Präoperative Lungenfunktionsanalyse und kardiorespiratorische Risikoabschätzung, aktueller Standard

 

 Buy Article Permissions and Reprints

Zusammenfassung

Ziel der präoperativen Lungenfunktionsanalyse und kardiologischen Funktionsdiagnostik ist es, Patienten mit einem erhöhten Komplikationsrisiko zu identifizieren und über Behandlungsmöglichkeiten und Risiken bestmöglich aufzuklären, sodass eine fundierte Therapieentscheidung getroffen werden kann. Die Identifikation von Patienten mit erhöhtem periinterventionellen Risiko durch die präoperative physiologische Diagnostik bildet auch die Grundlage für weitere Entwicklungen und Verbesserungen von Interventionen und Interventionstechniken, um das Komplikationsrisiko insgesamt reduzieren zu können. Die Erhebung einer ausführlichen Anamnese, eine eingehende körperliche Untersuchung sowie die Diagnostik mittels EKG und Spirometrie können erste Hinweise für das Vorliegen relevanter Komorbiditäten liefern. Bei elektiven Eingriffen muss präoperativ eine differenzierte Bewertung der Komorbiditäten erfolgen, da die Assoziation von zunehmendem Alter und operativer Letalität nicht auf das Alter allein, sondern auf das Spektrum an Komorbiditäten zurückzuführen ist. Die hier aufgeführte Diagnostik richtet sich nach den in Deutschland gültigen S3-Leitlinen der Deutschen Gesellschaft für Pneumologie von 2010. Sowohl deutsche als auch internationale Leitlinien empfehlen zur Indikationsstellung vor lungenresezierenden Eingriffen die interdisziplinäre Falldiskussion, bei der Thoraxchirurgen, Onkologen, Radioonkologen und Pneumologen gemeinsam entscheiden. Patienten im fortgeschrittenen Lebensalter sollten immer präoperativ erweitert kardiopulmonal untersucht werden.

Abstract

The aim of preoperative lung function analysis and diagnostic cardiology is to identify patients with an increased risk of complications and to best inform the patients about treatment options and risks so that an informed treatment decision can be made. The identification of patients at increased peri-interventional risk by preoperative physiological diagnostics also forms the basis for further developments and improvements of interventions and intervention techniques in order to reduce the risk of complications. The acquisition of a detailed medical history, a thorough physical examination, and the diagnosis using ECG and spirometry may provide the first evidence for the presence of relevant comorbidities. In elective surgery a detailed preoperative evaluation of comorbidities must be done. The association of age and operative mortality is not only due to age alone, but also involves the spectrum of comorbidities. The algorithms for Germany are based on the “S3 Guidelines of the German Society of Pneumology of 2010”. Both German and international guidelines recommend the discussion of each case before lung resections in an interdisciplinary case discussion with thoracic surgeons, oncologists, radio-oncologists and pulmonologists. Patients of advanced age should always be subjected to an extended preoperative cardiopulmonary investigation.

