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Author(s): Peter O.Ochieng, Ryan J.Horvath

  1. Patients scheduled for thoracic surgery should undergo the usual preoperative assessment as detailed in Chapter 1.
    1. Any patient undergoing elective thoracic surgery should be carefully screened for underlying bronchitis or pneumonia and treated appropriately before surgery.

      Diagnostic procedures such as bronchoscopy and lung biopsy may be indicated for persistent infection.

    2. In patients with tracheal stenosis or mediastinal masses, the history should focus on symptoms or signs of positional dyspnea, static versus dynamic airway collapse, and evidence of hypoxemia. The history may also suggest the probable location of the lesion.
  2. An arterial blood gas (ABG) may help clarify the severity of underlying pulmonary disease but is not routinely necessary.
  3. Pulmonary function tests (PFTs) are useful for assessing the pulmonary risk of lung resection. Forced expiratory volume in 1 second (FEV1) and diffusion capacity of the lung for carbon monoxide (DLCO) serve as initial predictors of postoperative outcomes. If either of these values is less than 80% of predicted, it should prompt additional studies beginning with postoperative predicted (PPO) FEV1 and DLCO. If both PPO FEV1 and PPO DLCO are ≥60%, then the patient is considered low risk for surgery. If either is <60% but both are ≥30%, then the patient undergoes stair-climbing test (SCT) or shuttle walk test (SWT). If SCT is ≥22 m or SWT ≥25 shuttles, the patient is considered low risk. If either PPO FEV1 and DLCO are <30% or performance on SCT and SWT is not satisfactory, cardiopulmonary exercise test to calculate maximum oxygen consumption (VO2 max) is needed. VO2 max >20 mL/kg/min or >75% indicates low-risk, while VO2 max of <10 mL/kg/min or <35% is high-risk group and surgery is not recommended. VO2 max 10 to 20 mL/kg/min or 35% to 75% indicates moderate-risk and VO2 max <10 mL/kg/min or <35% indicates high-risk group and surgery is not recommended. Quantitative ventilation/perfusion (V/Q) scan can also be used to calculate PPO FEV1 in patients scheduled to undergo pneumonectomy.
  4. Cardiac function should be assessed if there is a question about the relative contribution of cardiac and pulmonary diseases to the patient’s functional impairment. Echocardiography can be used to assess right ventricular function. Echocardiographic estimation of right ventricular systolic pressure can be used as a screening tool for pulmonary hypertension, although right heart catheterization is required for definitive diagnosis. This is especially important for procedures requiring clamping of a pulmonary artery (eg, pneumonectomy).
  5. Chest radiography, computed tomography (CT), and magnetic resonance imaging (MRI) are useful to determine the presence and extent of tracheobronchial, pulmonary and mediastinal pathology. Imaging studies can also reveal the nature and degree of involvement of other thoracic structures in the disease process. Three-dimensional CT reconstruction can be used to assess caliber of stenotic airway to guide anesthetic airway plan. These studies can also be helpful in planning for lung isolation if required.