Thoracic
Tests of pulmonary function
before thoracic surgery
Ving Yuen See Tho
Jonathan Mackay
Abstract
Pulmonary function tests form part of the comprehensive preoperative
assessment of patients undergoing thoracic surgery. They aim not only
to assess the severity and nature of the underlying lung pathology, but
also to determine whether a patient will be able to tolerate a pulmonary
resection. Tests which assess respiratory mechanics evaluate the mech­
anical delivery of oxygen to the alveoli and these include spirometry,
measurement of lung volumes and flow–volume analysis. The forced ex­
piratory volume in 1 second (FEV1) and the predicted postoperative FEV1
(ppoFEV1) in particular are useful predictors of postoperative respiratory
complications. Parenchymal function refers to the ability of the lung to
exchange oxygen and carbon dioxide between the pulmonary blood and
the alveoli, and this is assessed by determining the diffusing capacity
of carbon monoxide and arterial blood gas analysis. Cardiopulmonary
interaction, which is important in ensuring adequate cellular respira­
tion in skeletal muscle, is assessed using exercise tests that include
the formal cardiopulmonary exercise test and other surrogates such as
the 6-minute walk test, shuttle walk test and stair-climbing. Other tests
including ventilation perfusion scintigraphy and split-lung function tests
are also briefly mentioned.
Keywords exercise test; preoperative assessment; pulmonary diffusing
capacity; respiratory function tests; spirometry; thoracic surgery
Pulmonary function tests play an essential role in the preopera-
tive assessment of patients presenting for thoracic surgery. There
is no one single test of respiratory function which can accurately
evaluate a patient’s fitness for surgery and predict outcome, and
a combination of tests is often required. The ‘three-legged stool’
of pre-thoracotomy respiratory assessment comprises tests which
target three areas of lung function, namely respiratory ­mechanics,
parenchymal function and cardiopulmonary interaction.
Ving Yuen See Tho is an Associate Consultant Anaesthetist at the
Singapore General Hospital. She qualified from the Royal College of
Surgeons, Ireland, Dublin, and trained in cardiothoracic anaesthesia
at Papworth Hospital, Cambridge, UK. Her current interest is in
perioperative transoesophageal echocardiography. Conflicts of
interests: none declared.
Jonathan Mackay, MRCP, FRCA, is a Consultant Anaesthetist at Papworth
Hospital, Cambridge, UK. His special interests are cardiothoracic
anaesthesia and resuscitation. Conflicts of interest: none declared.
ANAESTHESIA AND INTENSIVE CARE MEDICINE 9:12
Respiratory mechanics
Spirometry
Spirometry involves the measurement of the forced expiratory
volume in 1 second (FEV1) and the forced vital capacity (FVC),
which is the largest volume of gas that can be forcibly exhaled
from the total lung capacity (TLC). The patient breathes into
a mouthpiece while wearing nose clips and performs the
FVC, generating a volume–time curve from which the FEV1
is derived. Percentage predicted values should be reported to
avoid bias against patients who are older, of smaller stature or
women, all of whom may tolerate lower levels of lung func-
tion. Assessment of bronchodilator response in order to deter-
mine the degree of airflow-limitation reversibility is normally
carried out as part of the test. An increase in FEV1 and/or FVC
of more than 12% of the control or 200 millilitres constitutes a
positive response.
In normal individuals, the FEV1 and FVC are greater than
80% of the predicted values, and the FEV1/FVC ratio is greater
than 70% of the predicted value. Table 1 shows the character-
istic changes in flow rates and lung volumes associated with
­obstructive and restrictive pulmonary diseases.
Lung volumes
Spirometry can also be used to measure lung volumes, excluding
the residual volume (RV) and any capacity which includes RV
in its definition. The functional residual capacity (FRC) is meas­
ured using helium dilution, nitrogen washout, body plethysmog-
raphy or imaging techniques. Measurement of lung volumes
may be more sensitive than the FEV1/FVC ratio in differentiat-
ing between obstructive and restrictive disorders. In restrictive
lung disease, TLC, FRC and RV are all decreased. In obstructive
disease, the FVC may be reduced owing to airway closure at
high lung volume, giving rise to a normal FEV1/FVC ratio. The
RV will, however, be abnormally high and this will confirm an
obstructive defect.
Flow–volume analysis
Flow–volume loops are performed using spirometry, and are use-
ful not only to detect obstructive and restrictive ventilatory defects
but also to identify any fixed or variable intra- and extrathoracic
airway obstruction by a tumour mass which would have an impact
on the anaesthetic management of these patients (Figure 1).
Changes in flow rates and lung volumes associated
with obstructive and restrictive pulmonary diseases
Measurement Obstructive disease Restrictive disease
FEV1 Decreased Normal or increased
FVC Decreased or normal Decreased
FEV1/FVC Decreased Normal or increased
TLC Normal or increased Decreased
RV Increased Decreased
FEV1, forced expiratory volume in 1 second; FVC, forced vital capacity;
TLC, total lung capacity; RV, residual volume.
Table 1
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
and cooperation, and this often results in an underestimation of
FEV1 and FVC. Despite this, they remain essential modalities in
the assessment of patients before lung resection. In particular,
the predicted postoperative FEV1 (ppoFEV1) is a significant inde-
pendent predictor of post-thoracotomy respiratory ­complications,
and represents the most valid test to date.
Lung parenchymal function
Diffusing capacity for carbon monoxide
The diffusing capacity of the lung refers to the overall ability
of the lung to transfer gas between the alveoli and the pulmon­
ary capillary blood. It is not only affected by the gas-diffusion
properties of the alveolar–capillary membrane, but also by fac-
tors which affect pulmonary capillary blood volume and reaction
rates of the gas with haemoglobin (Hb).
The single-breath carbon monoxide diffusing capacity (DLCO)
is the most commonly used technique, and involves the patient
taking a single vital capacity inspiration from residual volume of
a mixture of 0.3% carbon monoxide and 10% helium, followed
by a 10-second breath-hold and exhalation. Carbon monoxide is
used because its affinity for Hb is about 400 times greater that
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
limited. The calculation of DLCO is based on Fick’s law of diffu-
sion, and the derived formula is as follows:
DLCO = Vco/Palvco
where Vco is the rate of carbon monoxide transfer across the
alveolar membrane, and Palvco is the partial pressure of carbon
monoxide in the alveoli.

