Speaker's Highlight

• Don Sin University of British Columbia, St. Paul Hospital (Canada)
  Kenneth R. Chapman Toronto General Hospital Research Institute (Canada)
• Parameswaran Nair McMaster University (Canada)
  Carolyn Calfee UCSF (U.S.A.)
• Gregory P. Downey University of Colorado School of Medicine (U.S.A.)
  David A. Schwartz University of Colorado School of Medicine (U.S.A.)
• Neil Schluger Tuberculosis Control Branch, California Department of Public Health (U.S.A.)
  Nick Kim Critical Care & Sleep Medicine, University of California San Diego (U.S.A.)
• Nicola Hananiah Baylor College of Medicine (U.S.A.)
  Jae-Joon Yim Seoul National University College of Medicine (Republic of Korea)
• Koichiro Asano Tokai University School of Medicine (Japan)
  Diahn-Warng Perng Taipei Veterans General Hospital (Taiwan)
• Konstantinos Kostikas University of Ioannina (Greece)
  Karin Klooster University Medical Center Groningen (Kingdom of the Netherlands)

• Cardiopulmonary exercise testing before lung cancer surgery

  For people being assessed for lung cancer surgery, routine lung function tests may not fully show how the heart, lungs and muscles will respond to physical stress. Cardiopulmonary exercise testing (CPET) fills that gap by measuring the integrated response to exercise. It can help the clinical team judge whether a patient is likely to tolerate a lobectomy, pneumonectomy or another major thoracic procedure. Learn more about リウマチ患者の膵臓病変と消化器症状への対応.

  The test is especially useful when spirometry, diffusing capacity, imaging and medical history provide mixed signals. In Australia, decisions may involve respiratory physicians, thoracic surgeons, anaesthetists, physiotherapists and cancer multidisciplinary teams working across public hospitals, private facilities and regional referral networks.

  Why exercise capacity matters before surgery

  Removing part of a lung reduces the available respiratory reserve. The body must compensate by increasing breathing effort, cardiac output and oxygen extraction. A patient who appears reasonably well at rest may develop severe breathlessness or limited oxygen delivery during activity after surgery.

  CPET measures this whole-body response rather than examining the lungs in isolation. It can reveal reduced cardiovascular fitness, ventilatory limitation, impaired oxygen transfer or poor muscle conditioning. These findings support a more individualised risk assessment than age or resting spirometry alone.

  What the test measures

  During CPET, the patient exercises on a stationary bicycle, usually while wearing a mask connected to a metabolic analyser. The equipment records oxygen uptake, carbon dioxide production, ventilation, heart rate, blood pressure and, when appropriate, oxygen saturation. The workload rises gradually until symptoms or physiological limits require the test to stop.

  Key results include peak oxygen consumption (VO₂peak), the anaerobic threshold, the ventilatory equivalent for carbon dioxide and the oxygen pulse. A low VO₂peak can indicate limited exercise reserve, while an abnormal VE/VCO₂ response may suggest inefficient ventilation or pulmonary vascular disease. Results must be interpreted with symptoms, effort and comorbidities in mind.

  Who may benefit from CPET

  CPET is most valuable when a person is being considered for extensive resection or has borderline pulmonary function. It may also help when there is chronic obstructive pulmonary disease, interstitial lung disease, pulmonary hypertension, heart disease, frailty or an unclear cause of breathlessness.

  A patient’s overall condition matters as much as the tumour. Weight loss, anaemia, smoking-related deconditioning and reduced mobility can lower exercise performance. A careful review should include symptoms outside the respiratory system; discussion of pancreatic and digestive symptoms in rheumatic disease, for example, illustrates why broader systemic features should not be overlooked during medical assessment.

  How assessment is organised

  Before CPET, clinicians usually review chest imaging, spirometry, lung volumes and diffusing capacity. Predicted postoperative lung function may be estimated using the location and function of the segments planned for removal. A cardiac assessment may be added when there are symptoms, risk factors or an abnormal electrocardiogram.

  The test generally takes around 30 to 60 minutes, including preparation and recovery. Patients should wear comfortable clothing and suitable shoes, avoid a heavy meal shortly beforehand, and bring details of regular medicines. In Australia, testing may be arranged through a tertiary respiratory laboratory, cardiology service or hospital preoperative clinic, depending on local resources.

  Understanding risk without relying on one number

  There is no single CPET result that determines whether surgery is safe. VO₂peak and anaerobic threshold are often used as risk markers, but thresholds vary between guidelines, procedures and patient groups. A result must be considered alongside predicted postoperative FEV₁ and DLCO, exercise oximetry, frailty, renal function and the extent of resection.

  A poor result may lead to additional optimisation rather than automatic exclusion from surgery. Pulmonary rehabilitation, smoking cessation, nutritional support, inhaler review and treatment of anaemia can improve readiness. In selected cases, the team may consider a smaller resection, stereotactic radiotherapy or systemic treatment instead of an operation with excessive physiological risk.

  Australian considerations in practice

  Australia’s geography can affect access to specialist exercise testing. A patient in regional New South Wales, Queensland or Western Australia may need referral to Sydney, Brisbane, Perth or another major centre, with travel and appointment delays affecting the pathway. Telehealth can support consultation, although the exercise test itself requires an appropriately equipped laboratory.

  Local health-system arrangements also influence timing and cost. Public thoracic surgery services may coordinate CPET through a hospital network, while private patients may use cardiopulmonary laboratories linked to a private hospital. Smoking cessation support, pulmonary rehabilitation and follow-up availability differ between metropolitan and rural areas, so these practical factors should be discussed early.

  Turning results into a surgical plan

  CPET findings can guide conversations about postoperative monitoring, high-dependency care and rehabilitation. Someone with moderate impairment may still proceed with surgery if the expected cancer benefit is substantial and the team can reduce risk through prehabilitation and careful anaesthesia planning. Exercise results can also establish a baseline for recovery.

  The most useful process is a shared decision involving the patient and the multidisciplinary team. The discussion should cover the likely cancer outcome, surgical alternatives, possible complications, recovery demands and the patient’s personal priorities. CPET informs that conversation; it does not replace clinical judgement or the patient’s informed choice.

  For people facing lung cancer surgery, the central lesson is that resting tests show only part of physiological reserve. Cardiopulmonary exercise testing reveals how the heart, lungs and muscles work together under stress, helping Australian clinicians match the operation and preparation plan to the individual. The result to remember is simple: a thoughtful exercise assessment can turn an uncertain surgical risk into a clearer, safer plan.

  Richard Russell Nuffield Department of Clinical Medicine, University of Oxford (United Kingdom)
• Mona Bafadhel King’s College London (United Kingdom)
  David Jackson Guy’s and St Thomas’ Hospital, King’s College London (United Kingdom)
• James Chalmers University of Dundee (United Kingdom)
  David Price University of Aberdeen (United Kingdom)