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Alessandro Brunelli, MD, FCCP; Anthony W. Kim, MD, FCCP; Kenneth I. Berger, MD, FCCP; Doreen J. Addrizzo-Harris, MD, FCCP
Author and Funding Information

From the Department of Thoracic Surgery (Dr Brunelli), St. James’s University Hospital; Section of Thoracic Surgery (Dr Kim), Yale University School of Medicine; and the Department of Medicine (Dr Berger) and the Division of Pulmonary, Critical Care Medicine and Sleep Medicine (Dr Addrizzo-Harris), New York University School of Medicine.

Correspondence to: Doreen J. Addrizzo-Harris, MD, FCCP, Tisch Hospital, Division of Pulmonary, Critical Care Medicine and Sleep Medicine, New York University School of Medicine, 550 First Ave, New York, NY 10016; e-mail: Doreen.addrizzo@nyumc.org


Financial/nonfinancial disclosures: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2014;145(4):928. doi:10.1378/chest.14-0178
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To the Editor:

We thank Dr Papageorgiou and colleagues for their interest in our work. Predicted postoperative (PPO) pulmonary function values have a central role in the new American College of Chest Physicians functional algorithm.1 It is critical to prescribe additional testing such as exercise testing to further evaluate the fitness of the lung resection candidate.

We totally agree with the authors that quantitative chest CT scan is a valuable tool in estimating the functional loss after lung resection and that, in some reports but not in all, it has shown a more precise correlation with the actual residual function after lobectomy, measured months after operation. The segmental counting method suggested in the guidelines represents a generic suggestion. If a given center possibly can use a more sophisticated methodology to predict PPO values in all patients with lung cancer, we welcome this approach.

Advantages of the counting method include the ability to rapidly calculate PPO values in the outpatient clinic when the patient is first seen and interviewed. It must take into account only the functioning segments that participate in ventilation according to the available chest CT scan and bronchoscopy findings. Although quantitative CT scan may be, in some cases, more precise, the new American College of Chest Physicians functional algorithm is based on evidence-reporting values and thresholds derived from studies that, for the most part, used the segmental counting method.

We want to emphasize that in all cases, the PPO value cutoffs reflect only a generic classification of risk. In no case should the patient be excluded from surgery merely on the grounds of split lung function alone.

Another important consideration is that the correlation between predicted and observed pulmonary function is usually calculated by taking into account the definitive residual function at 3 to 6 months after surgical resection. This correlation may not apply in the immediate postoperative period when the measured functional loss is much larger than predicted.2 The immediate loss has been shown to be associated more with complications than the PPO values.3 Instruments or equations to predict the immediate functional loss would be most needed to refine risk stratification.4 Unfortunately, there is limited scientific evidence on this subject. For this reason, we preferred to rely on the existing large body of scientific evidence to propose the cutoffs shown in the algorithm.

References

Brunelli A, Kim AW, Berger KI, Addrizzo-Harris DJ. Physiologic evaluation of the patient with lung cancer being considered for resectional surgery: diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2013;143(5_suppl):e166S-e190S. [CrossRef]
 
Varela G, Brunelli A, Rocco G, et al. Measured FEV1 in the first postoperative day, and not ppoFEV1, is the best predictor of cardio-respiratory morbidity after lung resection. Eur J Cardiothorac Surg. 2007;31(3):518-521. [CrossRef]
 
Varela G, Brunelli A, Rocco G, et al. Predicted versus observed FEV1 in the immediate postoperative period after pulmonary lobectomy. Eur J Cardiothorac Surg. 2006;30(4):644-648. [CrossRef]
 
Brunelli A, Varela G, Rocco G, et al. A model to predict the immediate postoperative FEV1 following major lung resections. Eur J Cardiothorac Surg. 2007;32(5):783-786. [CrossRef]
 

Figures

Tables

References

Brunelli A, Kim AW, Berger KI, Addrizzo-Harris DJ. Physiologic evaluation of the patient with lung cancer being considered for resectional surgery: diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2013;143(5_suppl):e166S-e190S. [CrossRef]
 
Varela G, Brunelli A, Rocco G, et al. Measured FEV1 in the first postoperative day, and not ppoFEV1, is the best predictor of cardio-respiratory morbidity after lung resection. Eur J Cardiothorac Surg. 2007;31(3):518-521. [CrossRef]
 
Varela G, Brunelli A, Rocco G, et al. Predicted versus observed FEV1 in the immediate postoperative period after pulmonary lobectomy. Eur J Cardiothorac Surg. 2006;30(4):644-648. [CrossRef]
 
Brunelli A, Varela G, Rocco G, et al. A model to predict the immediate postoperative FEV1 following major lung resections. Eur J Cardiothorac Surg. 2007;32(5):783-786. [CrossRef]
 
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