This document discusses the diagnostic workup and pulmonary function testing of thoracic surgery patients. It outlines various imaging modalities like chest X-ray, CT, MRI, and bronchoscopy used to evaluate patients. Invasive procedures like mediastinoscopy, thoracentesis, and lung/pleural biopsies are also described. Pulmonary function tests evaluate lung volumes, airway function, and gas exchange to assess surgical risk and monitor disease. Thoracic surgery can reduce functional residual capacity and increase compliance, risking atelectasis and hypoxemia if not addressed.

1. Diagnostic work of thoracic surgery
patients and pulmonary function
test
By Dr Mengistu Kassa GSR IV
Moderator : Dr Azanew (chest
surgeon)
10/9/2021 1

2. Outlines
• Introduction
• Thoracic imaging
• Diagnostic procedures
• Pulmonary function test
• Summery
• Referance
10/9/2021 2

3. Introduction
• The physiologic evaluation of the thoracic
surgical patient must be individualized and
emphasizes on pulmonary and cardiac
function.
• The assessment of a patient’s ability to
tolerate lung resection from a
cardiopulmonary standpoint is fundamental to
patient selection for surgery.
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4. • Pulmonary complications are directly related
to the proximity of the planned procedure to
the diaphragm.
e.g FRC declines by an average of 35% after
thoracotomy and lung resection and by 30% after
upper abdominal surgery
• Thoracic surgery pts has significant incidence
of comorbid factors in addition to the primary
diagnosis
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5. • What is an acceptable surgical mortality in a
disease with 100% mortality?
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6. Patient evaluation
• Important Components of History in Preoperative
Evaluation
– Presenting symptoms and circumstances of diagnosis
– Prior diagnosis of pulmonary or cardiac disease
– Comorbid conditions: diabetes mellitus, liver disease, renal
disease
– Prior experiences with general anesthesia and surgery
– Cigarette smoking: the most common cause of chronic
lung disease
– Medications and allergies
– Alcohol use, including prior history of withdrawal
syndromes
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7. • Physical examination
– Anatomic abnormalities (e.g., scoliosis or chest wall
abnormalities)
– Findings on auscultation of the chest (e.g., decreased
breath sounds, wheezing, and rhonchi or rales)
– Signs of inadequate oxygenation (e.g., cyanosis, finger
clubbing, and use of accessory muscles for breathing)

8. Laboratory Studies
• Electrolytes, RFT, LFT, clotting parameters and
CBC are part of the preoperative assessment.
• ABG may have a role in documenting a
patient's baseline for future comparison
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9. Thoracic imaging
• Importance
– Surgical planning and
– To determination of the extent of
resection
• Chestx-ray
– Initial radiographic evaluation of
the chest
– Provide overview of the chest
with quick diagnostic information
– Important to examine all aspect
of the chest
– Adequate examination of the
chest needs at least two
projections—PA & Lateral
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10. Lateral CXR
• Some lesions in the chest
are apparent only in the
lateral view
– Small mediastinal lesions
– Masses in the anterior
portions of lung adjacent
to the mediastinum
– Lesion on the vertebral
column
– Lesions behind the heart
and the diaphragm on PA
view
– Small pleural effusions
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11.  Oblique view
• To determine whether a lesion
is in the lung or in the chest
wall
• To localize mediastinal lesions
especially with barium in the
esophagus
• Posteriorly placed lesions in the
lungs maintain constant
relation with the spine
• Anteriorly placed lesions n the
lung maintains constant
relationship with the heart
Lateral decubitus film
• Investigation of suspected
plural effusion
– Can demonstrate as little
as 50-100 ml of fluid
• Demonstration of air fluid
level in pulmonary
cavities
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12.  Lordotic view
• To investigate the apical portion of the lungs
• For confirmation of suspected lesions identified in the apex
• To demonstrate disease in the right middle lobe(collapsed)
 Expiratory CXR
• Helpful in assessing local or diffuse pulmonary air trapping
• Detection of small pneumothorax
• Investigation of endobronchial neoplasms
• Localization of endobronchial foreign bodies in children
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13. Supine radiographs
– When patient is unable to sit or stand
– In infants
– Consider magnification & ↑upper lobe perfusion
Digital CXR
– charged plate-rather than film- is used to record the
radiographic image.
– ability to transmit and view radiographs on a monitor
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14. Abnormalities of the lung on CXR
 Atelectasis
• Loss of volume of lung, lobe
or segment from any cause
• Five causes: Resorption,
passive , compression ,
Cicatrization and plate
atelectasis
• Displacement of the
interlobar fissure -> most
reliable sign
• Localized increase in density
of the collapsed lobe

