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Puri V, Zoole JB, Musick J, Krupnick AS, Kreisel D, Crabtree TD, Patterson GA, Meyers BF. Handheld Office-Based Spirometry versus Laboratory Spirometry in Low-Risk Patients Undergoing Lung Resection. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2011. [DOI: 10.1177/155698451100600409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Varun Puri
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO USA
| | - Jennifer B. Zoole
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO USA
| | - Joanne Musick
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO USA
| | - Alexander S. Krupnick
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO USA
| | - Daniel Kreisel
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO USA
| | - Traves D. Crabtree
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO USA
| | - G. Alexander Patterson
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO USA
| | - Bryan F. Meyers
- Division of Cardiothoracic Surgery, Department of Surgery, Washington University School of Medicine, St. Louis, MO USA
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Handheld Office-Based Spirometry versus Laboratory Spirometry in Low-Risk Patients Undergoing Lung Resection. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2011; 6:257-61. [DOI: 10.1097/imi.0b013e31822a3709] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Objective To compare handheld office spirometry with laboratory spirometry in evaluation of low-risk patients undergoing pulmonary resection. Methods Low-risk patients evaluated for lung resection were enrolled in a prospective study and underwent office and laboratory spirometry. Standard laboratory spirometry values were considered the gold standard. Values of forced expiratory volume in 1 second (FEV1) <1.5 L or FEV1% <60% were determined in advance to signal high risk. Results Thirty patients with mean age 64 ± 12 years and median Karnofsky performance status 100 (80–100) were evaluated. The mean FEV1-office spirometry and mean FEV1-laboratory spirometry were comparable (2.14 L vs 2.36 L) as were the mean FEV1%-office spirometry and FEV1%-laboratory spirometry (78% vs 85%). The differences were within limits established a priori. Laboratory spirometry identified 3 of 30 (10%) patients as high risk and office spirometry identified 5 of 30 (16%) patients as high risk, including the 3 patients identified by laboratory spirometry. The sensitivity of office spirometry for detecting high risk was 100% (3/3) and specificity was 93% (25/27). The negative predictive value of office spirometry was 100% (25/25). Office spirometry added a median of 1 minute to the office visit, whereas laboratory spirometry added 42 minutes. Eventually, 25 of 30 (83%) patients underwent lung resection. There were 12 lobar and 13 sublobar resections. One patient developed postoperative respiratory morbidity. This patient was high risk by office spirometry but not by laboratory spirometry. This patient was discharged on home oxygen. Conclusions Office spirometry FEV1 and FEV1% are clinically comparable to formal laboratory spirometry values. Office Spirometry saves time and possibly expense in the preoperative workup of patients evaluated for lung resection.
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Vuckovic KM, Fink AM. The 6-min walk test: is it an effective method for evaluating heart failure therapies? Biol Res Nurs 2011; 14:147-59. [PMID: 21586495 DOI: 10.1177/1099800411403918] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The 6-min walk (6MW) is a self-paced test for measuring functional capacity. Lower 6MW distances have been associated with adverse outcomes in patients with heart failure. The purpose of this article is to describe the history of the 6MW test and to evaluate its reliability, validity, and predictive value as well as the responsiveness of the test to therapies. In the literature we reviewed, reliability was affected by several factors including learning effects and protocol deviations. The 6MW distance was moderately correlated with peak oxygen consumption derived from cardiopulmonary exercise stress testing. In some studies the 6MW distance was predictive of hospitalization and mortality. In pharmacological and cardiac resynchronization trials the 6MW distance did not consistently detect clinical improvements. Despite limitations, the 6MW test is a viable alternative to stress testing for objectively evaluating functional capacity in some settings. We provide recommendations for using the 6MW test in future studies.
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Affiliation(s)
- Karen M Vuckovic
- Department of Biobehavioral Health Science, College of Nursing, University of Illinois at Chicago, Chicago, IL 60612, USA.
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Abstract
Preoperative evaluation of patients undergoing lung resection remains an interdisciplinary challenge. Despite substantial progress in anesthesiology, intensive care medicine and surgery, mortality of patients undergoing pneumonectomy remains high at 5-9%. Guidelines were developed to identify patients with an increased perioperative risk for morbidity and mortality. These guidelines are focused around the forced expiratory capacity (FEV) measured by spirometry, following further investigations in patients with limited FEV(1). Extended testing includes measurement of the diffusion capacity, calculation of postoperative predicted values of lung function and spiroergometry to determine maximal oxygen uptake. In this article the methods to measure parameters of lung function and gas exchange are described and evaluated in the context of the current guidelines.
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Cataneo DC, Kobayasi S, Carvalho LRD, Paccanaro RC, Cataneo AJM. Accuracy of six minute walk test, stair test and spirometry using maximal oxygen uptake as gold standard. Acta Cir Bras 2010; 25:194-200. [PMID: 20305888 DOI: 10.1590/s0102-86502010000200013] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2009] [Accepted: 12/07/2009] [Indexed: 11/22/2022] Open
Abstract
PURPOSE: To assess the accuracy of the variables stair climbing time (SCt), stair climbing power (SCP), six-minute walk test distance (6MWT), and forced expiratory volume in 1 second (FEV1) using maximal oxygen uptake on exercise (VO2max) as the gold standard. METHODS: Tests were performed in 51 patients. FEV1 was measured by spirometry and 6MWT was performed in a flat 120-m corridor. Stair climbing test was performed on a 6-flight stairway to obtain SCt and SCP. VO2max was measured by ergospirometry, using the Balke protocol. Pearson's linear correlation and p values were calculated between VO2max and the other variables tested. For accuracy calculations, variable cutoff points were obtained through receiver operating characteristic (ROC) curves, dividing individuals into normal or unhealthy. Kappa statistic was used to calculate concordance. RESULTS: Accuracy was: SCt - 86%, 6MWT - 80%, SCP - 71%, FEV1(L) - 67%, FEV1(%) - 63%. SCt and 6MWT showed 93.5% sensitivity when combined in parallel, and 96.4% specificity in series. CONCLUSION: SCt presented the best accuracy. SCt and 6MWT combined showed nearly 100% sensitivity or specificity. Thus, these simple exercise tests should be more routinely used, especially when an ergospirometer is not available to measure VO2max.