ANAESTHESIA AND INTENSIVE CARE MEDICINE 9:12 524 © 2008 Elsevier Ltd. All rights reserved.
 Thoracic

Interpretation of DLCO involves comparing results with ref-

erence values generated from studies on healthy populations. The interaction among the pulmonary,
­Various physiological factors also affect DLCO, including age, sex, cardiovascular and skeletal muscle systems
height, exercise, body position and altitude, and these factors are during exercise
taken into account when interpreting results. A healthy 45-year-old
Muscle O2 and CO2 Ventilation
male who is 175 cm tall should have a DLCO of 24 ml/min/mm Hg activity transport
· · ·
(VA + VD = VE)
at sea-level, and this increases by two- to threefold with exercise. Peripheral Pulmonary
Current studies show that DLCO and its corresponding predicted circulation circulation
postoperative value are well-recognized predictors of major mor-
CO2 production O2 flow Expired
bidity and mortality following lung resection. DLCO is indicated if
the perioperative risk is not clear based on ­spirometry results.
QCO VCO 2
2
Creatine PO4
Arterial blood gas analysis Muscle Heart blood Lungs
A baseline arterial blood gas (ABG) analysis forms part of the Pyruvate–Lactate
QO VO
preoperative respiratory assessment, particularly in patients with
2
2

significant respiratory disease. Evidence of hypoxaemia and/or

hypercapnoea should prompt further evaluation of the patient’s O2 consumption CO2 flow Inspired
respiratory function. Mitochondrion
An arterial blood sample is collected in a heparinized syringe
and passed through a blood gas analyser. The arterial pH, partial VA, ideal alveolar ventilation/time; VD, physiologic dead space
pressure of oxygen (Pao2) and carbon dioxide (Paco2) are directly ventilation/time; VE, total ventilation during expiration/time; QO2,
measured using a glass pH electrode, polarographic (Clark) oxygen O2 consumption; QCO2, CO2 production; VO2, O2 uptake; VCO2, CO2 output;
creatine PO4, creatine phosphate. Courtesy of Wasserman
electrode and Severinghaus carbon dioxide electrode respectively.
The actual and standard bicarbonate and base excess are calculated
Figure 2
from the pH and Paco2 using the Siggard-Anderson nomogram.