15. • Indirect signs
– Elevation of the ipsilateral
hemi diaphragm
– Deviation of trachea to the
involved side
– Compensatory
hyperaeration of the rest of
the ipsilateral lung
– Displacement of the hilum
toward the collapsed lobe
or segment
– Decrease in the size of the
bony hemithorax
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16. Localized pulmonary diseases
Round & clearly defined pulmonary densities
– malignancy(primary or metastatic)
– Loculated effusion
– Hydatid cyst
– Granulomatous disease e.g.TB
– Lung abscess
– Neurofibroma
Calcifications in the wall of the lesion
– dermoid cyst
– Thyroid
– Aneurysm
– Infectious pericarditis
NB-multiple sharply circumscribed densities almost invariably
indicate metastatic malignant disease
-cavitations of a solitary pulmonary density usually indicates
lung abscess ,primary bronchial cancers or fungal disease

18. Abnormalities of the pleura
Pleural effusion
• Homogenous opacity in the dependent position in the pleural
cavity
• Lateral radiograph→ minor blunting of posterior costophrenic sulcus
with as little as 50-100ml of fluid
• Lateral decubitus view
• PA radiograph →blunting of lateral costophrenic sulcus
• On occasion fluid may remain infrapulmonary and displace
the lung upward so that the lateral costophrenic angel
remains sharp

20. Pleural thickening
• Represents localized fibrosis of
the pleura
• Commonly seen at both apices
,the costophrenic angles,&
occasionally along the lateral
chest wall
• Causes
– Localized-old infarcts(tb),remote
pulmonary infarcts
– Generalized -healed hemothorax
&pyothorax
• Ddx-diffuse mesothelioma
• Bilateral pleural thickening and
calcifications-> favor benign
disease

21. Pneumothorax
• Thin line of visceral pleura
surrounding partially collapsed
lung
• Best seen at the apex in an
upright film
• Expiratory image accentuates
the pneumothorax
• Straight line of air-fluid level
→pneumhydrothorax
(meniscus-when no
pneumothorax)

22. Contrast examination
 largely replaced by CT &MRI
Barium swallow
• To demonstrate esophageal abnormalities (achalesia ,tumors)
• Location and nature of mediastinal mass (displacement of
esophagus )
• To identify previously unsuspected mediastinal LN
metastasis(in primary bronchial ca)
• To evaluate enlargement of cardiac chambers
Bronchography
• Instillation of contrast material in to the trachea
• To identify or to assess extent of bronchiectasis
• CT has replaced it

23. Air contrast studies
1 Diagnostic pneumothorax
• To investigate pleural lesions
2 diagnostic pneumoperitoneum
• To investigate diaphragmatic anomalies
or subphrenic abscess
3 diagnostic pneumomediastinum
• To investigate anterior mediastinum
lesions
• CT is better

24. Ultrasound
• Abdominal ultrasound
• Chest ultrasound
– Collections , cavitations,
• EBUS
– To localize mediastinal or hillar lymph nodes for TBFNA
– To localize peripheral pulmonary nodules for sampling.

26. COMPUTED TOMOGRAPHY
• Is the standard cross
sectional evaluation of the
chest
• Advantages
– Provides cross-sectional
images
– Greater tissue contrasts
– Differentiates solid lesions
from cystic or fatty lesions
– Detects area of necrotic or
calcification
• Most important in
mediastinal evaluation

27. Indications of thoracic CT
• Evaluation of abnormality identified by conventional
radiography
• Staging of lung cancer
• Detection of occult pulmonary metastasis
• Distinction of empayema from lung abscess
• Detection and evaluation of aortic dissection

28. HRCT
Indications of thoracic HRCT
• In symptomatic patients with a normal chest radiograph.
• Assessment of diffuse lung disease.
• As a guide to the type and site of lung biopsy.
• Detection or evaluation of
– Metastatic lesions,
– Solitary pulmonary nodules,
– Bullae,
– Bronchiectasis,
– Diffuse parenchymal disease.