• Literatur

• 1 Brunelli A, Kim AW, Berger KI et al. Diagnosis and management of lung cancer, 3rd ed. American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2013; 143: e166S-e190S
  CrossrefPubMedGoogle Scholar
• 2 Eagle KA, Berger PB, Calkins H et al. ACC/AHA guideline update for perioperative cardiovascular evaluation for noncardiac surgery – executive summary. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1996 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery). Circulation 2002; 105: 1257-1267
  PubMedGoogle Scholar
• 3 Deutsche Gesellschaft für Pneumologie und Beatmungsmedizin, Deutsche Krebsgesellschaft. Interdisziplinäre S3-Leitlinie: Prävention, Diagnostik, Therapie und Nachsorge des Lungenkarzinoms. Pneumologie 2010; 64: e1
  Article in Thieme ConnectPubMedGoogle Scholar
• 4 Löllgen H. Kardiopulmonale Funktionsdiagnostik. Documenta Geigy. 1. Aufl.. Wehr (Baden): Ciba-Geigy; 1983
  CrossrefGoogle Scholar
• 5 Bluman LG, Mosca L, Newman N et al. Preoperative smoking habits and postoperative pulmonary complications. Chest 1998; 113: 883-889
  CrossrefPubMedGoogle Scholar
• 6 Kroidl R, Schwarz S, Lehnigk B. Kursbuch Spiroergometrie. 2. Aufl.. Stuttgart: Thieme; 2009
  Google Scholar
• 7 Nakagawa M, Tanaka H, Tsukuma H et al. Relationship between the duration of the preoperative smoke-free period and the incidence of postoperative pulmonary complications after pulmonary surgery. Chest 2001; 120: 705-710
  CrossrefPubMedGoogle Scholar
• 8 Brunelli A, Refai MA, Salati M et al. Carbon monoxide lung diffusion capacity improves risk stratification in patients without airflow limitation: evidence for systematic measurement before lung resection. Eur J Cardiothorac Surg 2006; 29: 567-570
  CrossrefPubMedGoogle Scholar
• 9 Bolliger CT, Perruchoud AP. Functional evaluation of the lung resection candidate. Eur Respir J 1998; 11: 198-212
  CrossrefPubMedGoogle Scholar
• 10 Ferguson MK, Little L, Rizzo L et al. Diffusing capacity predicts morbidity and mortality after pulmonary resection. J Thorac Cardiovasc Surg 1988; 96: 894-900
  PubMedGoogle Scholar
• 11 Ferguson MK, Siddique J, Karrison T. Modeling major lung resection outcomes using classification trees and multiple imputation techniques. Eur J Cardiothorac Surg 2008; 34: 1085-1089
  CrossrefPubMedGoogle Scholar
• 12 Taube K, Konietzko N. Prediction of postoperative cardiopulmonary function in patients undergoing pneumonectomy. Thorac Cardiovasc Surg 1980; 28: 348-351
  Article in Thieme ConnectPubMedGoogle Scholar
• 13 Licker MJ, Widikker I, Robert J et al. Operative mortality and respiratory complications after lung resection for cancer: impact of chronic obstructive pulmonary disease and time trends. Ann Thorac Surg 2006; 81: 1830-1837
  CrossrefPubMedGoogle Scholar
• 14 Linden PA, Bueno R, Colson YL et al. Lung resection in patients with preoperative FEV1 < 35 % predicted. Chest 2005; 127: 1984-1990
  CrossrefPubMedGoogle Scholar
• 15 Brunelli A, Belardinelli R, Refai M et al. Peak oxygen consumption during cardiopulmonary exercise test improves risk stratification in candidates to major lung resection. Chest 2009; 135: 1260-1267
  CrossrefPubMedGoogle Scholar
• 16 Brutsche MH, Spiliopoulos A, Bolliger CT et al. Exercise capacity and extent of resection as predictors of surgical risk in lung cancer. Eur Respir J 2000; 15: 828-832
  CrossrefPubMedGoogle Scholar
• 17 Datta D, Lahiri B. Preoperative evaluation of patients undergoing lung resection surgery. Chest 2003; 123: 2096-2103
  CrossrefPubMedGoogle Scholar
• 18 Myers J, Froelicher VF. Exercise testing. Procedures and implementation. Cardiol Clin 1993; 11: 199-213
  PubMedGoogle Scholar
• 19 Trappe HJ, Löllgen H. Leitlinien zur Ergometrie. Z Kardiol 2000; 89: 821-837
