Reduction Of Postoperative Pulmonary Complications Research Articles

Effect of individualized intraoperative lung recruitment maneuver on postoperative pulmonary complications in patients undergoing upper abdominal surgeries under general anesthesia

ABSTRACT Background The concept of lung protective ventilation (LPV) during general anesthesia (GA) aims at minimizing lung injury and postoperative pulmonary complications (POPCs). Recruitment maneuver (RM) as a part of LPV may improve lung mechanics and oxygenation, but despite extensive research, definitive guidelines for the applications of intraoperative RMs have not been established yet. Methods This study was a prospective, single-blinded, randomized clinical trial. Sixty-six subjects undergoing non-laparoscopic upper abdominal surgeries under GA were randomly assigned into two equal groups. Control group (C) received tidal volume of 8 ml/kg predicted body weight (PBW) and positive end expiratory pressure (PEEP) of 5 cmH2O without RM. Recruitment group (R) received tidal volume of 8 ml/kg PBW with stepwise RMs and individualized PEEP titration after each RM. Compliance, plateau pressure, driving pressure, SpO2 and hemodynamics were monitored at each step of RM. POPCs, length of hospital stay and mortality were recorded postoperatively. Results There was a significant reduction in POPCs in (R) group than in (C) group (P = 0.03). Also, there was a significant increase in compliance before extubation in (R) group (P = 0.001). However, no significant difference was noted between both groups as regards mortality rate and length of hospital stay. Conclusion Individualized stepwise lung RM significantly decreases the incidence of POPCs when added to LPV in patients undergoing non-laparoscopic upper abdominal surgeries under GA.

Sugammadex Is Associated With Reduced Pulmonary Complications in Patients With Respiratory Dysfunction

IntroductionUse of sugammadex is associated with fewer postoperative pulmonary complications (PPCs). This study investigated the relationship between sugammadex and PPCs in specific patients with respiratory dysfunction. Materials and methodsWe reviewed the electronic medical and anesthesia records of patients with respiratory dysfunction who underwent laparoscopic gastric or intestinal surgery at a single center between May 1, 2018 and December 31, 2019. The patients were divided into the sugammadex group and the nonsugammadex group, based on whether they received sugammadex or neostigmine. Binary logistic regression analyses were used to characterize the differences in incidence of PPC. ResultsA total of 112 patients were included, of which 46 patients (41.1%) received sugammadex. In the logistic regression analysis, the incidences of PPC were fewer in the sugammadex group. Postoperative fever (odds ratio [OR] 0.330; 95% confidence interval [CI] 0.137-0.793, P = 0.0213), postoperative intensive care unit admission (OR 0.204; 95% CI 0.065-0.644, P = 0.007), cough (OR 0.143; 95% CI 0.061- 0.333, P < 0.001), pleural effusion (all) (OR: 0.280; 95% CI 0.104- 0.759, P = 0.012), pleural effusion (massive) (OR: 0.142; 95% CI 0.031- 0.653, P = 0.012), and difficulty in breathing (OR: 0.111; 95% CI 0.014-0.849, P = 0.039) showed significant differences between the two groups. ConclusionsSugammadex is associated with a reduction in PPC in patients with respiratory dysfunction.

Effect of driving pressure on early postoperative lung gas distribution in supratentorial craniotomy: a randomized controlled trial

