1. APPROACH OF PREOPERATIVE
PULMONARY RISK ASSESSMENT
Dr Nahid Sherbini
Pulmonary Fellow

2. Introduction
• Postoperative pulmonary complications morbidity and
mortality.
• In a study of patients undergoing elective abdominal
surgery, pulmonary complications >cardiac complications
and were associated with significantly longer hospital
stays
Incidence and hospital stay for cardiac and pulmonary complications after
abdominal surgery.
Lawrence VA, Hilsenbeck SG, Mulrow CD, Dhanda R, Sapp J, Page CP
J Gen Intern Med. 1995;10(12):671.

3. General complications
Atelectasis
Infection
Bronchitis
Pneumonia
Bronchospasm
Pulmonary embolism
Exacerbation of underlying
chronic lung disease
Respiratory failure and
prolonged invasive or NIV
OSA
ARDS
Specific cardiothoracic surgical
complications
Phrenic nerve injury
Pleural effusion
Bronchopleural fistula
Sternal wound infection and
empyema
Gastroesophageal anastomotic
leak
Postoperative arrhythmias

4. Incidence
• Varies 2- 70%
• The rate of postoperative pulmonary complications across
all types of surgery was 6.8 % in a systematic review.
Benefits from surgery ←→ Risk of complications
Preoperative pulmonary risk stratification for noncardiothoracic surgery:
systematic review for the American College of Physicians.
Smetana GW, Lawrence VA, Cornell JE, American College of Physicians
Ann Intern Med. 2006;144(8):58

5. SURGERY PULMONARY COMPLICATION
INCIDENCE
Thoracotomy and % 30
lung resection
Cardiac % 40
Esophagectomy % 25 - 50
Abdominal % 30
 Upper abdominal surgery has a complication risk which is 1,5 x
than lower abdominal surgery

6. PERIOPERATIVE PULMONARY
PHYSIOLOGY
Reduced lung volume after surgery is a major factor
Thoracic and upper abdominal in a restrictive pattern
* (VC) is reduced by 50- 60 %
* (FRC) is reduced by about 30%.
Meyers JR, Lembeck L, O'Kane H, Baue AE. Changes in functional residual
capacity of the lung after operation. Arch Surg 1975; 110:576.
Craig DB. Postoperative recovery of pulmonary function. Anesth Analg 1981

7. PERIOPERATIVE PULMONARY
PHYSIOLOGY
• Diaphragmatic dysfunction -postoperative pain and
splinting  Reduction of the FRC below closing volumes
atelectasis, pneumonia, &(V/Q) mismatching.
• Microatelectasis perfused but not ventilated impaired
gas exchange with consequent hypoxemia .
Ford GT, Whitelaw WA, Rosenal TW, et al. Diaphragm function after upper
abdominal surgery in humans. Am Rev Respir Dis 1983; 127:431.
Marshall BE, Wyche MQ Jr. Hypoxemia during and after anesthesia.
Anesthesiology 1972; 37:178.

8. PERIOPERATIVE PULMONARY
PHYSIOLOGY
• Residual effects of anesthesia depress the respiratory
drive Inhibition of cough and impairment of mucociliary
clearance of respiratory secretions.
A decrease in TV
increase in RR
Cough dynamics in oesophageal cancer: prevention of postoperative pulmonary complications.
Sugimachi K, Ueo H, Natsuda Y, Kai H, Inokuchi K, Zaitsu A
Br J Surg. 1982;69(12):734.

9. POSTOPERATIVE PULMONARY DYSFUNCTION
Alterations in ventilation and perfusion distrubution, in
respiratory mechanics
Postoperative Pulmonary Dysfunction
Postoperative Pulmonary Complications
Wynne R et al. AJCC 2004; 13: 384 - 93

10. Outlines of The Approach
• Patient related risk factors
• Procedure related risk factors
• Preoperative risk assessment
• Risk reduction strategies

11. Patient related risk factors
• Age
• Health state
• Obesity
• Smoking
• COPD
• Asthma
• Pulmonary hypertension
• Heart failure
• Metabolic factors

12. Age
• Minor risk factor
• Independent predictor
• Surgery should not be declined in elderly patients who are
otherwise acceptable surgical candidates.
Prediction of outcome of surgery and anesthesia in patients over 80.,Djokovic JL, Hedley-
Whyte J-JAMA. 1979;242(21):2301.
Postoperative intensive care admittance: the role of tobacco smoking.-Møller AM, Maaløe R,
Pedersen T-Acta Anaesthesiol Scand. 2001;45(3):345

13. Age
• >50 y was an important independent predictor of risk.
• When compared to patients <50 years old, 50 - 59 y, 60 -
69 y 70 - 79 y, & ≥80 y  (OR) of 1.50 , 2.28 , 3.90 , and
5.63 , respectively.
• Even healthy older patients carry a substantial risk of
pulmonary complications after surgery.
Preoperative pulmonary risk stratification for noncardiothoracic surgery:
systematic review for the American College of Physicians.
Smetana GW, Lawrence VA, Cornell JE, American College of Physicians
Ann Intern Med. 2006;144(8):581.

