This slide presentation covers areas about physiology of respiratory system related to surgery and anaesthesia, definition of postoperative pulmonary complications (PPCs), risk of PPCs, screening for PPC risk and specific management for patients with increased risk.
Pre operative pulmonary evaluation 2019Parthiv Mehta
Comprehensive over view of identification of risk factors and its assessment. understanding basics and specialized investigations, its interpretation and methodical use of algorithm.targeted to enhance identification of risks and prevention of complications
Pre operative pulmonary evaluation 2019Parthiv Mehta
Comprehensive over view of identification of risk factors and its assessment. understanding basics and specialized investigations, its interpretation and methodical use of algorithm.targeted to enhance identification of risks and prevention of complications
Anaesthetic Management of Elderly PatientsMd Rabiul Alam
The Scopes of the presentations are: Anaesthetic definition of elderly & workload, Brief on age-related changes, Importance of good anaesthetic evaluation, Practice of functional reserve/capacity assessment, Morbidity and Mortality, Decision of Surgery & Planning of Anaesthesia & Perioperative management in nutshell.
Anaesthetic Management of Elderly PatientsMd Rabiul Alam
The Scopes of the presentations are: Anaesthetic definition of elderly & workload, Brief on age-related changes, Importance of good anaesthetic evaluation, Practice of functional reserve/capacity assessment, Morbidity and Mortality, Decision of Surgery & Planning of Anaesthesia & Perioperative management in nutshell.
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The technique of pulmonary resection had dramatically changed from mass ligation of pulmonary hilum to individual ligation of hilar structures and recently to video-assisted thoracoscopic pulmonary resection. However, the safe performance of lung resection requires a perfect knowledge of hilar anatomy and a technique with which the surgeon is familiar.
Dr. Roberto Machado from the University of Illinois at Chicago presented an update on PAH at a Patient Education Conference on March 15, 2014 hosted by the Scleroderma Foundation, Greater Chicago Chapter.
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
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The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
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New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
5. Closing Volume
The volume in the lungs at which
its smallest airways collapse
The air remaining in the lung = Residual volume
Beyond equal pressure point (EPP)
intrapulmonary pressure > intraairway pressure
➡
airway collapse
6. Changes of FRC and CC: Conditions
Decreased FRC
Spine position
Obesity
Pregnancy
General anesthesia
Abdominal pain/splinting
Increased CC
Advanced age
Smoking
COPD
Pulmonary edema
Goldman DR, Brown FH, Guarnieri DM (eds) Perioperative Medicine. New York, McGraw-Hill, 1994.
7. Changes in Pulmonary Function with Surgery
Diaphragm
function
Gas exchangeLung volumes
Control of
breathing
Lung defense
mechanisms
Reduction
in lung volumes
Diaphragmatic
dysfunction
Impaired
gas exchange
Respiratory
depression
Impaired
cough reflex and
mucociliary function
11. Control of Breathing
Residual effects of
preanesthetic or
anesthetic agents
Depression of
hypercapnid/hypoxic
ventilatory drive
from narcotics
Decreased tidal volume
Reduced minute ventilation
Increased PaCO2
Decreased frequency of sigh breaths
Precipitation of sleep apnea
12. Lung Defense Mechanisms in Perioperative Period
coughing Mucociliary clearance
Damage of cilia and
mucous gland
by ET tube and/or
inhaled anaesthetics
Decreased
clearance velocity
by ET tube
Suppression
of cough
by opioids
Reduced muscle
strength due to
neuromuscular
blocking agents
InfectionV/Q mismatchingAtelectasis
15. Factors Associated with PPCs
PPCs
Preoperative
Post-
operative
Intra-
operative
Chronic lung disease
(esp. COPD)
Upper respiratory
tract infection
Age
Smoking
General health status
Nutritional status
Heart failure
pulmonary hypertension
Obesity
obstructive sleep apnea
Type of anaesthesia
Duration of anaesthesia
Surgical site
Type of surgical incision
Inadequate
pain control
Immobilization
16. Age
Age
≥80
70-79
60-69
50-59
Odd Ratio of developing pulmonary complications
0 2 4 6 8 10
1.5
2.28
3.9
5.63
Smetana GW, Lawrence VA, Cornell JE, American College of Chest Physicians. Ann Intern Med 2006; 144: 581.
Age >50 years was an important independent factor of risk
Preoperative
Factors
18. American Society of Anesthesiologist:
Physical Status Classification
Preoperative
Factors
Class Description
ASA 1 A normal healthy patient
ASA 2 A patient with mild systemic disease
ASA 3 A patient with severe systemic disease
ASA 4
A patient with severe systemic disease that is a
constant threat to life
ASA 5
A moribund patient who is not expect to survive
without the operation
ASA 6
A declared brain-dead patient whose organs are
being removed for donor purposes
ASA class >2
confers
!