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Brunelli A. Risk Assessment for Pulmonary Resection. Semin Thorac Cardiovasc Surg 2010; 22:2-13. [DOI: 10.1053/j.semtcvs.2010.04.002] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/05/2010] [Indexed: 12/20/2022]
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Perrault H, Baril J, Henophy S, Rycroft A, Bourbeau J, Maltais F. Paced-walk and step tests to assess exertional dyspnea in COPD. COPD 2010; 6:330-9. [PMID: 19863362 DOI: 10.1080/15412550903156317] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
This study reports on the development and test-retest reproducibility of a modified shuttle walking and step testing protocols to assess exertional dyspnea in patients with COPD. Patients with COPD randomly performed four externally paced 3-min bouts of shuttle walking at 1.5, 2.5, 4.0 and 6.0 km x h(- 1) or stepping at constant rate of 18, 22, 26 and 32 steps x min(- 1). Walking and stepping procedures were repeated once, on a separate occasion. Ventilation, heart rate, gas exchange parameters and dyspnea Borg scores were obtained at the end of each exercise bout. Most patients completed walking or stepping at the slow and middle speed cadences but only 33% completed walking at 6.0 km x h(- 1) and 40% completed stepping at 32 steps x min(- 1). Walking and stepping at progressively faster pace caused a progressive increase in ventilation and dyspnea. Test-retest Pearson correlation coefficients for ventilation, heart rate, gas exchange parameters and dyspnea scores over the four exercise bouts, all exceeded 0.80. Intra-class correlation coefficients were at least as strong as Pearson coefficients. Bland & Altman representation showed that for repeated Borg scores, 92 and 96% of points lied within 2 SD of the mean difference between test-retest values for walking and stepping. The majority of moderate and severe COPD patients completed the 3-min shuttle waking testing at 1.5 to 4.0 km x h(- 1) and the 3-min of step testing at rates between 18 and 26 steps x min(- 1). Both field tests were highly reproducible in patients with COPD.
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Affiliation(s)
- Hélène Perrault
- Respiratory Epidemiology and Clinical Research Unit of the Montreal Chest Institute, McGill University Health Center, Montreal, Quebec, Canada.
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Abstract
Lung cancer diagnosis and treatment has evolved to require the input and expertise of multiple diverse medical and surgical specialties. The approach to lung cancer patients requires the adherence to a few principles that include thorough use of staging modalities to assure the proper treatment for each patient, and an understanding of the limitations and advantages of each of these modalities. Evidence is continuing to emerge that supports the notion that diagnostic workup and treatment of lung cancer patients is best done within the context of a multidisciplinary team devoted to this purpose.
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Kashiwabara K, Sasaki JI, Mori T, Nomori H, Fujii K, Kohrogi H. Relationship Between Functional Preservation after Segmentectomy and Volume-Reduction Effects after Lobectomy in Stage I Non-small Cell Lung Cancer Patients with Emphysema. J Thorac Oncol 2009; 4:1111-6. [DOI: 10.1097/jto.0b013e3181ae59e2] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Villiot-Danger E. Un test d’escalier dans l’évaluation des patients atteints de BPCO. Rev Mal Respir 2009; 26:530-6. [DOI: 10.1016/s0761-8425(09)74672-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Bernstein WK, Deshpande S. Preoperative evaluation for thoracic surgery. Semin Cardiothorac Vasc Anesth 2009; 12:109-21. [PMID: 18635562 DOI: 10.1177/1089253208319868] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The goal of the preoperative evaluation for thoracic surgery is to assess and implement measures to decrease perioperative complications and prepare high-risk patients for surgery. Major respiratory complications, such as atelectasis, pneumonia, and respiratory failure, occur in 15% to 20% of patients and account for most of the 3% to 4% mortality rate. Development of pulmonary complications has been associated with higher postoperative mortality rates. Strategies aimed at preventing postoperative difficulties have the potential to reduce morbidity and mortality, decrease hospital stay, and improve resource use. One lung ventilation leads to a significant derangement of gas exchange, and hypoxemia can develop due to increased intrapulmonary shunting. Recent advances in anesthetic management, monitoring devices, improved lung isolation techniques, and improved critical care management have increased the number of patients who were previously considered inoperable. In addition, there is a growing tendency to offer surgery to patients with significant lung function impairment; hence a higher incidence of intraoperative gas-exchange abnormalities can be expected. The anesthesiologist must also consider the risks of denying or postponing a potentially curative operation in patients with lung cancer. Detailed consideration of the information provided by preoperative testing is essential to successful outcomes following thoracic surgery.
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Affiliation(s)
- Wendy K Bernstein
- Department of Anesthesiology, University of Maryland School of Medicine, Baltimore, Maryland 21201, USA.
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Brunelli A, Refai M, Xiumé F, Salati M, Sciarra V, Socci L, Sabbatini A. Performance at symptom-limited stair-climbing test is associated with increased cardiopulmonary complications, mortality, and costs after major lung resection. Ann Thorac Surg 2008; 86:240-7; discussion 247-8. [PMID: 18573431 DOI: 10.1016/j.athoracsur.2008.03.025] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2008] [Revised: 03/09/2008] [Accepted: 03/14/2008] [Indexed: 10/21/2022]
Abstract
BACKGROUND Exercise tests are increasingly used during preoperative evaluation before lung resection. This study assessed the association between performance at the symptom-limited stair-climbing test and postoperative cardiopulmonary morbidity, mortality, and costs after major lung resections. METHODS As part of their routine preoperative evaluation, 640 patients who had lobectomy (n = 533) or pneumonectomy (n = 107) for lung cancer from January 2000 through April 2007 performed a preoperative symptom-limited stair-climbing test. Sensitivity/specificity analysis was used to identify the best cutoff values of altitude climbed (number of steps x height of the step in m) associated with outcome. Univariate and multivariate regression analyses (validated by bootstrap) were used to test associations between preoperative and operative factors and postoperative cardiopulmonary complications, mortality, and postoperative costs. RESULTS The altitude reached at the stair-climbing test was reliably associated with increased cardiopulmonary complications (p = 0.04), mortality (p = 0.02), and costs (p < 0.0001). In patients who climbed less than 12 m, cardiopulmonary complications, mortality, and costs were 2-fold (p < 0.0001), 13-fold (p < 0.0001), and 2.5-fold higher, respectively, than in patients who climbed more than 22 m. CONCLUSIONS Performance at a maximal stair-climbing test was reliably associated with postoperative morbidity and mortality. We recommend the use of this simple and economic test in all lung resection candidates. Patients who perform poorly at the stair-climbing test should undergo a formal cardiopulmonary exercise test with measurement of oxygen consumption to optimize their perioperative management.