BackgroundNeurosurgical patients represent a high-risk population for postoperative pulmonary complications (PPCs). A lower intraoperative driving pressure (DP) is related to a reduction in postoperative pulmonary complications. We hypothesized that driving pressure-guided ventilation during supratentorial craniotomy might lead to a more homogeneous gas distribution in the lung postoperatively.MethodsThis was a randomized trial conducted between June 2020 and July 2021 at Beijing Tiantan Hospital. Fifty-three patients undergoing supratentorial craniotomy were randomly divided into the titration group or control group at a ratio of 1 to 1. The control group received 5 cmH2O PEEP, and the titration group received individualized PEEP targeting the lowest DP. The primary outcome was the global inhomogeneity index (GI) immediately after extubation obtained by electrical impedance tomography (EIT). The secondary outcomes were lung ultrasonography scores (LUSs), respiratory system compliance, the ratio of the partial pressure of arterial oxygen to the fraction of inspired oxygen (PaO2/FiO2) and PPCs within 3 days postoperatively.ResultsFifty-one patients were included in the analysis. The median (IQR [range]) DP in the titration group versus the control group was 10 (9–12 [7–13]) cmH2O vs. 11 (10–12 [7–13]) cmH2O, respectively (P = 0.040). The GI tract did not differ between groups immediately after extubation (P = 0.080). The LUSS was significantly lower in the titration group than in the control group immediately after tracheal extubation (1 [0–3] vs. 3 [1–6], P = 0.045). The compliance in the titration group was higher than that in the control group at 1 h after intubation (48 [42–54] vs. 41 [37–46] ml·cmH2O-1, P = 0.011) and at the end of surgery (46 [42–51] vs. 41 [37–44] ml·cmH2O-1, P = 0.029). The PaO2/FiO2 ratio was not significantly different between groups in terms of the ventilation protocol (P = 0.117). At the 3-day follow-up, no postoperative pulmonary complications occurred in either group.ConclusionsDriving pressure-guided ventilation during supratentorial craniotomy did not contribute to postoperative homogeneous aeration, but it may lead to improved respiratory compliance and lower lung ultrasonography scores.Clinical trial registrationClinicalTrials.gov NCT04421976.

Perioperative Pulmonary Support of the Elderly.

Purpose of ReviewWith the projected increase in the geriatric patient population, it is of the utmost importance to understand and optimize conditions in the perioperative period to ensure the best surgical outcome. Age-associated changes in respiratory physiology affect the surgical management of geriatric patients. This review focuses on perioperative pulmonary management of elderly individuals.Recent FindingsThe physiological changes associated with aging include both physical and biochemical alterations that are detrimental to pulmonary function. There is an increased prevalence of chronic lung disease such as COPD and interstitial lung disease which can predispose patients to postoperative pulmonary complications. Additionally, elderly patients, especially those with chronic lung disease, are at risk for frailty. Screening tools have been developed to evaluate risk and aid in the judicious selection of patients for surgical procedures. The concept of “prehabilitation” has been developed to best prepare patients for surgery and may be more influential in the reduction of postoperative pulmonary complications than postoperative rehabilitation. Understanding the age-associated changes in metabolism of drugs has led to dose adjustments in the intraoperative and postoperative periods, reducing respiratory depression and lung protective ventilation and minimally invasive procedures have yielded reductions in postoperative pulmonary complications.SummaryThe perioperative management of the geriatric population can be divided into three key areas: preoperative risk mitigation, intraoperative considerations, and postoperative management. Preoperative considerations include patient selection and thorough history and physical, along with smoking cessation and prehabilitation in a subset of patients. Operative aspects include careful selection of anesthetic agents, lung protective ventilation, and choice of surgical procedure. Postoperative management should focus on selective use of agents that may contribute to respiratory depression and encouragement of rehabilitation.

Ultrasound Guided Thoracic Paravertebral Block as an Analgesic Technique for Tracheoesophageal Fistula repair : A Case Report

Ultrasound has now become an eye of anaesthesiologist and has encouraged for its pervasive use. Its considerable use in the perioperative period for various invasive purposes has added an extra caution to prevent unforeseen complications over blind blocks. The ultrasound-guided thoracic paravertebral block provides excellent perioperative analgesia following thoracic surgery. It can be given as a single shot or a continuous infusion technique placing a catheter. Here the local anesthetic agent is deposited in the paravertebral space from where the spinal nerve emerges which are devoid of coverings and are sensitive to local anesthetics. Even a single-shot block provides analgesia of 4-6 dermatomal levels. The use of local anesthetics using ultrasound not only adds safety measures to minimize procedural complications but also reduces the perioperative requirement of opioids. It also helps in the reduction of postoperative pulmonary complications and early extubation following thoracic surgery. We report a case series where single-shot ultrasound-guided unilateral paravertebral blocks were used as an analgesic technique for the repair of tracheoesophageal fistula in neonates. After delivering anesthesia and confirming the correct placement of the endotracheal tube the neonate was kept on the left lateral position to undergo right thoracotomy and repair of fistula. Scanning at T4 level with a linear probe was done to identify the transverse process, pleura, costotransverse ligament, intercostal muscle, and the paravertebral space where the local anesthetic agent was deposited under aseptic precautions. Tenting of pleura was the endpoint for the completion of the block. The extensive use of various regional anesthetic technique has significantly improved the postoperative outcome of the patients along with adequate perioperative pain management.

