1. Preop evaluation for pulmonary surgery
Dr. S. Parthasarathy MD., DA., DNB, MD (Acu), Dip. Diab. Dip. Software statistics PhD ( physiology), IDRA , FICA

2. Why actually we need this topic ?
In US lung resection surgeries / year
Because newer gadgets have made diagnosis earlier and surgery better !!
Is it operable with acceptable risk ?
Not making fit alone
We can suggest to the surgical team !

3. Yes there are problems !!
Major respiratory complications—atelectasis, pneumonia, and respiratory failure — occur in 15% to 20% of
patients and account for the majority of the expected 3% to 4% mortality rate.

4. Three legged race !! Mechanics Diffusion Gas exchange PFT DLCO ABG ??
Clinical history

5. Functional capacity
Smoker
H/O COPD, bronchiectasis
Co existing diseases
Pulmonary hypertension and cardiac
Tuberculosis , steroids , ATT and liver disease
Metastasis

6. Other history
The presence of wheezing, rales, rhonchi, or other abnormal breath sounds suggests the need for further medical intervention–
Clubbing dysphagia horner s syndrome hoarseness
ECG changes – pulmonary hypertension
Or Low QRS complexes – hyperinflation

7. Suppose left lower lobectomy – 10/ 42 = 24 %
FEV1 FVC MVV
Suppose left lower lobectomy – 10/ 42 = 24 %
65 %
65 %× (1- 24/ 100) = 49 %

8. Right lower lobectomy ! 12/ 42 = 30 %
Preop FEV1 = 62 %
62 % × (1-30/100) = 43.4 %

9. PEFR - simple
PEF of less than 200 L/m indicates that effective coughing is difficult and pulmonary complications rate are high

10. Ppo FEV1 = 40 % or more – less risk .
Ppo FEV1 = 40 % or more – less risk
Ppo FEV1 = 30 % = anticipate dangers !
Pneumonectomy FEV1, 2 L or 60% of predicted; MVV, 55% of predicted; Dlco, 50% of predicted; and FEF25–75%, 1.6 L/s.
For lobectomy, the criteria are: FEV1, 1 L; MVV, 40% of predicted; FEF25–75%, 0.6 L/s; and Dlco, 50% of predicted

11. Problem in PFT in India !! Reliability of the test !!
Patients to understand and repeat !
An easy 20 % rise we have seen if we do it again after ten minutes
Believe the test 100% only if we are sure

12. Studies abroad ! Are for malignancies !! But in India
In India we have more infective causes
Destroyed lungs prior
Normal lung beside
I am less worried

13. DLCO
DLCO, also known as the TLCO, is a measurement of the conductance or ease of transfer for CO molecules from alveolar gas to the hemoglobin of the red blood cells in the pulmonary circulation.
It often is helpful for evaluating the presence of possible parenchymal lung disease when spirometry and/or lung volume determinations suggest a reduced vital capacity, RV, and/or TLC ml/min/Hg

14. Single breath wash out technique
A ppo DLco less than 40% predicted correlates with both increased respiratory and cardiac complications and is usually independent of the FEV1.
Preop chemo given – DLCO better than FEV1

15. ABG
Arterial blood gas data such as partial pressure of oxygen in the blood (PaO2) less than 60 mm Hg or
partial pressure of carbon dioxide in the blood (PaCO2) greater than 45 mm Hg have been used as cutoff values for pulmonary resection

16. Cardiopulmonary Interaction
maximal oxygen consumption (VO2max) is the most useful predictor of post thoracotomy outcome.
Less than 15 ml / kg/min – risks
Less than 10 ml/kg/min – danger

17. Flight of stairs more two – 12 ml/kg/minute
6 minute walk test
Distance / 30 is the approx VO2 max
Example
600 meters in 6 minutes
600/30 = 20 ml/kg/minute – OK
Flight of stairs more two – 12 ml/kg/minute

18. Prince et al
A new index, designated the predicted postoperative product (PPP), obtained by multiplying the percentage of predicted postoperative FEV1 by the percentage of predicted postoperative DLCO
< 1650 – risk is more

19. V/Q scanning Yes we can do !
The difference between the ventilation and perfusion study in predicting postoperative loss of function was not significant although the predicted values from the ventilation study tended to be slightly closer to the postoperative spirometric measurements.
Yes we can do !

20. Pictures from the internet for closed academic purpose only
V/Q scanning
Pictures from the internet for closed academic purpose only

21. Those who reach a walk distance >400 m on the shuttle walk test or are able to climb >22 m on the stair climbing test are also considered at low risk

22. Costly and laborious equipment
Everything is not OK
Differential lung tests
tests assessing differential lung function
include broncho spirometry,
lateral position testing,
total unilateral pulmonary artery occlusion.
Costly and laborious equipment

23. Unfavourable factors Resection close to diaphragm
Duration of surgery more than 2 hours
Non endoscopic
Old age
obesity

24. Three legged race !!

25. Pictures are for non commercial academic closed loop use only

27. Transthoracic Echocardiography
Rule out pulmonary hypertension
(major increase in risk for pneumonectomy
with pulmonary hypertension)
PASP > 45 – danger ahead !

28. 4 M s of lung cancer !!
1. Mass effects: Obstructive pneumonia, lung abscess, SVC syndrome, tracheobronchial distortion, Pancoast syndrome, recurrent laryngeal nerve or phrenic nerve paresis, chest wall or mediastinal extension
2. Metabolic effects: Lambert-Eaton syndrome, hypercalcemia, hyponatremia, Cushing syndrome
3. Metastases: Particularly to brain, bone, liver, adrenal
4. Medications: Chemotherapy agents, pulmonary toxicity-- (bleomycin, mitomycin), cardiac toxicity (doxorubicin), renal toxicity (cisplatin)

29. Dangers of bullae
Risk of rupture with positive pressure and ? pneumothorax
Increased dead space
Compression of healthy adjacent lung

30. Thoracoscopy – be slightly lineant
spirometry threshold for increased risk for VATS seems to be a ppoFEV1 of 30% versus 40% for open thoracotomy

31. Consider easy airway or not !

32. Other routine tests
XRay chest PA
CT chest

33. Pneumonectomy for Destroyed lung behave better -- Can be extubated than malignancies with adjoining normal lung

34. Optimization S top smoking L oosen secretions R emove secretions
D ilate airways
E ducate patient

35. SLRDE
Pulmonary complications are decreased in thoracic surgical patients who cease smoking for more than 4 weeks before surgery…
Administer mucolytics, Hydrate well
Antibiotics
bronchodilators
Physiotherapy , incentive spirometry postop analgesia

36. Summary History Xray , CT, routine test PFT PPO FEV1 Dlco , VQ scan
CPET
Risk factors
SLRDE
Thank you