between two cones set 10 metres apart in time to a set of auditory

Cardiopulmonary interaction
Exercise tests
The aim of exercise testing is to assess the interaction among the
pulmonary, cardiovascular and skeletal muscle systems during
a period of exertion. In order to meet the demands of cellular
respiration in exercising muscle, there must be adequate pulmo-
nary ventilation and blood flow for oxygen and carbon dioxide
transport, as illustrated by Wasserman (Figure 2).
The formal cardiopulmonary exercise test (CPET) is a com-
puterized breath-by-breath analysis of respiratory gas exchange
at rest and during a period of exercise. Despite the need for
complex equipment and trained personnel, it remains the ‘gold
standard’ for assessment of cardiopulmonary function. A variety
of parameters are recorded, and the measured maximal oxygen
consumption (Vo2max) has been found to be a significant predic-
tor of post-thoracotomy outcome. The calculation of Vo2max is
based on the Fick equation as follows:
VO2max = (SVmax × HRmax) × (CaO2max − CvO2max)
where SV is the stroke volume, HR is the heart rate, Cao2 is the
arterial oxygen content, and Cvo2 is the mixed venous oxygen
content. Any factor which affects any one or more of the four
variables in the Fick equation will have an impact on the Vo2max,
for example a reduction in SV in heart failure or a reduction in
blood oxygen content in pulmonary disease.
The 6-minute walk test (6MWT) and the shuttle walk test (SWT)
are surrogate tests for CPET, but the data on the value of these
tests in predicting Vo2max are limited. The 6MWT involves measur-
ing the maximum distance a patient can walk at his or her own
pace in 6 minutes, and a distance of <600 metres correlates with
a Vo2max of <15 ml/kg/min. The SWT requires the patient to walk
bleeps and the test is stopped when the patient is too breathless
to keep up with the bleeps. The best of two results is taken, and
anything less than 25 shuttles or 250 metres is associated with a
Vo2max of <15 ml/kg/min. Exercise oximetry to detect desatura-
tion is often simultaneously carried out during these tests.
Stair-climbing lacks proper standardization, but is frequently
performed because of its simplicity and ease. The patient walks
up stairs at his or her own pace without stopping, and the num-
ber of flights he or she is able to ascend is recorded. There is no
exact definition of a ‘flight’, but it is often taken as 20 steps at 15
centimetres per step. The ability to climb five flights indicates an
FEV1 of >2 litres and a Vo2max of >20 ml/kg/min. Climbing three
flights indicates an FEV1 of >1.7 litres and is associated with an
average risk. A patient is considered very high risk if he or she is
unable to climb one flight as this is associated with a Vo2max of
< 10 ml/kg/min.
Other tests
Ventilation perfusion (V/Q) scintigraphy measures what per-
centage the portion of lung to be resected contributes to over-
all ventilation and perfusion. If the diseased region is minimally
functioning, it is reasonable to predict that there will be little
impact on postoperative lung function. This test is particularly
useful in patients undergoing a pneumonectomy, and should
also be considered in any patient who has a ppoFEV1 of <40%.
Split-lung function tests aim to simulate respiratory condi-
tions after lung resection. Unilateral exclusion of a lung or lobe
with a double-lumen tube or bronchial blocker is not done today
because it is poorly tolerated by the awake patient and is difficult
to perform. Unilateral occlusion of a pulmonary artery using a
balloon catheter aims to estimate the effects of pulmonary liga-
tion on pulmonary artery pressures. Owing to a lack of sufficient

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
part of the routine respiratory assessment. ◆
Further reading
Albouaini K, Egred M, Alahmar A, Wright DJ. Cardiopulmonary exercise
testing and its application. Heart 2007; 93: 1285–92.
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(2): 89–108.
ANAESTHESIA AND INTENSIVE CARE MEDICINE 9:12
Colice GL, Shafazand S, Griffin JP, et al. Physiologic evaluation of the
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
resection. Anesthesiol Clin North Am 2001; 19: 411–33.
Thys D. Textbook of cardiothoracic anaesthesiology. Columbus, OH:
McGraw-Hill Professional, 2001.
Wasserman K. Diagnosing cardiovascular and lung pathophysiology
from exercise gas exchange. Chest 1997; 112: 1091–101.
West JB. Pulmonary pathophysiology: the essentials, 7th edn.
Philadelphia: Lippincott Williams & Wilkins, 2007.
526 © 2008 Elsevier Ltd. All rights reserved.