Contraindications for Lung Resection Based on Preoperative Pulmonary Function Tests

Evaluation of Pulmonary Function

The European Respiratory Society recommends that an FEV1 of 1 liter is significantly below the minimum threshold for safe resection, with a recommended minimum threshold of 1.5 liters for lobectomy and 2.0 liters for pneumonectomy 1
A low FEV1 value would likely result in a predicted postoperative FEV1 (ppoFEV1) well below 40% of predicted value, which is associated with mortality rates of 16-50% 3
When ppoFEV1 falls below 30%, mortality rates as high as 60% have been reported 3
The American Thoracic Society indicates that preoperative PO2 of 60 mmHg is not an absolute contraindication, though it indicates impaired oxygenation 2
The American College of Chest Physicians states that preoperative PCO2 of 50 mmHg indicates hypercapnia but is not an absolute contraindication; studies show patients with hypercapnia can undergo surgery with acceptable outcomes 2
A normal FEV1/VC ratio of 75% is not a contraindication, according to the British Thoracic Society 1
The European Respiratory Society notes that MBC (Maximum Breathing Capacity) of 60% is not a standard contraindication criterion in current guidelines 1, 2

If FEV1 > 1.5 L for lobectomy or > 2.0 L for pneumonectomy, the American College of Chest Physicians recommends proceeding with surgery without further pulmonary testing 1
The European Respiratory Society suggests calculating predicted postoperative FEV1 (ppoFEV1) using the appropriate formula for pneumonectomy: ppoFEV1 = preoperative FEV1 × (1 - fraction of total perfusion for resected lung) 2
The American Thoracic Society recommends measuring DLCO and calculating predicted postoperative DLCO (ppoDLCO) 2
If both ppoFEV1 and ppoDLCO > 60% predicted, the American College of Chest Physicians considers this low risk and recommends proceeding with surgery 4
If either ppoFEV1 or ppoDLCO is 30-60% predicted, the European Respiratory Society suggests performing exercise testing (stair climb or shuttle walk test) 4
If either ppoFEV1 or ppoDLCO < 30% predicted, the American Thoracic Society considers this high risk and recommends performing cardiopulmonary exercise testing (CPET) 4

The Society for Thoracic Surgeons notes that modern surgical techniques like VATS (video-assisted thoracic surgery) may allow for safer resection in patients with borderline pulmonary function 5
The American College of Chest Physicians recommends considering limited resections (wedge or segmental) for high-risk patients instead of lobectomy or pneumonectomy 6
The European Respiratory Society states that oxygen saturation < 90% on room air is an additional risk factor that should be considered 3
The combination of low FEV1 and low DLCO significantly increases perioperative risk, according to the American Thoracic Society 2