14. General health status
• Functional dependence and impaired sensorium each
increase postoperative pulmonary risk .
(ASA) classification correlates well with pulmonary risk
(significant preexisting lung disease would be classified in a
higher ASA class)
ASA class >2 confers a 4.87 fold increase in risk .
Preoperative pulmonary risk stratification for noncardiothoracic surgery:
systematic review for the American College of Physicians.
Smetana GW, Lawrence VA, Cornell JE, American College of Physicians
Ann Intern Med. 2006;144(8):581.

15. AMERICAN SOCIETY OF ANAESTHESIA(ASA) CLINICAL SCORE
• ASA- I No systemic disorder
• ASA- II Mild disorder
• ASA- III Moderate disorder *
• ASA- IV Severe disorder
• ASA- V Cause of death

16. ASA

17. Smoking
• Current cigarette smokers have an increased risk ,even in
the absence of chronic lung disease .
• A prospective cohort study of 410 patients undergoing
elective, noncardiac surgery found that smoking was
associated with a greater than five-fold increase in the
postoperative complication rate (OR = 5.5) .
A prospective survey of the incidence of postoperative pulmonary complications. Wightman JA
Br J Surg. 1968;55(2):85.
Preoperative smoking habits and postoperative pulmonary complications.
Bluman LG, Mosca L, Newman N, Simon DG -Chest. 1998;113(4):88

18. Smoking
• Smoking history of 40 pack years or more →↑risk
of pulmonary complications
• stopped smoking < 2 months : stopped for > 2
months = 4:1 (57% : 14.5%)
• quit smoking > 6 months : never smoked = 1:1
(11% : 11.9%)
Preoperative smoking habits and postoperative pulmonary complications.Bluman LG, Mosca L,
Newman N, Simon DG /Chest. 1998;113(4):883.
Relationship between the duration of the preoperative smoke-free period and the incidence of
postoperative pulmonary complications after pulmonary surgery./Nakagawa M, Tanaka H, Tsukuma
H, Kishi Y/Chest. 2001;120(3):705

19. COPD
• Unadjusted relative risks have ranged 2.7 to 6.0 .
• A more recent systematic review  impact was
less than previously estimated . multivariable
analysis to adjust for patient-related
confounders odds ratio for postoperative
pulmonary complications was 2.36 (CI 1.90-2.93).
Preoperative pulmonary evaluation. /Smetana GW
N Engl J Med. 1999;340(12):937.
Preoperative pulmonary risk stratification for noncardiothoracic surgery: systematic review for the American
College of Physicians. Smetana GW, Lawrence VA, Cornell JE, American College of Physicians
Ann Intern Med. 2006;144(8):581.

20. Asthma
• Despite early reports indicating that patients with asthma
had higher rate.
• Recent studies have found no link for patients with well-
controlled asthma. The largest studied 706 patients with
asthma undergoing general surgery .
Perioperative respiratory complications in patients with asthma.
Warner DO, Warner MA, Barnes RD, Offord KP, Schroeder DR, Gray DT,
Yunginger JW /Anesthesiology. 1996;85(3):460.

21. Obesity
• Morbid obesity →
restrictive lung disease
↓ thoracic compliance
alveolar hypoventilation

22. Obesity
• Obesity is not a significant risk factor not affect patient
selection for otherwise high-risk procedures
• A systematic review found that, among 8 studies using
multivariate analysis, only one study identified obesity as
an independent predictor .
Preoperative pulmonary risk stratification for noncardiothoracic surgery: systematic
review for the American College of Physicians.
Smetana GW, Lawrence VA, Cornell JE, American College of Physicians
Ann Intern Med. 2006;144(8):581.