29. Lung cancer
• CT is routine pre-op
investigation for staging
• Helps in determining
– the size of the primary lesion
– extension of the primary
tumor
– presence of hillar or
mediastinal
lymphadenopathy

30. Tracheobronchial tree
involvement
– Direct invasion of the trachea
can be identified
– Presence and extent of
extraluminal involvement

31.  Empayema
• Are enclosed within the pleural
cavity and conform to the shape of
the chest wall
• Mostly have thin smooth wall
especially along the inner margins
• Compresses the lung
 Abscess
• Originate within the parenchyma
and remain spherical
• Has thickened irregular walls and
margins

32. Malignant mesothelioma
• Appear as thick pleurally based
coat of soft tissue enclosing the
lung
• CT is the most effective form of
imaging available to identify the
extent of involvement with
malignant mesothelioma

33. MRI
Uses:
– Assessment of diseases of the heart, mediastinum, pleura, and chest
wall
Advantages
– Excellent tissue contrast,
– Multiplanar imaging capability,
– Sensitivity to blood flow, and
– Lack of ionizing radiation
Disadvantages
– Limited spatial resolution
– Difficulties in imaging the pulmonary parenchyma

34. MRI
• Assessment of the apices,
diaphragm, and spinal column
• Evaluation of pleural disease
• Evaluation of paraspinal masses
• Assessment of local tumor
extension and delineation of
blood vessel invasion
• Metastatic invasion of the bone
marrow
CT
• Evaluation of lung parenchymal
disease
• Evaluation of mediastinal lymph
nodes and lymphoma staging
• Assessment of cortical bony
metastases
• Staging of bronchogenic
carcinoma (in most cases)
• Aortic aneurysms and dissection
• Detection of pulmonary
embolism

35. Bronchoscopy
Diagnostic
•Sever cough
•Change in cough
•Abnormal chest radiograph
•Hemoptysis
•Wheeze
•Unresolved pneumonia
•Abnormal sputum cytology
•Diffuse lung disease
•Opportunistic infections
•Bacteriologic sampling
•Metastatic malignancy
•Smoke inhalation
•Air way obstruction
•Bronchoalveolar lavage
•Upper esophageal cancer
Therapeutic
•Atelectasis
•Lung abscess
•Foreign body
•Stricture
•Laser
Other indications
•Prolonged intubation
•Bronchography
•lobar gas sampling
•Management of massive hemoptysis

36. Flexible fibrooptic bronchoscopy
• Is safe and reliable
technique for evaluation of
the tracheobronchial tree
• Insertion tubes ranging in
diameter from 3.6 to 6.0
mm. The working channels
of these range from 1.2 to
3.2 mm in diameter
• Performed using topical
anesthesia & IV sedation

37.  Advantage
• Patient comfort
• Segmental visualization
• Segmental biopsy
• Peripheral biopsy
• Transbronchial needle
aspiration
• Bedside aspiration
• Bronchoscopy on ventilator
• Bypass distortion
• Phototherapy
• Brachytherapy
• Laser bronchoscopy
 Disadvantage
• Small channel
• Breakdown
• sterilization

38. Rigid bronchoscopy
• Those commonly used in
adults have an internal
diameter of 6,7 or 8mm and
are 40cm length
• Suspected malignancy
→brushing and biopsy
(diagnostic yield above 90%)

39.  Advantages
• Foreign body removal
• Massive hemoptysis
• Dilate stricture
• Tracheal obstruction
• Laser bronchoscopy
 Disadvantages
• General anesthesia
• Visualize segment
• Biopsy segment
• Peripheral biopsy of upper
lobe

40. CONTRAINDICATION
* Relative
contraindication for
biopsy, but not
inspection.

41. Invasive diagnostic procedures
• Scalene node biopsy
– Tumor is found in 85% of patients with palpable nodes but
in < 5% of patients with nonpalpable nodes.
• Mediastinoscopy
– Direct biopsy of lymph nodes.(+Ve nodes may either indicate the
need for preoperative chemotherapy or unresectability.)
– For diagnosing other pulmonary problems, such as
sarcoidosis, lymphoma, and various fungal infections

42. • Mediastinotomy
• Subperichondrial excision of 2nd or 3rd costal cartilage
• For Lt upper lobe lesions
• VATS is procedure of choice
• Thoracentesis
• For Infections &malignancies.
• Positive cytologic findings prove a tumor to be inoperable.
• Pleural biopsy(percutaneous ,open)
• Yields +ve diagnosis in 60%-80% of patients with TB or cancer
when a pleural effusion or pleural-based mass is present
• If pleural fluid analysis fails to dx in a suspected patient

43. • Lung biopsy
– May be used for localized peripheral lesion or a diffuse
parenchymal process.
– Replaced by VATS & transbronchoscopic biopsy with
bronchoalviolar lavage
 CT directed fine needle aspiration biopsy
• Excellent method for obtaining tissue for tumor diagnosis.
• Low sensitivity
– Indication-
• Lung metastasis with known primary
• Multiple pulmonary nodules
• Solitary nodules
Open lung biopsy
• if needle biopsy fails to diagnose the problem

