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Flow–volume analysis
Pulmonary function tests play an essential role in the preopera- Flow–volume loops are performed using spirometry, and are use-
tive assessment of patients presenting for thoracic surgery. There ful not only to detect obstructive and restrictive ventilatory defects
is no one single test of respiratory function which can accurately but also to identify any fixed or variable intra- and extrathoracic
evaluate a patient’s fitness for surgery and predict outcome, and airway obstruction by a tumour mass which would have an impact
a combination of tests is often required. The ‘three-legged stool’ on the anaesthetic management of these patients (Figure 1).
of pre-thoracotomy respiratory assessment comprises tests which
target three areas of lung function, namely respiratory mechanics,
parenchymal function and cardiopulmonary interaction. Changes in flow rates and lung volumes associated
with obstructive and restrictive pulmonary diseases
ANAESTHESIA AND INTENSIVE CARE MEDICINE 9:12 523 © 2008 Elsevier Ltd. All rights reserved.
Thoracic
Flow–volume loops
a Expiration b c
Flow rate Q
Volume V V V
Inspiration
d e f
Flow rate Q
Volume V V V
a Normal lung. b Obstructive defect. Flow rate is low in relation to lung volume and a concave appearance of the expiratory limb is seen following the point of
maximal flow. c Restrictive defect. Maximal flow rate and lung volume are reduced. d Fixed large airway obstruction, e.g. secondary to a tumour or foreign body in a
bronchus. Inspiratory and expiratory flow rates are reduced. e Variable intrathoracic large airway obstruction. f Variable extrathoracic large airway obstruction
Figure 1
Spirometric assessment is very dependent on patient effort The single-breath carbon monoxide diffusing capacity (DLCO)
and cooperation, and this often results in an underestimation of is the most commonly used technique, and involves the patient
FEV1 and FVC. Despite this, they remain essential modalities in taking a single vital capacity inspiration from residual volume of
the assessment of patients before lung resection. In particular, a mixture of 0.3% carbon monoxide and 10% helium, followed
the predicted postoperative FEV1 (ppoFEV1) is a significant inde- by a 10-second breath-hold and exhalation. Carbon monoxide is
pendent predictor of post-thoracotomy respiratory complications, used because its affinity for Hb is about 400 times greater that
and represents the most valid test to date. that for oxygen, thus permitting carbon monoxide to move rap-
idly across the alveolar membrane without any ‘back pressure’.
The rate of transfer of carbon monoxide is said to be diffusion
Lung parenchymal function
limited. The calculation of DLCO is based on Fick’s law of diffu-
Diffusing capacity for carbon monoxide sion, and the derived formula is as follows:
The diffusing capacity of the lung refers to the overall ability
of the lung to transfer gas between the alveoli and the pulmon DLCO = Vco/Palvco
ary capillary blood. It is not only affected by the gas-diffusion
properties of the alveolar–capillary membrane, but also by fac- where Vco is the rate of carbon monoxide transfer across the
tors which affect pulmonary capillary blood volume and reaction alveolar membrane, and Palvco is the partial pressure of carbon
rates of the gas with haemoglobin (Hb). monoxide in the alveoli.
ANAESTHESIA AND INTENSIVE CARE MEDICINE 9:12 524 © 2008 Elsevier Ltd. All rights reserved.
Thoracic
ANAESTHESIA AND INTENSIVE CARE MEDICINE 9:12 525 © 2008 Elsevier Ltd. All rights reserved.
Thoracic
predictive value on postoperative outcome, it is not performed as Colice GL, Shafazand S, Griffin JP, et al. Physiologic evaluation of the
part of the routine respiratory assessment. ◆ patient with lung cancer being considered for resectional surgery.
ACCP evidence-based clinical practice guidelines (2nd edn). Chest
2007; 132(3 Suppl): 161S–77S.
Slinger PD, Johnston MR. Preoperative assessment for pulmonary
Further reading resection. Anesthesiol Clin North Am 2001; 19: 411–33.
Albouaini K, Egred M, Alahmar A, Wright DJ. Cardiopulmonary exercise Thys D. Textbook of cardiothoracic anaesthesiology. Columbus, OH:
testing and its application. Heart 2007; 93: 1285–92. McGraw-Hill Professional, 2001.
British Thoracic Society, Society of Cardiothoracic Surgeons of Great Wasserman K. Diagnosing cardiovascular and lung pathophysiology
Britain and Ireland Working Party. BTS guidelines: guidelines on from exercise gas exchange. Chest 1997; 112: 1091–101.
the selection of patients with lung cancer for surgery. Thorax 2001; West JB. Pulmonary pathophysiology: the essentials, 7th edn.
56(2): 89–108. Philadelphia: Lippincott Williams & Wilkins, 2007.
ANAESTHESIA AND INTENSIVE CARE MEDICINE 9:12 526 © 2008 Elsevier Ltd. All rights reserved.