Preoperative Pulmonary Rehabilitation Research Articles

New-onset atrial fibrillation following coronary bypass surgery predicts long-term mortality

duration of follow-up (SAS 9.3; SAS Institute, CaryNC) using repeat measure, with alpha set at 0.05. Results: 76 patients were included. 39 (51%) were female. Mean age was 60.1 7.9 yrs (range 48-75 yrs). Mean followupwas 92.2 8.4 months (range 24-120months). All patients underwent pre-operative pulmonary rehabilitation. 64 patients underwent thoracoscopic procedure (85% bilateral), 3 sternotomy and 9 hemisternotomy. Baseline mean forced expired volume in one second (FEV1) was 0.8L 0.2L (31.7% predicted 8.2%), total lung capacity (TLC) was 7.7L 1.4L, residual volume (RV) was 4.9L 1.1L, diffusing capacity of carbon monoxide (DLCO) was 38.9% 12.2% predicted and 6MWT distance was 364.9m 104.9m. 32 patients (42.1%) developed complications post-operatively. Thirty-day mortality was 2.6% (n=2). Mean FEV1 and DLCO rose significantly to 1.2 0.3L and 43.1 11.9% respectively at 3 months post-procedure (p<0.001), however these parameters returned to baseline by 4 years. TLC fell significantly to 6.8L 1.2L at three months (p<0.001) but returned to baseline at 5 years. RV was significantly improved until 8 yrs (at 4.2L 1.3L, p<0.005), and 6MWT improvement persisted up to 9 yrs (431.3m 85.8m; p<0.005). Discussion: In our cohort, LVRS was associated with longterm improvement in functional capacitywith lower operative mortality compared with historical studies. The sustained improvement in exercise capacity and sustained reduction inRVsuggests functional benefitmaybedue to improvements in lung mechanics and reduction in dynamic hyperinflation.

Cardiopulmonary exercise testing screening and pre-operative pulmonary rehabilitation reduce postoperative complications and improve fast-track recovery after lung cancer surgery: A study for 342 cases.

BackgroundAn evaluation of cardiopulmonary exercise testing (CPET) screening and pre-operative pulmonary rehabilitation in reducing postoperative complications and improving fast-track recovery in high-risk patients who undergo resection for lung cancer.MethodsOf 342 potential lung cancer cases, 142 high-risk patients were finally divided into two groups: group R (n = 71) underwent an intensive pre-operative pulmonary rehabilitation program (PRP), followed by lobectomy; group S (n = 71) underwent only lobectomy with conventional management. Postoperative complications, average days in hospital, postoperative days in hospital, and cost were analyzed.ResultsThe 142 high-risk patients were screened by smoking history and CPET. Sixty-eight patients had bronchial hyperresponsiveness (BHR) and 47 patients had peak expiratory flow <250 L/minute by CPET. The rate of postoperative total complications in group R (16.90%) was significantly lower than in group S (83.31%) (P = 0.00), as was the rate of postoperative pulmonary complications PPC: group R (12.81%) versus S (13.55%) (P = 0.009); the PPC in the left lung (17.9%) was higher than in the right lung (2.3%) (P = 0.00). The average days in hospital in group S was significantly higher than in group R (P = 0.03). There was no difference between groups in average hospital cost (P = 0.304).ConclusionPre-operative screening using CPET is conducive to identifying high-risk patients for lung resection. Pre-operative pulmonary rehabilitation is helpful to reduce postoperative complications and improve fast-track recovery.

Pulmonary physiotherapy effect on patients undergoing open cardiac surgery

Backgrounds and Objectives — Respiratory complications after open heart surgeries are common problems which can lead to death if not properly managed. The aim of this study was to evaluate the role of pulmonary rehabilitation before and after surgery for reducing the risk of pulmonary complications after surgery also correlations of the six-minute walk test and respiratory following open heart surgery. Material and Methods — In a randomized clinical trial, 60 patients undergoing heart surgery were divided into two groups randomly (groups A and B). In group A it was performed physiotherapy before and after chest physiotherapy surgery, but on patients in group B were done only chest physiotherapy after surgery. Effects of preoperative pulmonary rehabilitation were compared between two groups, using spirometry and six-minute walk test. Results — Thirty nine of males (65%) and 21 females (35%) with a mean age of 8.10±9.56 was been analyzed. The mean difference in predicted forced vital capacity (CI95%: 1.3 to 8.7) and predicted peak flow indices (CI95%: 1.9 to 9.4) of spirometery indicator was significant, also evaluation of six-minute walk test showed, mean difference in walking distant (CI95%: 8.8 to 21.0) and mean oxyhemoglobin saturation (CI95%: 0.59 to 1.67) in group A was more than group B. Inverse correlation of heart rate with forced vital capacity showed that patients with more restriction had more heart rate during the walking test. Conclusion — Pulmonary rehabilitation program before surgery is recommended to reduce complications of heart surgery. Further evaluations are necessary in relation to the sensitivity and specificity of six-minute walk test parameters alone in the evaluation of respiratory performance.

