Pulmonary Clearance for Pre-Operative Surgery

Key Risk Factors to Assess

Advanced age (≥65 years) significantly increases risk of postoperative pulmonary complications, with odds ratios of 2.09 for patients 60-69 years and 3.04 for those 70-79 years compared to younger patients 1
Chronic obstructive pulmonary disease (COPD) is the most commonly identified risk factor for postoperative pulmonary complications (odds ratio 1.79) 1
Functional dependence, congestive heart failure, weight loss, and obstructive sleep apnea are significant risk factors that should be evaluated 2, 3, 4
Myelopathy may increase risk of postoperative pneumonia and pulmonary embolism in spine surgery patients 5

For lung resection surgery, post-bronchodilator FEV1 values are critical: patients are generally suitable for lobectomy if FEV1 >1.5 liters and for pneumonectomy if FEV1 >2.0 liters 6, 7
Full pulmonary function tests with transfer factor (TLCO) should be included in additional testing for patients not clearly operable based on spirometry alone 6
Oxygen saturation measurement at rest should be included in additional testing for patients not clearly operable based on spirometry alone 6
Quantitative isotope perfusion scan should be considered if pneumonectomy is being considered 6, 7
Estimated postoperative FEV1 and TLCO as percentage of predicted values can be used to assess risk:
Exercise testing is recommended for patients with unclear risk after initial assessment:

Preoperative spirometry and chest radiography should not be used routinely for predicting postoperative pulmonary complication risk 1
There is insufficient evidence to support any specific preoperative diagnostic test for predicting postoperative pulmonary adverse events in spine surgery 2, 3, 4
Clinicians should perform appropriate preoperative pulmonary tests based on clinical presentation of active pulmonary symptoms or to confirm suspected pulmonary disease 2, 3, 8

Patients with risk factors should be counseled regarding increased risk of perioperative and postoperative pulmonary adverse events 2, 3, 4
Appropriate preoperative pulmonary interventions should be implemented to treat active pulmonary symptoms or suspected pulmonary disease 8

Patients with cardiac murmurs should have an echocardiogram 6, 7
Patients with recent myocardial infarction (within 6 weeks) should normally not undergo lung resection surgery 6, 7
Patients with multiple adverse medical factors should have their management discussed at a multidisciplinary meeting between a chest physician, surgeon, and oncologist 6, 7
Nutritional status assessment, including body mass index and serum albumin measurement, should be included in preoperative evaluation 6, 7

Inadequate attention to postoperative pulmonary complications, which are as prevalent and contribute similarly to morbidity, mortality, and length of stay as cardiac complications 1