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Brunelli A, Salati M. Preoperative evaluation of lung cancer: predicting the impact of surgery on physiology and quality of life. Curr Opin Pulm Med 2008; 14:275-81. [DOI: 10.1097/mcp.0b013e328300caac] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Abstract
Preoperative evaluation before lung resection has been frequently addressed in modern medical literature. Actual or predicted pulmonary volumes are considered relevant to predict the risk of surgery. Nevertheless, ppoFEV1 underestimates the real functional loss in the immediate postoperative period when most of the complications occur. Not all patients, however, have comparable functional changes after lobectomy. Minimal impairment or even improvements have been demonstrated in COPD cases after lobectomy. Efforts should be directed to an accurate prediction of the immediate postoperative pulmonary volumes for a better evaluation of high-risk patients caused by respiratory impairment. Future developments are needed on the role of measuring preoperative DLCO and how to evaluate a patient's general cardiorespiratory status. Evidence underlines the relevance of routine evaluation of preoperative DLCO at rest or, better, during exercise for a thorough assessment of patient's capability to adapt to a stressful situation (Fig. 3). Only by improving knowledge about the general condition of the patient, can one assess the physiologic response to surgery. Widespread use of sophisticated or simple exercise tests and measurements or daily activity using motion detectors can identify high-risk patients with otherwise acceptable pulmonary volumes. Another suggested investigation issue is to develop different relevant outcome parameters, not only from the surgeon's point of view but also from the patient's perspective, such as postoperative QOL-related variables or delayed outcomes. Finally, multidisciplinary investigation teams, including experts in mathematical modeling, are essential to improve the quality and validity of the developed models. Although knowledge about perioperative physiologic changes has increased, clinicians are still far from finding a way to put all this knowledge down and make it applicable for an individual patient. Multicentric cooperation and evaluation of large prospectively recorded databases are essential to develop evidence-based clinical guidelines on preoperative evaluation.
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Koegelenberg CFN, Diacon AH, Irani S, Bolliger CT. Stair climbing in the functional assessment of lung resection candidates. Respiration 2008; 75:374-9. [PMID: 18272936 DOI: 10.1159/000116873] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2007] [Accepted: 11/27/2007] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Algorithms for the pre-operative evaluation of lung resection candidates with impaired lung function invariably include maximum oxygen uptake (VO(2)MAX) as a critical parameter of functional reserves, with a VO(2)MAX >or=20 ml/kg/min generally considered sufficient for pneumonectomy. Stair climbing is a low-cost alternative to assess exercise capacity. OBJECTIVES As stair climbing is not standardised, we aimed to compare the altitude reached and the speed of ascent with VO(2)MAX measured by cycle ergometry. METHODS We prospectively enrolled 44 pulmonary resection candidates (mean age: 47.6 +/- 12.5 years) with an FEV(1) <80%. Patients were asked to climb as high and as fast as they could, to a maximum elevation of 20 m. The altitude reached and the average speed of ascent were compared to VO(2)MAX. RESULTS Forty-three patients reached a 20-metre elevation. Thirteen of them, as well as the patient who did not reach this height, had a VO(2)MAX <20 ml/kg/min. There was a linear correlation between speed of ascent and VO(2)MAX/kg (R(2) = 0.67), but not between altitude and VO(2)MAX/kg. All 24 patients with a speed >or=15 m/min had a VO(2)MAX >or=20 ml/kg/min. Thirty-nine of 40 patients with a speed >or=12 m/min had a VO(2)MAX >or=15 ml/kg/min. CONCLUSIONS The average speed of ascent during stair climbing was an accurate semiquantitative predictor of VO(2)MAX/kg, whereas altitude was not. We were able to identify potential cut-off values for lobectomy or pneumonectomy. Pending validation with clinical endpoints, stair climbing may replace formal exercise testing at much lower costs in a large proportion of lung resection candidates.
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Ferguson MK, Lehman AG, Bolliger CT, Brunelli A. The Role of Diffusing Capacity and Exercise Tests. Thorac Surg Clin 2008; 18:9-17, v. [DOI: 10.1016/j.thorsurg.2007.11.001] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Bapoje SR, Whitaker JF, Schulz T, Chu ES, Albert RK. Preoperative Evaluation of the Patient With Pulmonary Disease. Chest 2007; 132:1637-45. [DOI: 10.1378/chest.07-0347] [Citation(s) in RCA: 94] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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Colice GL, Shafazand S, Griffin JP, Keenan R, Bolliger CT. Physiologic evaluation of the patient with lung cancer being considered for resectional surgery: ACCP evidenced-based clinical practice guidelines (2nd edition). Chest 2007; 132:161S-77S. [PMID: 17873167 DOI: 10.1378/chest.07-1359] [Citation(s) in RCA: 282] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND This section of the guidelines is intended to provide an evidence-based approach to the preoperative physiologic assessment of a patient being considered for surgical resection of lung cancer. METHODS Current guidelines and medical literature applicable to this issue were identified by computerized search and evaluated using standardized methods. Recommendations were framed using the approach described by the Health and Science Policy Committee. RESULTS The preoperative physiologic assessment should begin with a cardiovascular evaluation and spirometry to measure the FEV(1). If diffuse parenchymal lung disease is evident on radiographic studies or if there is dyspnea on exertion that is clinically out of proportion to the FEV(1), the diffusing capacity of the lung for carbon monoxide (Dlco) should also be measured. In patients with either an FEV(1) or Dlco < 80% predicted, the likely postoperative pulmonary reserve should be estimated by either the perfusion scan method for pneumonectomy or the anatomic method, based on counting the number of segments to be removed, for lobectomy. An estimated postoperative FEV(1) or Dlco < 40% predicted indicates an increased risk for perioperative complications, including death, from a standard lung cancer resection (lobectomy or greater removal of lung tissue). Cardiopulmonary exercise testing (CPET) to measure maximal oxygen consumption (Vo(2)max) should be performed to further define the perioperative risk of surgery; a Vo(2)max of < 15 mL/kg/min indicates an increased risk of perioperative complications. Alternative types of exercise testing, such as stair climbing, the shuttle walk, and the 6-min walk, should be considered if CPET is not available. Although often not performed in a standardized manner, patients who cannot climb one flight of stairs are expected to have a Vo(2)max of < 10 mL/kg/min. Data on the shuttle walk and 6-min walk are limited, but patients who cannot complete 25 shuttles on two occasions will likely have a Vo(2)max of < 10 mL/kg/min. Desaturation during an exercise test has not clearly been associated with an increased risk for perioperative complications. Lung volume reduction surgery (LVRS) improves survival in selected patients with severe emphysema. Accumulating experience suggests that patients with extremely poor lung function who are deemed inoperable by conventional criteria might tolerate combined LVRS and curative-intent resection of lung cancer with an acceptable mortality rate and good postoperative outcomes. Combining LVRS and lung cancer resection should be considered in patients with a cancer in an area of upper lobe emphysema, an FEV(1) of > 20% predicted, and a Dlco of > 20% predicted. CONCLUSIONS A careful preoperative physiologic assessment will be useful to identify those patients who are at increased risk with standard lung cancer resection and to enable an informed decision by the patient about the appropriate therapeutic approach to treating their lung cancer. This preoperative risk assessment must be placed in the context that surgery for early-stage lung cancer is the most effective currently available treatment for this disease.
