p re operative evaluation for pulmonary surgery chananya karunasumetta, md. division of...
TRANSCRIPT
![Page 1: P RE OPERATIVE EVALUATION FOR PULMONARY SURGERY Chananya Karunasumetta, MD. Division of Cardiothoracic Surgery Department of Surgery Queen Sirikit Heart](https://reader037.vdocuments.net/reader037/viewer/2022110320/56649cc55503460f9498ef4a/html5/thumbnails/1.jpg)
PRE OPERATIVE EVALUATION FOR PULMONARY SURGERY
Chananya Karunasumetta, MD. Chananya Karunasumetta, MD.
Division of Cardiothoracic SurgeryDivision of Cardiothoracic Surgery
Department of Surgery Department of Surgery
Queen Sirikit Heart Center of the NortheastQueen Sirikit Heart Center of the Northeast
Srinagarind Hospital, Khonkaen UniversitySrinagarind Hospital, Khonkaen University
![Page 2: P RE OPERATIVE EVALUATION FOR PULMONARY SURGERY Chananya Karunasumetta, MD. Division of Cardiothoracic Surgery Department of Surgery Queen Sirikit Heart](https://reader037.vdocuments.net/reader037/viewer/2022110320/56649cc55503460f9498ef4a/html5/thumbnails/2.jpg)
COMMON PROCEDURE
PneumonectomyLobectomy Wedge ResectionSegmentectomy
![Page 3: P RE OPERATIVE EVALUATION FOR PULMONARY SURGERY Chananya Karunasumetta, MD. Division of Cardiothoracic Surgery Department of Surgery Queen Sirikit Heart](https://reader037.vdocuments.net/reader037/viewer/2022110320/56649cc55503460f9498ef4a/html5/thumbnails/3.jpg)
MORTALITY RATES
Pneumonectomy : 6.8% - Bi lobectomy : 4.4 % Lobectomy : 3.9 % Lesser Resection : 1.4 % ( Damhuis et al., Eur Respir J 1996 ; 9:7-
10 )
![Page 4: P RE OPERATIVE EVALUATION FOR PULMONARY SURGERY Chananya Karunasumetta, MD. Division of Cardiothoracic Surgery Department of Surgery Queen Sirikit Heart](https://reader037.vdocuments.net/reader037/viewer/2022110320/56649cc55503460f9498ef4a/html5/thumbnails/4.jpg)
PR
EO
PER
TA
TIV
E
EV
ALU
ATIO
N F
OR
LU
NG
R
ES
EC
TIO
N
Patient
Disease
Operation
![Page 5: P RE OPERATIVE EVALUATION FOR PULMONARY SURGERY Chananya Karunasumetta, MD. Division of Cardiothoracic Surgery Department of Surgery Queen Sirikit Heart](https://reader037.vdocuments.net/reader037/viewer/2022110320/56649cc55503460f9498ef4a/html5/thumbnails/5.jpg)
PREOPERTATIVE EVALUATION
![Page 6: P RE OPERATIVE EVALUATION FOR PULMONARY SURGERY Chananya Karunasumetta, MD. Division of Cardiothoracic Surgery Department of Surgery Queen Sirikit Heart](https://reader037.vdocuments.net/reader037/viewer/2022110320/56649cc55503460f9498ef4a/html5/thumbnails/6.jpg)
PART IPART I: FITNESS FOR SURGERY
AgeAge
Pulmonary function
Pulmonary function
Cardiovascular fitness
Cardiovascular fitness
Weight loss, performance status and nutrition
Weight loss, performance status and nutrition
![Page 7: P RE OPERATIVE EVALUATION FOR PULMONARY SURGERY Chananya Karunasumetta, MD. Division of Cardiothoracic Surgery Department of Surgery Queen Sirikit Heart](https://reader037.vdocuments.net/reader037/viewer/2022110320/56649cc55503460f9498ef4a/html5/thumbnails/7.jpg)
PART IPART I: FITNESS FOR SURGERY
AgeAge
Pulmonary function
Pulmonary function
Cardiovascular fitness
Cardiovascular fitness
Weight loss, performance status and nutrition
Weight loss, performance status and nutrition
![Page 8: P RE OPERATIVE EVALUATION FOR PULMONARY SURGERY Chananya Karunasumetta, MD. Division of Cardiothoracic Surgery Department of Surgery Queen Sirikit Heart](https://reader037.vdocuments.net/reader037/viewer/2022110320/56649cc55503460f9498ef4a/html5/thumbnails/8.jpg)
PART IPART I: FITNESS FOR SURGERY
AgeAge Advancing age increase risk
Surgery for clinically stage I and II in patients over 70 years = younger patients