Influencing factor of postoperation fast-track recovery and in hospital cost after lobctomy for lung cancer

背景与目的肺癌手术方式变化对其住院费用和快速康复的影响不太明确，本研究旨在探讨肺癌患者外科治疗住院费用和术后快速康复的临床影响因素。方法收集2010年1月-2011年10月华西医院胸外科单个医疗组176例肺癌手术病例的临床资料进行分析。结果胸腔镜肺叶切除术组住院费用（video-assisted thoracic surgery, VATS）（47, 308.21 ¥）高于开胸手术组（45, 664.31 ¥）（P=0.007）；体重指数（body mass index, BMI）≥24 kg/m2患者的住院费用（51, 186.99 ¥）高于BMI＜24 kg/m2（41, 701.64 ¥）的肺癌患者（P=0.032）。住院日VATS手术组（5.70 d）短于开胸手术组（7.10 d）（P＜0.001）。结论手术方式和肺康复训练有助于肺癌手术患者术后的快速康复，但也增加了住院费用。

Preoperative pulmonary rehabilitation in patients with non-small cell lung cancer and chronic obstructive pulmonary disease

IntroductionThe aim of this study was to assess the effects of preoperative pulmonary rehabilitation (PPR) on preoperative clinical status changes in patients with chronic obstructive pulmonary disease (COPD) and non-small cell lung cancer (NSCLC), and net effects of PPR and cancer resection on residual pulmonary function and functional capacity.Material and methodsThis prospective single group study included 83 COPD patients (62 ±8 years, 85% males, FEV1 = 1844 ±618 ml, Tiffeneau index = 54 ±9%) with NSCLC, on 2–4-week PPR, before resection. Pulmonary function, and functional and symptom status were evaluated by spirometry, 6-minute walking distance (6MWD) and Borg scale, on admission, after PPR and after surgery.ResultsFollowing PPR significant improvement was registered in the majority of spirometry parameters (FEV1 by 374 ml, p < 0.001; VLC by 407 ml, p < 0.001; FEF50 by 3%, p = 0.003), 6MWD (for 56 m, p < 0.001) and dyspnoeal symptoms (by 1.0 Borg unit, p < 0.001). A positive correlation was identified between preoperative increments of FEV1 and 6MWD (r s = 0.503, p = 0.001). Negative correlations were found between basal FEV1 and its percentage increment (r s = –0.479, p = 0.001) and between basal 6MWD and its percentage change (r s = –0.603, p < 0.001) during PPR. Compared to basal values, after resection a significant reduction of most spirometry parameters and 6MWD were recorded, while Tiffeneau index, FEF25 and dyspnoea severity remained stable (p = NS).ConclusionsPreoperative pulmonary rehabilitation significantly enhances clinical status of COPD patients before NSCLC resection. Preoperative increase of exercise tolerance was the result of pulmonary function improvement during PPR. The beneficial effects of PPR were most emphasized in patients with initially the worst pulmonary function and the weakest functional capacity.