23. Obstructive sleep apnea (OSA)
• An emerging risk factor for postoperative pulmonary
complications.
• Increases the risk of critical respiratory events
immediately after surgery, including early hypoxemia and
unplanned reintubation.
Practice guidelines for the perioperative management of patients with obstructive sleep apnea: a report by the
American Society of Anesthesiologists Task Force on Perioperative Management of patients with obstructive
sleep apnea.
Gross JB, Bachenberg KL, Benumof JL, Caplan RA, Connis RT, CotéCJ, Nickinovich DG, Prachand V, Ward
DS, Weaver EM, Ydens L, Yu S, American Society of Anesthesiologists Task Force on Perioperative
Management
Anesthesiology. 2006;104(5):1081.

24. OSA
• The largest study to date ,evaluated 3.4 million general
surgical and 2.6 million orthopedic patients from an
administrative database . Patients with OSA were more
likely to develop respiratory failure (OR 1.95, CI 1.91-
1.98) and aspiration pneumonia (OR 1.37, CI 1.33-1.41).
Comparable rates :
GS OR 5.20 (CI 5.05-5.37)
ORTHOOR 1.41 (CI 1.35-1.47)
Screening ??
Perioperative pulmonary outcomes in patients with sleep apnea after noncardiac surgery.
Memtsoudis S, Liu SS, Ma Y, Chiu YL, Walz JM, Gaber-Baylis LK, Mazumdar M
Anesth Analg. 2011 Jan;112(1):113-21. Epub 2010 Nov 16

25. Pulmonary hypertension
• Increases complication rates after surgery, including in
patients with mild to moderate pulmonary hypertension.
• Regardless of the underlying etiology.
Noncardiothoracic nonobstetric surgery in mild-to-moderate pulmonary hypertension.
Price LC, Montani D, Jaïs X, Dick JR, Simonneau G, Sitbon O, Mercier FJ, Humbert M
Eur Respir J. 2010;35(6):1294.
Impact of pulmonary hypertension on the outcomes of noncardiac surgery: predictors of perioperative
morbidity and mortality.
Ramakrishna G, Sprung J, Ravi BS, Chandrasekaran K, McGoon MD
J Am Coll Cardiol. 2005;45(10):16

26. Heart failure
• The risk higher in patients with heart failure than in those
with COPD.
• Systematic review pooled adjusted odds ratio for
pulmonary complications were 2.93 (95% CI 1.02-8.43)
for heart failure patients and 2.36 (1.90-2.93) for patients
with COPD.
Preoperative pulmonary risk stratification for noncardiothoracic surgery: systematic
review for the American College of Physicians.
Smetana GW, Lawrence VA, Cornell JE, American College of Physicians
Ann Intern Med. 2006;144(8):581.

27. Metabolic factors
• Albumin less than 3 g/dL OR 2.53
• Blood urea nitrogen (BUN) >30 mg/Dl OR 2.29
• A systematic review found that the magnitude of risk
associated with a low serum albumin was similar to the
degree of the most important patient-related risk factors
and a stronger predictor of risk than an elevated BUN

28. Procedure related risk factors
• Surgical site
• Duration and type of anesthesia
• Type of neuromuscular blockade

29. Surgical site
• The most important predictor of pulmonary complications
• The incidence of complications is inversely related to the
distance of the surgical incision from the diaphragm
• The complication rates for upper abdominal and thoracic
surgery are the highest (range 10% to 40%)
Preoperative pulmonary risk stratification for noncardiothoracic surgery: systematic
review for the American College of Physicians.
Smetana GW, Lawrence VA, Cornell JE, American College of Physicians
Ann Intern Med. 2006;144(8)

30. Surgical site (cont.)
• Upper abdomen
• Incisions cross the abd. muscle,↓ diaphragmatic motility → ↓VC
• Lateral thoracotomy
• Incision of the intercostal muscle, introduction of a pleural drain →
pleural effusion, post-op pain → ↓ thoracic compliance

31. Surgical site (cont.) Thoracotomy
• Without pulmonary
disease
• VC ↓ to 60~70% of the pre-
operative value
• With pulmonary disease
• The effects of thoracotomy
are amplified
• Thoractomy → thoracic
pain → ↓deep breathing,
effective coughing →
atelectasis, bronchial
mucous retention,
worsening of gas exchange

32. Surgical site (cont.)
Video-assisted thoracoscopic surgery
(VATS)
• Reduced pain ,Postoperative complications, release
and responses of proinflammatory cytokines, and better
ventilatory function.
• VATS lobectomy in NSCLC at clinical stage I could well
be acceptable
• with 97.2% 8-year survival rate , better than outcomes by
thoracotomy.

