Primary spontaneous PTX - no inciting event

Secondary spontaneous PTX caused by underlying lung disease (COPD, asthma, emphysema)

Pulmonary changes with age

With increased age:

• increased FRC (ERV & RV) and residual volume. Decreased vital capacity. Total lung capacity is preserved
• DLCO decreases with age
• overall lung compliance is decreased

Pulmonary fibrosis

• Decreased lung volumes and decreased DLCO

Pre-op PFT are mandatory before lung resection

First check pre-operative FEV1 and DLCO, if both > 80% proceed to surgery.

FEV1 >800 cc required post-op for pneumonectomy

If either <80% then need predicted post-operative lung function below

If the predicted post-operative of residual lung function FEV1 and DLCP is > 60% = low risk, proceed with lobectomy

No further PFT is required

DLCO >60% → will need post-op FEV1 of 35-40% minimum

• FEV1 <60% → predicted post-op FEV1 = measured FEV1 and multiplying it by 1 - # of segments to be resected
• → FEV1 35-40% will tolerate a lobectomy
• DLCO <60% has post-op complications

If either predicted post-operative functions are between 30-60%

→ Exercise screening test (stair climbing, walking 400 meters) should be performed → if screening satisfactory → low risk, proceed with lobectomy

V/Q scan to assess amount of perfusion

• Multiply percentage of perfusion with post-op FEV1 value to assess post-op FEV1

If either predicted post-operative functions are < 30% → then need formal cardiopulmonary testing

→ VO2 max >75% predicted or >20 cc/kg/min → lung resection

→ VO2 max <35% or <10 cc/kg/min → high risk, no lung resection

If can’t do lobectomy → segmentectomy

Cut off values below are no longer recommended, the above is new standard

Pneumonectomy: Need FEV1 > 2.0 L (>80% expected), and DLCO >60%

Lobectomy: Need FEV1 > 1.5 L

If any numbers below these get V/Q. find portion of lung to be resected percentage and subtract from FEV1 = Predicted postoperative percent

Post op pulmonary complications

Risk factors: Age >50, COPD, CHF, ASA > 2, albumin < 3.5, OSA, pulm HTN, smoking, incisions closer to diaphragm

• Age related lung structure changes
  • Decreased thoracic compliance → decreased compliance overall, increased residual volumes
  • Increase in FRC = TLC - IC
  • Expiratory reserve volume decreases with age
  • FVC (measures total amount of air exhaled during a maximal effort) - decreases by about 0.3 L per decade
  • FEV1 - decreases by 0.2-0.3 L per decade
  • FEV1/FVC ratio for >65 yo is 65%. Normal is 70%. Only slightly decreased
  • Decreased tidal volume, increased V/Q mismatch, diaphragm flattening, greater reliance on accessory muscles for breathing

Stop smoking, even if just 1 week prior to surgery (previously thought this would thicken secretions debunked)

Pre-operative albumin of <3.0 is the single greatest laboratory predictor of adverse pulmonary events post-surgery

Nasogastric tubes increases the risk of PNA and atelectasis

Atelectasis - alveolar collapse 2/2 mucus plug or shallow breathing → “pulmonary shunt” → blood flow is unaffected, air exchange is impeded due to alveolar collapse

Tx: PPV vs IS, minimize narcotics

Pulmonary complications

Risk factors: age >50, COPD, poorly controlled asthma, smoking, OSA, interstitial lung dz, pulmonary HTN, heart failure, current respiratory infection

Procedure related risks: thoracic surgery, upper abd surgery, long procedure times, general anesthesia

STOP-Bang questionnaire

Focuses on identification of OSA

PFT for any lung resection + COPD/asthma or unexplained dyspnea/exercise intolerance

High risk

• FEV1 <70% of predicted
• FVC <70% predicted
• FEV1/FVC <65%

• Arrow = COPD → reduced forced expiratory fraction (FEF), shrunken loop pattern

MC after resection

• Persistent air leak – wedge/segmentectomy
• Atelectasis – lobectomy = MC complication following lung surgery
• Arrhythmias – pneumonectomy
• Broncho pleural fistula – pneumonectomy
  • Bronchopleural fistula – high frequency ventilation can assist with closure
• Post-pneumonectomy syndrome
  • Causes dynamic compression of the airway 2/2 mediastinal shift → dyspnea, strider, recurrent PNA
  • Dx: CXR, CT scan, Bronchoscopy
  • Tx: saline filled tissue expander in post-pneumonectomy space
• Thoracic Anatomy
• Pulmonary Function
• Lung CA
• Pneumothorax
• Hemothorax
• Empyema
• Lung abscess
• Parapneumonic (pleural) effusion
• Chylothorax
• Chylous ascites
• Lung collapse
• Thoracic bleeding
• Tracheoesophageal fistula