44. • Video-assisted thoracic surgery (VATS)
– Advantage -avoidance of a rib-spreading thoracotomy
– permits major procedures to be performed through minor
incisions
– Applications -diagnosis or management of
• Idiopathic exudative pleural effusion
• Known malignant pleural effusion
• Diffuse interstitial lung disease
• Recurrent pneumothorax or persistent air leak
• Indeterminate peripheral solitary pulmonary nodules
• Mediastinal cyst
• Anatomic lobectomy (in experienced hands only)

45. Pulmonary function test
• Evaluates 1 or more major aspects of the respiratory system
– Lung volumes (FRC,TLC,RV,MV)
– Airway function (simple spirometry,FVC,MVV,MI(E)P
– Gas exchange (blood gas analysis ,pulse oxymetry ,capnography)
– lung mechanics
• Indications
– Detect disease
– Evaluate extent and monitor course of disease
– Evaluate treatment
– Assess risk for surgical procedures

46. Effects of surgery on pulmonary function
• The type of operation , incision used and underlying
pathology have a varying deleterious effects on PF.
• FRC is single most important lung volume measurement
asso. with the development of pulmonary complications
after most operations.
• Factors are associated with a postoperative decrease in FRC
– GA,
– Increased intra-abdominal pressure and,
– Type of incisions used
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47. • Interaction of FRC with CV of the lung is key in understanding
postoperative pulmonary complications
• Factors that ↑ CV include advancing age, tobacco use, fluid overload,
bronchospasm, and the presence of airway secretions.
• Normally, FRC is about 50% and CV is about 30% of TLC.
• ↓FRC or ↑CV results in premature airway closure and atelectasis.
• The resulting V/Q mismatch causes hypoxia, and trapping of secretions→
pneumonitis → respiratory insufficiency.
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48. Lung volume measurements
• The measurement of TLC and RV is useful in the evaluation
of the lung resection candidate.
• Vital capacity is decreased when TLC is reduced or RV is
increased , or by a combination factors.
• Contributing factor will be identified by pre op assessment.
• RV requires helium equilibration, nitrogen washout, or
body plethysmography techniques to determine
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49. Relative changes in lung volumes associated with lung
diseases
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51. Spirometry
• MVV & FEV1—were more sensitive in assessing pulmonary
sufficiency than VC.
• Reductions in VC -> restrictive ventilatory defects, Reductions in
MVV and FEV1 -> obstructive ventilatory abnormalities.
• Operative mortality and long-term postoperative respiratory
insufficiency is related to VC.
• Mortality was related to abnormalities of MVV and FEV1.
• The general guidelines of FEV1 of <2.0 L and MVV <50% of predicted
as indicative of ↑ risk for major lung surgery
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52. 52
FVC
•Total volume of air that can be
exhaled forcefully from TLC
•The majority of FVC can be exhaled
in <3 seconds in normal people,
FEV1
•Volume of air forcefully expired from
full inflation in the 1st second
•Normal people can exhale more than
75-80% of their FVC in the first
second; thus the FEV1/FVC can be
utilized to characterize lung disease

53.  Obstructive disorders
• Limitation of expiratory
airflow
– Examples: asthma, COPD
• Decreased: FEV1, FEV1/FVC
ratio (<0.8)
• Increased or normal: TLC
 Restrictive diseases
• Diminished lung volume due
to:
– Change in alteration in lung
parenchyma (interstitial lung
disease)
– Disease of pleura, chest wall
(e.G. Scoliosis), or
neuromuscular apparatus
(e.G. Muscular dystrophy)
• Decreased TLC, FVC
• Normal or increased:
FEV1/FVC ratio

54. • The severity of reductions in the FVC and/or the FEV1 can be
characterized as:
 Mild - 70-79% of predicted
 Moderate - 60-69% of predicted
 Moderately severe - 50-59%
 Severe - 35-49% of predicted
 Very severe - Less than 35% of predicted

55. 10/9/2021 55

56. Predicted postoperative function
• Quantitative pulmonary scintigraphy in patients determined
to be at increased risk for major lung resection on the basis of
a decreased MVV should be routine
• Assessment for lung surgery typically involves prediction of a
postoperative FEV1 by using the preoperative FEV1.
• Postoperative FEV1 = Preoperative FEV1 x
Q% of the remaining lung
• E.g. if the preoperative FEV1 is 1.6 L and the lung to be
resected demonstrates 40% perfusion, the postoperative
FEV1 would be 1.6 x 0.6 = 0.96 L.