Universal quantitative neuromuscular blockade monitoring at an academic medical center—A multimodal analysis of the potential impact on clinical outcomes and total cost of care

BackgroundQuantitative train-of-four monitoring is not currently the standard of care when using neuromuscular blockade, although it has the potential to eliminate the complications of residual neuromuscular blockade. There are major costs associated with the complications of residual neuromuscular blockade as well as the purchase of quantitative train-of-four monitors. The aim of this study was to determine the cost effectiveness of universal quantitative train-of-four ratio monitoring as it pertains to purchase and use of quantitative train-of-four monitors in comparison with potential costs of managing possible complications of residual neuromuscular blockade such as reintubation and pneumonia. MethodsThis observational study was conducted by the anesthesiology service for an urban academic medical center. All patients included were undergoing general endotracheal anesthesia with the use of neuromuscular blocking agents who were extubated at the end of their procedure. Qualitative and quantitative train-of-four ratio monitoring prior to extubation were compared to estimate the local incidence of residual post-operative neuromuscular blockade. The hospital electronic medical record and financial database were used to estimate the number of patients at risk for post-operative pneumonia or re-intubation, as well as the marginal costs associated with these complications. The incidence of residual post-operative neuromuscular blockade at the time of extubation was determined. The variable costs of care for patients who did or did not suffer either pneumonia or re-intubation in the postoperative period was compared to the annual cost of universal quantitative train-of-four ratio monitoring. ResultsA sensitivity analysis demonstrated that universal quantitative train-of-four ratio monitoring would result in a net cost savings for a broad range of efficacy estimates with regard to the reduction of post-operative pulmonary complications. ConclusionsIntroduction of universal quantitative train-of-four ratio monitoring may be justified based solely on the potential institutional cost savings.

Weak evidence, supplemented with common sense for reduction in postoperative pulmonary complications

A clinical decision report appraising: Kaminski PN, Forgiarini LA, Jr., Andrade CF. Early respiratory therapy reduces postoperative atelectasis in children undergoing lung resection. Respir Care. 2013;58(5):805-809. https://doi.org/10.4187/respcare.01870 for prevention of postoperative pulmonary complications following thoracic surgery for a patient who is not able to participate in incentive spirometry.

Does preoperative pulmonary rehabilitation/physiotherapy improve patient outcomes following lung resection?

A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed was whether preoperative physiotherapy (pulmonary prehabilitation) is beneficial for patients undergoing lung resection. Altogether 177 papers were found using the reported search, of which 10 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. A meta-analysis by Li et al. showed that patients who received a preoperative rehabilitation programme (PRP) had reduced incidence of postoperative pulmonary complications (PPCs) (odds ratio 0.44, 95% CI 0.27-0.71), reduced length of stay (LOS) (-4.23 days, 95% CI -6.14 to -2.32 days) and improved 6-min walking distance (71.25 m, 95% CI 39.68-102.82) and peak oxygen uptake consumption (VO2 peak) (3.26, 95% CI 2.17-4.35). A meta-analysis by Steffens et al. showed that PPCs were reduced in patients with PRP (relative risk 0.49, 95% CI 0.33-0.73) and reduced LOS (-2.86 days, 95% CI -5.40 to -0.33). The results of 3 additional meta-analyses, 4 randomized controlled trials and 1 observational study all provide further support to PRP in enhanced recovery after surgery and the improvement in exercise capacity. We conclude that PRP improves exercise capacity in patients undergoing surgical resection for lung cancer. Moderate quality evidence supports preoperative exercise providing significant reduction in PPCs and hospital LOS. Referral to exercise programmes should be considered in patients awaiting lung resection, particularly those deemed borderline for suitability for surgical resection.