Does preoperative pulmonary rehabilitation effect outcomes in patients with low forced expiratory volume in 1 second undergoing lung cancer resection

Does preoperative pulmonary rehabilitation effect outcomes in patients with low forced expiratory volume in 1 second undergoing lung cancer resection

High-intensity training and cardiopulmonary exercise testing in patients with chronic obstructive pulmonary disease and non-small-cell lung cancer undergoing lobectomy

Peak VO2, as measure of physical performance is central to a correct preoperative evaluation in patients with both non-small-cell lung cancer (NSCLC) and chronic obstructive pulmonary disease (COPD) because it is closely related both to operability criteria and the rate of postoperative complications. Strategies to improve peak VO2, as a preoperative pulmonary rehabilitation programme (PRP), should be considered favourably in these patients. In order to clarify the role of pulmonary rehabilitation, we have evaluated the effects of 3-week preoperative high-intensity training on physical performance and respiratory function in a group of patients with both NSCLC and COPD who underwent lobectomy. We studied 40 patients with both NSCLC and COPD, age < 75 years, TNM stages I-II, who underwent lobectomy. Patients were randomly divided into two groups (R and S): Group R underwent an intensive preoperative PRP, while Group S underwent only lobectomy. We evaluated peak VO2 in all patients at Time 0 (T0), after PRP/before surgery in Group R/S (T1) and 60 days after surgery, respectively, in both groups (T2). There was no difference between groups in peak VO2 at T0, while a significant difference was observed both at T1 and T2. In Group R, peak VO2 improves significantly from T0 to T1: 14.9 ± 2.3-17.8 ± 2.1 ml/kg/min ± standard deviation (SD), P < 0.001 (64.5 ± 16.5-76.1 ± 14.9% predicted ± SD, P < 0.05) and deteriorates from T1 to T2: 17.8 ± 2.1-15.1 ± 2.4, P < 0.001 (76.1 ± 14.9-64.6 ± 15.5, P < 0.05), reverting to a similar value to that at T0, while in Group S peak VO2 did not change from T0 to T1 and significantly deteriorates from T1 to T2: 14.5 ± 1.2-11.4 ± 1.2 ml/kg/min ± SD, P < 0.00001 (60.6 ± 8.4-47.4 ± 6.9% predicted ± SD, P < 0.00001). PRP was a valid preoperative strategy to improve physical performance in patients with both NSCLC and COPD and this advantage was also maintained after surgery.

Preoperative rehabilitation in patients with thoracic tumors and borderline abnormal spirometry results: Preliminary report.

e18529 Background: The role of preoperative pulmonary rehabilitation is unclear. The aim of the study is short-term efficacy of pulmonary rehabilitation in patients with thoracic tumors and borderline abnormal spirometry results before thoracic surgery. Methods: We observed 12 patients (7 women, 5 men) in mean age of 64 (range 46-82) years. Clinical inclusion criteria were: diagnosis of thoracic tumors and reduced values of FEV1 and FVC predicting postoperative complications. Spirometry and 6MWT were chosen for evaluation of lung function and physical performance during rehabilitation. These tests were performed twice during screening phase to eliminate the factors of learning, and were repeated after first and second week of rehabilitation. Pulmonary rehabilitation included two weeks of training on the treadmill with individually selected speed, physiotherapy exercises and breathing training with using of Triflo. Results: The analyses of results of spirometry and 6MWT before and after 2 weeks of pulmonary rehabilitation indicated the significant differences in values of: 1)FEV1 (L): 1,38 ± 0,23 vs 1,61 ± 0,29 (p=0,01) 2) FEV1 (%N): 56,3 ± 13,9 vs 67,8 ± (p=0,007) 3) FVC (L): 2,24 ± 0,37 vs 2,74 ± 0,67 (p=0,03) 4) FVC (%N): 73,5 ± 15,7 vs 91,2 ± 12,7 (p=0,01) 5) 6MWT distance (m): 251 ± 79 vs 310 ± 74 (p=0,003). Although improvement after rehabilitation, 3 patients were disqualified from lobectomy due to unsatisfactory performance status. Another 3 patients experienced complications during perioperative period. Analysis of pulmonary rehabilitation efficacy showed that 6 patients with favourite outcome after thoracic surgery differed significantly in comparing to others. They achieved significantly higher difference in following parameters: 1) FEV1 (L): 0,4 vs 0,06 (p=0,02) 2) FVC (L): 0,91 vs 0,09 (p=0,02) 3) 6MWT distance (m): 93 vs 25 (p=0,016). Conclusions: A two-week pulmonary rehabilitation leads to significant improvement of lung function and physical performance in patients with thoracic tumors and borderline abnormal spirometry results. A clinically significant increase of absolute values of FEV1, FVC and 6MWT distance may indicate a favourite outcome after thoracic surgery.