33. Surgical site (cont.)
• Heart-surgery
• usually require median sternotomy
• functionally better tolerated than lateral thoracotomy (due to
preserves the pleural space)
• respiratory function is generally well preserved, except for a
transitory reduction in pulmonary volumes.

34. Duration and type of anaesthesia
• Anesthesia time of > 3.5 -4hours →↑incidence of
pulmonary complications
• in a very high risk patient→ a less ambitious, briefer
procedure
• general anesthesia > epidural analgesia ,neuromuscular blocker and
local anesthesia
Postoperative intensive care admittance: the role of tobacco smoking.
Møller AM, Maaløe R, Pedersen T
Acta Anaesthesiol Scand. 2001;45(3):3

35. Type of neuromuscular blockade
• Pancuronium, a long-acting neuromuscular blocker
• a higher incidence of postoperative residual neuromuscular
blockade
• a higher incidence of postoperative pulmonary complications in
those patients with residual neuromuscular blockade
Residual neuromuscular blockade and critical respiratory events in the
postanesthesia care unit.
Murphy GS, Szokol JW, Marymont JH, Greenberg SB, Avram MJ, Vender JS
Anesth Analg. 2008;107(1):13

36. PREOPERATIVE RISKS
ASSESSMENT

37. ASSIGNMENT OF PREOPERATIVE RISKS
CLINICAL EVALUATION (Basic rule)
• History
 Present / history of lung disease
 Respiratory symptoms (dyspnea, cough)
 Smoking
 Other co morbid diseases
 Drugs
 Atopy (individual or family) history
 Exercise intolerance

38. ASSIGNMENT OF PREOPERATIVE RISKS
• Physical Examination
 Symptoms of increased sputum secretion (ralles)
 Obstruction findings (Wheezing, prolonged expiration)
 Symptoms of emphysema
 Symptoms of respiratory insufficiency
 Hypertension, arrthymia, tachycardia

39. ASSIGNMENT OF PREOPERATIVE RISKS
AND
• Arterial blood gas
• Chest X-Ray
• Functional Evaluation (Spirometry,Diffusion
Capacity)
• Exercise Tests

40. ARTERIAL BLOOD GASES –A DIFFERENT POINT OF VİEW
• PaO2 < 50 mmHg Risk
• PaO2 < 60 mmHg, PaCO2 > 50 mmHg
Nagasaki F, Chest 1982; 82: 25-29
• PaCO2 > 45 mmHg resection with high risk
Morice RC, Chest 1992; 101: 356-361
Bolliger CT, ERJ 1998; 11:198-212
CCP, Ann Inter Med 1990; 112: 793-794

41. ARTERIAL BLOOD GASES – GENERAL OPINION
• Hypercarbia in patients with COPD (PaCO2 > 45 mmHg), is not a
certain contrendication but is believed to be with high surgical risk
• Hypoxemia, is not a significiant predictor of complication alone
Prediction of postoperative pulmonary complications in oesophagogastric cancer surgery.
Fan ST, Lau WY, Yip WC, Poon GP, Yeung C, Lam WK, Wong KK
Br J Surg. 1987;74(5):408.

42. EVALUATION OF PREOPERATIVE RISKS
• RADIOLOGICAL EVALUATION
 There is no role of CXR in evaluating postoperative risks in
healthy persons, but it must be performed.
 Preoperative CXR is essential for patients >60Y with cardiac or
pulmonary problems
Value of routine preoperative chest x-rays: a meta-analysis.
Archer C, Levy AR, McGregor M
Can J Anaesth. 1993;40(11):102

43. EVALUATION OF PREOPERATIVE RISKS
EXERCISE TESTS
• Walking test (6min)
• Stair climbing test
• Step test
• “Shuttle walk” test
• Bicycle ergometery ( MVO2 )
* Routine use before general surgery is not recommended
EXCEPT FOR LUNG RESECTION

44. PFT
• Two reasonable goals to use of preoperative PFTs
1. Identification of a group of patients for whom the risk of the
proposed surgery is not justified by the benefit
2. Identification of a subset of patients at higher risk for whom
aggressive perioperative management is warranted

45. PFT
• These tests simply confirm the clinical impression of disease severity
in most cases, adding little to the clinical estimation of risk
• Overused

