What are the perioperative care recommendations for a patient with squamous lung cancer (SQC) undergoing surgery, considering potential comorbid conditions such as chronic obstructive pulmonary disease (COPD) or asthma?

Perioperative Care for Squamous Lung Cancer Surgery

All patients with squamous lung cancer undergoing surgical resection require systematic cardiopulmonary risk stratification using predicted postoperative (PPO) FEV1 and DLCO values, with exercise testing reserved for those with PPO values <60%, and mandatory smoking cessation plus pulmonary rehabilitation for high-risk patients. 1

Preoperative Pulmonary Function Assessment Algorithm

Initial Spirometry and Diffusion Capacity

• Measure baseline FEV1 and DLCO in all surgical candidates to establish risk stratification 1, 2, 3
• Calculate predicted postoperative (PPO) values using segmental counting method for lobectomy or quantitative perfusion scan for pneumonectomy 2
• Patients with PPO FEV1 >60% AND PPO DLCO >60% are low-risk and can proceed to surgery without further pulmonary testing 1, 2, 3

Moderate Risk Stratification (PPO 30-60%)

• Patients with PPO FEV1 OR PPO DLCO between 30-60% require exercise testing 1, 2
• Begin with shuttle walk test as initial screening: <25 shuttles (250m) or oxygen desaturation >4% indicates high surgical risk 1, 2
• If shuttle walk is inadequate, proceed to formal cardiopulmonary exercise testing (CPET) 1, 2

High Risk Stratification (PPO <30%)

• Patients with PPO FEV1 <30% OR PPO DLCO <30% require mandatory CPET 1, 2
• CPET risk stratification by VO2 peak: >20 mL/kg/min (low risk), 10-20 mL/kg/min (moderate risk), <10 mL/kg/min or <35% predicted (high risk) 2
• VO2 max <15 mL/kg/min indicates prohibitive surgical risk; consider non-surgical options 1, 3

Critical caveat: Patients undergoing neoadjuvant chemotherapy require repeat pulmonary function testing with DLCO measurement after completion of therapy, as chemotherapy significantly reduces DLCO and increases respiratory mortality risk 1, 4

Cardiac Risk Assessment

Mandatory Initial Evaluation

• Obtain preoperative ECG on all patients undergoing lung resection 1, 2
• Document active cardiac conditions: unstable angina, recent MI, decompensated heart failure, significant arrhythmias, severe valvular disease 5
• Patients with MI within 6 weeks should not undergo elective surgery; those with MI within 6 months require cardiology consultation 1, 2

Risk Stratification Using Recalibrated Thoracic RCRI

• Apply the recalibrated thoracic revised cardiac risk index (RCRI) for cardiac risk assessment 1
• Major risk factors requiring formal cardiology evaluation: unstable coronary syndromes, decompensated heart failure, severe valvular disease, significant arrhythmias 1
• Intermediate risk factors: history of ischemic heart disease, compensated heart failure, diabetes mellitus, renal insufficiency, cerebrovascular disease 1
• Patients with reasonable functional capacity (able to climb one flight of stairs comfortably) and only intermediate risk factors do not require further cardiac testing 1

Additional Cardiac Testing

• All patients with audible cardiac murmur require echocardiography 1
• Patients with poor functional capacity and intermediate risk factors need ECG-monitored exercise test and echocardiography with cardiology consultation 1
• Patients with significant coronary lesions on angiography should be considered for revascularization before lung resection 1, 2

Special Considerations for COPD/Emphysema Patients

Lung Volume Reduction Surgery Candidates

• In patients with upper lobe emphysema who are LVRS candidates, combined LVRS and lung cancer resection is recommended 1
• This approach may provide a lung volume reduction effect that improves postoperative function 1
• Evaluate emphysema anatomy, tumor location, and LVRS candidacy using CT imaging for hyperexpansion 1

Restrictive Lung Disease

• Patients with interstitial lung disease (ILD) or idiopathic pulmonary fibrosis (IPF) face higher associated risks even with adequate spirometry 1
• Consider non-surgical modalities (SBRT, radiofrequency ablation) for severely impaired patients with FEV1 <30% 1

Mandatory Perioperative Interventions

Smoking Cessation

• All actively smoking patients require tobacco dependence treatment before surgery 1
• Smoking cessation provides both short-term perioperative and long-term survival benefits 1

Pulmonary Rehabilitation

• Patients deemed high-risk (PPO FEV1 or PPO DLCO <60% AND VO2 max <10 mL/kg/min or <35%) require preoperative or postoperative pulmonary rehabilitation 1
• This intervention reduces perioperative complications and improves functional recovery 1

Nutritional Assessment

• Measure body mass index and serum albumin as routine preoperative assessment 1, 5
• Preoperative weight loss ≥10% indicates high risk for advanced disease and postoperative complications 1, 5
• Low nutritional values convey increased risk requiring optimization before surgery 1

Performance Status and Comorbidity Optimization

• Patients with WHO performance status ≥2 require particularly careful staging assessment and comorbidity evaluation 1, 5
• All comorbidities should be evaluated and optimized before surgery 1
• Attempting to optimize patient condition prior to surgery is beneficial, especially for those with poor preoperative condition 1

Cerebrovascular Disease Assessment

• All patients with history of stroke, transient ischemic attacks, or carotid bruits require carotid Doppler studies 1
• Patients with significant stenoses (>70%) require assessment by vascular surgeon or stroke medicine consultant preoperatively 1
• Previous stroke is a minor risk factor for perioperative cardiac complications but increases overall risk 1

Multidisciplinary Decision-Making

• Patients anatomically suitable for resection but with multiple adverse medical factors require formal multidisciplinary discussion between chest physician, surgeon, and oncologist 1
• This is particularly critical for patients with combined cardiac and pulmonary risk factors 1
• High-risk patients (mortality >10% for major resections) should be counseled about alternative surgical options or non-surgical options 2

Common pitfall: Do not dismiss surgery based solely on age; fully evaluate cardiopulmonary fitness considering tumor stage, life expectancy, performance status, and comorbidities 2, 5. However, elderly patients (>70 years) with stage III disease face compounded risk from both disease stage and age-related comorbidities requiring careful assessment 6.