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

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

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Preoperative Pulmonary Function Evaluation in Lung Resection Ri / CR Slide 2 Pulmonary Function Test Preoperative pulmonary evaluation of patients with lung cancer concerns both resectability and operability. resectability: TNM staging operability: how much tissue can be safely removed Slide 3 Commonly Used Parameters FEV 1 (Forced Expiratory Volume in 1 second) FVC (Functional Vital Capacity) FEV 1 /FVC MVV (Maximum Voluntary Ventilation) = MBC (Maximum Breathing Capacity) DLCO (Diffusing Capacity of Carbon Monoxide) VO 2 max (Maximum Oxygen Consumption) Slide 4 FEV 1 best parameter to predict risk of post-op complications (including death) ppoFEV 1 (predicted postoperative FEV 1 ) Am J of Med (2005) 118, 578583 Chest (2003) 123, 2096-2103 Resp Med (2004) 98, 598-605 Slide 5 MVV (MBC) largest volume breathed voluntarily in 1 min an estimate of the peak ventilation available to meet physiological demands represents respiratory muscle strength and correlates with post-op morbidity Am J of Med (2005) 118, 578583 Chest (2003) 123, 2096-2103 Resp Med (2004) 98, 598-605 Slide 6 DLCO independent predictor for risk of post-op complications (including death) reflects alveolar membrane integrity and pulmonary capillary blood flow low DLCO implies significant emphysema, and reduced pulmonary capillary vascular bed Am J of Med (2005) 118, 578583 Chest (2003) 123, 2096-2103 Resp Med (2004) 98, 598-605 Slide 7 VO 2 max (Exercise Test) exercise capacity (measured as VO 2 max) predictor of post-op complications (including death) exercise oximetry stair climbing shuttle walking 6-minute walk test helps to identify high-risk patients who can safely undergo lung resection Am J of Med (2005) 118, 578583 Slide 8 VO 2 max Eugene et al VO 2 max > 1 L/min little complications Smith et al VO 2 max > 20 ml/kg/min post-op complications 10% VO 2 max = 15~20 ml/kg/min post-op complications 66% VO 2 max < 15 ml/kg/min post-op complications 100% Markos et al oxygen desaturation during a 12-min walk, ppoDLCO and ppoFEV 1 were more reliable predictors of post-op mortality Chest (2003) 123, 2096-2103 Slide 9 Other Parameters FEF 25-75% : highly variable ABG: hypercapnia (>45 mmHg) PPP (predicted postoperative product) product of ppoFEV 1 and ppoDLCO Am J of Med (2005) 118, 578583 Slide 10 Postoperative Lung Function Pulmonary function is affected by lung resection, extent varies: pneumonectomy: FEV 1 : 34~36% FVC: 36~40% VO 2 max: 20~28% lobectomy: FEV 1 : 9~17% FVC: 7~11% VO 2 max: 0~13% Am J of Med (2005) 118, 578583 Slide 11 Lung Resection may undergoes up to 3 testing phases: 1 st phase (whole-lung tests): room-air ABG, simple spirometry, lung volume, (DLCO, exercise test) i. PaCO 2 > 45 mmHg ii. FEV 1 or MVV 50% if any combination of the above exists proceed to 2 nd phase Chapter 49, Millers Anesthesiology, 6th Edition Slide 12 Lung Resection 2 nd phase (single-lung tests): ventilation/perfusion of each lung quantitative CT scanning i. ppoFEV 1 70% blood flow to the diseased lung if any of the above exists proceed to 3 rd phase Chapter 49, Millers Anesthesiology, 6th Edition Slide 13 Prediction of Post-op Lung Function Methods to predict postoperative pulmonary function: segment method radionuclide scanning techniques quantitative computed tomography Slide 14 Segment Method 19 total segments (right 10, left 9) estimated post-op pulmonary function = (pre-op pulmonary function) * (post-op remaining segments) / 19 subsegments also being used (total of 42 subsegments) Am J of Med (2005) 118, 578583 Slide 15 Radionuclide Scanning Techniques inhaled 133 Xe or intravenous 99 Tc-labeled macroaggregates estimation by quantifying the perfusion to a specific area: ppoFEV 1 = preoperative FEV 1 * % of radioactivity contributed by nonoperated lung Am J of Med (2005) 118, 578583 Slide 16 Quantitative Computed Tomography -500~-910 Hounsfield unit is used to estimate functional lung volume correlates better than radionuclide scanning method AJR (2002) 178, 667672 Slide 17 Lung Resection 3 rd phase (mimic post-op condition): temporary balloon occlusion (with or without exercise) skill-demanding, rarely performed Chapter 49, Millers Anesthesiology, 6th Edition Ann Thorac Cardiovasc Surg (2004) 10, 333-339 Slide 18 Testing Phases Chapter 49, Millers Anesthesiology, 6th Edition Slide 19 Pulmonary Function Test Chapter 49, Millers Anesthesiology, 6th Edition Slide 20 Pre-opPredicted Post-op FVC (L)3.202.69 FEV 1 (L)1.66 (>1.2~1.0)1.40 (>1) FEV 1 /FVC (%)51.9 (>40) RV/TLC (%)55.0 MVV (L/min) % predicted (%) 53.3 (>40) 69.9 (>40) VO 2 max (L/min) VO 2 max (ml/kg/min) 0.944 ( 15,