Older PO, Levett DZH

Ann Am Thorac Soc. 2017 Jul;14(Supplement_1):S74-S83. doi:
10.1513/AnnalsATS.201610-780FR

The surgical patient population is increasingly elderly and comorbid and poses
challenges to perioperative physicians. Accurate preoperative risk stratification
is important to direct perioperative care. Reduced aerobic fitness is associated
with increased postoperative morbidity and mortality. Cardiopulmonary exercise
testing is an integrated and dynamic test that gives an objective measure of
aerobic fitness or functional capacity and identifies the cause of exercise
intolerance. Cardiopulmonary exercise testing provides an individualized estimate
of patient risk that can be used to predict postoperative morbidity and
mortality. This technology can therefore be used to inform collaborative
decision-making and patient consent, to triage the patient to an appropriate
perioperative care environment, to diagnose unexpected comorbidity, to optimize
medical comorbidities preoperatively, and to direct individualized preoperative
exercise programs. Functional capacity, evaluated as the anaerobic threshold and
peak oxygen uptake ([Formula: see text]o2peak) predicts postoperative morbidity
and mortality in the majority of surgical cohort studies. The ventilatory
equivalents for carbon dioxide (an index of gas exchange efficiency), is
predictive of surgical outcome in some cohorts. Prospective cohort studies are
needed to improve the precision of risk estimates for different patient groups
and to clarify the best combination of variables to predict outcome. Early data
suggest that preoperative exercise training improves fitness, reduces the
debilitating effects of neoadjuvant chemotherapy, and may improve clinical
outcomes. Further research is required to identify the most effective type of
training and the minimum duration required for a positive effect.