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Official reprint from UpToDate www.uptodate.com ©2016 UpToDate

AuthorSteven E Weinberger, MD

Section EditorTalmadge E King, Jr, MD

Deputy EditorGeraldine Finlay, MD

Preoperative evaluation for lung resection

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 non–small 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 (FEV ) 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 (FEV ) 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 (FEV ) has become the primary spirometric

value used for preoperative assessment. The FEV 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 FEV (<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 FEV in excess of 2 L (or >80 percent

predicted) generally tolerate pneumonectomy, whereas those with a preoperative FEV greater than 1.5 L

tolerate lobectomy [4,6]. However, it has been difficult to identify a single absolute value of preoperative FEV

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:

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 FEV 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 FEV (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 FEV 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 FEV 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 FEV 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 FEV [5,6,25,28]. Predicted

postoperative function is calculated using preoperative values of FEV 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) FEV is calculated by the formula: ePO

FEV = preop FEV x (number of segments remaining postoperatively/total number of lung segments [normally

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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 FEV .

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Differences in the severity of underlying lung disease and the contribution to total lung function of the

portion of lung to be resected.

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Differences in size, age, gender, and race of patients undergoing lung resection.●

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18]) [29]. The value obtained is then compared to the predicted value for FEV for that individual’s height, age,

and gender to obtain the percent predicted postoperative FEV . In one study, a predicted postoperative FEV

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 FEV 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 FEV .

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 FEV in a

patient undergoing pneumonectomy [7]. In this method, the formula for calculating predicted postoperative FEV

(PPO FEV ) is as follows (calculator 2):

PPO FEV = preoperative FEV 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 FEV according to the

following formula (calculator 1):

PPO FEV = preoperative FEV 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 FEV 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 FEV 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 FEV 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 FEV 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 FEV , 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 FEV and DLCO in assessing suitability for lung resection.

Arterial PO2 — Baseline (resting) arterial PO 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

PO may actually improve following pulmonary resection [33,34].

Arterial PCO2 — Hypercapnia (arterial PCO 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 PCO less than

45 mmHg and those with a preoperative PCO 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 FEV 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 (FEV ) 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 FEV 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

FEV , PPO DLCO, and/or low technology exercise testing do not clearly define the patient’s 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:

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 (VO 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 (VO 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 VO 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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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].

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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).

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maximal oxygen consumption (VO max); invasive hemodynamic measurements during exercise provide little

additional useful data [43]. An early report demonstrated no mortality in patients able to achieve a VO max in

excess of 1 L/min, compared with 75 percent mortality in those with a VO max below 1 L/min [44].

Expressing VO 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 VO max greater than 20 mL/kg per min had a postoperative complication, whereas all six patients

with a VO 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 VO max of 15 mL/kg per min or greater, survived surgery and had

an acceptable postoperative complication rate [46]. Patients with VO max <10 mL/kg per min are at very high

risk for perioperative complications and mortality [25,47,48].

The VO max can also be expressed as a percentage of the predicted value. One report found that a VO 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 VO 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 VO 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 VO max >20 mL/kg per minute are considered to be suitable for any type of lung resection,

including pneumonectomy. Patients with VO max between 10 and 15 mL/kg per min have increased risk for

mortality, and other factors, including PPO FEV , 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 VO max values (between 10 and 20

mL/kg per min) and postoperative predicted FEV and DLCO values ≥30 percent, resection up to the calculated

extent is acceptable [32]. On the other hand, if either the postoperative predicted FEV or DLCO is <30 percent,

the predicted postoperative (PPO) VO max is calculated. If the PPO VO 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 VO

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 FEV 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 FEV 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 PCO , 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 FEV 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.

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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 (FEV ) >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.)

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For patients with preoperative FEV <2 L (or <80 percent predicted) or DLCO <80 percent predicted, the

predicted postoperative (PPO) FEV 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 FEV

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.)

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For patients with either PPO FEV 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 FEV or PPO DLCO is <30

percent, a formal cardiopulmonary exercise test is indicated with measurement of maximal oxygen

consumption (VO max). (See 'Integrated cardiopulmonary exercise testing' above and 'Stair climbing'

above.)

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Cardiopulmonary exercise testing (CPET) is useful when the results of PPO FEV , PPO DLCO, and/or low

technology exercise testing do not clearly define the patient’s risk as either high or low. (See 'Integrated

cardiopulmonary exercise testing' above and 'Guidelines' above.)

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Patients who can achieve a VO 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.

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For those with VO max values in between 10 and 20 mL/kg per minute, the predicted postoperative

(PPO) VO max is calculated. If the PPO VO 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 VO

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 FEV or DLCO is <30 percent predicted.

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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 resection algorithm.

Actual risks affected by parameters defined here and:

Patient factors: Comorbidities, age.

Structural aspects: Center (volume, specialization).

Process factors: Management of complications.

Surgical access: Thoracotomy versus minimally invasive.

ppoDLCO: predicted postoperative diffusing capacity for carbon monoxide; ppoDLCO%:

percent predicted postoperative diffusing capacity for carbon monoxide; ppoFEV : predicted

postoperative FEV ; ppoFEV %: percent predicted postoperative FEV ; SCT: stair climb

test; SWT: shuttle walk test; CPET: cardiopulmonary exercise test; VO max: maximal oxygen

consumption.

* For pneumonectomy candidates, we suggest to use Q scan to calculate predicted

postoperative values of FEV 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 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.

Δ PpoFEV 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.

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Disclosures: Steven E Weinberger, MD Nothing to disclose. Talmadge E King, Jr, MD Consultant/Advisory Boards: InterMune[pulmonary f ibrosis (pirfenidone)]; ImmuneWorks [pulmonary f ibrosis]; Boehringer Ingelheim [IPF (nintedanib)]; GlaxoSmithKline[pulmonary f ibrosis]; Daiichi Sankyo [pulmonary f ibrosis]. 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 vettingthrough a multi-level review process, and through requirements for references to be provided to support the content. Appropriatelyreferenced content is required of all authors and must conform to UpToDate standards of evidence.

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