Algorithm for pulmonary preoperative assessment of patients requiring lung resection

ppoDLCO: predicted postoperative diffusing capacity for carbon monoxide; ppoDLCO%: percent predicted postoperative diffusing capacity for carbon monoxide; ppoFEV₁: predicted postoperative FEV₁; ppoFEV₁%: percent predicted postoperative FEV₁; SCT: stair climb test; SWT: shuttle walk test; CPET: cardiopulmonary exercise test; VO₂max: maximal oxygen consumption.
* For pneumonectomy candidates, we suggest to use Q scan to calculate predicted postoperative values of FEV₁ 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 FEV₁ 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 PpoFEV₁ 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 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.