46. ACP GUIDELINES 2006
• Not use preoperative spirometry routinely for predicting
the risk of postoperative pulmonary complications .
Obtain in:
1. COPD or asthma if clinical evaluation cannot determine
if the patient is at their best baseline and that airflow
obstruction is optimally reduced.
2. Dyspnea or exercise intolerance that remains
unexplained after clinical evaluation.
3. ALL for lung resection
PFTs should not be used as the primary factor to deny
surgery

47. SPIROMETERY
 Postoperative risk (Gass & Olsen, 1986)
 FVC < % 70
 FEV1 < % 70 Complication risk
 FEV1 / FVC < % 65
• A normal PFT does not demonstrate a lower postoperative
complication rate

48. PREOPERATIVE PULMONARY FUNCTION TESTS
Severe COPD (FEV1 < % 50)
• Preoperative PFT not predict postoperative
pulmonary complication risk
• Surgery time
• ASA class predict significiantly
• Surgery type
Kroenke L. Arch Intern Med 1992

49. PULMONARY RISK INDEXES
 Cardiopulmonary Risk Index
Epstein SK. Chest 1993;104:694
 Lawrence Risk Index
Lawrence WA. Chest 1996; 110: 744
 Brooks – Brunn Risk Index
Brooks-Brunn JA. Chest 1997;111: 564
 Multifactorial Risk Index
Arozullah AM. Ann Surg 2000; 232: 242

50. Variant Score
BMI > 27 kg/m2 1
Cigarette (last 8 weeks) 1
Productive coughing (last 5 days) 1
Wheezing (last 5 days) 1
FEV1/FVC < % 70 (predicted) 1
PaCO2 > 45 mmHg 1
Total 6
Pulmonary risk index: Factors that increase postoperative pulmonary
complications
> 4: Pulmonary risk % 73.4
< 4: Pulmonary risk % 11
PULMONARY RISK INDEX

51. Score
History Age > 70 5
MI (last 6 month) 10
Physical examination JVD or S3 11
Aortic valve stenosis 3
ECG Non-sinusoidal rhtym, atrial premature
pulse
7
> 5 / min. Ventricular premature pulse 7
Status PO2 < 60 or PCO2 > 50 3
K > 3 or HCO3 < 20
BUN > 50 or Creatinin > 3
Chronic liver disease.
Non-cardiac dis. Bed treatment.
Surgery Thorac , abdom, aortic 3
Emergency surgery 4
Total 53
Class 1: 0-5
Class 2: 6-12
Class 3: 13-25
Class 4: > 25
GOLDMAN’ S CARDIAC RISK INDEX

52. CARDIOPULMONARY RISK SCORE
• Cardiac risk index score : 1 - 4
• Pulmonary risk index score : 0 – 6
Cardiopulmonary risk index score = 1-10
Cardiac ( 1- 4 ) + Pulmonary ( 0 - 6 )
Index > 4 : Complication risk 22 times higher
Index < 2 : No Complication
Epstein SK. Chest 1993;104:694.

53. MULTIFACTORIAL RISK INDEX (Postoperative respiratoryinsufficiency)
 Type of surgery
 Abdominal aort aneurisym 27
 Thoracic 21
 Upper abdom., neurochirurgia, per.vascular 14
 Neck 11
 Emergency surgery 11
 Albumin < 3.0 g/dL 9
 BUN > 30 g/dL 8
 Functional addiction ( partial or complete) 7
 COPD 6
 Age > 70 6
 Age 60 - 69 4
Arozullah AM. Ann Surg 2000; 232: 242

54. MULTIFACTORIAL RISK INDEX
Degree Score Resp. Insufficiency %
1 < 10 0.5
2 11-19 1.8
3 20-27 4.2
4 28-40 10.1
5 > 40 26.6
Arozullah AM. Ann Surg 2000; 232: 242

55. RESECTION SURGERY

56. SPECIFIC EVALUATION OF LUNGS
AIM
• Severity of existing pathology and its reversibility
• Estimation of predicted pulmonary function after resection

57. RESECTION SURGERY
• General Evaluation
• Respiratory Function
 Spirometry – FEV1
 Diffusion Capacity
 Postoperative FEV1 (FVC, DLCO, VO2 max)
• ABG
• Exercise Capacity

58. Assessment for lung resection

59. RESECTION SURGERY- SPIROMETRY
 FEV1 is primary parameter
 Pneumonectomy: Preoperative FEV1 > 2 L ( > % 80
predicted )
 Lobectomy : Preoperative FEV1 > 1 L
 Wedge and segmental resection = 0.6 L

