Zusammenfassung
Die präoperative Einschätzung der Lungenfunktion von Patienten vor lungenresezierenden Verfahren stellt eine interdisziplinäre Herausforderung dar. Trotz medizinischer Fortschritte in den Fachgebieten der Anästhesie, Intensivmedizin und Chirurgie liegt die Letalitätsrate von Patienten nach Pneumonektomie weiterhin bei 5–9%. Zur präoperativen Identifikation von Patienten mit einem erhöhten perioperativen Morbiditäts- und Letalitätsrisiko wurden Stufenschemata der präoperativen Evaluation der Lungenfunktion entwickelt, deren Basis die Spirometrie und die Messung der Diffusionskapazität darstellt. Bei Funktionseinschränkung folgen Messungen zur Einschätzung der postoperativen Lungenfunktion sowie die Bestimmung der maximalen Sauerstoffaufnahme zur präoperativen Risikostratifikation. Im Folgenden werden die Untersuchungsmethoden zur Erfassung von Lungenfunktionsparametern und Parametern des pulmonalen Gasaustausches beschrieben und deren Wertigkeit unter Berücksichtigung aktueller Leitlinien diskutiert.
Abstract
Preoperative evaluation of patients undergoing lung resection remains an interdisciplinary challenge. Despite substantial progress in anesthesiology, intensive care medicine and surgery, mortality of patients undergoing pneumonectomy remains high at 5–9%. Guidelines were developed to identify patients with an increased perioperative risk for morbidity and mortality. These guidelines are focused around the forced expiratory capacity (FEV) measured by spirometry, following further investigations in patients with limited FEV1. Extended testing includes measurement of the diffusion capacity, calculation of postoperative predicted values of lung function and spiroergometry to determine maximal oxygen uptake. In this article the methods to measure parameters of lung function and gas exchange are described and evaluated in the context of the current guidelines.
Literatur
Brunelli A, Charloux A, Bolliger CT et al (2009) The European Respiratory Society and European Society Of Thoracic Surgeons clinical guidelines for evaluating fitness for radical treatment (surgery and chemoradiotherapy) in patients with lung cancer. Eur J Cardiothorac Surg 36(1):181–184
Kroidl RF, Schwarz S, Lehnigk B (2006) Cardiopulmonary exercise testing. Pneumologie 60(3):149–170
Colice GL, Shafazand S, Griffin JP et al (2007) Physiologic evaluation of the patient with lung cancer being considered for resectional surgery: ACCP evidenced-based clinical practice guidelines (2. Aufl.). Chest 132 [Suppl 3]:161–177
British Thoracic Society, Society of Cardiothoracic Surgeons of Great Britain and Ireland Working Party (2001) BTS guidelines: guidelines on the selection of patients with lung cancer for surgery. Thorax 56(2):89–108
Harbour R, Miller J (2001) A new system for grading recommendations in evidence based guidelines. BMJ 323(7308):334–336
McCrory DC, Lewis SZ, Heitzer J et al (2007) Methodology for lung cancer evidence review and guideline development: ACCP evidence-based clinical practice guidelines (2. Aufl.). Chest 132 [Suppl 3]:23–28
Damhuis RA, Schutte PR (1996) Resection rates and postoperative mortality in 7,899 patients with lung cancer. Eur Respir J 9(1):7–10
Society for Cardiothoracic Surgery in Great Britain and Ireland (2007) Audits and comments. scts.org/sections/audit/index.html. Cited 25 Oct 2007
Schulz C, Emslander HP, Riedel M (1999) Risk assessment of patients before lung surgery. Chirurg 70(6):664–673
Birim O, Zuydendorp HM, Maat AP et al (2003) Lung resection for non-small-cell lung cancer in patients older than 70: mortality, morbidity, and late survival compared with the general population. Ann Thorac Surg 76(6):1796–1801
Brock MV, Kim MP, Hooker CM et al (2004) Pulmonary resection in octogenarians with stage I non-small cell lung cancer: a 22-year experience. Ann Thorac Surg 77(1):271–277
Fukuse T, Satoda N, Hijiya K et al (2005) Importance of a comprehensive geriatric assessment in prediction of complications following thoracic surgery in elderly patients. Chest 127(3):886–891
Fleisher LA, Beckman JA, Brown KA et al (2007) ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery): Developed in Collaboration With the American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, and Society for Vascular Surgery. Circulation 116(17):1971–1996
