Anesthesiology APPLIED Exam › Thoracic and respiratory

Preoperative pulmonary evaluation and lung resection criteria

Thoracic and respiratory·~5 min read· Physician-reviewed✓ Sourced · 3

Stem

A 67-year-old man, 74 kg, with a 45 pack-year history who still smokes, is scheduled for an open right lower lobectomy for a 3 cm adenocarcinoma. He has COPD and walks a block before stopping. Post-bronchodilator FEV1 is 62% predicted and DLCO is 48% predicted. The tumor does not obstruct any airway. Room-air SpO2 is 94%.

Question

Is he fit for a lobectomy, and what further testing do you want before you anesthetize him?

Ideal answer

HeadlineIt depends on what he keeps: predicted postoperative FEV1 and DLCO both fall between 30% and 60%, so he needs a low-technology exercise test before I call him fit.¹

Calculate by segments: 62 times 14 over 19. The right lower lobe has five of his nineteen functional segments, so ppoFEV1 is roughly 46%; ppoDLCO is about 35%.¹
Stair climb ≥22 metres or shuttle walk ≥400 metres makes him acceptable for lobectomy; failing sends him to cardiopulmonary exercise testing for VO2max.¹
Screen his heart in parallel, because the walk limitation may be cardiac; COPD optimized with bronchodilators and no active infection.
Tobacco dependence treatment now, because the guideline recommends it for every smoker going to lung resection.¹
Double-lumen tube, thoracic epidural or paravertebral catheter, protective one-lung ventilation and early extubation; postoperative pulmonary complications are his main risk, and I tell him so.

Breaking down the answer

Calculate, do not eyeball — predicted postoperative values come from segment counting for a lobectomy (preoperative value × remaining functional segments / total functional segments) and from a quantitative perfusion scan for a pneumonectomy.¹ Showing the arithmetic shows organization.
Use both FEV1 and DLCO — the algorithm is built on both, and the lower of the two decides the next step; above 60% for both, no more testing is needed.¹
Step up the testing in order — 30–60% earns a stair climb or shuttle walk rather than surgery or formal testing outright; 30% or less goes straight to formal exercise testing.¹ Matching test intensity to risk is judgment.
VO2max is the final arbiter — above 20 mL/kg/min or 75% predicted is low risk; below 10 mL/kg/min or 35% predicted means counseling about sublobar resection, minimally invasive surgery or nonoperative treatment.¹
Score general surgical risk too — ARISCAT gives points for age, low SpO2, recent respiratory infection, anemia, upper abdominal or intrathoracic incision, duration and emergency status; an intrathoracic incision alone scores 24.²
Cessation pays twice — it improves short-term perioperative outcomes and long-term survival.¹

Follow-up question

He stops after climbing 14 metres, short of breath. Cardiopulmonary exercise testing shows a VO2max of 9 mL/kg/min with no ischemia. The surgeon still wants to proceed with an open lobectomy next week. What do you do?

Follow-up answer

HeadlineA VO2max under 10 mL/kg/min makes a major anatomic resection through a thoracotomy high risk.¹ I tell the surgeon directly.

I ask for the case to go to the multidisciplinary tumor board rather than the schedule. The guideline position is to counsel him about a minimally invasive approach, a sublobar resection, or nonoperative treatment such as stereotactic radiotherapy.¹ I sit down with him and explain the risk in plain numbers he can weigh. If he and the team still choose surgery, I plan ICU care, a thoracic epidural, lung-protective ventilation and early mobilization, and I reassess after pulmonary rehabilitation and smoking cessation, because both can change his numbers.

Pitfalls that cost points

Quoting a single absolute FEV1 in litres instead of predicted postoperative percent values.
Ordering routine preoperative spirometry for non-thoracic surgery; outside lung resection it adds little.³

Rapid-fire

Q: Which patient factors raise pulmonary risk in non-thoracic surgery? A: COPD, ASA class 2 or higher, functional dependence, poorly controlled asthma, smoking and low albumin; well-controlled asthma and obesity alone do not.³

Q: Which operations carry the most pulmonary risk? A: Aortic and thoracic surgery, then upper abdominal, neurosurgery, vascular and neck surgery; emergency and long cases add risk.³

Q: What ARISCAT score means high risk? A: 45 or more, the class with the highest complication rate in the development cohort.²

Q: Which postoperative measures reduce pulmonary complications? A: Lung expansion maneuvers, good epidural analgesia, and selective rather than routine nasogastric decompression.³

Q: How do you calculate predicted postoperative values for a pneumonectomy? A: From a quantitative perfusion scan: preoperative value × (1 − fraction of perfusion to the lung being removed).¹

Numbers to know

Item	Value
ppoFEV1 and ppoDLCO, no further test	Both >60% predicted¹
Low-technology exercise test	Either <60% but both >30%¹
Stair climb / shuttle walk failure	<22 m climbed / <400 m walked¹
VO2max low risk	>20 mL/kg/min or >75% predicted¹
VO2max high risk	<10 mL/kg/min or <35% predicted¹
ARISCAT risk classes	<26 low, 26–44 intermediate, ≥45 high²

Sources

1.Physiologic Evaluation of the Patient With Lung Cancer Being Considered for Resectional Surgery (ACCP evidence-based guideline, 3rd ed) · American College of Chest Physicians (CHEST 2013;143(5 Suppl):e166S–e190S), 2013 · uthsc.eduBrunelli et al. Recs 3.2.1, 3.9.1, 3.9.2, 7.4.2 and the Section 4 algorithm.
2.Prediction of postoperative pulmonary complications in a population-based surgical cohort (ARISCAT) · Anesthesiology, 2010 · hospitaldelmar.catCanet et al. Seven predictors (Table 6) and risk classes (Table 7); overall PPC incidence 5.0%.
3.Preoperative pulmonary evaluation: identifying and reducing risks for pulmonary complications · Cleveland Clinic Journal of Medicine, 2006 · ccjm.orgSmetana GW. CCJM 2006;73 Suppl 1:S36–S41.

Facts on this page were checked against these sources on Oct 15, 2026. Guidelines change; confirm doses against current institutional protocols.