Role of Pulmonary Vascular Resistance Measurements in Preoperative Evaluation of Candidates for Pulmonary Resection

Fee, Henry J.; Holmes, Elena C.; Gewirtz, Henry; Ramming, Kenneth P.; Alexander, J.

doi:10.1097/00132586-197904000-00062

Cited by 14 publications

(28 citation statements)

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“…OLSEN et al [73] found neither Ppa nor the calculated pulmonary vascular resistance (PVR) on submaximal exercise predictive of postoperative complications. The latter finding is in contrast to an early, often cited report by FEE et al [56], who found a PVR of <190 dyn·s·cm -5 at rest or on exercise a criterion of operability (table 1). At our institution, BRÜNDLER et al [74] reported on 637 patients in whom right heart catheterization was performed.…”

Section: Pulmonary Haemodynamicscontrasting

confidence: 74%

Functional evaluation of the lung resection candidate

Bolliger¹,

Perruchoud²

1998

Eur Respir J

163

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Advances in operative technique and perioperative care have considerably reduced surgical morbidity and mortality after pulmonary resections. Various single and combined parameters of functional operability have been proposed to assess the surgical risk. Pulmonary function tests adequately assess the pulmonary risk, and baseline or stress electrocardiography, echocardiography and nuclear cardiac studies assess the cardiac risk.Patients with normal or only slightly impaired pulmonary function (forced expiratory volume in one second (FEV1) and transfer factor of the lung for carbon monoxide (TL,CO) ≥80% of predicted) and no cardiovascular risk factors can undergo pulmonary resections up to a pneumonectomy without further investigation. For others, exercise testing, pulmonary split-function studies, or a combination of these two methods are recommended. Exercise testing, most frequently performed as a symptom-limited test with the measurement of maximal oxygen uptake (V 'O 2 ,max), assesses both the pulmonary and cardiovascular reserves. A V'O 2 ,max of <10 mL·kg -1 ·min -1 is generally considered prohibitive for any resection, a value of >20 mL·kg -1 ·min -1 or >75% of predicted normal, safe for major resections. Split-function studies are radionuclide-based estimations of the predicted postoperative (ppo) values of various parameters. The currently used ppo-parameters are FEV1-ppo, TL,CO-ppo and, most recently, V'O 2 ,max-ppo. Suggested cutoff values for safe resection are: for FEV1-ppo and TL,CO-ppo ≥40% pred; and for V 'O 2 ,max ≥35% pred, combined with an absolute value of ≥10 mL·kg -1 ·min -1 . The lowest acceptable ppo-values will still have to be established by additional prospective studies.In the long-term, resections involving not more than one lobe usually lead to an early functional deficit followed by later recovery. The permanent functional loss in pulmonary function is small (≤10%) and exercise capacity is only slightly reduced or not at all. Pneumonectomy, on the other hand, leads to an early permanent loss of about 33% in pulmonary function and 20% in exercise capacity. Thus, pulmonary function tests alone overestimate the functional loss after lung resection. Eur Respir J 1998; 11: 198-212 The dramatic increase in the incidence of bronchogenic carcinoma has made this disease the most frequent malignancy worldwide. In industrialized nations, the majority of lung resection candidates suffer from bronchogenic carcinoma, whereas only some decades ago benign conditions, such as destroyed lung parenchyma after tuberculosis, had to be removed. The prognosis of bronchogenic carcinoma remains sombre as about 75-85% are inoperable at the time of diagnosis [1], and despite recent advances in chemo-and radiotherapy regimens, surgical resection remains the only curative form of treatment [2].Depending on their extent, pulmonary resections lead to permanent loss of pulmonary function. In healthy people, resections up to a pneumonectomy are tolerated remarkably well. Lung cancer patients, however, are...

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Section: Pulmonary Haemodynamicscontrasting

confidence: 74%

Functional evaluation of the lung resection candidate

Bolliger¹,

Perruchoud²

1998

Eur Respir J

163

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“…It has been suggested that preoperative measurements of VCO 2max , 19,20 O 2 D, 21 or CI 22 during exercise are more precise than the preoperative P pa to predict the postlobectomy condition. However, these data were obtained from patients undergoing lobectomy, whose postoperative respiratory function deteriorated after lobectomy.…”

Section: Discussionmentioning

confidence: 99%

Different Effects of Lung Volume Reduction Surgery and Lobectomy on Pulmonary Circulation