Multidisciplinary Team-Based Approach for Comprehensive Preoperative Pulmonary Rehabilitation Including Intensive Nutritional Support for Lung Cancer Patients

BackgroundTo decrease the risk of postoperative complication, improving general and pulmonary conditioning preoperatively should be considered essential for patients scheduled to undergo lung surgery.ObjectiveThe aim of this study is to develop a short-term beneficial program of preoperative pulmonary rehabilitation for lung cancer patients.MethodsFrom June 2009, comprehensive preoperative pulmonary rehabilitation (CHPR) including intensive nutritional support was performed prospectively using a multidisciplinary team-based approach. Postoperative complication rate and the transitions of pulmonary function in CHPR were compared with historical data of conventional preoperative pulmonary rehabilitation (CVPR) conducted since June 2006. The study population was limited to patients who underwent standard lobectomy.ResultsPostoperative complication rate in the CVPR (n = 29) and CHPR (n = 21) were 48.3% and 28.6% (p = 0.2428), respectively. Those in patients with Charlson Comorbidity Index scores ≥2 were 68.8% (n = 16) and 27.3% (n = 11), respectively (p = 0.0341) and those in patients with preoperative risk score in Estimation of Physiologic Ability and Surgical Stress scores >0.3 were 57.9% (n = 19) and 21.4% (n = 14), respectively (p = 0.0362). Vital capacities of pre- and post intervention before surgery in the CHPR group were 2.63±0.65 L and 2.75±0.63 L (p = 0.0043), respectively; however, their transition in the CVPR group was not statistically significant (p = 0.6815). Forced expiratory volumes in one second of pre- and post intervention before surgery in the CHPR group were 1.73±0.46 L and 1.87±0.46 L (p = 0.0012), respectively; however, their transition in the CVPR group was not statistically significant (p = 0.6424).ConclusionsCHPR appeared to be a beneficial and effective short-term preoperative rehabilitation protocol, especially in patients with poor preoperative conditions.

Barriers to the Provision of Optimal Palliative Care in a Patient Awaiting Lung Transplantation

Idiopathic Pulmonary Fibrosis (IPF) is a chronic, progressive, fatal form of diffuse interstitial lung disease, which is associated with substantial mortality and morbidity. Lung transplantation has become one of the treatments of choice for patients with advanced IPF and has shown a 75% reduction in risk of death compared with patients who remained on the waiting list. Patients undergoing lung transplantation are required to participate in preoperative and postoperative pulmonary rehabilitation. This case report describes palliative and end of life care in a patient with end stage pulmonary fibrosis listed for lung transplantation and discusses the transition from curative restorative care and palliative care to end of life care. The goals of care of patients waiting for lung transplantation should be reviewed regularly and clarified as the clinical condition of the patient changes. End of life care should not only be considered in terminally ill patients or patients who do not fulfil the criteria for lung transplantation, but should also be raised with patients on the lung transplant waiting list. The goal of palliative care is to “enhance quality of life for patient and family, optimize function, and help with decision making” and thus it can be delivered concurrently with life prolonging care.

Comprehensive Preoperative Pulmonary Rehabilitation Including Intensive Nutrition Support for Lung Cancer Patients

Comprehensive Preoperative Pulmonary Rehabilitation Including Intensive Nutrition Support for Lung Cancer Patients

Preoperative Pulmonary Rehabilitation Versus Chest Physical Therapy in Patients Undergoing Lung Cancer Resection: A Pilot Randomized Controlled Trial