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Affiliation(s)
- Gene L Colice
- Director, Pulmonary, Critical Care, and Respiratory Services, Washington Hospital Center, 110 Irving St NW, Washington, DC 20010, USA.
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Bayram AS, Candan T, Gebitekin C. Preoperative maximal exercise oxygen consumption test predicts postoperative pulmonary morbidity following major lung resection. Respirology 2007; 12:505-10. [PMID: 17587416 DOI: 10.1111/j.1440-1843.2007.01097.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND OBJECTIVE Pulmonary resection carries a significant morbidity and mortality. The utility of maximal oxygen uptake test (VO(2)max) to predict cardiopulmonary complications following major pulmonary resection was evaluated. METHODS Following standard preoperative work-up and VO(2)max testing, 55 patients (49 male; mean age 59 years, range 20-74) underwent major pulmonary surgery: lobectomy (n = 31), bilobectomy (n = 6) and pneumonectomy (n = 18). An investigator blinded to the preoperative assessment prospectively collected data on postoperative cardiopulmonary complications. Patients were divided into two groups according to preoperative VO(2)max and also according to FEV(1). The frequency of postoperative complications in the groups was compared. RESULTS Complications were observed in 19 (34.5%) patients, 11 of which were pulmonary (20%). There were two deaths (3.6%), both due to respiratory failure. Preoperative FEV(1) failed to predict postoperative respiratory complications. Five of 36 patients with a preoperative FEV(1) > 2 L suffered pulmonary complications, compared with six of 19 patients with FEV(1) < 2 L. Cardiopulmonary complications were not observed in patients with VO(2)max > 15 mL/kg/min (n = 27); however, 11 patients with VO(2)max < 15 mL/kg/min (n = 28) suffered cardiopulmonary complications (P < 0.05). CONCLUSION VO(2)max predicts postoperative pulmonary complications following major lung resection, and the risk of complications increases significantly when the preoperative VO(2)max is less than 15 mL/kg/min.
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Affiliation(s)
- Ahmet Sami Bayram
- Medical Faculty, Department of Thoracic Surgery, Uludag University, Bursa, Turkey.
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Brunelli A, Rocco G, Varela G. Predictive Ability of Preoperative Indices for Major Pulmonary Surgery. Thorac Surg Clin 2007; 17:329-36. [DOI: 10.1016/j.thorsurg.2007.07.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Weinstein H, Bates AT, Spaltro BE, Thaler HT, Steingart RM. Influence of preoperative exercise capacity on length of stay after thoracic cancer surgery. Ann Thorac Surg 2007; 84:197-202. [PMID: 17588411 DOI: 10.1016/j.athoracsur.2007.02.003] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2005] [Revised: 01/29/2007] [Accepted: 02/02/2007] [Indexed: 11/17/2022]
Abstract
BACKGROUND Stress testing is frequently used to assess cardiac risk before thoracic surgery. However, the relationship between treadmill exercise capacity and length of stay (LOS) has not been investigated. We hypothesized that exercise capacity, a strong predictor of long-term prognosis, can also predict LOS after thoracic cancer surgery. METHODS Accordingly, 191 consecutive patients who had exercise stress testing before major thoracic cancer surgery were retrospectively grouped by poor (<4 metabolic equivalents [METs], n = 31), fair (4 to 7 METs, n = 107), good (7 to 10 METs, n = 30), and excellent (>10 METs, n = 23) exercise capacity. The relationship between exercise capacity and LOS was then determined. RESULTS Average LOS was inversely related to exercise capacity, with a nearly twofold increase in LOS between the excellent and poor exercise groups (4.8 versus 9.2 days). This relationship remained significant even after controlling for operation type, history of dyspnea, sex, and smoking history in analysis of covariance. Prolonged hospital stay (10 days or more) was strongly predicted by exercise capacity. Failure to exceed 4 METs was associated with a high risk of prolonged stay (9 of 31, 39%), whereas none of the 23 patients who exceeded 10 METs had a prolonged stay. CONCLUSIONS Treadmill exercise capacity has independent predictive value for LOS and risk of prolonged stay after thoracic cancer surgery. These findings have important implications for risk assessment and cost, suggesting that preoperative programs designed to improve exercise capacity may favorably influence LOS and associated costs.
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Affiliation(s)
- Howard Weinstein
- Department of Medicine, Division of Cardiology, Memorial Sloan-Kettering Cancer Center, New York, New York 10021, USA.
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Benzo R, Kelley GA, Recchi L, Hofman A, Sciurba F. Complications of lung resection and exercise capacity: a meta-analysis. Respir Med 2007; 101:1790-7. [PMID: 17408941 PMCID: PMC1994074 DOI: 10.1016/j.rmed.2007.02.012] [Citation(s) in RCA: 107] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2006] [Revised: 02/14/2007] [Accepted: 02/16/2007] [Indexed: 01/14/2023]
Abstract
RATIONALE While exercise capacity, expressed as maximal oxygen consumption (VO2max), has been proposed to be the best predictor of postoperative cardiopulmonary complications after surgical resection in lung cancer patients, the literature remains controversial. The purpose of this study was to use the meta-analytic approach to determine if VO2max, expressed as either ml kg(-1) min(-1) or as a percentage of predicted, differed between patients who develop postoperative cardiopulmonary complications versus those that do not. METHODS Studies were retrieved via (1) computerized literature searches, (2) cross referencing from retrieved articles, and (3) expert review of our reference list. Trials were included if they reported preoperative VO2max values (ml kg(-1) min(-1) or percentage of predicted) and had patients in which postoperative cardiopulmonary complications occurred. RESULTS Fourteen studies representing a total of 955 men and women met our criteria for inclusion. Across all designs and categories, random-effects modeling demonstrated that patients without postoperative pulmonary complications had significantly higher levels of VO2max in ml kg(-1) min(-1) (mean difference=3.0, 95% confidence interval (CI), 1.9-4.0) as well as VO2max as a percentage of predicted (mean difference=8, 95% CI, 3.3-12.8). CONCLUSION After a systematic review of the literature, we found that exercise capacity, expressed as VO2max, is lower in patients that develop clinically relevant complications after curative lung resection. These results are important for the practicing clinician because they answer the literature controversy on the usefulness of measuring preoperative exercise capacity and reinforce the current guidelines on decision making for lung resection.
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Affiliation(s)
- Roberto Benzo
- Division of Pulmonary & Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA 15213, USA.
