SESSION TITLE: Surgery Global Case Reports
SESSION TYPE: Global Case Report
PRESENTED ON: Tuesday, October 29, 2013 at 01:30 PM - 02:30 PM
INTRODUCTION: Lung function assessment is important to evaluate the operative risk of a patient prior to a lobectomy. Standard procedure includes a complete pulmonary function test and cardiopulmonary exercise test. Those tests can be harder to obtain in patients who have a permanent tracheostomy. We describe two patients who presented with both a laryngeal cancer with stridor necessitating urgent permanent laryngectomy and a lung mass compatible with primary lung cancer. Both patients had no prior pulmonary function test available and both were known smokers. In this case report, we describe our method to obtain a flow volume curve and a cardiopulmonary exercise test in the presence of a permanent tracheostomy without the use of an internal cannula. To our knowledge, these are the first cases reported in the literature.
CASE PRESENTATION: Patient 1: A 56-year-old woman presented to our pulmonary clinic with stridor. A large polypoid mass originating from the vocal cords was discovered upon bronchoscopy. It was occluding the airway at 95%. The extended work up revealed a left lower lobe mass and no other sign of metastatic disease. The diagnosis was compatible with two primary cancers. She was directed to urgent laryngectomy with permanent tracheostomy. Because of her vocal cord tumor, a pulmonary function test was impossible to perform pre-operatively. During her follow up evaluation, she performed a flow volume curve and a cardiopulmonary exercise test. Her FEV1 was 66% (1.34 L) with a FEV1/FVC of 67%. She obtained a VO2/kg of 16.7. She underwent a lower lobectomy without any complication. Patient 2: A 55-year-old woman presented to the emergency department with a history of stridor. She was found to have a laryngeal cancer originating from the vocal cords. She underwent a laryngectomy with a permanent tracheostomy. She was also found to have a right upper lobe nodule proven to be an epidermoid lung cancer. In the absence of enlarged lymph nodes, she was considered for a surgical management of her lung tumor. She was evaluated at our clinic. She underwent a flow volume curve and a cardiopulmonary exercise test. The flow volume curve was difficult to get and she barely obtained a FEV1 of 0,97L (40%). She obtained a VO2/kg of 18.8. After a discussion over the risks and benefits, she accepted to go for a lobectomy the next week.
DISCUSSION: Flow-volume curve: We used a small mask over the permanent tracheostomy making sure there was a complete seal. No internal cannula was necessary. The test was stopped after three similar curves were obtained according to the ATS criteria. (The flow volume curve and pictures will be available at presentation) Cardiopulmonary exercise test : We used the same small mask connected to the usual sensor. A respiratory therapist was holding the mask in place over the permanent tracheostomy during the test. A complete seal was obtained. The test was done according to the ATS criteria. (Results and pictures will be available at presentation). After a review of the literature, no case was found of lung function assessment in patients with permanent tracheostomy. Those patients are often considered unfit for surgery or they undergo lobectomy without knowing their lung capacity. This method still need to be validated. It could be done by performing the test in patients with tracheostomy who had a prior pulmonary function test before their airway surgery.
CONCLUSIONS: It is feasible to assess lung function in patients with permanent tracheostomy. The method of measurement used in this case report has never been described in the literature. We did not have to use any invasive cannula and we obtained a reliable result allowing for a safe curative surgery of lung cancer in these patients.
Reference #1: ATS/ACCP statement on cardiopulmonary exercice testing. American thoracic society, American college of chest physicians. Am J Respir Crit Care Med. 2003 Jan 15;167(2):211-77.
DISCLOSURE: The following authors have nothing to disclose: Elaine Dumoulin, Brian Grondin-Beaudoin, Carl Labrosse, Yannick Poulin
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