Poldermans D, Bax JJ, Boersma E et al (2009) Guidelines for pre-operative cardiac risk assessment and perioperative cardiac management in non-cardiac surgery: The Task Force for Preoperative Cardiac Risk Assessment and Perioperative Cardiac Management in Non-cardiac Surgery of the European Society of Cardiology (ESC) and endorsed by the European Society of Anaesthesiology (ESA). Eur Heart J 30(22):2769–2812
Mishra PK, Pandey R, Shackcloth MJ et al (2009) Cardiac comorbidity is not a risk factor for mortality and morbidity following surgery for primary non-small cell lung cancer. Eur J Cardiothorac Surg 35(3):439–443
Volpino P, Cangemi R, Fiori E et al (2007) Risk of mortality from cardiovascular and respiratory causes in patients with chronic obstructive pulmonary disease submitted to follow-up after lung resection for non-small cell lung cancer. J Cardiovasc Surg 48(3):375–383
Tisi GM (1979) Preoperative evaluation of pulmonary function. Validity, indications, and benefits. Am Rev Respir Dis 119(2):293–310
German Society of Pneumology (1994) Recommendations for preoperative diagnosis of lung function. Pneumologie 48 [Suppl 1]:296–299
Brunelli A, Berrisford RG, Rocco G et al (2009) The European Thoracic Database project: composite performance score to measure quality of care after major lung resection. Eur J Cardiothorac Surg 35(5):769–774
Quanjer PH, Tammeling GJ, Cotes JE et al (1993) Lung volumes and forced ventilatory flows. Report Working Party Standardization of Lung Function Tests, European Community for Steel and Coal. Official Statement of the European Respiratory Society. Eur Respir J Suppl 16:5–40
Brunelli A, Refai MA, Salati M et al (2006) Carbon monoxide lung diffusion capacity improves risk stratification in patients without airflow limitation: evidence for systematic measurement before lung resection. Eur J Cardiothorac Surg 29(4):567–570
Matsubara Y, Takeda S, Mashimo T (2005) Risk stratification for lung cancer surgery: impact of induction therapy and extended resection. Chest 128(5):3519–3525
Berrisford R, Brunelli A, Rocco G et al (2005) The European Thoracic Surgery Database project: modelling the risk of in-hospital death following lung resection. Eur J Cardiothorac Surg 28(2):306–311
Kearney DJ, Lee TH, Reilly JJ et al (1994) Assessment of operative risk in patients undergoing lung resection. Importance of predicted pulmonary function. Chest 105(3):753–759
Wu MT, Chang JM, Chiang AA et al (1994) Use of quantitative CT to predict postoperative lung function in patients with lung cancer. Radiology 191(1):257–262
Kristersson S, Lindell SE, Svanberg L (1972) Prediction of pulmonary function loss due to pneumonectomy using 133 Xe-radiospirometry. Chest 62(6):694–698
Olsen GN, Block AJ, Tobias JA (1974) Prediction of postpneumonectomy pulmonary function using quantitative macroaggregate lung scanning. Chest 66(1):13–16
Bolliger CT, Guckel C, Engel H et al (2002) Prediction of functional reserves after lung resection: comparison between quantitative computed tomography, scintigraphy, and anatomy. Respiration 69(6):482–489
Ferguson MK, Vigneswaran WT (2008) Diffusing capacity predicts morbidity after lung resection in patients without obstructive lung disease. Ann Thorac Surg 85(4):1158–1164; discussion 1164–1165
Ferguson MK, Lehman AG, Bolliger CT et al (2008) The role of diffusing capacity and exercise tests. Thorac Surg Clin 18(1):9–17, v
Singh SJ, Morgan MD, Hardman AE et al (1994) Comparison of oxygen uptake during a conventional treadmill test and the shuttle walking test in chronic airflow limitation. Eur Respir J 7(11):2016–2020
Pollock M, Roa J, Benditt J et al (1993) Estimation of ventilatory reserve by stair climbing. A study in patients with chronic airflow obstruction. Chest 104(5):1378–1383
Brunelli A, Al Refai M, Monteverde M et al (2002) Stair climbing test predicts cardiopulmonary complications after lung resection. Chest 121(4):1106–1110
Loewen GM, Watson D, Kohman L et al (2007) Preoperative exercise Vo2 measurement for lung resection candidates: results of Cancer and Leukemia Group B Protocol 9238. J Thorac Oncol 2(7):619–625
Win T, Jackson A, Sharples L et al (2005) Cardiopulmonary exercise tests and lung cancer surgical outcome. Chest 127(4):1159–1165