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Cataneo DC, Cataneo AJM. Acurácia do teste de escada utilizando o consumo máximo de oxigênio como padrão-ouro. J Bras Pneumol 2007; 33:128-33. [PMID: 17724530 DOI: 10.1590/s1806-37132007000200005] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2006] [Accepted: 08/03/2006] [Indexed: 11/21/2022] Open
Abstract
OBJETIVO: Determinar a acurácia dos atributos do teste de escada (TE) de altura definida utilizando como padrão-ouro o consumo máximo de oxigênio (VO2 máx). MÉTODOS: O TE foi realizado com incentivo, em escada (6 lances; 72 degraus; 12,16 m de altura total), em 51 pacientes. O 'tempo' de subida foi cronometrado e o 'trabalho' e a 'potência' calculados. O VO2 máx foi obtido por ergoespirometria, utilizando-se o protocolo de Balke. Foram calculados a correlação linear de Pearson (r) e os valores de p entre as variáveis do TE e o VO2 máx. Para o cálculo da acurácia, o ponto de corte do VO2 máx foi estabelecido em 25 mL/kg/min, estratificando os indivíduos em normais ou alterados. Os pontos de corte para os atributos do TE foram obtidos através da curva receiver operating characteristic. A estatística Kappa (k) foi utilizada para estudo da concordância. RESULTADOS: Obtiveram-se os seguintes valores para a variável 'tempo': ponto de corte = 40 s; x= 41 ± 15,5 s; r = -0,707; p < 0,005; especificidade = 89%; sensibilidade = 83%; acurácia = 86% e k = 0,724. Para a variável 'potência', obteve-se ponto de corte = 200 w; x= 222,3 ± 95,2 w; r = 0,515; p < 0,005; especificidade = 67%; sensibilidade = 75%; acurácia = 71% e k = 0,414. A correlação de 'trabalho' com o VO2 máx não foi significativa, sendo esse atributo descartado. CONCLUSÃO: Dos atributos testados do TE, tendo como padrão-ouro o VO2 máx, a variável 'tempo' foi a que apresentou a melhor acurácia.
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Affiliation(s)
- Daniele Cristina Cataneo
- Department of Thoracic Surgery, Júlio de Mesquita Filho Universidade Estadual Paulista-UNESP, Paulista State University at Botucatu School of Medicine, Botucatu, SP, Brazil.
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Shaw A. Genetics of postoperative complications following thoracic surgery. Semin Cardiothorac Vasc Anesth 2007; 10:327-45. [PMID: 17200090 DOI: 10.1177/1089253206294368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The field of complex trait-gene interaction research has expanded exponentially in recent years, and new insights into the ways patients respond to surgical stimuli have arisen from this body of work. From a physiological systems perspective, thoracic surgical procedures (thoracotomy in particular) represent a massive input stimulus, and it is, therefore, not surprising that approximately 30% of these patients experience an adverse postoperative event. The best risk prediction models have typically explained about 60% to 70% of the risk, leaving a large residual component unaccounted for. It is quite possible that there is a genetic (heritable) component to this residual risk. This article explores some of the concepts underlying gene-disease interactions, the preliminary work that has been done to date in this area, and finally discusses some of the more important methodological issues involved in complex trait association study design.
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Affiliation(s)
- Andrew Shaw
- Division of Cardiothoracic Anesthesia and Critical Care Medicine, Duke University Medical Center, Durham, NC 27710, USA.
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78
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Michelet P, Jaber S, Eledjam JJ, Auffray JP. Prise en charge anesthésique de l'œsophagectomie: avancées et perspectives. ACTA ACUST UNITED AC 2007; 26:229-41. [PMID: 17270381 DOI: 10.1016/j.annfar.2006.11.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2006] [Accepted: 11/21/2006] [Indexed: 01/06/2023]
Abstract
Oesophagectomy is still characterized by a high postoperative mortality and respiratory morbidity. Nevertheless, epidemiological, medical and surgical advances have improved the management of this surgical procedure. The anaesthesiologist influence is present at each level, from the preoperative evaluation to the management of postoperative complications. The preoperative period is improved by the use of assessment scores, the better knowing of respiratory risk factors and of the neoadjuvant therapy adverse effects. The main objective of the operative period is to ensure a rapid weaning procedure and stability of the respiratory and haemodynamic functions, warranting the anastomotic healing. The interest of the association between respiratory rehabilitation and thoracic epidural analgesia is highlighted in the postoperative period. The management of postoperative complications, mainly represented by respiratory failure and anastomotic leakages, requires a multidisciplinary analysis. The potential interest of non-invasive ventilation and of the modulation of postoperative inflammatory response needs further investigation.
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Affiliation(s)
- P Michelet
- Département d'anesthésie-réanimation, hôpital Sainte-Marguerite, 270, boulevard Sainte-Marguerite, 13009 Marseille, France.
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79
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Brunelli A, Xiumé F, Refai M, Salati M, Marasco R, Sciarra V, Sabbatini A. Evaluation of Expiratory Volume, Diffusion Capacity, and Exercise Tolerance Following Major Lung Resection. Chest 2007; 131:141-7. [PMID: 17218568 DOI: 10.1378/chest.06-1345] [Citation(s) in RCA: 83] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Lung resections determine a variable functional reduction depending on the extent of the resection and the time elapsed from the operation. The objectives of this study were to prospectively investigate the postoperative changes in FEV(1), carbon monoxide lung diffusion capacity (Dlco), and exercise tolerance after major lung resection at repeated evaluation times. METHODS FEV(1), Dlco, and peak oxygen consumption (Vo(2)peak) calculated using the stair climbing test were measured in 200 patients preoperatively, at discharge, and 1 month and 3 months after lobectomy or pneumonectomy. Preoperative and repeated postoperative measures were compared, and a time-series, cross-sectional regression analysis was performed to identify factors associated with postoperative Vo(2)peak. RESULTS One month after lobectomy, FEV(1), Dlco, and Vo(2)peak values were 79.5%, 81.5%, and 96% of preoperative values and recovered up to 84%, 88.5%, and 97% after 3 months, respectively. One month after pneumonectomy, FEV(1) percentage of predicted, Dlco percentage of predicted, and Vo(2)peak values were 65%, 75%, and 87% of preoperative values, and were 66%, 80%, and 89% after 3 months, respectively. Three months after lobectomy, 27% of patients with COPD had improved FEV(1), 34% had improved Dlco, and 43% had improved Vo(2)peak compared to preoperative values. The time-series, cross-sectional regression analysis showed that postoperative Vo(2)peak values were directly associated with preoperative values of Vo(2)peak, and postoperative values of FEV(1) and Dlco, and were inversely associated with age and body mass index. CONCLUSIONS Our findings may be used during preoperative counseling and for deciding eligibility for operation along with other more traditional measures of outcome.
