Exercise tolerance

Exercise tolerance is the most useful overall assessment of general fitness as it is a summation of respiratory and cardiac factors, as well as taking into account de-conditioning and motivation. Even those who do not exercise well because of arthritis tend not to do well with surgery. If they have restricted their activities they will lack the cardio-respiratory conditioning required.

Always ask the patient himself about his exercise capacity. Do not rely on the letter from the physician who is buttering up the patient to get him accepted for surgery. While he may see it as an achievement to get one in under your radar, he does not have to face the patient and family when things are not going well.

WHO/ECOG performance status is NOT a good discriminator for fitness for surgery

WHO/ECOG performance status is useful in deciding who is fit for radical radiotherapy or for the quite toxic chemotherapy required for non-small cell lung cancer. Grade 3 and 4 are automatically unfit for the potentially curative therapies but may be suitable for palliative regimes. Grade 2 patients can often tolerate chemotherapy or radiotherapy but most will not tolerate surgery.

WHO/ECOG status is NOT a good discriminator for judging whether a patient is fit for the required surgery. Virtually no patients are Grade 0 by the time they have had a lifetime’s smoking, related co-morbidities and a delay in diagnosis of their cancer. Grade 1 covers nearly all surgical candidates from wedge resection to pneumonectomy. It also covers all patients from those bedbound for 49% of the day to those less fit than their surgeon!

Clinical

For most patients enough information is obtained from questioning to get a reasonable assessment of exercise tolerance. It is important to make sure that the patient refers to recent exercise, not what they used to do 6 months ago before they developed haemoptysis and lost three stone in weight (If they have lost more than a stone (14 pounds)  or 10% of body weight due to a lung cancer, they are unlikely to be fit for any radical treatment.

If someone is still working they are most liely to be fit. Do beware of those who work as ‘security men’ and sit in a hut all day!

The two questions I ask are:

1. 1.How far can you walk on the flat?
   

2. 2.How do you manage stairs or hills?
   

1. On the flat
   

2. It is useful to know how far, how fast, and how often they need to stop. Ask if they have a dog and what size dog - someone who walks a large dog a couple of times a day will be fitter than someone whose only exercise is to walk from the front door to the car.
   

3. Patients will often fudge the issue, trying hard for surgery which they do not appreciate can kill them. Often the relatives have a more honest assessment, but be aware that they have different motives than the patient, and your first duty is to the patient not the relatives. To get a more concrete assessment, ask specific questions like ‘did you walk from the car park or were you dropped at the front door?’ “Did you have to stop on the way?” “Can you walk the length of the ward?”
   

4. Stairs/hills
   

5. “What are you like on stairs?” often elicits the answer “there are no stairs in the house”. That in itself reflects their ability but press them further. “What about hills?” Ask where they live and are there hills about. Do they walk to the corner shop - in Belfast a standard distance of about 400 metres! Beware the patient who manages the couple of hundred metres  downhill to get his paper in the morning but has to get a lift back.
   

6. A lot of people can get up one flight of stairs slowly at the end of the day. If they need the bathroom downstairs because they can’t get up and down easily or they need to stop on the stairs it is not a good sign. Ask “would you be able to head back up the stairs if you forgot something?” Many will admit that they would have difficulty a second time.
   

3. Stair test
   

4. I find that, when all other tests are done, the most discriminating test is the stair climb. If you watch our physiotherapists you will notice they keep the patient talking as they walk. They also now use a portable pulse oximeter to quantify the desaturation that occurs.
   

5. A rough guide is that a stair climb of approximately 40 x 15cm steps is enough for lobectomy and 60 steps for pneumonectomy. I would suggest that a more representative test is that the ability to keep talking to 60 steps denotes fitness for pneumonectomy, and 40 steps while talking, fit for lobectomy. These figures have not been validated but Brunelli and colleagues have done a lot of work on this easily performed test.
   

6. Brunelli.pdf et al showed that inability to perform a 12m stair climb (80 standard 15cm steps) correlated with poor outcome after lung resection.
   

7. Brunelli A, Al Refai M, Monteverde M, Borri A, Salati M, Fianchini A. Stair climbing test predicts cardiopulmonary complications after lung resection. Chest. 2002 Apr;121(4):1106-10.
   

8. 
   

9. Alessandro Brunelli, Armando Sabbatini, Francesco Xiume', Alessandro Borri, Michele Salati, Rita Daniela Marasco, and Aroldo Fianchini. Inability to perform maximal stair climbing test before lung resection: a propensity score analysis on early outcome. Eur. J. Cardiothorac. Surg., Mar 2005; 27: 367 - 372.
   

Shuttle walk (6 minute walk)

1. Holden et al found that “A 6-min walk distance of greater than 1,000 feet and a stair climb of greater than 44 steps were predictive of successful surgical outcome. Preoperative exercise testing is a useful adjunct to traditional spirometric testing in evaluation of the high-risk surgical patients.” However other authors have not found the shuttle test  to be as useful as a stair climb. The shuttle test was designed to assess severity of COPD (and pulmonary hypertension and cardiac failure) and may be more suitable for LVRS than for lung resection. Generally when a physician quotes the shuttle walk in reference to fitness for lung resection, I automatically regard the patient as unfit!
   

2. Holden DA, Rice TW, Stelmach K, Meeker DP. Exercise testing, 6-min walk, and stair climb in the evaluation of patients at high risk for pulmonary resection. Chest. 1992 Dec;102(6):1774-9.
   

Cardiopulmonary exercise stress treadmill (CPEST) dose provide more information to assist the decision on fitness for surgery.