Prapaporn Pornsuriyasak, M.D. Pulmonary and Critical Care Medicine Ramathibodi Hospital

Transcription

1 Prapaporn Pornsuriyasak, M.D. Pulmonary and Critical Care Medicine Ramathibodi Hospital

2 Only 20-30% of patients with lung cancer are potential candidates for lung resection Poor lung function alone ruled out >1/3 of patients who presented with anatomically resectable disease Damhuis RA, Schütte PR. Eur Respir J 1996; 9:7 10 Baser S et al. Clin Lung Cancer 2006; 7:

3 Median duration 25 months for screendetected stage I lung cancer vs 13 months for symptom-detected stage I disease Likelihood of early mortality from lung resection, and potential for loss of lung function following resection are important considerations in preoperative pulmonary evaluation of candidates for lung resection Sobue T, et al. Cancer 1992; 69:

4 Reported surgical mortality rates vary from 1% to 5% Thoracoscore using data obtained from >15,000 patients Risk factors: patient age, sex, dyspnea score, ASA score, performance status, priority of surgery, diagnosis, procedure class, and comorbid disease: renal, FEV1, BMI Allen MS. Ann Thorac Surg 2006; 81: Falcoz PE. J Thorac Cardiovasc Surg 2007;133:

5 Postoperative FEV1 Diffusing capacity of the lung for carbon monoxide (Dlco) Peak oxygen consumption (VO2 peak)

6 Smaller declines in FEV1 after lobectomy in COPD (0% -8%) vs without COPD (16% -20%) Declines in Dlco and VO2 peak are more variable (3% -20% in COPD vs 0% -21% without COPD) Bobbio A et al Eur J Cardiothorac Surg 2005; 28:

7 Lobectomy: continue to recover pulmonary function for approximately 6 months after surgery Pneumonectomy: improvement is generally limited after 3 months Loss of lung function may vary significantly with the location of the resection eg, resection of emphysematous portion will result in less loss of function Brunelli A, et al. Chest 2007; 131:

8 Inappropriate in female, elderly, short stature ACCP. Chest 2007;132:161S %DLCO preop: better correlation with postop death than FEV1 Average risk Estimate %ppo FEV1 and %ppo DLCO

9 ACCP. Chest 2007;132:161S Estimate %ppo FEV1 and %ppo DLCO Exercise Testing Average risk Increased risk Increased risk

10 Number of bronchopulmonary segments removed compared with the total number (19) in both lungs RUL lobectomy (3 segments) preoperative FEV1 of 1.6 L (80% of predicted normal) ppo-fev1= /19 =1.35 L ppo-fev1%= 80% 16/19 = 67%

11 For pneumonectomy For lobectomy

12 Recommendations: Level of recommendation 2+=, Grade C The first estimated residual lung function will be calculated based on segment counting. Only not totally obstructed segment taken into account: patency of bronchus (bronchoscopy), and segment structure (CT scan) should be preserved. Patients with borderline funtion need imaging based calculation of residual lung function ventilation-perfusion scintigraphy for pneumonectomy or quantitiative CT scan before lobectomy or pneumonectomy

13 Ischemic heart disease Heart failure Insulin dependent DM Previous stroke/tia Cr> 2mg/dl Eur Respir J 2009

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15 ppofev1 was a predictor of cardiopulmonary morbidity in patients with normal pulmonary function, but it was not associated with morbidity in those with airflow limitation (94 patients with FEV1 < 70%)

16 Predictors of morbidity were age and operation performed via thoracotomy, not just FEV1 and DLCO Different predictors of morbidity between young and elderly patients: Young patients: FEV1, extent of resection and histology Elderly: smoking history, co-morbidities: hypertension and renal insufficiency, and DLCO Takamochi K. Interact Cardiovasc Thorac Surg 2011;12:739

17 Recommendations: Level of recommendation 2+=, Grade C ppo FEV1 should not be used alone to select patient with lung cancer for lung resection especially in patients with moderate to severe COPD ppo FEV1 tends to underestimate the functional loss in the early postop phase and not a reliable predictor of complications in COPD patients ppo FEV1 of 30% predicted is suggested as high risk threshold

18 450 (45%) with COPD, 558 (55%) without COPD Lobectomy (75%), bilobectomy (8%), and pneumonectomy (17%) Overall mortality 5.8%, pulmonary morbidity (14%), and overall morbidity 31.4% Pulmonary morbidity and operative mortality were related to ppo DLCO, age, and performance status in patients with and without COPD ppo DLCO was the single strongest predictor of pulmonary morbidity and operative mortality in both patient groups Ferguson and Vigneswaran et al. Ann Thorac Surg 2008;85:

19 Effect of ppodlco on pulmonary morbidity and mortality in patients with and without COPD FEV1/FVC <70% FEV1/FVC >70% Ferguson and Vigneswaran et al. Ann Thorac Surg 2008;85:

20 Recommendation: DLCO<60%predicted associated with mortality and <80% associated with pulmonary complications DLCO should be routinely measured during pre-operative evaluation of lung resection candidates regardless of whether the spirometric evaluation is abnormal. A ppodlco value of 30% of predicted is suggested as hig h risk threshold for this parameter when included in an algorithm for assessment of pulmonary reserve before surgery (Figure 2). 1. Level of evidence: 2++; Grade of recommendation: B Wyser C. Am J Respir Crit Care Med 1999;159:1450-6

