showed no difference in postoperative complications between patients with a preoperative PCO2 less than
45 mmHg and those with a preoperative PCO2 of 45 mmHg or higher (17 versus 13 percent, respectively)
[30,35]. Thus, hypercapnia per se is not a contraindication to surgery, although surgery is frequently precluded
in hypercapnic patients because of a low predicted postoperative FEV1 or poor exercise performance [6].
EXERCISE TESTING The role of preoperative exercise testing in the evaluation of patients prior to
thoracotomy has evolved significantly over the past few decades [36]. As a comprehensive physiologic
evaluation, a patient's performance on exercise testing is dependent upon the interactions among pulmonary
function, cardiovascular function, and oxygen utilization by peripheral tissues. Exercise testing can take many
forms, ranging from stair climbing to complete cardiopulmonary exercise testing with measurement of anaerobic
threshold, oxygen consumption, and the level of work achieved. (See "Exercise physiology" and "Functional
exercise testing: Ventilatory gas analysis".)
For patients with either postoperative predictive (PPO) forced expiratory volume in one second (FEV1) or PPO
diffusing capacity for carbon monoxide (DLCO) <60 percent predicted, but both >30 percent predicted, a low
technology exercise test (either stair climb or a shuttle walk test) should be performed. If either PPO FEV1 or
PPO DLCO is <30 percent, a formal cardiopulmonary exercise test can be performed with measurement of
maximal oxygen consumption. Cardiopulmonary exercise testing (CPET) is useful when the results of PPO
FEV1, PPO DLCO, and/or low technology exercise testing do not clearly define the patients risk as either high
or low.
Stair climbing For many years, surgeons have utilized stair climbing as a preoperative screening tool.
Though poorly standardized, this form of testing has been shown to identify patients at increased risk for lung
resection [37-42]. As examples:
In a prospective series of 640 lobectomy and pneumonectomy candidates, attainment of a lower altitude
(less than 12 meters) on a symptom-limited stair climbing test was associated with increased
cardiopulmonary complications, mortality, and cost, compared with climbing to a higher altitude (22
meters) [40].
A prospective series of 160 patients studied one day prior to lung resection found that those who were able
to climb more than eight flights of stairs, at their own pace, were less likely to experience complications
than those who could climb fewer than seven flights of stairs (6.5 versus 50 percent) [39]. Patients who
climbed between seven and eight flights of stairs had an intermediate risk of complications (30 percent).
The American College of Chest Physicians uses a cutoff of 22 m on the stair climbing test. Patients whose
exercise ability falls below the designated cutoff are at increased risk for perioperative mortality and
cardiopulmonary complications, and are recommended for formal cardiopulmonary exercise testing with
measurement of maximal oxygen consumption (VO2 max) [7].
Incremental shuttle walk test The incremental shuttle walk test (ISWT) is a 12 level test in which the
subject walks at a progressively increasing speed for 12 minutes over a course, in which each 10 meter trip
between cones is a shuttle. An ISWT distance greater than 400 meters has been associated with a maximum
oxygen uptake (VO2 max) 15 mL/kg per minute. (See "Overview of pulmonary function testing in adults",
section on 'Incremental shuttle walk test'.)
The European Respiratory Society guidelines note that the ISWT distance underestimates exercise capacity at
the lower range and suggests a cutoff of 40 shuttles (400 m) [7]. Patients whose ISWT distance falls below this
cutoff are at increased risk for perioperative mortality and cardiopulmonary complications, and it is suggested
that they undergo formal cardiopulmonary exercise testing with measurement of VO2 max [7].
Integrated cardiopulmonary exercise testing The most important measurement during cardiopulmonary
exercise testing that correlates with postoperative complications is the level of work achieved, as measured by
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maximal oxygen consumption (VO2 max); invasive hemodynamic measurements during exercise provide little
additional useful data [43]. An early report demonstrated no mortality in patients able to achieve a VO2 max in
excess of 1 L/min, compared with 75 percent mortality in those with a VO2 max below 1 L/min [44].
Expressing VO2 max in terms of mL/kg per min, which takes into account the patient's body mass, may
increase the predictive power of the test. One study, for example, found that only one of 10 patients able to
achieve a VO2 max greater than 20 mL/kg per min had a postoperative complication, whereas all six patients
with a VO2 max below 15 mL/kg per min experienced a postoperative complication [45]. Similar findings have
been noted in other studies [5,46,47]. As an example, 20 patients who were considered to be at high risk for
resection by standard criteria, but who had a VO2 max of 15 mL/kg per min or greater, survived surgery and had
an acceptable postoperative complication rate [46]. Patients with VO2 max <10 mL/kg per min are at very high
risk for perioperative complications and mortality [25,47,48].
The VO2 max can also be expressed as a percentage of the predicted value. One report found that a VO2 max
<43 percent of predicted was associated with a 90 percent probability of developing serious postoperative
complications [49]. A cutoff value below 60 percent predicted was thought to be prohibitive for resections
involving more than one lobe, whereas a value above 75 percent predicted suggested a good outcome,
regardless of the extent of resection. Two subsequent studies, including a total of 280 patients with potentially
operable lung cancer, also noted increased mortality among those with VO2 max <50 percent of predicted
[50,51].
Guidelines The guidelines of the American College of Chest Physicians (ACCP) and those of the European
Respiratory Society and the European Society of Thoracic Surgery (ERS/ESTS) differ slightly in the exact
timing and indications for cardiopulmonary exercise testing (CPET) in the evaluation of a patient for potential
lung resection [7,32]. For a figure showing the ACCP algorithm, please see Figure 2 in the guidelines at:
http://journal.publications.chestnet.org/pdfaccess.ashx?ResourceID=3675833&PDFSource=13 and for a figure
showing the ERS/ESTS algorithm, please see Figure 2 in the guidelines at
http://erj.ersjournals.com/content/34/3/782.full.pdf+html (algorithm 1).
The ACCP and the ERS/ESTS both consider patients with VO2 max <10 mL/kg per min or <35 percent
predicted to be at high risk for perioperative death and cardiopulmonary complications [7,32]. In contrast,
patients with VO2 max >20 mL/kg per minute are considered to be suitable for any type of lung resection,
including pneumonectomy. Patients with VO2 max between 10 and 15 mL/kg per min have increased risk for
mortality, and other factors, including PPO FEV1, PPO DLCO, and comorbidities, should also be taken into
account in decision-making for these patients.
The ERS/ESTS guidelines suggest that, for patients with intermediate VO2 max values (between 10 and 20
mL/kg per min) and postoperative predicted FEV1 and DLCO values 30 percent, resection up to the calculated
extent is acceptable [32]. On the other hand, if either the postoperative predicted FEV1 or DLCO is <30 percent,
the predicted postoperative (PPO) VO2 max is calculated. If the PPO VO2 max is <10 mL/kg per min or <35
percent, it is recommended that the patient seek nonresectional options. On the other hand, if the PPO VO2
max is 10 mL/kg per min or 35 percent predicted, surgical resection is not absolutely contraindicated.
However, the relatively high risk suggested by the low postoperative predicted FEV1 or DLCO necessitates a
shared decision-making process in which the patient fully understands the relatively high risk.
CONCOMITANT VOLUME REDUCTION SURGERY Lung volume reduction surgery (LVRS), now being used
in carefully selected patients with advanced emphysema, may impact the resectability of lung tumors in this
patient population [52-56]. Resectional surgery for lung cancer that simultaneously removes severely
emphysematous lung tissue may actually improve rather than worsen lung function through increasing lung
elastic recoil and diaphragmatic efficiency. (See "Lung volume reduction surgery in COPD".).
As an example, one series reported the results of 14 patients with severe emphysema in whom pulmonary
nodules were detected during the course of preoperative evaluation for LVRS and who then underwent combined
resection and LVRS [53]. One postoperative death occurred, but the FEV1 significantly increased among
survivors, from a mean preoperative value of 676 mL to a mean of 886 mL following the operation. Significant
improvements were also seen in arterial PCO2, dyspnea index, and six-minute walk distance. Most tumors were
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removed by wedge resection, with only 3 of 14 patients undergoing complete lobectomy.