ObjectiveTo evaluate the effect of 4 weeks of pulmonary rehabilitation (PR) versus chest physical therapy (CPT) on the preoperative functional capacity and postoperative respiratory morbidity of patients undergoing lung cancer resection. DesignRandomized single-blinded study. SettingA teaching hospital. ParticipantsPatients undergoing lung cancer resection (N=24). InterventionsPatients were randomly assigned to receive PR (strength and endurance training) versus CPT (breathing exercises for lung expansion). Both groups received educational classes. Main Outcome MeasuresFunctional parameters assessed before and after 4 weeks of PR or CPT (phase 1), and pulmonary complications assessed after lung cancer resection (phase 2). ResultsTwelve patients were randomly assigned to the PR arm and 12 to the CPT arm. Three patients in the CPT arm were not submitted to lung resection because of inoperable cancer. During phase 1 evaluation, most functional parameters in the PR group improved from baseline to 1 month: forced vital capacity (FVC) (1.47L [1.27–2.33L] vs 1.71L [1.65–2.80L], respectively; P=.02); percentage of predicted FVC (FVC%; 62.5% [49%–71%] vs 76% [65%–79.7%], respectively; P<.05); 6-minute walk test (425.5±85.3m vs 475±86.5m, respectively; P<.05); maximal inspiratory pressure (90±45.9cmH2O vs 117.5±36.5cmH2O, respectively; P<.05); and maximal expiratory pressure (79.7±17.1cmH2O vs 92.9±21.4cmH2O, respectively; P<.05). During phase 2 evaluation, the PR group had a lower incidence of postoperative respiratory morbidity (P=.01), a shorter length of postoperative stay (12.2±3.6d vs 7.8±4.8d, respectively; P=.04), and required a chest tube for fewer days (7.4±2.6d vs 4.5±2.9d, respectively; P=.03) compared with the CPT arm. ConclusionsThese findings suggest that 4 weeks of PR before lung cancer resection improves preoperative functional capacity and decreases the postoperative respiratory morbidity.

Preoperative pulmonary rehabilitation in patients with lung cancer and chronic obstructive pulmonary disease

Impaired cardiopulmonary reserve is the main cause of inoperability in non-small-cell lung cancer (NSCLC). This study aims to evaluate the role of a preoperative pulmonary rehabilitation (PPR) programme in the improvement of functional parameters, which can enable an increase in the number of patients eligible for surgery. From January 2008 to June 2011, we observed a uniform group of 27 patients with NSCLC and chronic obstructive pulmonary disease (COPD). It showed: (i) a body mass index of 21.5 ± 2 kg/m2;; (ii) forced expiratory volume in 1 s (FEV(1)) of 1.14 ± 0.7 l; (iii) maximal peak of oxygen consumption (VO(2)max) of 12.9 ± 1.8 ml/kg/min; (iv) carbon monoxide diffusing capacity (DLCO) of 72 ± 3% predicted; (v) stage IB of lung cancer. All patients underwent a 4-week PPR programme, 6 days a week and were re-evaluated before inclusion for surgery. The rehabilitation programme was completed by all patients and extended by 2 weeks in nine patients, in order to obtain a further functional improvement. A statistically significant increase has been in the values of PaO(2) (60 ± 10 vs 82 ± 12 mmHg), of VO(2)max (12.9 ± 1.8 vs 19.2 ± 2.1 ml/kg/min, P = 0.00001) and of FEV(1) (1.14 ± 0.7 vs 1.65 ± 0.8 l, P = 0.02). All patients underwent a lobectomy, with a postoperative morbidity of 15%. A 4 to 6-week PPR programme prepares the NSCLC and COPD patients properly for the surgical approach, reducing the functional limitations of inoperability.

Clinical applications of lung function tests: A revisit

The development and clinical application of lung function tests have a long history, and the various components of lung function tests provide very important tools for the clinical evaluation of respiratory health and disease. Spirometry, measurement of the diffusion factor, bronchial provocation tests and forced oscillation techniques have found diverse clinical applications in the diagnosis and monitoring of respiratory diseases, such as chronic obstructive pulmonary disease, interstitial lung diseases and asthma. However, there are some practical issues to be resolved, including the establishment of reference values for individual test parameters and the roles of these tests in preoperative risk assessment and pulmonary rehabilitation. Novel measurements, including negative expiratory pressure, the fraction of exhaled nitric oxide and analysis of exhaled breath condensate, may provide new insights into physiological abnormalities or airway inflammation in respiratory diseases, but their clinical applications need to be further evaluated. The clinical application of lung function tests continues to face challenges, which may be overcome by further improvement of conventional techniques for lung function testing and further specification of new testing techniques.