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80
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Brunelli A, Xiume' F, Al Refai M, Salati M, Marasco R, Sabbatini A. Gemcitabine-Cisplatin Chemotherapy Before Lung Resection: A Case-Matched Analysis of Early Outcome. Ann Thorac Surg 2006; 81:1963-8. [PMID: 16731114 DOI: 10.1016/j.athoracsur.2006.01.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2005] [Revised: 12/23/2005] [Accepted: 01/03/2006] [Indexed: 11/23/2022]
Abstract
BACKGROUND The objective of the present study was to assess whether neoadjuvant chemotherapy with gemcitabine and cisplatin was associated with an increased incidence of morbidity and mortality after major lung resection for lung cancer. METHODS We analyzed 570 patients who underwent lobectomy or pneumonectomy for nonsmall-cell lung cancer at our institution from January 2000 through June 2005. Of these, 70 patients underwent three cycles of gemcitabine-cisplatin chemotherapy before operation for locally advanced disease. Propensity scores were constructed to match those patients undergoing neoadjuvant chemotherapy and lung resection with those undergoing surgery alone. The propensity score analysis yielded two groups of 70 well-matched pairs that were compared in terms of baseline characteristics and early outcome (morbidity, mortality, length of postoperative stay, intensive care unit admission). RESULTS The two case-matched groups had similar morbidity (p = 0.8), mortality (p = 0.4), perioperative blood transfusions (p = 0.8) and intensive care unit admission rates (p = 0.8). Likewise, the length of postoperative stay did not differ between the groups (p = 0.9). CONCLUSIONS Gemcitabin-cisplatin neoadjuvant chemotherapy appears to be safe before major lung resection. This finding warrants its use for efficacy studies of locally advanced and even early-stage lung cancer.
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Maslow A, Bert A, Ng T. Case 6-2005 thoracotomy after myocardial infarction and intracoronary stenting: a balance between myocardial recovery and procedural risk. J Cardiothorac Vasc Anesth 2005; 19:794-800. [PMID: 16326310 DOI: 10.1053/j.jvca.2005.07.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2005] [Indexed: 11/11/2022]
Affiliation(s)
- Andrew Maslow
- Department of Anesthesiology, Rhode Island Hospital, Brown Medical School, Providence, RI 02903, USA.
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Birim O, Kappetein AP, van Klaveren RJ, Bogers AJJC. Prognostic factors in non-small cell lung cancer surgery. Eur J Surg Oncol 2005; 32:12-23. [PMID: 16297591 DOI: 10.1016/j.ejso.2005.10.001] [Citation(s) in RCA: 69] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2005] [Accepted: 10/04/2005] [Indexed: 11/17/2022] Open
Abstract
AIMS Complete surgical resection of primary tumours remains the treatment with the greatest likelihood for survival in early-stage non-small cell lung cancer (NSCLC). Although TNM stage is the most important prognostic parameter in NSCLC, additional parameters are required to explain the large variability in postoperative outcome. The present review aims at providing an overview of the currently known prognostic markers for postoperative outcome. METHODS We performed an electronic literature search on the MEDLINE database to identify relevant studies describing the risk factors in NSCLC surgery. The references reported in all the identified studies were used for completion of the literature search. RESULTS Poor pulmonary function, cardiovascular disease, male gender, advanced age, TNM stage, non-squamous cell histology, pneumonectomy, low hospital volume and little experience of the surgeon were identified as risk factors for postoperative outcome. However, with the exception of TNM stage and extent of resection, the literature demonstrates conflicting results on the prognostic power of most factors. The role of molecular biological factors, neoadjuvant treatment and adjuvant treatment is not well investigated yet. CONCLUSIONS The advantage of knowing about the existence of comorbidity and prognostic risk factors may provide the clinician with the ability to identify poor prognostic patients and establish the most appropriate treatment strategy. The assessment of prognostic factors remains an area of active investigation and a promising field of research in optimising therapy of NSCLC patients.
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Affiliation(s)
- O Birim
- Department of Cardio-Thoracic Surgery, Erasmus MC, Rotterdam, The Netherlands
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83
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Holsinger FC, Laccourreye O, Weinstein GS, Diaz EM, McWhorter AJ. Technical Refinements in the Supracricoid Partial Laryngectomy to Optimize Functional Outcomes. J Am Coll Surg 2005; 201:809-20. [PMID: 16256926 DOI: 10.1016/j.jamcollsurg.2005.06.260] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2005] [Accepted: 06/16/2005] [Indexed: 10/25/2022]
Affiliation(s)
- F Christopher Holsinger
- Department of Head and Neck Surgery, The University of Texas, MD Anderson Cancer Center, Houston, TX 77030-4009, USA
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84
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Win T, Jackson A, Groves AM, Sharples LD, Charman SC, Laroche CM. Comparison of shuttle walk with measured peak oxygen consumption in patients with operable lung cancer. Thorax 2005; 61:57-60. [PMID: 16244091 PMCID: PMC2080711 DOI: 10.1136/thx.2005.043547] [Citation(s) in RCA: 77] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND The relationship between the shuttle walk test and peak oxygen consumption in patients with lung cancer has not previously been reported. A study was undertaken to examine this relationship in patients referred for lung cancer surgery to test the hypothesis that the shuttle walk test would be useful in this clinical setting. METHODS 125 consecutive patients with potentially operable lung cancer were prospectively recruited. Each performed same day shuttle walking and treadmill walking tests. RESULTS Shuttle walk distances ranged from 104 m to 1020 m and peak oxygen consumption ranged from 9 to 35 ml/kg/min. The shuttle walk distance significantly correlated with peak oxygen consumption (r = 0.67, p<0.001). All 55 patients who achieved more than 400 m on the shuttle test had a peak oxygen consumption of at least 15 ml/kg/min. Seventy of 125 patients failed to achieve 400 m on the shuttle walk test; in 22 of these the peak oxygen consumption was less than 15 ml/kg/min. Nine of 17 patients who achieved less than 250 m had a peak oxygen consumption of more than 15 ml/kg/min. CONCLUSION The shuttle walk is a useful exercise test to assess potentially operable lung cancer patients with borderline lung function. However, it tends to underestimate exercise capacity at the lower range compared with peak oxygen consumption. Our data suggest that patients achieving 400 m on the shuttle walk test do not require formal measurement of oxygen consumption. In patients failing to achieve this distance we recommend assessment of peak oxygen consumption, particularly in those unable to walk 250 m, because a considerable proportion would still qualify for surgery as they had an acceptable peak oxygen consumption.
