The use of CPET in the preoperative evaluation of patients considered for lung resection was proposed more than 30 years ago. Eugene and colleagues highlighted the ability of maximum oxygen consumption (VO2max) (expressed as absolute value in ml) in predicting the postoperative complications better than the pulmonary function test in a group of 19 patients [4]. Some years later Bolliger and colleagues corroborated these data publishing two different papers in larger cohorts of patients [5, 6]. They emphasized the role of VO2max expressed as percent of predicted value in defining the risk of lung resection. In particular, in a series of 125 surgical candidates for anatomic lung resection submitted to an exhaustive preoperative evaluation including CPET, they found that 90 % of the patients with a VO2max <60 % of predicted values experienced a postoperative complication.

During the last 10 years, many other papers confirmed the role of CPET as the gold standard in the functional preoperative evaluation of lung resection candidates. These papers, as shown in Fig. 8.1 were selected and analyzed for the present review, following the above mentioned criteria. Table 8.1summarizes the original articles studying the association between VO2max measured during CPET and the postoperative risk of morbidity and mortality following lung resection.

In 2005 Win and colleagues [7] published a prospective study on 101 patients evaluated by CPET and then submitted to curative lung surgery. They found that the VO2max expressed as percentage of predicted was the only parameter associated with surgical complications and death and concluded that a VO2max <50 % of predicted should identify a high risk category of patients.

In 2007, two different studies confirmed the role of VO2max, expressed as ml/kg/min, as a predictor of cardiopulmonary complications including death. Bayram and colleagues [8] in a cohort of 55 patients submitted to major lung resection found a correlation between poor surgical outcome and a VO2max <15 ml/kg/min. They registered no cardiopulmonary morbidity or mortality for patients with a VO2max >15 ml/kg/min. Similarly, Loewen and colleagues reported the data of the Protocol 9,238 of the Cancer and Leukemia Group B investigating the ability of VO2 measurement in predicting the surgical risk in lung resection [9]. Again, they found that the patients with a VO2max <15 ml/kg/min were exposed to a higher risk of postoperative respiratory failure and death.