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Transcript of Cu 4360450 b 74111
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Preoperative Pulmonary FunctionEvaluation in Lung Resection
Ri/
CR
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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
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Commonly Used Parameters
FEV1(Forced Expiratory Volume in 1 second)
FVC (Functional Vital Capacity)
FEV1/FVC
MVV (Maximum Voluntary Ventilation)= MBC (Maximum Breathing Capacity)
DLCO (Diffusing Capacity of Carbon Monoxide)
VO2 max (Maximum Oxygen Consumption)
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FEV1
best parameter to predict risk of post-op
complications (including death)
ppoFEV1 (predicted postoperative FEV1)
Am J of Med (2005) 118, 578583
Chest (2003) 123, 2096-2103Resp Med (2004) 98, 598-605
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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, 578583
Chest (2003) 123, 2096-2103Resp Med (2004) 98, 598-605
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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, 578583
Chest (2003) 123, 2096-2103Resp Med (2004) 98, 598-605
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VO2 max (Exercise Test)
exercise capacity (measured as VO2 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, 578583
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VO2 max
Eugene et al
VO2 max > 1 L/min little complications
Smith et al
VO2 max > 20 ml/kg/min post-op complications 10%
VO2 max = 15~20 ml/kg/min post-op complications 66%
VO2 max < 15 ml/kg/min post-op complications 100%
Markos et al
oxygen desaturation during a 12-min walk, ppoDLCO and
ppoFEV1 were more reliable predictors of post-op mortality
Chest (2003) 123, 2096-2103
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Other Parameters
FEF25-75%: highly variable
ABG: hypercapnia (>45 mmHg)
PPP (predicted postoperative product)
product of ppoFEV1 and ppoDLCO
Am J of Med (2005) 118, 578583
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Postoperative Lung Function
Pulmonary function is affected by lung
resection, extent varies:
pneumonectomy:
FEV1: 34~36%
FVC: 36~40%
VO2max: 20~28%
lobectomy:
FEV1: 9~17%
FVC: 7~11%
VO2max: 0~13%
Am J of Med (2005) 118, 578583
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Lung Resection
may undergoes up to 3 testing phases:
1st phase (whole-lung tests): room-air ABG, simple spirometry, lung
volume, (DLCO, exercise test)
i. PaCO2 > 45 mmHg
ii. FEV1 or MVV < 50% predicted
iii. RV/TLC > 50%
if any combination of the above exists proceed to 2nd phase
Chapter 49, Millers Anesthesiology, 6th Edition
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Lung Resection
2nd phase (single-lung tests): ventilation/perfusion of each lung
quantitative CT scanning
i. ppoFEV1 < 0.85 L
ii. > 70% blood flow to the diseased lung
if any of the above exists
proceed to 3rd phase
Chapter 49, Millers Anesthesiology, 6th Edition
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Prediction of Post-op Lung Function
Methods to predict postoperative
pulmonary function:
segment method
radionuclide scanning techniques
quantitative computed tomography
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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, 578583
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Radionuclide Scanning Techniques
inhaled 133Xe or intravenous 99Tc-labeled
macroaggregates
estimation by quantifying the perfusion to a
specific area:
ppoFEV1 = preoperative FEV1 * % of radioactivity
contributed by nonoperated lung
Am J of Med (2005) 118, 578583
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Quantitative Computed Tomography
-500~-910 Hounsfield unit is used to
estimate functional lung volume
correlates better than radionuclide
scanning method
AJ R (2002) 178, 667672
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Lung Resection
3rd phase (mimic post-op condition): temporary balloon occlusion (with or without
exercise) skill-demanding, rarely performed
Chapter 49, Millers Anesthesiology, 6th EditionAnn Thorac Cardiovasc Surg (2004) 10, 333-339
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Testing Phases
Chapter 49, Millers Anesthesiology, 6th Edition
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Pulmonary Function Test
Chapter 49, Millers Anesthesiology, 6th Edition
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Pre-op Predicted Post-op
FVC (L) 3.20 2.69
FEV1 (L) 1.66 (>1.2~1.0) 1.40 (>1)
FEV1/FVC (%) 51.9 (>40)RV/TLC (%) 55.0
MVV (L/min)
% predicted (%)
53.3 (>40)
69.9 (>40)
VO2 max (L/min)
VO2 max (ml/kg/min)
0.944 (15,
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Reference
1. Anesthesia for thoracic surgery, Miller: Millers Anesthesiology(2005) 6th Edition, chapter
49
2. Pulmonary function testing, Miller: Millers 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, 578583
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
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Thank you for your attention!
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predicted VO2 = 5.8 * weight in kg + 151 + 10.1 (W of workload)