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Affiliation(s)
- T Win
- Thoracic Oncology Unit, Papworth Hospital, Cambridge, UK.
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85
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Abstract
Fig. 2 is an algorithm for the preoperative pulmonary evaluation of the lung resection candidate. Patients should undergo routine spirometry and diffusion capacity testing. If the FEV1 and DLCO are greater than 80% predicted, no further study is needed. When these parameters are less than 80%, some estimation of postoperative function is likely needed, taking into account the proposed resection. Patients with ppoFEV1 or ppoDLCO less than 40% are at increased risk of perioperative complications or death and should undergo formal exercise testing. A VO2max or ppoVO2max less than 10 mL/kg/min is associated with prohibitive risk for anatomic lung resection, and alternative treatment modalities should be considered.
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Affiliation(s)
- Aditya K Kaza
- Section of General Thoracic Surgery, Division of Cardiothoracic Surgery, University of Colorado Health Sciences Center, 4200 East 9th Avenue, C-310, Denver, CO 80262, USA
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Stanzani F, Oliveira MAD, Forte V, Faresin SM. Escalas de risco de Torrington e Henderson e de Epstein: aplicabilidade e efetividade nas ressecções pulmonares. J Bras Pneumol 2005. [DOI: 10.1590/s1806-37132005000400005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
OBJETIVO: Comparar a incidência de complicações pulmonares e cardiopulmonares estimadas, respectivamente, pelas escalas de Torrington e Henderson e de Epstein, em amostra populacional submetida à ressecção pulmonar para tratamento de câncer de pulmão. MÉTODOS: Dados de doentes submetidos à ressecção de um lobo pulmonar ou mais foram retirados de dois bancos de dados montados de forma prospectiva, oriundos de dois hospitais terciários. As medidas de desfecho analisadas foram complicações pulmonares, cardíacas e óbito. Teste exato de Fisher foi usado para avaliar a concordância das taxas de complicações obtidas com as estimadas previamente. RESULTADOS: A escala de Torrington e Henderson foi aplicada em 50 doentes (12 apresentaram risco leve, 32 moderado e 6 grave) e subestimou a taxa de complicações pulmonares nas categorias leve e moderado (p = 0,0003 e p = 0,0006, respectivamente), porém foi capaz de reconhecer os pacientes com alto risco de desenvolver complicações. A escala de Epstein foi aplicada em 38 doentes (4 apresentaram risco alto e 34 baixo) e também subestimou a taxa de complicações cardiopulmonares pós-operatórias da categoria de risco leve, que continha a maioria dos doentes (p < 0,0001), mas reconheceu, também, os pacientes com chance alta de complicar. CONCLUSÃO: As duas escalas não foram adequadas para estimar ocorrência de complicações pulmonares e cardiopulmonares na maioria dos doentes.
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Abstract
PURPOSE OF REVIEW Pulmonary resection remains the only curative treatment option for lung cancer surgery. This review summarizes recent advances in the preoperative functional evaluation of the patient with lung cancer. RECENT FINDINGS The workup of patients with bronchogenic carcinoma covers three areas: tumor type, tumor extent, and patient cardiopulmonary reserves. Significant advances have been made in the latter two areas. Traditionally lobectomy was regarded as the minimum resection for lung cancer; new studies are challenging this view and suggesting that segmentectomy is acceptable for stage Ia cancers < or =20 mm. An important change relating to cardiopulmonary reserves of the patient is the shift in emphasis toward early exercise testing and, in particular, the use of stair climbing as a surrogate marker of maximal oxygen consumption. New studies confirm the benefit of combined lung volume reduction surgery and lung cancer surgery in certain patients who might otherwise be excluded from surgery because of poor lung function. SUMMARY Advances in the preoperative workup of lung cancer patients and in surgical techniques are permitting resections in previously inoperable patients. A new, simplified algorithm for the preoperative workup of lung cancer patients assessing the value of stair climbing as a surrogate marker of maximal oxygen consumption is proposed.
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Affiliation(s)
- Chris T Bolliger
- Respiratory Research Unit, Medical School, Faculty of Health Sciences Tygerberg Academic Hospital and University of Stellenbosch, Cape Town, South Africa.
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Biccard BM. Relationship between the inability to climb two flights of stairs and outcome after major non-cardiac surgery: implications for the pre-operative assessment of functional capacity. Anaesthesia 2005; 60:588-93. [PMID: 15918830 DOI: 10.1111/j.1365-2044.2005.04181.x] [Citation(s) in RCA: 91] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Functional capacity is an integral component of the pre-operative evaluation of the cardiac patient for non-cardiac surgery. Stair climbing capacity has peri-operative prognostic importance. It may predict survival after lung resection and complications after major non-cardiac surgery. However, stair climbing cannot determine the aerobic metabolic capacity necessary to survive the peri-operative stress response. The potential benefits and current limitations of cardiopulmonary exercise testing to determine peri-operative aerobic capacity are discussed. Principles for the selection of an appropriate screening test of aerobic function are put forward.
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Affiliation(s)
- B M Biccard
- Department of Anaesthetics, Nelson R. Mandela School of Medicine, Private Bag 7, Congella 4013, South Africa.
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Mazzone PJ, Arroliga AC. Lung cancer: Preoperative pulmonary evaluation of the lung resection candidate. Am J Med 2005; 118:578-83. [PMID: 15922686 DOI: 10.1016/j.amjmed.2004.12.024] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2004] [Revised: 12/22/2004] [Accepted: 12/29/2004] [Indexed: 11/23/2022]
Abstract
Lung resection provides the best chance of cure for individuals with early stage non-small cell lung cancer. Naturally, lung resection will lead to a decrease in lung function. The population that develops lung cancer often has concomitant lung disease and a reduced ability to tolerate further losses in lung function. The goal of the preoperative pulmonary assessment of individuals with resectable lung cancer is to identify those individuals whose short- and long-term morbidity and mortality would be unacceptably high if surgical resection were to occur. Pulmonary function measures such as the forced expiratory volume in 1 second and the diffusing capacity for carbon monoxide are useful predictors of postoperative outcome. In situations in which lung function is not normal, the prediction of postoperative lung function from preoperative results and the assessment of exercise capacity can be performed to further clarify risks. Published guidelines help to direct the order of testing, permitting us to offer resection to as many patients as possible.
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Affiliation(s)
- Peter J Mazzone
- Department of Pulmonary, Allergy, and Critical Care Medicine, The Cleveland Clinic Foundation, OH, USA.