21 Stair climbing test Function walk test - 6 min walk test - Shuttle walk test

22 Introduced in 1960 for preoperative assessment of thoracic surgery Simple, inexpensive but poorly standardized Recorded as number of stairs climbed, flight of stairs ascended, time required to ascend Postoperative mortality: 11% (> 2 flights) vs > 50% (< 2 flights) Screen < 22 meters should proceed for more sophisticated exercise test

23 640 major lung resections from 2000 through April 2007 Age 66.7 y (>70 years,41%) Cardiac co-morbidity 49% Moderate-to-severe COPD 24% Neoadjuvant chemotherapy 16% Average stair climbing time 111 (50-250) Mean height climbed 19m (4-27) No complications related to exercise

24 Height at stair climbing test and outcomes % of patients <12m 12-22m >22m Total morbidity Pulmonary complications Cardiovascular complications 4 1 Mortality Brunelli A et al, Ann Thorac Surg 2008

25 Mortality < 12 m 20% (2/10) m 2% (1/46) > 22 m 0 (0/17) Brunelli A et al, Ann Thorac Surg 2008

26 Measure how far patients can walk along a flat corridor at normal pace in 6 minutes Other measures include SpO2, Heart rate, dyspnea and leg fatigue symptoms Distance < 200 m predicts high 6-month mortality following lung volume reduction surgery, < 300 m linked to poor outcome after aortic valve surgery Agnew N. Continuing Education in Anesthesia, Critical Care and Pain 2010;10:33

27 References Bagg RL. Respiration 1984 Markos J et al. Am Rev Respir Dis 1989 Holden DA, et al. Chest 1992 Pierce RJ et al. Am J Respir Crit Care Med 1994 Non-predictive Non-predictive Findings Predictive of mortality in pts with FEV1 <1.6L Predictive of respir failure but not of mortality or other complications

28 Patients walking at the speeds increasing every minute by 0.17 m/s in time to audio signal Distance > 350 m on SWT predicts low mortality after esophagectomy Murray P. Br J Anaesth 2007;99:809-11

29 It has been estimated by regression analysis that 25 shuttles on the shuttle walk test indicate a VO2peak of 10 ml/kg/min This cut-off value 400 m was suggested in functional algorithm by BTS as selection criteria for surgery Singh SJ, et al. Comparison of oxygen uptake during a conventional treadmill test and the shuttle walking test in chronic airflow limitation. Eur Respir J 1994; 7: 2016 Lim E et al. Thorax 2010; 65(suppl 3):iii1 iii27

30 Recommendations: 1. Shuttle walk test distance underestimates exercise capacity at the lower range and was not found to discriminate between patients with and without complications. Thus, it should not be used alone to select patients for operation. It could be used as a screening test: patients walking less than 400m may have peakvo2 lower than 15 ml/kg/min. Level of evidence 2+; Grades of recommendation C 2. Standardized symptom-limited stair climbing test is a cost-effective test capable to predict morbidity and mortality after lung resection better than traditional spirometric values. It should be used as a first line functional screening test to select those patients that can undergo safely to operation (height of ascent > 22m) or those who need more sophisticated exercise tests (cf paragraph 2-3-3) in order to optimize their perioperative management Level of evidence 2++; Grades of recommendation B 3. The 6-min walk test should not be used to select patients for operation. Level of evidence 2+; Grades of recommendation C

31 Oxygen saturation <90% and desaturation >4% with exercise are associated with increased risk of complications Gerard G. Continuing Education in Anesthesia, Critical Care and Pain 2006;6:97-100

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33 Continuous monitoring of various parameters Easy standardization and good reproducibility of results Peak VO2 is the single most important parameter as direct measure of exercise capacity Assessment of over-all cardio-pulmonary reserves, and find the reason for exercise limitation, such as pulmonary, cardiovascular, or musculo-skeletal limitations

34 Stratification of outcomes by peak VO VO2< VO VO VO2 > ,5 3, mortality total morbidity cardiac morbidity pulmonary morbidity Brunelli A et al. Chest 2009

35 Recommendations: 1- Cardio-pulmonary exercise tests are performed in controlled environment, reproducible and safe. PeakVO2 measured during an incremental exercise on treadmill or cycle should be regarded as the most important parameter to consider, as a measure of exercise capacity and highly predictive of postoperative complications. Level of evidence 2++; Grade of recommendations B 2- The following basic cut-off values for peakvo2 should be considered : peakvo2> 75% of predicted value or 20mL/min/kg qualifies for pneumonectomy peakvo2 < 35% or 10 ml/min/kg indicates high risk for any resection. Evidence is thin to recommend cut-off values for lobectomy Level of evidence 2++; Grade of recommendations C

36 O2 sat> 90% No diffuse lung disease No co-morbidity

37 Smoking cessation - within 1 month preceding surgery did not significantly affect perioperative morbidity or mortality vs longer abstention associated with better outcomes Pulmonary rehabilitation Mason DP, et al. Ann ThoracSurg 2009; 88:

38 The value of spirometry is increased when it is done with good quality, interpreted properly, and used in high-risk population as a case-finding DLCO is recommended in preoperative assessment regardless of whether there is abnorrnal spirometric result

39 Low-tech tests can be used as first-line screening tests in case CPET not available: stair climbing Any patients with insufficient performance should be referred for CPET CPET is the gold-standard for preop evaluation of lung resection candidates It provides detailed information on the potential deficits of the oxygen transport system, allowing optimization of perioperative management