Benzo R, Kelley GA, Recchi L et al (2007) Complications of lung resection and exercise capacity: a meta-analysis. Respir Med 101(8):1790–1797
Pierce RJ, Copland JM, Sharpe K et al (1994) Preoperative risk evaluation for lung cancer resection: predicted postoperative product as a predictor of surgical mortality. Am J Respir Crit Care Med 150(4):947–955
Ribas J, Diaz O, Barbera JA et al (1998) Invasive exercise testing in the evaluation of patients at high-risk for lung resection. Eur Respir J 12(6):1429–1435
Miyoshi S, Yoshimasu T, Hirai T et al (2000) Exercise capacity of thoracotomy patients in the early postoperative period. Chest 118(2):384–390
Varela G, Brunelli A, Rocco G et al (2006) Predicted versus observed FEV1 in the immediate postoperative period after pulmonary lobectomy. Eur J Cardiothorac Surg 30(4):644–648
Brunelli A, Varela G, Rocco G et al (2007) A model to predict the immediate postoperative FEV1 following major lung resections. Eur J Cardiothorac Surg 32(5):783–786
Edrich T, Sadovnikoff N (2010) Anesthesia for patients with severe chronic obstructive pulmonary disease. Curr Opin Anaesthesiol 23(1):18–24
Qaseem A, Snow V, Fitterman N et al (2006) Risk assessment for and strategies to reduce perioperative pulmonary complications for patients undergoing noncardiothoracic surgery: a guideline from the American College of Physicians. Ann Intern Med 144(8):575–580
Lawrence VA, Dhanda R, Hilsenbeck SG et al (1996) Risk of pulmonary complications after elective abdominal surgery. Chest 110(3):744–750
Boldt J, Piper S, Uphus D et al (1999) Preoperative microbiologic screening and antibiotic prophylaxis in pulmonary resection operations. Ann Thorac Surg 68(1):208–211
Schussler O, Alifano M, Dermine H et al (2006) Postoperative pneumonia after major lung resection. Am J Respir Crit Care Med 173(10):1161–1169
Schussler O, Dermine H, Alifano M et al (2008) Should we change antibiotic prophylaxis for lung surgery? Postoperative pneumonia is the critical issue. Ann Thorac Surg 86(6):1727–1733
Nakagawa M, Tanaka H, Tsukuma H et al (2001) Relationship between the duration of the preoperative smoke-free period and the incidence of postoperative pulmonary complications after pulmonary surgery. Chest 120(3):705–710
Warner DO (2005) Preoperative smoking cessation: the role of the primary care provider. Mayo Clin Proc 80(2):252–258
Warner DO, Sarr MG, Offord KP et al (2004) Anesthesiologists, general surgeons, and tobacco interventions in the perioperative period. Anesth Analg 99(6):1766–1773, table of contents
Warner MA, Offord KP, Warner ME et al (1989) Role of preoperative cessation of smoking and other factors in postoperative pulmonary complications: a blinded prospective study of coronary artery bypass patients. Mayo Clin Proc 64(6):609–616
Hofer S, Plachky J, Fantl R et al (2006) Postoperative pulmonale Komplikationen: Prophylaxe nach nichtkardiochirurgischen Eingriffen. Anaesthesist 55(4):473–484
Konietzko N (1992) Assessment of the preoperative risk of existing lung diseases. Internist (Berl) 33(6):379–386
Konietzko N, Petro W, Brockmann M et al (1986) Bronchialkarzinom und pulmonale Hypertonie. Bedeutung für die Lungenresektion. Dtsch Med Wochenschr 111(48):1830–1833
Ross AF, Ueda K (2010) Pulmonary hypertension in thoracic surgical patients. Curr Opin Anaesthesiol 23(1):25–33
Ammash NM, Connolly HM, Abel MD et al (1999) Noncardiac surgery in Eisenmenger syndrome. J Am Coll Cardiol 33(1):222–227
Lai HC, Lai HC, Wang KY et al (2007) Severe pulmonary hypertension complicates postoperative outcome of non-cardiac surgery. Br J Anaesth 99(2):184–190
Ramakrishna G, Sprung J, Ravi BS et al (2005) Impact of pulmonary hypertension on the outcomes of noncardiac surgery: predictors of perioperative morbidity and mortality. J Am Coll Cardiol 45(10):1691–1699
Kreider ME, Hansen-Flaschen J, Ahmad NN et al (2007) Complications of video-assisted thoracoscopic lung biopsy in patients with interstitial lung disease. Ann Thorac Surg 83(3):1140–1144
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Mutlak, H., Czerner, S., Winter, H. et al. Präoperative Evaluation und Risikoeinschätzung in der Thoraxchirurgie. Anaesthesist 59, 918–928 (2010). https://doi.org/10.1007/s00101-010-1765-z
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DOI: https://doi.org/10.1007/s00101-010-1765-z