Effects of training interventions prior to thoracic or abdominal surgery: a systematic review

Introduction: Developments in the areas of anaesthesia, analgesia, and pre- and postoperative care have decreased the risk of postoperative pulmonary complications (PPCs) after abdominal and thoracic surgery. Preoperative educational and training interventions to optimize patient status may further reduce these risks.Objectives: To evaluate the level of evidence for educational and training interventions before abdominal and thoracic surgery.Methods: A literature search for clinical studies evaluating effects of different educational and training interventions in adults before major, open abdominal or thoracic surgery was done in the following databases: MEDLINE/PubMed, CINAHL, PEDro, and Cochrane. Reference lists of articles that were identified were searched for additional relevant studies. All searches were limited to full-length articles written in English. Published trials evaluating preoperative treatment postoperatively were included. The randomized controlled trials were evaluated concerning their internal validity and the degree of evidence for different interventions was set.Results: Nineteen articles were included. The results indicated that there were: no evidence that preoperative information or general or deep breathing exercises before admission were effective in preventing PPC, a low degree of evidence that preoperative pulmonary rehabilitation was effective in preventing PPC, increasing peak expiratory flow, and shortening ventilation time and the hospital stay, a moderate degree of evidence that inspiratory muscle training (IMT) increased muscle endurance, and a low degree of evidence that IMT decreased PPC and shortened hospital stay.Conclusion: There is currently evidence that pulmonary rehabilitation and breathing exercises including IMT are effective in preventing PPC and should therefore be considered in clinical practice.

A survey of physiotherapeutic provision for patients undergoing thoracic surgery in the UK

ObjectivesEvaluation of physiotherapeutic provision for patients undergoing open thoracotomy and lung surgery in the UK. Timing of physiotherapy, modalities used and factors influencing practice were also investigated. DesignSurvey. SettingTertiary centres performing thoracic surgery. ParticipantsForty UK centres were identified, and senior physiotherapists were invited to participate. MethodsA postal survey was distributed to identified centres in August 2008, with further follow-up of non-responders. This was adapted from a similar study conducted in Australia and New Zealand. ResultsThirty-one responses were received (78%). Pre-operative physiotherapy was provided by 87% of respondents: 10% provided physiotherapy for all patients and 77% only provided physiotherapy for high-risk patients. Pre-operative pulmonary rehabilitation was reported in 13% of centres. Postoperative physiotherapeutic assessment was undertaken routinely by 97% of respondents: 81% provided physiotherapy to all patients, and 16% only provided physiotherapy when a specific problem was identified. The treatments given were relatively standardised. The provision of physiotherapy following hospital discharge was generally very sparse. ConclusionThis study provides a guide for physiotherapists working with patients undergoing thoracic surgery to use to compare their current practices. Postoperative physiotherapy is provided extensively to UK patients undergoing open thoracotomy. However, pre-operative provision is more variable and is mainly provided for high-risk patients. Despite the subsequent publication of pre- and postoperative pulmonary rehabilitation studies, UK physiotherapy practice remained similar to that reported in Australia and New Zealand. Further research in this field is necessary to investigate the role of pre-operative physiotherapy, the role of pre- and postoperative pulmonary rehabilitation, and the effectiveness of routine postoperative physiotherapy.

Perioperative Short-term Pulmonary Rehabilitation for Patients Undergoing Lung Volume Reduction Surgery

Although pulmonary rehabilitation is recommended for patients undergoing lung volume reduction surgery, the optimal method of pulmonary rehabilitation is unclear. The aim of this study was to determine the feasibility and safety of perioperative short-term pulmonary rehabilitation. We enrolled candidates for lung volume reduction surgery from 1999 to 2006 and retrospectively evaluated the feasibility and safety of perioperative short-term pulmonary rehabilitation for these patients. The program included the progressive exercise training on a treadmill for approximately 3 weeks. Two primary endpoints, feasibility and safety, were determined by the adherence rates of the program session and the adverse events. Pulmonary function and exercise capacity were evaluated at baseline and the termination of pre- and postoperative short-term pulmonary rehabilitation. Twenty-two patients were enrolled in this study. All patients completed our program without any serious adverse events. The mean values of adherence rates of the preoperative, postoperative, and overall period were, 89.1%, 95.1%, and 92.1%, respectively. All values of pulmonary function tests, except for forced vital capacity, significantly improved at the termination of postoperative short-term pulmonary rehabilitation in comparison to those at the termination of preoperative short-term pulmonary rehabilitation. The values of the 6-minute walk distance, total exercise time, and maximal workload on incremental exercise test were significantly improved by preoperative short-term pulmonary rehabilitation, and their values were maintained until the termination of postoperative short-term pulmonary rehabilitation. The results indicated that it is both feasible and safe to perform perioperative short-term pulmonary rehabilitation.