A Clinical and Budgetary Impact Analysis of Introducing Sugammadex for Routine Reversal of Neuromuscular Blockade in a Hypothetical Cohort in the US.

IntroductionSugammadex rapidly reverses the effects of rocuronium- and vecuronium-induced neuromuscular blockade (NMB), offering a more complete and predictable NMB recovery than cholinesterase inhibitors. Despite clinical benefits, cost pressures on hospital budgets influence the choice of the NMB reversal method. This study evaluated clinical and healthcare system payer’s budget impacts associated with sugammadex in the US for routine reversal of moderate or deep rocuronium- or vecuronium-induced NMB in adults undergoing surgery.MethodsA 1-year decision analytic model was constructed reflecting a set of procedures using rocuronium or vecuronium that resulted in moderate or deep NMB at the end of surgery. Two scenarios were considered for a hypothetical cohort of 100,000 patients: without sugammadex versus with sugammadex. Comparators included neostigmine (+glycopyrrolate) and no neuromuscular blocking agents (NMBAs). Total costs (in 2019 US dollars) to a healthcare system [net of costs of reversal agents and overall cost offsets via reduction in postoperative pulmonary complications (PPC)] were compared.ResultsA total of 9971 surgical procedures utilized rocuronium or vecuronium, resulting in moderate (91.0% of cases) or deep (9.0%) blockade at the end of surgeries. In the with sugammadex scenario, sugammadex replaced neostigmine in 4156 of 9585 procedures versus the without sugammadex scenario that used only neostigmine for NMB reversal. Introducing sugammadex reduced PPC events by 12% (58 cases) among the modeled procedures, leading to a budget impact of –$3,079,703 (–$309 per modeled procedure, or a 10.9% reduction in total costs). The results did not vary qualitatively in one-way sensitivity analyses.ConclusionsThe additional costs of sugammadex for the reversal of rocuronium- or vecuronium-induced NMB could be offset by improved outcomes (i.e., reduced PPC events), and potentially lead to overall healthcare budgetary savings versus reversal with neostigmine or spontaneous recovery. This study provides insights into savings that can be obtained beyond the anesthesia budget, reducing the broader clinical and budgetary burden on the hospital.

Respiratory and Hemodynamic Effects of Prophylactic Alveolar Recruitment During Liver Transplant: A Randomized Controlled Trial.

Prolonged surgical retraction may cause atelectasis. We aimed to recruit collapsed alveoli, stepwise, monitored by lung dynamic compliance and observe effects on arterial oxygenation and systemic and graft hemodynamics. Secondarily, we observed alveolar recruitment effects on postoperative mechanical ventilation, international normalized ratio, and pulmonary complications. For 58 recipients (1 excluded), randomized with optimal positive end-expiratory pressure (n = 28) versus control (fixed positive end-expiratory pressure, 5 cm H₂O; n = 29), alveolar recruitment was initiated (pressure-controlled ventilation guided by lung dynamic compliance) to identify optimal conditions. Ventilation shifted to volume-control mode with 0.4 fraction of inspired oxygen, 6 mL/kg tidal volume, and 1:2 inspiratory-to-expiratory ratio. Alveolar recruitment was repeated postretraction and at intensive care unit admission. Primary endpoints were changes in lung dynamic compliance, arterial oxygenation, and hemodynamics (cardiac output, invasive arterial and central venous pressures, graft portal and hepatic vein flows). Secondary endpoints were mechanical ventilation period and postoperative international normalized ratio, aspartate/alanine aminotransferases, lactate, and pulmonary complications. Alveolar recruitment increased positive end-expiratory pressure, lung dynamic compliance, and arterial oxygenation (P < .01) and central venous pressure (P = .004), without effects on corrected flow time (P = .7). Cardiac output and invasive arterial pressure were stable with (P = .11) and without alveolar recruitment (P = .1), as were portal (P = .27) and hepatic vein flow (P = .30). Alveolar recruitment reduced postoperative pulmonary complications (n = 0/28 vs 8/29; P = .001), without reduction in postoperative mechanical ventilation period (P = .08). International normalization ratio, aspartate/alanine aminotransferases, and lactate were not different from control (P > .05). Stepwise alveolar recruitment identified the optimal positive end-expiratory pressure to improve lung mechanics and oxygenation with minimal hemodynamic changes, without liver graft congestion/dysfunction, and was associated with significant reduction in postoperative pulmonary complications.