60. DIFFUSION CAPACITY
• DLCO < % 50 major resection is
contrendicated
Cander L. A J Cardiol 1963
• DLCO < % 60 mortality risk % 24
• ppoDLCO < % 40 mortality risk % 33
Markos J, Mullan BP, Hillman DR, et al. Preoperative assessment as a predictor of
mortality and morbity after lung resection. Am Rev Respir Dis 1989; 139: 902-910

61. Split lung function studies
• Predicting post-resection pulmonary function
• Predicted postoperative FEV1 (ppoFEV1) is the most valid single test
available
• ppoFEV1 = preoperative FEV1 × (1– %functional tissue
removed/100)
• lung function can be calculated by counting the number of
segments removed
• The lungs contain 19 segments (3 right upper lobes, 2 right
middle lobes, 5 right lower lobes, 3 left upper lobes, 4 left lower
lobes, 2 left lingula)

62. Split lung function studies(cont.)
• Ventilation-perfusion(V/Q) scan
• Quantitatve CT

63. FEV1 AFTER RESECTION (QUANTITATIVE SCINTIGRAPHY)
PNEUMONECTOMY
Estimated
Postoperative FEV1 = Preoperative FEV1 X perfusion percent of remaining lung
LOBECTOMY
Estimated
Postoperative FEV1 = Preoperative FEV1 X Remaining segments after resection
Total segments of both lungs

64. FEV1 AFTER RESECTION
If a part of resected segments is bronchoscopically obstructed
Estimated
Postoperative FEV1 = Preoperative FEV1 X [( 19-a ) - b]
19 – b
a- Resected obstructed segments
b- Resected open segments

65. CARDIOPULMONARY EXERCISE TESTS
• Important in lung resection surgery
VO2 max = Aerobic capacity: amount of O2 requirement for major muscle
groups for 5-15 minutes
• Recommendation of BTS and ACCP
 VO2max > 15 ml/kg/d Operable
 VO2max < 15 ml/kg/d High risk
BTS Guidelines: Guidelines on the selection of patients with lung cancer surgery. Thorax 2001; 56:89-108
Beckles MA, Spiro SG, Colice GL et al. The physiologic evaluation of patients with lung cancer being
considered for resectional surgery. Chest 2003; 123: 105S-114S

66. CARDIOPULMONARY EXERCISE TESTS
Resection decision
• VO2max > % 75 Good prognosis
• VO2max > % 60 More than one lobe is
contrendicated
• VO2max < % 43 Any type of resection is
contrendicated
Bolliger CT,Jordan P,Soler M, et al. AJRCCM 1995;151:1472-1480

67. CARDIOPULMONARY EXERCISE TESTS
• Absolute value must be used
 Eugene J, Brown SE, Light RV, et al. Surg Forum 1982; 33: 260-262
 Smith TP, Kinasewitz GT, Tucker WY, et al. Am Rev Respir Dis 1984: 730-734
 Bechard D, Wetstein L. Ann Thorac Surg 1987; 44: 344-349
• Absolute value or % value does not make a difference
 Keddissi JI, Kinasewits GT. Chest 2005; 127: 1092-1094

68. CARDIOPULMONARY EXERCISE TESTS
• % value must be used
 Bolliger CT, Soler M, Stulz P, et al. Respiration 1994; 61:181-186
 Bolliger CT,Jordan P,Soler M, et al. AJRCCM 1995;151:1472-1480
 Win T, JacksonA, Sharples L, et al. Chest 2005;127:1159-1165
 Morice RC, Peters Ej,Ryan MB,et al.Chest 1992;101:356-361
 Richter Larsen K, Svendsen UG, Nilman N, et al. Eur Respir J 1997;10:1559-
1565

69. Assessment for lung resection

70. Date of download: 11/11/2012
Copyright © American College of Chest Physicians. All rights reserved.
Physiologic Evaluation of the Patient With Lung Cancer Being Considered for Resectional Surgery*: ACCP
Evidenced-Based Clinical Practice Guidelines (2nd Edition)
CHEST. 2007;132(3_suppl):161S-177S. doi:10.1378/chest.07-1359
Preoperative physiologic assessment of perioperative risk. CXR = chest radiograph.

72. Stepwise approach to preoperative pulmonary assessment.
Bapoje S R et al. Chest 2007;132:1637-1645
©2007 by American College of Chest Physicians

73. Risk reduction strategies
• Pre-operative strategies
• Intra-operative strategies
• Post-operative strategies

75. THANK YOU