  CrossrefPubMedGoogle Scholar
• 20 Brunelli A, Refai M, Xiume F et al. Performance at symptom-limited stair-climbing test is associated with increased cardiopulmonary complications, mortality, and costs after major lung resection. Ann Thorac Surg 2008; 86: 240-247
  CrossrefPubMedGoogle Scholar
• 21 Holden DA, Rice TW, Stelmach K et al. Exercise testing, 6-min walk, and stair climb in the evaluation of patients at high risk for pulmonary resection. Chest 1992; 102: 1774-1779
  CrossrefPubMedGoogle Scholar
• 22 Bittner V, Weiner DH, Yusuf S. Prediction of mortality and morbidity with a 6-minute walk test in patients with left ventricular dysfunction. JAMA 1993; 270: 1702-1707
  CrossrefPubMedGoogle Scholar
• 23 Baldi S, Ruffini E, Harari S et al. Does lobectomy for lung cancer in patients with chronic obstructive pulmonary disease affect lung function?. J Thorac Cardiovasc Surg 2005; 130: 1616-1622
  CrossrefPubMedGoogle Scholar
• 24 Hadeli KO, Siegel EM, Sherrill DL et al. Predictors of oxygen desaturation during submaximal exercise in 8,000 patients. Chest 2001; 120: 88-92
  CrossrefPubMedGoogle Scholar
• 25 Hollaus PH, Wilfing G, Wurnig PN et al. Risk factors for the development of postoperative complications after bronchial sleeve resection for malignancy: a univariate and multivariate analysis. Ann Thorac Surg 2003; 75: 966-972
  CrossrefPubMedGoogle Scholar
• 26 Devereaux PJ, Mrkobrada M, Sessler DI et al. Aspirin in patients undergoing noncardiac surgery. N Engl J Med 2014; 370: 1494-1503
  CrossrefPubMedGoogle Scholar
• 27 British Thoracic Society, Society of Cardiothoracic Surgeons of Great Britain and Ireland Working Party. BTS guidelines: guidelines on the selection of patients with lung cancer for surgery. Thorax 2001; 56: 89-108
  CrossrefPubMedGoogle Scholar
• 28 POISE Study Group. Devereaux PJ, Yang H, Yusuf S et al. Effects of extended-release metoprolol succinate in patients undergoing non-cardiac surgery (POISE trial): a randomised controlled trial. Lancet 2008; 371: 1839-1847
  CrossrefPubMedGoogle Scholar
• 29 Barnett HJ, Taylor DW, Eliasziw M et al. Benefit of carotid endarterectomy in patients with symptomatic moderate or severe stenosis. North American Symptomatic Carotid Endarterectomy Trial Collaborators. N Engl J Med 1998; 339: 1415-1425
  CrossrefPubMedGoogle Scholar
• 30 Jeger RV, Probst C, Arsenic R et al. Long-term prognostic value of the preoperative 12-lead electrocardiogram before major noncardiac surgery in coronary artery disease. Am Heart J 2006; 151: 508-513
  CrossrefPubMedGoogle Scholar
• 31 Noordzij PG, Boersma E, Bax JJ et al. Prognostic value of routine preoperative electrocardiography in patients undergoing noncardiac surgery. Am J Cardiol 2006; 97: 1103-1106
  CrossrefPubMedGoogle Scholar
• 32 Klocke FJ, Baird MG, Lorell BH et al. ACC/AHA/ASNC guidelines for the clinical use of cardiac radionuclide imaging – executive summary. J Am Coll Cardiol 2003; 42: 1318-1333
  CrossrefPubMedGoogle Scholar
• 33 Kertai MD, Boersma E, Bax JJ et al. A meta-analysis comparing the prognostic accuracy of six diagnostic tests for predicting perioperative cardiac risk in patients undergoing major vascular surgery. Heart 2003; 89: 1327-1334
  CrossrefPubMedGoogle Scholar
• 34 Vahanian A, Baumgartner H, Bax J et al. Guidelines on the management of valvular heart disease: the Task Force on the Management of Valvular Heart Disease of the European Society of Cardiology. Eur Heart J 2007; 28: 230-268
  CrossrefPubMedGoogle Scholar
• 35 Bolliger CT, Solèr M, Stulz P et al. Evaluation of high-risk lung resection candidates: pulmonary haemodynamics versus exercise testing. A series of five patients. Respiration 1994; 61: 181-186