4.87X
increased risk
(95% CI 3.34-7.10)
19. Chronic Obstructive Pulmonary Disease
Preoperative
Factors
Increased
sputum
production
Airway
inflammation
and edema
Loss of
radial traction
& Elastic recoil
Decreased
airway radius
!
Increased
closing volume
6X
more likely to have
major postoperative
pulmonary complications
20. Asthma
Preoperative
Factors Patients with asthma who are
well controlled
and have a peak flow measurement of
>80% predicted
can proceed to surgery with average risk
22. Effects of Obesity on Pulmonary Function
Low lung volume
➡
Decreased FRC
➡
Decreased airway radius
➡
Atelectasis
➡
V/Q mismatching
However,
obesity has NOT consistently been shown to be a risk factor for PPCs
Obesity should NOT affect patient selection for otherwise high-risk procedure
Preoperative
Factors
23. Obstructive Sleep Apnea
Preoperative
Factors
Odd Ratio (OR)
for postoperative respiratory failure
1.95
(95% CI 1.91-1.98)
Higher incidence of:
Unplanned ICU transfers
Longer length of stay
Pneumonia
Respiratory failure
26. Type of Anesthesia
Intraoperative
Factors
General anesthesia leads to a
!
HIGHER RISK
!
of clinically important
pulmonary complications
than does
epidural or spinal anesthesia
Rodgers A, Walker N, Schug S, et al. BMJ 2000; 321: 1493.
29. History & Physical Examination
COPD
!
CAT score/mMRC
History of exacerbation
Decreased laryngeal height
increased AP diameter
Wheezing/rhonchi
Obesity/OSA
!
Body mass index
Mallampati class
Epworth Sleepiness Score
!
Asthma
!
ACT score, Level of control
History of exacerbation
Wheezing/rhonchi
31. Pulmonary Function Tests
Patients with COPD or asthma with
uncertain optimal symptom/disease
control
Patients with unexplained dyspnea or
exercise intolerance
2006 American College of Physicians guideline:
NOT to be used as the primary factor to deny surgery
NOT to be routinely ordered
Qaseem A, Snow V, Fitterman N. et al. Ann Intern Med 2006; 144: 575.
32. Arozullah Respiratory Failure Index
Preoparative predictor Point value
Abdominal aortic aneurysm 27
Thoracic 21
Neurosurgery, upper abdominal, peripheral vascular 14
Neck 11
Emergency surgery 11
Albumin <3.0 g/dL 9
BUN >30 mg/dL 8
Partially or fully dependent functional status 7
History of chronic obstructive pulmonary disease 6
Age >70 years 6
Age 60-69 years 4
Type of surgery
General
health status
Age
33. Performance of the Arozullah Respiratory Failure Index
Class Point total Percent respiratory failure
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, Daley J, Handerson WG, Khuri S. Ann Surg 2000; 232: 242.
34. Canet Risk Index
Factor Adjusted odds ratio Risk score
Age ≤50 years 1 0
51-80 1.4 (0.6-3.3) 3
>80 5.1 (1.9-13.3) 16
Preoperative O 1 0
91-95% 2.2 (1.2-4.2) 8
≤90% 10.7 (4.1-28.1 24
Respiratory infection in the last month 5.5 (2.6-11.5) 17
Preoperative anemia (Hb ≤10 g/dL) 3.0 (1.4-6.5) 11
Canet J, Gallart L, Gomar C, et al. Anesthesiology 2010; 113: 1338.
35. Canet Risk Index
Factor Adjusted odds ratio Risk score
Surgical incision in upper abdomen 1 0
>80 5.1 (1.9-13.3) 16
Duration of surgery ≤2 hours 1 0
2-3 hours 2.2 (1.2-4.2) 8
>3 hours 10.7 (4.1-28.1 24
Emergency surgery 5.5 (2.6-11.5) 17
High risk (42.1%)
≥45 points
Moderate risk (13.3)%)
26-44 points
Low risk (1.6%)
<26 points
Pulmonary complication rate:
37. Perioperative Risk Evaluation: Obstructive Sleep Apnea
Factor Points
A. Severity of sleep apnea based on sleep study (or clinical indicator)
None 0
Mild 1
Moderate 2
Severe 3
B. Invasiveness of surgery and anaesthesia
Superficial surgery under local or peripheral nerve block without sedation 0
Superfacial surgery with moderate sedation or general anaesthesia 1
Peripheral surgery with spinal or epidural anaesthesia 1
Peripheral surgery with general anaesthesia 2
Airway surgery with moderate sedation 2
Major surgery, general anaesthesia
!
