SSD Laboratorio di Fisiopatologia Respiratoria e Centro del Sonno, AOU San Luigi Orbassano, Torino, Italy.
Eur J Cardiothorac Surg. 2010 Jul;38(1):14-9. doi: 10.1016/j.ejcts.2010.01.032. Epub 2010 Mar 30.
Surgical resection is the treatment of choice to cure patients with non-small-cell lung cancer (NSCLC); nevertheless, the assessment of the lower limit of surgical tolerance remains difficult. Ventilatory inefficiency (measured as the ventilation to CO(2) production ratio (V'(E)/V'(CO2) slope) is a survival predictor in pulmonary hypertension (PH) and chronic heart failure (CHF) and is considered a marker of PH in chronic obstructive pulmonary disease (COPD). The aim of this study was to investigate the role of V'(E)/V'(CO2) slope as preoperative mortality and morbidity predictor in COPD patients submitted to lung resection for NSCLC and considered operable according to current standards.
A retrospective analysis was performed in 145 consecutive COPD patients with lung cancer (128 males and 17 females), with a mean age of 64 years (range: 41-82 years) who were referred for preoperatory evaluation. Because of bronchial obstruction or reduced pulmonary diffusion capacity for carbon monoxide (D(L,CO)), all these patients were considered operable only after a cardiopulmonary exercise test showed a preserved cardiopulmonary function.
A total of 98 lobectomies, eight bilobectomies and 39 pneumonectomies (13 left and 26 right) were performed. Twenty-one patients (14.5%) suffered severe cardio-respiratory complications; 15/106 patients (14.2%) after lobectomy/bilobectomy and 6/39 (15.4%) after pneumonectomy. Five patients (3.4%) died within 30 days after surgery (3/106 after lobectomy/bilobectomy (2.8%) and 2/39 after pneumonectomy (5.1%)). Considering all functional parameters before surgery and the postoperative predicted values, a logistic regression analysis individuated the V'(E)/V'(CO2) slope as the only independent mortality predictor (odds ratio (OR): 1.24 z=2.77; p<0.007). The V'(O2 peak) was instead the best predictor for the occurrence of severe cardiopulmonary postoperative complications (OR: 0.05, z=-2.39, p<0.02).
In COPD patients, a high V'(E)/V'(CO2) slope before lung resection is an independent mortality predictor even in the presence of an acceptable cardiopulmonary performance. COPD patients with high V'(E)/V'(CO2) slope before surgery must be carefully screened to exclude pulmonary hypertension, especially before surgical procedures with large parenchymal exeresis.
手术切除是非小细胞肺癌（NSCLC）患者的治疗选择；然而，评估手术耐受的下限仍然很困难。通气效率低下（以通气到 CO（2）产生比（V'（E）/V'（CO2）斜率）衡量）是肺动脉高压（PH）和慢性心力衰竭（CHF）的生存预测指标，并被认为是慢性阻塞性肺疾病（COPD）中 PH 的标志物。本研究旨在探讨 V'（E）/V'（CO2）斜率作为 COPD 患者术前死亡率和发病率预测因子的作用，这些患者因 NSCLC 接受肺切除术，并且根据当前标准被认为是可手术的。
对 145 例连续 COPD 肺癌患者（128 名男性和 17 名女性）进行回顾性分析，平均年龄 64 岁（范围：41-82 岁），这些患者均因支气管阻塞或一氧化碳弥散能力降低（D（L，CO））而接受术前评估。由于所有这些患者的心肺运动试验显示心肺功能正常，仅在术后才可进行手术。
共进行了 98 例肺叶切除术、8 例双肺叶切除术和 39 例全肺切除术（13 例左全肺切除术和 26 例右全肺切除术）。21 例（14.5%）发生严重心肺并发症；15/106 例（14.2%）肺叶切除术/双肺叶切除术和 6/39 例（15.4%）全肺切除术。5 例（3.4%）术后 30 天内死亡（3/106 例肺叶切除术/双肺叶切除术（2.8%）和 2/39 例全肺切除术（5.1%））。考虑所有术前功能参数和术后预测值，逻辑回归分析确定 V'（E）/V'（CO2）斜率是唯一独立的死亡率预测因子（比值比（OR）：1.24，z=2.77；p<0.007）。V'（O2 峰值）是预测严重心肺术后并发症发生的最佳指标（OR：0.05，z=-2.39，p<0.02）。
在 COPD 患者中，即使心肺功能可接受，肺切除术前高 V'（E）/V'（CO2）斜率也是独立的死亡率预测因子。术前 V'（E）/V'（CO2）斜率较高的 COPD 患者必须仔细筛选，以排除肺动脉高压，尤其是在进行大面积肺切除术之前。
