preoperative pulmonary function evaluation in lung resection ri 李佩蓉 / 王奐之 cr 顏郁軒
TRANSCRIPT
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Preoperative Pulmonary Function Preoperative Pulmonary Function Evaluation in Lung ResectionEvaluation in Lung Resection
Ri 李佩蓉 / 王奐之CR 顏郁軒
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Pulmonary Function TestPulmonary 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 ParametersCommonly 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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FEVFEV11
• best parameter to predict risk of post-op complications (including death)
• ppoFEV1 (predicted postoperative FEV1)
Am J of Med (2005) 118, 578–583Am J of Med (2005) 118, 578–583Chest (2003) 123, 2096-2103Chest (2003) 123, 2096-2103
Resp Med (2004) 98, 598-605Resp Med (2004) 98, 598-605
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MVV (MBC)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, 578–583Am J of Med (2005) 118, 578–583Chest (2003) 123, 2096-2103Chest (2003) 123, 2096-2103
Resp Med (2004) 98, 598-605Resp Med (2004) 98, 598-605
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DLCODLCO
• 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, 578–583Am J of Med (2005) 118, 578–583Chest (2003) 123, 2096-2103Chest (2003) 123, 2096-2103
Resp Med (2004) 98, 598-605Resp Med (2004) 98, 598-605
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VOVO22 max (Exercise Test) 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, 578–583Am J of Med (2005) 118, 578–583
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VOVO22 max 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, 2096-2103Chest (2003) 123, 2096-2103
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Other ParametersOther Parameters
• FEF25-75%: highly variable
• ABG: hypercapnia (>45 mmHg) • PPP (predicted postoperative product)
– product of ppoFEV1 and ppoDLCO
Am J of Med (2005) 118, 578–583Am J of Med (2005) 118, 578–583
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Postoperative Lung FunctionPostoperative Lung Function
• Pulmonary function is affected by lung resection, extent varies:– pneumonectomy:
• FEV1: 34~36%↓
• FVC: 36~40%↓
• VO2 max: 20~28%↓
– lobectomy:• FEV1: 9~17%↓
• FVC: 7~11%↓
• VO2 max: 0~13%↓
Am J of Med (2005) 118, 578–583Am J of Med (2005) 118, 578–583
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Lung ResectionLung Resection
• may undergoes up to 3 testing phases:
• 1st phase (whole-lung tests): • room-air ABG, simple spirometry, lung volum
e, (DLCO, exercise test)
i. PaCO2 > 45 mmHgii. FEV1 or MVV < 50% predictediii. RV/TLC > 50%
• if any combination of the above exists→ proceed to 2nd phase
Chapter 49, Miller’s Anesthesiology, 6th EditionChapter 49, Miller’s Anesthesiology, 6th Edition
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Lung ResectionLung Resection
• 2nd phase (single-lung tests):• ventilation/perfusion of each lung• quantitative CT scanning
i. ppoFEV1 < 0.85 Lii. > 70% blood flow to the diseased lung
• if any of the above exists→ proceed to 3rd phase
Chapter 49, Miller’s Anesthesiology, 6th EditionChapter 49, Miller’s Anesthesiology, 6th Edition
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Prediction of Post-op Lung FunctionPrediction of Post-op Lung Function
• Methods to predict postoperative pulmonary function:– segment method– radionuclide scanning techniques– quantitative computed tomography
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Segment MethodSegment 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, 578–583Am J of Med (2005) 118, 578–583
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Radionuclide Scanning TechniquesRadionuclide 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, 578–583Am J of Med (2005) 118, 578–583
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Quantitative Computed TomographyQuantitative Computed Tomography
• -500~-910 Hounsfield unit is used to estimate functional lung volume
• correlates better than radionuclide scanning method
AJR (2002) 178, 667–672AJR (2002) 178, 667–672
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Lung ResectionLung Resection
• 3rd phase (mimic post-op condition):– temporary balloon occlusion (with or without exe
rcise) → skill-demanding, rarely performed
Chapter 49, Miller’s Anesthesiology, 6th EditionChapter 49, Miller’s Anesthesiology, 6th EditionAnn Thorac Cardiovasc Surg (2004) 10, 333-339Ann Thorac Cardiovasc Surg (2004) 10, 333-339
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Testing PhasesTesting Phases
Chapter 49, Miller’s Anesthesiology, 6th EditionChapter 49, Miller’s Anesthesiology, 6th Edition
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Pulmonary Function TestPulmonary Function Test
Chapter 49, Miller’s Anesthesiology, 6th EditionChapter 49, Miller’s 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 (<1)15.9 (>15, <20)
Oxy-Hb drop in exercise (%) None (<5%)
CaseCase
The patient should therefore be safe to undergo RUL lobectomy.
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ReferenceReference
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
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Thank you for your attention!Thank you for your attention!
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predicted VO2 = 5.8 * weight in kg + 151 + 10.1 (W of workload)