Haniuda¹,

Kubo²,

Aoki³

et al. 2000

Annals of Surgery

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ObjectiveTo clarify the effects of lung volume reduction surgery (LVRS) on cardiopulmonary circulation during exercise in comparison with pulmonary lobectomy for lung cancer. Summary Background DataLVRS improves pulmonary function and dyspnea symptoms acutely in selected patients with heterogeneous emphysema. However, there are few data concerning the effects of LVRS on the cardiopulmonary circulation, especially during exercise. MethodsPulmonary function tests and pulmonary hemodynamic study at rest and during exercise were performed before and 6 months after LVRS (seven patients) or pulmonary lobectomy (eight patients). In the workload test, an electrically braked bicycle ergometer (25 w) was used in the supine position for at least 2 minutes or until exhaustion or breathlessness developed. ResultsAfter lung lobectomy, the values of vital capacity, percentage of predicted vital capacity, forced expiratory volume in 1 second, percentage of predicted forced expiratory volume in 1 second, residual volume/total lung capacity, and maximal voluntary ventilation deteriorated significantly. Six months after LVRS, however, vital capacity, percentage vital capacity showed no significant change, and forced expiratory volume in 1 second, percentage of forced expiratory volume in 1 second, diffusing capacity for carbon monoxide, and maximal voluntary ventilation showed marked improvement. Cardiac index was changed neither at rest nor during exercise in either group by the operation. Although postoperative pulmonary arterial pressure in the lobectomy group was significantly increased by the exercise, LVRS did not affect postoperative pulmonary arterial pressure at rest or during exercise. Pulmonary capillary wedge pressure in the lobectomy group showed no significant change after the operation, whereas LVRS ameliorated the marked elevation of pulmonary capillary wedge pressure observed during exercise. After lobectomy, significant increases in the pulmonary vascular resistance index were observed at rest and during exercise. LVRS markedly increased the pulmonary vascular resistance index at rest but not during exercise. In the lobectomy group, the postoperative flow-pressure curve moved upward, and its gradient became steeper than the preoperative one. In the LVRS group, the curve moved upward in a parallel fashion. These results show that much more right-sided heart work is needed to achieve the same cardiac output against higher pulmonary arterial pressure, not only after lobectomy but also LVRS. ConclusionThe current study demonstrated that the effects of LVRS on the cardiopulmonary circulation were not negligible, especially during exercise, and successful LVRS may depend on improved respiratory function and also preserved cardiac function that can tolerate the damage to the pulmonary vascular bed induced by this operation.Lung volume reduction surgery (LVRS) has been introduced to treat severe emphysema 1 and is now an established procedure to treat patients with diffuse emphysema. 2,3 Recently, several reports 1,2,4 -...

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“…They were, however, still considered eligible for lobectomy if they fulfilled at least one of the two criteria: ( I ) mean PAP of <35 mm Hg combined with a PVR of < 190 dyn s c n r5 at moderate exercise (40 W) [14][15][16][17] or (2) a VO;mM of >15 ml/kg/min [2,3],…”

Section: Criteria O F Eligibility Fo R Surgetymentioning

confidence: 99%

Evaluation of High-Risk Lung Resection Candidates: Pulmonary Haemodynamics versus Exercise Testing

Solèr²,

Stulz³

et al. 1994

Respiration

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We compared the value of exercise testing and measurement of pulmonary haemodynamics (PH) in the pre-operative assessment of 5 patients (mean age: 64 years, 3 men) with clinical stage I or II bronchogenic carcinoma and severe chronic obstructive pulmonary disease. They were considered at high risk due to poor pulmonary function tests (PFT); (one or more of the following): (1) radionuclide calculated postlobectomy FEV₁ < 30% predicted, (2) diffusion capacity or transfer factor < 60% predicted, combined with a fall in PaO₂ on maximal exercise of > 5 mm Hg, (3) a PaCO₂ at rest of > 45 mm Hg. Maximal oxygen uptake (VO_2max) during symptom-limited cycle ergometry and PH were measured in these 5 patients. They were considered eligible for lobectomy if they fulfilled at least one of the two criteria: (1) mean pulmonary artery pressure (PAP) of < 35 mm Hg and pulmonary vascular resistance of < 190 dyn·s·cm-5 at moderate exercise (40 W), (2) a VO_2MAX of > 15 ml/kg/min. Six months postoperatively PFT and VO_2max were measured again. PAP40W was 21, 38, 38, 46 and 52 mm Hg, respectively, which would have excluded 4/5 patients from surgery. VO_2max was 21.7, 14.9, 13.4, 19.2 and 18.6 ml/kg/min, respectively, which would have excluded 2/5 patients. Expressed in percent predicted, however, VO_2MAX was > 69% in all 5 patients, indicating only mild impairment of exercise capacity in the 2 patients with < 15 ml/kg/min VO_2MAX· Therefore all 5 patients were offered surgery and underwent lobectomy. Apart from 1 prolonged air leak no complications occurred, the mean hospital stay was 16 days (13-21). At 6 months their PFT and VO_2max were unchanged. In conclusion, in our series of patients with marginal pulmonary function, exercise testing with the determination of VO_2max was superior to PH measurements for the prediction of operability. It seems that VO_2max should be expressed as a percent of predicted; however, our findings will need confirmation by future studies with bigger sample sizes.

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Role of Pulmonary Vascular Resistance Measurements in Preoperative Evaluation of Candidates for Pulmonary Resection

Cited by 14 publications

References 0 publications

Functional evaluation of the lung resection candidate

Functional evaluation of the lung resection candidate

Different Effects of Lung Volume Reduction Surgery and Lobectomy on Pulmonary Circulation

Evaluation of High-Risk Lung Resection Candidates: Pulmonary Haemodynamics versus Exercise Testing

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