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90
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Robles AM, Shure D. Optimization of lung function before pulmonary resection: pulmonologists' perspectives. Thorac Surg Clin 2004; 14:295-304. [PMID: 15382761 DOI: 10.1016/s1547-4127(04)00018-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Many risk factors for morbidity and mortality with lung resection have been identified. Factors such as age, gender, and cancer stage cannot be altered, but lung function can be optimized by treating COPD or asthma with bronchodilators, corticosteroids, or antibiotics (when indicated) and by inspiratory muscle training. Although smoking cessation 2 months in advance of surgery may not be feasible, cessation nevertheless should be encouraged because it may decrease postoperative inflammation and in the long-term may decrease the risk of recurrence. In addition, morbidity and mortality can be minimized by careful patient selection using lung scanning or CT to determine predicted postoperative functions (FEV1% and DLco%) and some form of exercise testing, such as cardiopulmonary exercise testing or simple stair climbing. When the risk of surgery is high, any benefit from possible cure must be weighed against the risk of long-term disability or death. Although much data are available to guide clinicians in these decisions, there still is no one test that provides the answer in individual cases. The art and science of medicine must merge at this point.
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Richardson JD, Cocanour CS, Kern JA, Garrison RN, Kirton OC, Cofer JB, Spain DA, Thomason MH. Perioperative risk assessment in elderly and high-risk patients. J Am Coll Surg 2004; 199:133-46. [PMID: 15217641 DOI: 10.1016/j.jamcollsurg.2004.02.023] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2002] [Revised: 02/20/2004] [Accepted: 02/24/2004] [Indexed: 12/20/2022]
Affiliation(s)
- J David Richardson
- Department of Surgery, University of Louisville School of Medicine, Louisville, KY 40292, USA
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López-Encuentra A, Pozo-Rodríguez F, Martín-Escribano P, Martín de Nicolás JL, Díaz de Atauri MJ, Palomera J, Marrón C. Surgical lung cancer. Lung Cancer 2004; 44:327-37. [PMID: 15140546 DOI: 10.1016/j.lungcan.2003.12.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2003] [Revised: 12/15/2003] [Accepted: 12/16/2003] [Indexed: 11/30/2022]
Abstract
STUDY OBJECTIVE To identify those variables that are associated with operative morbidity or mortality in cases of thoracotomy in lung cancer. SETTING Third level university hospital. PATIENTS Consecutive patients with thoracotomy due to lung cancer operated on between 1994 and 1997 (n = 115). METHODS Pre- and postoperative variables potentially associated with operative morbidity or mortality were retrieved prospectively as follows: demographic and clinical characteristics of the patients, cardiopulmonary function characteristics, tumour characteristics, and treatment characteristics. A bivariate analysis of all variables under evaluation was carried out in order to identify those variables associated with operative morbidity and mortality. A multivariable analysis of the selected variables was then conducted using a logistic model. RESULTS The predicted postoperative product (predicted FEV1 x predicting diffusing capacity of carbon monoxide), the carbon monoxide diffusion coefficient (Kco) and the contralateral pulmonary perfusion are variables that relate to the overall morbidity or mortality (number of events 63, 55%) (-2 log likelihood chi2 = 22.9; R2 = 0.27). For variables associated with postoperative morbidity, the best associative model combines functional variables (diffusion, predicted FEV1), endoscopic variables (obstructed segments to be resected), clinical variables (comorbidity) and an important postoperative variable, the pathological tumoural staging (pN) (number of events 49, 43%) (-2 log likelihood chi2 = 32.9; R2 = 0.36). CONCLUSION The numerous variables under analysis are poorly associated with morbidity or mortality after thoracotomy in lung cancer. With regard to postoperative morbidity, the best associative models combine information that is known pre- and postoperatively and which is provided by both the patient and the tumour.
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Affiliation(s)
- Angel López-Encuentra
- Pneumology Service, Hospital Universitario 12 de Octubre, Avenida Andalucía 5.4, Madrid 28041, Spain.
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Brunelli A, Monteverde M, Al Refai M, Fianchini A. Stair climbing test as a predictor of cardiopulmonary complications after pulmonary lobectomy in the elderly. Ann Thorac Surg 2004; 77:266-70. [PMID: 14726076 DOI: 10.1016/s0003-4975(03)01327-4] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
BACKGROUND The objective of this study was to assess the role of a symptom-limited stair climbing test in predicting postoperative cardiopulmonary complications in elderly candidates for lung resection. METHODS A consecutive series of 109 patients more than 70 years of age who underwent pulmonary lobectomy for lung carcinoma from January 2000 through May 2003 formed the prospective database of this study. All patients in the analysis performed a preoperative symptom-limited stair climbing test. Univariate and multivariate analyses were performed to identify predictors of postoperative cardiopulmonary complications. RESULTS At univariate analysis, the patients with complications had a lower forced expiratory capacity percentage of predicted (p = 0.048), predicted postoperative forced expiratory volume in 1 second percentage of predicted (p = 0.049), climbed a lower height at preoperative stair climbing test (p = 0.0004), and presented a greater proportion of cardiac comorbiditiy with respect to the patients without complications (p = 0.02). After logistic regression analysis, significant predictors of postoperative complications resulted in the presence of a concomitant cardiac disease (p = 0.04) and a low height climbed preoperatively (p = 0.0015). CONCLUSIONS A symptom-limited stair climbing test was a safe and simple instrument capable of predicting cardiopulmonary complications in the elderly after lung resection.
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Affiliation(s)
- Alessandro Brunelli
- Department of Respiratory Diseases, "Umberto I degrees " Regional Hospital, Ancona, Italy.
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Brunelli A, Fianchini A. Stair climbing test in lung resection candidates with low predicted postoperative FEV1. Chest 2003; 124:1179. [PMID: 12970060 DOI: 10.1378/chest.124.3.1179] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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Abstract
Lung resection remains the treatment of choice in the curative approach to nonsmall cell lung cancer. Because most lung cancer patients are current or former smokers, they are at increased risk of chronic obstructive pulmonary disease and coronary artery disease, conditions associated with increased surgical morbidity and mortality. Careful preoperative assessment of the cardiopulmonary reserves is therefore of great importance. Various single and combined parameters for the functional assessment before surgery have been proposed. Currently the emphasis is on the determination of forced expiratory volume in the first second, the diffusing capacity for carbon monoxide, and exercise testing with the measurement of maximal oxygen uptake. Adherence to established algorithms for this preoperative evaluation, advances in operative technique (video-assisted thoracoscopic surgery and combined operations of lung cancer surgery with lung volume reduction surgery), and perioperative care permit resections in patients who until recently would have been considered functionally inoperable.
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Affiliation(s)
- Pierre Antoine Fuentes
- Department of Thoracic Surgery, Ste Marguerite Hospital-CHU Sud, 270 Bd Ste Marguerite, 13274 Marseille Cedex 9, France.
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