Age over 80 alone is not a contraindication to lobectomy or wedge resection
Pneumonectomy is associated with a higher mortality risk in the elderly
![Page 9: P RE OPERATIVE EVALUATION FOR PULMONARY SURGERY Chananya Karunasumetta, MD. Division of Cardiothoracic Surgery Department of Surgery Queen Sirikit Heart](https://reader037.vdocuments.net/reader037/viewer/2022110320/56649cc55503460f9498ef4a/html5/thumbnails/9.jpg)
PART IPART I: FITNESS FOR SURGERY
AgeAge
Pulmonary function
Pulmonary function
Cardiovascular fitness
Cardiovascular fitness
Weight loss, performance status and nutrition
Weight loss, performance status and nutrition
![Page 10: P RE OPERATIVE EVALUATION FOR PULMONARY SURGERY Chananya Karunasumetta, MD. Division of Cardiothoracic Surgery Department of Surgery Queen Sirikit Heart](https://reader037.vdocuments.net/reader037/viewer/2022110320/56649cc55503460f9498ef4a/html5/thumbnails/10.jpg)
PART IPART I: FITNESS FOR SURGERY
Pulmonary function
Pulmonary function
• Step I : Preop lung function• Arterial Blood Gas• Spirometry Analysis• DLCO
• Step II : Postop lung function• PPO FEV1,PPO DLCO• -Quantitative Ventilation P
erfusion Scan• Quantitative CT Scan
• Step III : Cardiopulmonary exercise test• Shuttle walk• Exercise Testing: Oxygen
Uptake (VO2 Max)
![Page 11: P RE OPERATIVE EVALUATION FOR PULMONARY SURGERY Chananya Karunasumetta, MD. Division of Cardiothoracic Surgery Department of Surgery Queen Sirikit Heart](https://reader037.vdocuments.net/reader037/viewer/2022110320/56649cc55503460f9498ef4a/html5/thumbnails/11.jpg)
STEP 1 : PRE OP ASSESSMENT
ABG
Spriro-
meter
DLCO
![Page 12: P RE OPERATIVE EVALUATION FOR PULMONARY SURGERY Chananya Karunasumetta, MD. Division of Cardiothoracic Surgery Department of Surgery Queen Sirikit Heart](https://reader037.vdocuments.net/reader037/viewer/2022110320/56649cc55503460f9498ef4a/html5/thumbnails/12.jpg)
STEP 2 POST OP ASSESSMENT
PPO FEV1 >40%, PPO DLCO >40% and SaO2 >90% on air: average risk
PPO FEV1 <40%, PPO DLCO <40% : high risk.
![Page 13: P RE OPERATIVE EVALUATION FOR PULMONARY SURGERY Chananya Karunasumetta, MD. Division of Cardiothoracic Surgery Department of Surgery Queen Sirikit Heart](https://reader037.vdocuments.net/reader037/viewer/2022110320/56649cc55503460f9498ef4a/html5/thumbnails/13.jpg)
Quantitative Ventilation-Perfusion ScanHighly accurate
Inhaled 133Xe or IV 99Tc
Normally: 19 Segments (10 R & 9 L) Right Lung (3/2/5): 55 % & Left Lung(3/2/4): 45%
STEP 2 POST OP ASSESSMENT
![Page 14: P RE OPERATIVE EVALUATION FOR PULMONARY SURGERY Chananya Karunasumetta, MD. Division of Cardiothoracic Surgery Department of Surgery Queen Sirikit Heart](https://reader037.vdocuments.net/reader037/viewer/2022110320/56649cc55503460f9498ef4a/html5/thumbnails/14.jpg)
Using 133Xe Inhalation:PPO FEV1 of < 1 L . (Kristersson S et al.Chest 1972; 62:696–
698)
Using 99Tc Macroaggregate of Albumin Perfusion:PPO FEV1 of < 0.8 L is indicative of
surgical inoperability. (Olsen GN et al. Chest 1974;
66:13–16)
STEP 2 POST OP ASSESSMENT
![Page 15: P RE OPERATIVE EVALUATION FOR PULMONARY SURGERY Chananya Karunasumetta, MD. Division of Cardiothoracic Surgery Department of Surgery Queen Sirikit Heart](https://reader037.vdocuments.net/reader037/viewer/2022110320/56649cc55503460f9498ef4a/html5/thumbnails/15.jpg)
STEP 3 CARDIOPULMONARY EXERCISE TEST
Shuttle walk • A best distance on two shuttle walk
tests of <25 shuttles (250 m) • desaturation during the test of more
than 4% SaO2
Stair Climbing and Walking
Tests
•climb three flights of stairs lobectomy.