  CrossrefPubMedGoogle Scholar
• 36 Benzo R, Wigle D, Novotny P et al. Preoperative pulmonary rehabilitation before lung cancer resection: results from two randomized studies. Lung Cancer 2011; 74: 441-445
  CrossrefPubMedGoogle Scholar
• 37 Lingnau W, Strohmenger HU. Responsibility of the anaesthesiologist in the preoperative risk evaluation. Anaesthesist 2002; 51: 704-715
  CrossrefPubMedGoogle Scholar
• 38 Maisel AS, Bhalla V, Braunwald E. Cardiac biomarkers: a contemporary status report. Nat Clin Pract Cardiovasc Med 2006; 3: 24-34
  CrossrefPubMedGoogle Scholar
• 39 Gersh BJ, Braunwald E, Rutherford JD. Chronic coronary artery disease. In: Braunwald E, ed. Heart Disease. 5th ed.. Philadelphia: WB Saunders Company; 1997: 1289-1365
  Google Scholar
• 40 White WB, Lund-Johansen P, Omvik P. Assessment of four ambulatory blood pressure monitors and measurements by clinicans versus intraarterial blood pressure at rest and during exercise. Am J Cardiol 1990; 65: 60-66
  PubMedGoogle Scholar
• 41 Ellestad MH, Stuart RJ. Exercise Stress Testing: Principles and clinical Application. In: Chatterjee K, Parmley WW, eds. Cardiology. Philadelphia: JB Lippincott Company; 1992. Kap.45
  Google Scholar
• 42 Lele SS, Scalia G, Thomson H. Mechanism of exercise hypotension in patients with ischemic heart disease: role of neurocardiogenically mediated vasodilation. Circulation 1994; 90: 2701-2709
  CrossrefPubMedGoogle Scholar
• 43 Wilson NV, Meyer BM. Early prediction of hypertension using exercise blood pressure. Prev Med 1981; 10: 62-68
  CrossrefPubMedGoogle Scholar
• 44 Bolliger CT. Functional reserve before lung resection: how low can we go?. Respiration 2009; 78: 20-22
  CrossrefPubMedGoogle Scholar
• 45 Priebe HJ. Perioperative myocardial infarction – aetiology and prevention. Br J Anaesth 2005; 95: 3-19
  CrossrefPubMedGoogle Scholar
• 46 Miller jr. JI. Physiologic evaluation of pulmonary function in the candidate for lung resection. J Thorac Cardiovasc Surg 1993; 105: 347-351
  PubMedGoogle Scholar
• 47 Wang TJ, Larson MG, Levy D et al. Plasma natriuretic peptide levels and the risk of cardiovascular events and death. N Engl J Med 2004; 350: 655-663
  CrossrefPubMedGoogle Scholar
• 48 Tsimikas S, Willerson JT, Ridker PM. C-reactive protein and other emerging blood biomarkers to optimize risk stratification of vulnerable patients. J Am Coll Cardiol 2006; 47: C19-C31
  CrossrefPubMedGoogle Scholar
• 49 Sabatine MS, Morrow DA, Giugliano RP et al. Implications of upstream glycoprotein II b/III a inhibition and coronary artery stenting in the invasive management of unstable angina/non-ST-elevation myocardial infarction: (TIMI) IIIB trial and (TACTICS)-TIMI 18 trial. Circulation 2004; 109: 874-880
  CrossrefPubMedGoogle Scholar
• 50 Pierce RJ, Copland JM, Sharpe K et al. Preoperative risk evaluation for lung cancer resection: predicted postoperative product as a predictor of surgical mortality. Am J Respir Crit Care Med 1994; 150: 947-955
  CrossrefPubMedGoogle Scholar
• 51 Mark DB, Shaw L, Harrell jr. FE et al. Prognostic value of a treadmill exercise score in outpatients with suspected coronary artery disease. N Engl J Med 1991; 325: 849-853
  CrossrefPubMedGoogle Scholar
• 52 Feringa HHH, Bax JJ, Elhendy A et al. Association of plasma N-terminal pro-B-type natriuretic peptide with postoperative cardiac events in patients undergoing surgery for abdominal aortic aneurysm or leg bypass. Am J Cardiol 2006; 98: 111-115
  CrossrefPubMedGoogle Scholar
• 53 Cerfolio RJ, Minnich DJ, Bryant AS. General thoracic surgery is safe in patients taking clopidogrel (Plavix). J Thorac Cardiovasc Surg 2010; 140: 970-976
  CrossrefPubMedGoogle Scholar