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Preoperative Pulmonary Function Evaluation in Lung Resection Ri 李佩蓉 / 王奐之 CR 顏郁軒.

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Presentation on theme: "Preoperative Pulmonary Function Evaluation in Lung Resection Ri 李佩蓉 / 王奐之 CR 顏郁軒."— Presentation transcript:

1 Preoperative Pulmonary Function Evaluation in Lung Resection Ri 李佩蓉 / 王奐之 CR 顏郁軒

2 Pulmonary Function Test Preoperative pulmonary evaluation of patients with lung cancer concerns both resectability and operability. –resectability: TNM staging –operability: how much tissue can be safely removed

3 Commonly Used Parameters FEV 1 (Forced Expiratory Volume in 1 second) –FVC (Functional Vital Capacity) –FEV 1 /FVC MVV (Maximum Voluntary Ventilation) = MBC (Maximum Breathing Capacity) DLCO (Diffusing Capacity of Carbon Monoxide) VO 2 max (Maximum Oxygen Consumption)

4 FEV 1 best parameter to predict risk of post-op complications (including death) ppoFEV 1 (predicted postoperative FEV 1 ) Am J of Med (2005) 118, 578–583 Chest (2003) 123, 2096-2103 Resp Med (2004) 98, 598-605

5 MVV (MBC) largest volume breathed voluntarily in 1 min an estimate of the peak ventilation available to meet physiological demands represents respiratory muscle strength and correlates with post-op morbidity Am J of Med (2005) 118, 578–583 Chest (2003) 123, 2096-2103 Resp Med (2004) 98, 598-605

6 DLCO independent predictor for risk of post-op complications (including death) reflects alveolar membrane integrity and pulmonary capillary blood flow low DLCO implies significant emphysema, and reduced pulmonary capillary vascular bed Am J of Med (2005) 118, 578–583 Chest (2003) 123, 2096-2103 Resp Med (2004) 98, 598-605

7 VO 2 max (Exercise Test) exercise capacity (measured as VO 2 max) predictor of post-op complications (including death) –exercise oximetry –stair climbing –shuttle walking –6-minute walk test helps to identify high-risk patients who can safely undergo lung resection Am J of Med (2005) 118, 578–583

8 VO 2 max Eugene et al VO 2 max > 1 L/min  little complications Smith et al VO 2 max > 20 ml/kg/min  post-op complications 10% VO 2 max = 15~20 ml/kg/min  post-op complications 66% VO 2 max < 15 ml/kg/min  post-op complications 100% Markos et al oxygen desaturation during a 12-min walk, ppoDLCO and ppoFEV 1 were more reliable predictors of post-op mortality Chest (2003) 123, 2096-2103

9 Other Parameters FEF 25-75% : highly variable ABG: hypercapnia (>45 mmHg) PPP (predicted postoperative product) –product of ppoFEV 1 and ppoDLCO Am J of Med (2005) 118, 578–583

10 Postoperative Lung Function Pulmonary function is affected by lung resection, extent varies: –pneumonectomy: FEV 1 : 34~36%↓ FVC: 36~40%↓ VO 2 max: 20~28%↓ –lobectomy: FEV 1 : 9~17%↓ FVC: 7~11%↓ VO 2 max: 0~13%↓ Am J of Med (2005) 118, 578–583

11 Lung Resection may undergoes up to 3 testing phases: 1 st phase (whole-lung tests): room-air ABG, simple spirometry, lung volume, (DLCO, exercise test) i. PaCO 2 > 45 mmHg ii. FEV 1 or MVV 50% if any combination of the above exists → proceed to 2 nd phase Chapter 49, Miller’s Anesthesiology, 6th Edition

12 Lung Resection 2 nd phase (single-lung tests): ventilation/perfusion of each lung quantitative CT scanning i. ppoFEV 1 70% blood flow to the diseased lung if any of the above exists → proceed to 3 rd phase Chapter 49, Miller’s Anesthesiology, 6th Edition

13 Prediction of Post-op Lung Function Methods to predict postoperative pulmonary function: –segment method –radionuclide scanning techniques –quantitative computed tomography

14 Segment Method 19 total segments (right 10, left 9) estimated post-op pulmonary function = (pre-op pulmonary function) * (post-op remaining segments) / 19 subsegments also being used (total of 42 subsegments) Am J of Med (2005) 118, 578–583

15 Radionuclide Scanning Techniques inhaled 133 Xe or intravenous 99 Tc-labeled macroaggregates estimation by quantifying the perfusion to a specific area: ppoFEV 1 = preoperative FEV 1 * % of radioactivity contributed by nonoperated lung Am J of Med (2005) 118, 578–583

16 Quantitative Computed Tomography -500~-910 Hounsfield unit is used to estimate functional lung volume correlates better than radionuclide scanning method AJR (2002) 178, 667–672

17 Lung Resection 3 rd phase (mimic post-op condition): –temporary balloon occlusion (with or without exercise) → skill-demanding, rarely performed Chapter 49, Miller’s Anesthesiology, 6th Edition Ann Thorac Cardiovasc Surg (2004) 10, 333-339

18 Testing Phases Chapter 49, Miller’s Anesthesiology, 6th Edition

19 Pulmonary Function Test Chapter 49, Miller’s Anesthesiology, 6th Edition

20 Pre-opPredicted Post-op FVC (L)3.202.69 FEV 1 (L)1.66 (>1.2~1.0)1.40 (>1) FEV 1 /FVC (%)51.9 (>40) RV/TLC (%)55.0 MVV (L/min) % predicted (%) 53.3 (>40) 69.9 (>40) VO 2 max (L/min) VO 2 max (ml/kg/min) 0.944 ( 15, <20) Oxy-Hb drop in exercise (%)None (<5%) Case The patient should therefore be safe to undergo RUL lobectomy.

21 Reference 1. Anesthesia for thoracic surgery, Miller: Miller’s Anesthesiology (2005) 6th Edition, chapter 49 2. Pulmonary function testing, Miller: Miller’s Anesthesiology (2005) 6th Edition, chapter 26 3. Mazzone et al., Lung cancer: preoperative pulmonary evaluation of the lung resection candidate. Am J of Med (2005) 118, 578–583 4. Datta et al., Preoperative evaluation of patients undergoing lung resection surgery. Chest (2003) 123, 2096-2103 5. Wang et al., Pulmonary function tests in preoperative pulmonary evaluation. Resp Med (2004) 98, 598-605 6. Tanita et al., Review of preoperative functional evaluation for lung resection using the right ventricular hemodynamic functions. Ann Thorac Cardiovasc Surg (2004) 10, 333- 339 7. Wu et al., Prediction of postoperative lung function in patients with lung cancer: comparison of quantitative CT with perfusion scintigraphy. AJR (2002) 178, 667-672

22 Thank you for your attention!

23 predicted VO 2 = 5.8 * weight in kg + 151 + 10.1 (W of workload)


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