•five flights of stairs Pneumonectomy.
VO2peak (Maximal oxygen
consumption)
•<15 ml/kg/min indicates that a patient is a high risk for surgery
![Page 16: P RE OPERATIVE EVALUATION FOR PULMONARY SURGERY Chananya Karunasumetta, MD. Division of Cardiothoracic Surgery Department of Surgery Queen Sirikit Heart](https://reader037.vdocuments.net/reader037/viewer/2022110320/56649cc55503460f9498ef4a/html5/thumbnails/16.jpg)
PART IPART I: FITNESS FOR SURGERY
AgeAge
Pulmonary function
Pulmonary function
Cardiovascular fitness
Cardiovascular fitness
Weight loss, performance status and nutrition
Weight loss, performance status and nutrition
![Page 17: P RE OPERATIVE EVALUATION FOR PULMONARY SURGERY Chananya Karunasumetta, MD. Division of Cardiothoracic Surgery Department of Surgery Queen Sirikit Heart](https://reader037.vdocuments.net/reader037/viewer/2022110320/56649cc55503460f9498ef4a/html5/thumbnails/17.jpg)
PART IPART I: FITNESS FOR SURGERY
Cardiovascular fitness
Cardiovascular fitness
• ECG
• Murmur echo
• MI Sx 6 wk
![Page 18: P RE OPERATIVE EVALUATION FOR PULMONARY SURGERY Chananya Karunasumetta, MD. Division of Cardiothoracic Surgery Department of Surgery Queen Sirikit Heart](https://reader037.vdocuments.net/reader037/viewer/2022110320/56649cc55503460f9498ef4a/html5/thumbnails/18.jpg)
CARDIAC RISK FACTOR
![Page 19: P RE OPERATIVE EVALUATION FOR PULMONARY SURGERY Chananya Karunasumetta, MD. Division of Cardiothoracic Surgery Department of Surgery Queen Sirikit Heart](https://reader037.vdocuments.net/reader037/viewer/2022110320/56649cc55503460f9498ef4a/html5/thumbnails/19.jpg)
PART IPART I: FITNESS FOR SURGERY
Cardiovascular fitness
Cardiovascular fitness
![Page 20: P RE OPERATIVE EVALUATION FOR PULMONARY SURGERY Chananya Karunasumetta, MD. Division of Cardiothoracic Surgery Department of Surgery Queen Sirikit Heart](https://reader037.vdocuments.net/reader037/viewer/2022110320/56649cc55503460f9498ef4a/html5/thumbnails/20.jpg)
PART IPART I: FITNESS FOR SURGERY
AgeAge
Pulmonary function
Pulmonary function
Cardiovascular fitness
Cardiovascular fitness
Weight loss, performance status and nutrition
Weight loss, performance status and nutrition
![Page 21: P RE OPERATIVE EVALUATION FOR PULMONARY SURGERY Chananya Karunasumetta, MD. Division of Cardiothoracic Surgery Department of Surgery Queen Sirikit Heart](https://reader037.vdocuments.net/reader037/viewer/2022110320/56649cc55503460f9498ef4a/html5/thumbnails/21.jpg)
PERFORMANCE STATUS
![Page 22: P RE OPERATIVE EVALUATION FOR PULMONARY SURGERY Chananya Karunasumetta, MD. Division of Cardiothoracic Surgery Department of Surgery Queen Sirikit Heart](https://reader037.vdocuments.net/reader037/viewer/2022110320/56649cc55503460f9498ef4a/html5/thumbnails/22.jpg)
PART IIPART II: OPERABILITY
Diagnosis and staging
Operability and adjuvant therapy
Operations available
![Page 23: P RE OPERATIVE EVALUATION FOR PULMONARY SURGERY Chananya Karunasumetta, MD. Division of Cardiothoracic Surgery Department of Surgery Queen Sirikit Heart](https://reader037.vdocuments.net/reader037/viewer/2022110320/56649cc55503460f9498ef4a/html5/thumbnails/23.jpg)
DIAGNOSIS AND STAGING