The magnitude and duration of benefit of LVRS, as well as optimal patient selection criteria, have not been
precisely defined. However, current clinical guidelines from the American College of Chest Physicians suggest
considering combining LVRS and lung cancer resection if the cancer is in an area of upper lobe emphysema,
and if the patient's FEV1 and DLCO are both >20 percent predicted [25].
CARDIOVASCULAR RISK Patients at risk for lung cancer and COPD are also frequently at risk for
preoperative morbidity related to coronary heart disease and may also need preoperative cardiovascular
evaluation. Evaluation of cardiac risk is discussed separately. (See "Evaluation of cardiac risk prior to
noncardiac surgery".)
SUMMARY AND RECOMMENDATIONS Given the poor prognosis for patients with lung cancer that is not
treated surgically, every effort should be made to identify those patients who will tolerate resection. Although the
level of acceptable risk for postoperative complications is somewhat subjective, utilizing a series of widely
available preoperative tests provides a method of defining a specific patient's risk. An algorithm describing the
American College of Chest Physicians guidelines is provided in Figure 2 in the guidelines at
http://journal.publications.chestnet.org/pdfaccess.ashx?ResourceID=6566227&PDFSource=13 (algorithm 1).
For a figure showing the European Respiratory Society/European Society of Thoracic Surgery algorithm, please
see Figure 2 in the guidelines at http://erj.ersjournals.com/content/34/3/782.full.pdf+html.
Given the high prevalence of COPD among patients with lung cancer, screening spirometry and DLCO should be
obtained in all patients prior to lung resection.
Patients with preserved lung function should tolerate resection well in the absence of other comorbid
conditions. Preoperative values of forced expiratory volume in one second (FEV1) >2 L (or >80 percent
predicted) and DLCO >80 percent predicted suggest that the patient should be able to tolerate surgery
including pneumonectomy. (See 'Preoperative pulmonary function' above.)
For patients with preoperative FEV1 <2 L (or <80 percent predicted) or DLCO <80 percent predicted, the
predicted postoperative (PPO) FEV1 and DLCO should be calculated, based upon the preoperative values
and the fractional functional contribution of the lung to be resected (calculator 1 and calculator 2). The
fractional contribution of the lung to be resected can be estimated with quantitative perfusion scanning or
anatomic calculation, based on the number of segments to be resected. Patients with both PPO FEV1
and PPO DLCO >60 percent predicted are considered low risk and acceptable for surgical resection. (See
'Predicted postoperative pulmonary function' above and 'Current guidelines' above.)
For patients with either PPO FEV1 or PPO DLCO <60 percent predicted, but both >30 percent predicted,
a low technology exercise test (either stair climb or a shuttle walk test) should be performed. If the patient
fails to meet cutoffs for the stair climb or shuttle walk test or if either the PPO FEV1 or PPO DLCO is <30
percent, a formal cardiopulmonary exercise test is indicated with measurement of maximal oxygen
consumption (VO2 max). (See 'Integrated cardiopulmonary exercise testing' above and 'Stair climbing'
above.)
Cardiopulmonary exercise testing (CPET) is useful when the results of PPO FEV1, PPO DLCO, and/or low
technology exercise testing do not clearly define the patients risk as either high or low. (See 'Integrated
cardiopulmonary exercise testing' above and 'Guidelines' above.)
Patients who can achieve a VO2 max >20 mL/kg per minute are likely to have an acceptable rate of
postoperative complications, whereas those with a value <10 mL/kg per min (or less than 35 percent
predicted) are probably best managed by nonsurgical modalities.
For those with VO2 max values in between 10 and 20 mL/kg per minute, the predicted postoperative
(PPO) VO2 max is calculated. If the PPO VO2 max is <10 mL/kg per min or <35 percent, surgical
candidacy is poor and nonresectional options should be sought. On the other hand, if the PPO VO2
max is 10 mL/kg per min or 35 percent, resection is not absolutely contraindicated, but the patient
must understand the higher risk if either the PPO FEV1 or DLCO is <30 percent predicted.
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49. Bolliger CT, Jordan P, Solr M, et al. Exercise capacity as a predictor of postoperative complications in
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Topic 6973 Version 17.0
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GRAPHICS
Algorithm for pulmonary preoperative assessment of patients
requiring lung resection
Physiologic evaluation resec tion algorithm.