57. Quantitative perfusion scan (anterior view) of a patient with a
proximal right-upper-lobe lung cancer
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58. Diffusing Capacity of the Lung(DLco)
• Is a measure of the volume of a dilute sample of carbon
monoxide that is taken up by the lungs during a single breath
held for 10 seconds
• Evaluates - the integrity of the alveolocapillary
Membrane and
-the pulmonary capillary blood flow
• Dlco is the best predictor of pulmonary complication
• Substantial ↓es in DLCO occur after lung resection 20%,30%
,41% for wedge resection, lobectomy, pneumonectomy
respectively

59. Exercise capacity and oxygen consumption
• Most agree that the finding of a VO2max of <10 mL/kg
per minute , VO2max of 10-15 mL/kg per minute &
VO2max of >15 mL/kg per minute high , intermdiate
and standard risk for complications respectively.
• In a prospective study, VO2max was identified as an
independent predictor of postoperative complications
after major lung resection
10/9/2021 59

60. Arterial Blood Gas analysis
• ABGs provide 3 assessments of the function of the respiratory
system:
– Evaluation of oxygenation (pao2 [mm hg] and a-a oxygen
gradient PO2),
– Evaluation of the adequacy of ventilation (paco2 [mm hg]),
and evaluation of the lung's role in
acid-base balance of the arterial
Blood (ph, paco2).

61. Arterial Blood Gas analysis
 Informations obtained
• Measured:- pH, PaCO2 (mm Hg or kilopascal)
-PaO2 (mm Hg or kilopascal), and,
-total hemoglobin (tHb, g/dL),
-oxyhemoglobin (O2Hb [%]), and
metHb (%)
• Calculated-Total bicarbonate (HCO3 [mEq/L]),
- base excess or deficit (mEq/L),
- oxygen content (CO2 [mL] O2/dL
or volume%)

62. – Elevated Pco2 is associated with increased surgical risk
more significantly than hypoxia.
– Pco2 >43- 45 mm Hg
• Suggests severe disease, with nearly a 50% functional
loss of the lung,
• May be associated with underlying pulmonary
hypertension,

63. Pulmonary Hemodynamics
• Abnormally elevated pulmonary vascular
resistance or pulmonary artery pressure at rest,
during exercise, or with unilateral pulmonary
artery occlusion has been associated with a high
rate of operative mortality after lung resection.
• Presence of substantial pulmonary hypertension
is a strong CI to major lung resection.
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64. Age and Performance Status
• Advanced age has long been a risk factor for lung resection.
• A performance status of 2 (<50% of waking time out of bed,
but unable to perform self-care) to 4 (bedridden) as poor
candidates for major lung resection.
• Each 1-point worsening in performance status increases the
risk for postoperative mortality by a factor of 1.7.
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65. Risk-assessment
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66. Performance tests of functional capacity
• Clinicians have used tests of ambulation as a
semiquantitative assessment of functional
capacity.
• Report suggesting that patients able to climb
three flights of stairs (54 steps) have adequate
reserve for lobectomy and approximately five
flights for pneumonectomy
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67. 10/9/2021 67

68. Assessment of functional operability
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69. Clinical predictors of increased perioperative
cardiovascular risk
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70. Goldman cardiac risk index
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71. 10/9/2021 71

72. Types of surgery based on PFT results
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73. Effects of lung resection
1-Thoracotomy effect
• Even if no lung is resected VC declines by 25% in the early
post op period (Normalizes in 4 to 6 weeks)
2-Lung tissue removal effect
• The degree of pulmonary dysfunction vs tissue removed
• Reduction of pulmonary capillary bed →pulmonary
hypertension →corpulmonale →death
• Reduction of ventilatory capacity →acute/CRF
• Inoperability - inability of the patient to tolerate the loss of
lung volume

74. Pulmonary function criteria for lung resection
Spirometric Questionable Operable
- FVC
- FEV1
- FEV1/FVC ratio
- MVV
Gas exchange
-DLco
-Paco2 mmHg
<60% predicted
<60% predicted
<50%
<50% predicted
<60% predicted
>45 mmHg
>60%
>60%
>50%
>50%
>60%
<45 mmHg

75. REFERENCES
• Sabisten and Spencer Surgery of Chest 9th ed
• Shield’s General Thoracic surgery 8th ed
• General thoracic surgery 7th ed.
• Gyton text book of physiology,11th ed.
• Adult chest surgery
• Manual of radiographic interpritation for
general practitioners,WHO
• UpToDate

76. •Thank you
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