3
Airway surgery, general anaesthesia 3
38. Perioperative Risk Evaluation: Obstructive Sleep Apnea
Factor Points
C. Requirement for postoperative opioids
None 0
Low dose oral opioids 1
High-dose oral opioids, parenteral or neuraxial opioids 3
Total score (Score in A plus the greater of the score for either B or C)
Gross JB, Bachenberg KL, Benumof JL, et al. Anesthesiology 2006; 104: 1081-93.
Significantly increased risk
5-6 points
Increased risk
4 points
Low risk
<4 points
39. Risk Assessment: Non-resective-lung Surgery
History and physical examination
Seeking known risk factors for pulmonary complications
Low risk:
Proceed to surgery without
further evaluation
Positive Negative
Identify risk(s) presents
in the patient
Chest x-ray*
Pulmonary function test*
Moderate risk:
Perioperative treatment
to reduce risk
Normal
High risk:
Reconsider indication for
surgery
Perioperative treatment
to reduce risk
Consider shorter procedure
Consider epidural/spiral
anesthesia
Abnormal
43. Smoking Cessation
surgery patients and rapid referral to a smoking-
n program could maximize the cessation period be-
gery, resulting in greater reductions in postoperative
ations in the secondary care setting.
14. Theadom A, Cropley M. Effects of preoperative smoking cessation on
the incidence and risk of intraoperative and postoperative complica-
tions in adult smokers: a systematic review. Tob Control. 2006;15:
352-358.
Figure 3 Meta-regression plot, effect of time of cessation on complications.
153al Smoking Cessation Reduces Perioperative Complications
Mills E, Eyawo O, Lockhart I, et al. Am J Med 2011; 124:144.
Relative Risk (RR)
for postoperative complications
!
0.81
(95% CI 0.70-0.93)
in former smokers
!
0.59
(95% CI 0.41-0.85)
in patients who had ≥4 weeks
smoking cessation
Even cessation of smoking for 2 days may have some benefits:
less carboxyhemoglobin, less effects from nicotine,
improved mucociliary clearance
44. Deep Breathing & Incentive Spirometry
Equally effective (deep breathing vs
incentive spirometry)
50% reduction of postoperative
pulmonary complications
Incentive spirometry is recommended
after upper abdominal and thoracic surgery
45. Continuous Positive Airway Pressure
Improved oxygenation
Reduced incidence of
pneumonia, intubation, and
admission to an ICU
However, CPAP may cause
patient discomfort
gastric distension
barotrauma
Zarbock A, Mueller E, Netzer S, et al. Chest 2009; 135: 1252.
commended as a secondary intervention for
refractory atelectasis
➡
46. Specific Management: COPD
Continue current medications (if stable)
Give regular bronchodilator therapy
(Ipratropium/Tiotropium) for 24 hr prior to
surgery until 24 hr postextubation
Give systemic steroid (e.g. dexamethasone 4
mg iv) 1-2 doses 12 hr prior to surgery in
severe symptomatic patient or patient with
frequent exacerbation
Continue systemic steroid for 3-5 days in
severe cases (but no more than 7 days)
47. Specific Management: Asthma
For patient with controlled asthma:
Continue current asthma medications
Apply inhaled rapid-acting beta agonist 2-4 puffs or
nebulizer treatment within 30 minutes of intubation
Give nebulizer treatment in the perioperative period
(~24 h after extubation)
For patient with partly or uncontrolled asthma:
Systemic glucocorticoid (e.g., dexamethasone 4 mg)
1-2 doses in 12 hour prior to surgery may be used
Systemic glucocorticoid may be continued for 3-5 days
in severe cases
48. Specific Management: Morbid Obesity
Administer induction drugs, opioids, and
neuromuscular agents using ideal body
weight (IBW) NOT total body weight
Positioning in“ramped”and“reversed
Trendelenberg”position
Awake intubation in patient when mask
oxygenation is inadequate
Application of 100% oxygen with PEEP 10
cmH2O for 5 minutes before the induction
of anesthesia ± PEEP 10 cmH2O thereafter
50. General Evaluation Steps
1 2 3
4
5
Spirometry DLCO
Predicted
postoperative FEV1
Predicted
postoperative DLCO
Simple
exercise test
Cardiopulmonary
exercise test
FEV1 2 L for
pneumonectomy
FEV1 1.5L
for lobectomy
>80% of Predicted
normal
DLCO
>80% predicted
PPO FEV1
>60% predicted
!
PPO DLCO
>60% predicted
>400 m
shuttle walk test
!
>22 m
stair climbing test
Unexplained
symptoms?
>30%
<30% VO2 max
>20 mL/kg/min
Averaged risk Increased risk High risk