Ac tual risks affec ted by parameters defined here and:
Patient fac tors: Comorbidities, age.
Struc tural aspec ts: Center (volume, spec ialization).
Proc ess fac tors: Management of c omplic ations.
Surgic al ac c ess: Thorac otomy versus minimally invasive.
ppoDLCO: predicted postoperative diffusing capacity for carbon monoxide; ppoDLCO%:
percent predicted postoperative diffusing capacity for carbon monoxide; ppoFEV 1 : predicted
postoperative FEV 1 ; ppoFEV 1 %: percent predicted postoperative FEV 1 ; SCT: stair climb
test; SWT: shuttle walk test; CPET: cardiopulmonary exercise test; VO 2 max: maximal oxygen
consumption.
* For pneumonectomy candidates, we suggest to use Q scan to calculate predicted
postoperative values of FEV 1 or DLCO (PPO values = preoperative values X [1 - fraction of
total perfusion for the resected lung]), where the preoperative values are taken as the best
measured postbronchodilator values. For lobectomy patients, segmental counting is indicated
to calculate predicted postoperative values of FEV 1 or DLCO (PPO values = preoperative
values X [1 - y/z]), where the preoperative values are taken as the best measured
postbronchodilator value and the number of functional or unobstructed lung segments to be
removed is y and the total number of functional segments is z.