H&P CXR CT chest (including upper abdomen and
adrenals) CBC, platelets Chemistry profile Smoking cessation Pulmonary function test, bronchoscope
![Page 24: P RE OPERATIVE EVALUATION FOR PULMONARY SURGERY Chananya Karunasumetta, MD. Division of Cardiothoracic Surgery Department of Surgery Queen Sirikit Heart](https://reader037.vdocuments.net/reader037/viewer/2022110320/56649cc55503460f9498ef4a/html5/thumbnails/24.jpg)
CA LUNG STAGING
![Page 25: P RE OPERATIVE EVALUATION FOR PULMONARY SURGERY Chananya Karunasumetta, MD. Division of Cardiothoracic Surgery Department of Surgery Queen Sirikit Heart](https://reader037.vdocuments.net/reader037/viewer/2022110320/56649cc55503460f9498ef4a/html5/thumbnails/25.jpg)
DIAGNOSIS AND STAGING
![Page 26: P RE OPERATIVE EVALUATION FOR PULMONARY SURGERY Chananya Karunasumetta, MD. Division of Cardiothoracic Surgery Department of Surgery Queen Sirikit Heart](https://reader037.vdocuments.net/reader037/viewer/2022110320/56649cc55503460f9498ef4a/html5/thumbnails/26.jpg)
DIAGNOSIS AND STAGING
![Page 27: P RE OPERATIVE EVALUATION FOR PULMONARY SURGERY Chananya Karunasumetta, MD. Division of Cardiothoracic Surgery Department of Surgery Queen Sirikit Heart](https://reader037.vdocuments.net/reader037/viewer/2022110320/56649cc55503460f9498ef4a/html5/thumbnails/27.jpg)
RECOMMEND
PFT, bronchoscope , CT scan : all
Mediastinoscope : all except T1 a,b peripheral lesion
MRI brain : stage IIb (T3 invasion, No)
![Page 28: P RE OPERATIVE EVALUATION FOR PULMONARY SURGERY Chananya Karunasumetta, MD. Division of Cardiothoracic Surgery Department of Surgery Queen Sirikit Heart](https://reader037.vdocuments.net/reader037/viewer/2022110320/56649cc55503460f9498ef4a/html5/thumbnails/28.jpg)
Gene L. Colice, Chest 2007
![Page 29: P RE OPERATIVE EVALUATION FOR PULMONARY SURGERY Chananya Karunasumetta, MD. Division of Cardiothoracic Surgery Department of Surgery Queen Sirikit Heart](https://reader037.vdocuments.net/reader037/viewer/2022110320/56649cc55503460f9498ef4a/html5/thumbnails/29.jpg)
Average risk
![Page 30: P RE OPERATIVE EVALUATION FOR PULMONARY SURGERY Chananya Karunasumetta, MD. Division of Cardiothoracic Surgery Department of Surgery Queen Sirikit Heart](https://reader037.vdocuments.net/reader037/viewer/2022110320/56649cc55503460f9498ef4a/html5/thumbnails/30.jpg)
Srinivas R. Bapoje, Chest 2007
![Page 31: P RE OPERATIVE EVALUATION FOR PULMONARY SURGERY Chananya Karunasumetta, MD. Division of Cardiothoracic Surgery Department of Surgery Queen Sirikit Heart](https://reader037.vdocuments.net/reader037/viewer/2022110320/56649cc55503460f9498ef4a/html5/thumbnails/31.jpg)
CONCLUSION HX & PE Part 1 : Fitness
Age PFT
Step 1 : Pre op assessment
Step 2 : Predict post op function
Step 3 : Cardiopulmonary exercise test
Cardiac status Performance status
Part 2 : Operability Diagnosis and
staging PFT,
bronchoscope, CT scan
Mediastinoscope
MRI brain Bone scan
![Page 32: P RE OPERATIVE EVALUATION FOR PULMONARY SURGERY Chananya Karunasumetta, MD. Division of Cardiothoracic Surgery Department of Surgery Queen Sirikit Heart](https://reader037.vdocuments.net/reader037/viewer/2022110320/56649cc55503460f9498ef4a/html5/thumbnails/32.jpg)