Original article
General thoracic
Cardiopulmonary Testing Before Lung Resection: What Are Thoracic Surgeons Doing?

Presented at the Fifty-fifth Annual Meeting of The Society of Thoracic Surgeons, San Diego, CA, Jan 26-29, 2019.
https://doi.org/10.1016/j.athoracsur.2019.04.057Get rights and content

Background

Cardiopulmonary assessment for lung resection is important for risk stratification, and the American College of Chest Physicians (ACCP) guidelines provide decision support. We ascertained the cardiopulmonary assessment practices of thoracic surgeons and determined whether they are guideline concordant.

Methods

An anonymous survey was emailed to 846 thoracic surgeons who participate in The Society of Thoracic Surgeons General Thoracic Surgery Database. We analyzed survey responses by practice type (general thoracic [GT] versus cardiothoracic [CT]) and years in practice (0-9, 10-19, and ≥20) with the use of contingency tables. We compared adherence of survey responses with the guidelines.

Results

The response rate was 24.0% (n = 203). Most surgeons (n = 121, 59.6%) cited a predicted postoperative forced expiratory volume in 1 second or diffusing capacity of lung for carbon monoxide threshold of 40% for further evaluation. Experienced surgeons (≥20 years) were more likely to have a threshold that varies by surgical approach (31.3% versus 23.5% with 10-19 years of experience and 15.9% for 0-9 years of experience, P = .007). Overall, 52.2% refer patients with cardiovascular risk factors to cardiology and 42.9% refer patients with abnormal stress testing. CT surgeons were more likely to refer all patients to cardiology than GT surgeons (17.6% versus 2.4%, P < .001). Only one respondent (0.5%) was 100% adherent to the ACCP guidelines, and 4.4% and 45.8% were 75% and 50% adherent, respectively.

Conclusions

Among thoracic surgeons, there is variation in preoperative cardiopulmonary assessment practices, with differences by practice type and years in practice, and marked discordance with the ACCP guidelines. Further study of guideline adherence linked to postoperative morbidity and mortality is warranted to determine whether adherence affects outcomes.

Section snippets

Methods

We developed an anonymous, online survey that used a Research Electronic Data Capture (Data Capture, Nashville, TN) application. The survey (Supplemental Material) queried practices of thoracic surgeons about cardiopulmonary assessment before elective lung resection. The survey was emailed to 846 surgeons in the United States who participate in The Society of Thoracic Surgeons (STS) General Thoracic Surgery Database. Survey questions were written to assess the cardiopulmonary testing practices

Demographic Characteristics

There were 203 respondents (24.0%). Most were men, aged 40 to 49 years, practiced at an academic center, and performed primarily GT surgical procedures (Table 1). Compared with nonrespondents, a higher proportion of respondents practiced exclusively GT surgery at an academic center, were women, and were younger.

Preoperative Pulmonary Assessment

When asked about assessment of pulmonary function before elective lung resection (excluding pneumonectomy), nearly all respondents always ordered preoperative spirometry (Table 2). Most

Comment

Our survey of thoracic surgeons’ preoperative evaluation strategies of thoracic surgeons revealed heterogeneity in practice patterns. Most surgeons agreed on the importance of preoperative spirometry and Dlco testing, although fewer agreed on calculating ppo values. The interpretation of PFT results and the subsequent testing varied among surgeons. According to the ACCP guidelines, all patients should undergo spirometry and Dlco testing with calculation of ppoFEV1 and ppoDlco (Grade 1B

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