For patients with a positive high-risk cardiac evaluation deemed to be stable to proceed to
surgery we suggest to perform both pulmonary function tests and cardiopulmonary exercise
test for a more precise definition of risk.
PpoFEV 1 or ppoDLCO cut off values of 60% predicted values has been chosen based on
indirect evidences and expert consensus opinion.
Definition of risk: Low risk: The expected risk of mortality is below 1%. Major anatomic
resections can be safely performed in this group. Moderate risk: Morbidity and mortality rates
may vary according to the values of split lung functions, exercise tolerance and extent of
resection. Risks and benefits of the operation should be thoroughly discussed with the
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patient. High risk: The risk of mortality after standard major anatomic resections may be
higher than 10%. Considerable risk of severe cardiopulmonary morbidity and residual
functional loss is expected. Patients should be counseled about alternative surgical (minor
resections or minimally invasive surgery) or nonsurgical options.
From: Brunelli A, Kim AW, Berger KI, Addrizzo-Harris DJ. Physiologic evaluation of the patient with
lung cancer being considered for resectional surgery: Diagnosis and management of lung cancer,
3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest
2013;143:e166S. Reproduced with permission from the American College of Chest Physicians.
Copyright 2013.
Graphic 93550 Version 1.0
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Disclosures
Disclosures: Steven E Weinberger, MD Nothing to disclose. Talm adge E King, Jr, MD Consultant/Advisory Boards: InterMune
[pulmonary fibrosis (pirfenidone)]; ImmuneWorks [pulmonary fibrosis]; Boehringer Ingelheim [IPF (nintedanib)]; GlaxoSmithKline
[pulmonary fibrosis]; Daiichi Sankyo [pulmonary fibrosis]. Geraldine Finlay, MD Nothing to disclose.
Contributor disclosures are review ed for conflicts of interest by the editorial group. When found, these are addressed by vetting
through a multi-level review process, and through requirements for references to be provided to support the content. Appropriately
referenced content is required of all authors and must conform to UpToDate standards of evidence.
Conflict of interest policy
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Preoperative Evaluation For Lung Resection

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Preoperative evaluation for lung resection

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Preoperative evaluation for lung resection

Preoperative evaluation for lung resection

Preoperative evaluation for lung resection

Preoperative evaluation for lung resection

Preoperative evaluation for lung resection

Preoperative evaluation for lung resection

removed by wedge resection, with only 3 of 14 patients undergoing complete lobectomy.

Preoperative evaluation for lung resection

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Preoperative evaluation for lung resection

outcome. Eur Respir J 2005; 25:594.

Preoperative evaluation for lung resection

Preoperative evaluation for lung resection

Physiologic evaluation resec tion algorithm.

removed is y and the total number of functional segments is z.

Preoperative evaluation for lung resection

Preoperative evaluation for lung resection

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