Preoperative pulmonary rehabilitation before lung cancer resection: Results from two randomized studies

Complete surgical resection is the most effective curative treatment for lung cancer. However, many patients with lung cancer also have severe COPD which increases their risk of postoperative complications and their likelihood of being considered “inoperable.” Preoperative pulmonary rehabilitation (PR) has been proposed as an intervention to decrease surgical morbidity but there is no established protocol and no randomized study has been published to date.We tested two preoperative PR interventions in patients undergoing lung cancer resection and with moderate-severe COPD in a randomized single blinded design. Outcomes were length of hospital stay and postoperative complications.The first study tested 4 weeks of guideline-based PR vs. usual care: that study proved to be very difficult to recruit as patients and providers were reluctant to delay surgery. Nine patients were randomized and no differences were found between arms.The second study tested ten preoperative PR sessions using a customized protocol with nonstandard components (exercise prescription based on self efficacy, inspiratory muscle training, and the practice of slow breathing) (n=10) vs. usual care (n=9). The PR arm had shorter length of hospital stay by 3 days (p=0.058), fewer prolonged chest tubes (11% vs. 63%, p=0.03) and fewer days needing a chest tube (8.8 vs. 4.3 days p=0.04) compared to the controlled arm.A ten-session preoperative PR intervention may improve post operative lung reexpansion evidenced by shorter chest tube times and decrease the length of hospital stay, a crude estimator of post operative morbidity and costs. Our results suggest the potential for short term preoperative pulmonary rehabilitation interventions in patients with moderate-severe COPD undergoing curative lung resection. 4 weeks of conventional preoperative PR seems non feasible.

The Role of Pulmonary Rehabilitation in the Lung Cancer Patient

Lung cancer is the most common deadly malignancy in the United States. It is estimated that 219,440 men and women in the United States will be diagnosed with lung cancer and 159,390 will die of lung cancer in 2009. The overall 5-year survival rate is 15.6%; however, survival rates are much higher (52.6%) for patients who are diagnosed when the cancer is confined to the primary site. Unfortunately, a minority of patients (15%) are diagnosed at this stage. Although the most effective treatment for lung cancer is surgical resection, many patients have significant underlying chronic lung disease as well as other comorbidities, which may increase perioperative risk and possibly exclude them from undergoing surgery. Preoperative assessment is essential for proper risk stratification, but there are important questions that remain to be answered as to (1) whether preoperative or postoperative pulmonary rehabilitation can result in less perioperative morbidity and mortality, (2) whether the institution of preoperative pulmonary rehabilitation can allow more patients to undergo potentially curative surgical resection, and (3) whether pulmonary rehabilitation can play a role in those patients not eligible for surgery.

Outcomes After Unilateral Lung Volume Reduction

For patients with end-stage emphysema undergoing lung volume reduction surgery (LVRS), we have preferred a bilateral (BLVRS) approach to achieve maximum benefit with a single procedure. A unilateral (ULVRS) approach has been used in certain patients in whom BLVRS is contraindicated. Between January 1993 and December 2006, 43 consecutive patients underwent ULVRS. The study excluded patients undergoing giant bullectomy. Relative contraindications for BLVRS were unilateral emphysema, 21; unilateral emphysema plus other factors, 2; and other factors alone, 10. Preoperative pulmonary rehabilitation was required. Postrehabilitation data were used as the baseline for analyses. Outcome measurements for ULVRS were compared with BLVRS results. After ULVRS, the mean increase in forced expiratory volume in 1 second (FEV(1)) from postrehabilitation values was 32% at 6 months (p <or= 0.001) and 28% at 3 years (p = 0.036). The FEV(1) was not significantly improved at 5 years. The mean reduction in residual volume after ULVRS was 23% at 6 months (p <or= 0.001) and 38% at 5 years (p = 0.001). Supplemental oxygen requirements declined initially postoperatively. One patient (2%) died in the hospital. The 90-day mortality was 0%. Kaplan-Meier survival after ULVRS was 97.7%, 80.9%, and 45.5%, at 1, 3, and 5 years. ULVRS produces improvements in pulmonary function, exercise capacity, and quality of life with an acceptable morbidity and mortality in patients for whom BLVRS is contraindicated, but the benefits are of lower magnitude than those achieved with BLVRS.