Tidal volume during 1-lung ventilation: A systematic review and meta-analysis

BackgroundThe selection of tidal volumes for 1-lung ventilation remains unclear, because there exists a trade-off between oxygenation and risk of lung injury. We conducted a systematic review and meta-analysis to determine how oxygenation, compliance, and clinical outcomes are affected by tidal volume during 1-lung ventilation. MethodsA systematic search of MEDLINE and EMBASE was performed. A systematic review and random-effects meta-analysis was conducted. Pooled mean difference estimated arterial oxygen tension, compliance, and length of stay; pooled odds ratio was calculated for composite postoperative pulmonary complications. Risk of bias was determined using the Cochrane risk of bias and Newcastle-Ottawa tools. ResultsEighteen studies were identified, comprising 3693 total patients. Low tidal volumes (5.6 [±0.9] mL/kg) were not associated with significant differences in partial pressure of oxygen (−15.64 [−88.53-57.26] mm Hg; P = .67), arterial oxygen tension to fractional intake of oxygen ratio (14.71 [−7.83-37.24]; P = .20), or compliance (2.03 [−5.22-9.27] mL/cmH2O; P = .58) versus conventional tidal volume ventilation (8.1 [±3.1] mL/kg). Low versus conventional tidal volume ventilation had no significant impact on hospital length of stay (−0.42 [−1.60-0.77] days; P = .49). Low tidal volumes are associated with significantly decreased odds of pulmonary complications (pooled odds ratio, 0.40 [0.29-0.57]; P < .0001). ConclusionsLow tidal volumes during 1-lung ventilation do not worsen oxygenation or compliance. A low tidal volume ventilation strategy during 1-lung ventilation was associated with a significant reduction in postoperative pulmonary complications.

Perioperative strategies for the reduction of postoperative pulmonary complications.

Postoperative pulmonary complications (PPCs), estimated between 2.0% and 5.6% in the general surgical population and 20-70% for upper abdominal and thoracic surgeries, are a significant factor leading to poor patient outcomes. Efforts to decrease the incidence of PPCs such as bronchospasm, atelectasis, exacerbations of underlying chronic lung conditions, infections (bronchitis and pneumonia), prolonged mechanical ventilation, and respiratory failure, begins with a detailed preoperative risk evaluation. There are several available preoperative tests to estimate the risk of PPCs. However, the value of some of these studies to estimate PPCs remains controversial and is still debated. In this review, the preoperative risk assessment of PPCs is examined along with preoperative pulmonary tests to estimate risk, intraoperative, and procedure-associated risk factors for PPCs, and perioperative strategies to decrease PPCs. The importance of minimizing these events is reflected in the fact that nearly 25% of postoperative deaths occurring in the first week after surgery are associated with PPCs. This review provides important information to help clinical anesthesiologists to recognize potential risks for pulmonary complications and allows strategies to create an appropriate perioperative plan for patients.

Perioperative interventions for prevention of postoperative pulmonary complications: systematic review and meta-analysis

ObjectiveTo identify, appraise, and synthesise the best available evidence on the efficacy of perioperative interventions to reduce postoperative pulmonary complications (PPCs) in adult patients undergoing non-cardiac surgery.DesignSystematic review and meta-analysis...

Preoperative intervention with long-acting bronchodilators for the reduction of postoperative pulmonary complications in untreated patients with obstructive lung disease.

Obstructive lung disease (OLD) is a risk factor for postoperative pulmonary complications (PPC) and is incidentally discovered during preoperative evaluation. The key treatments for OLD are inhaled long-acting bronchodilators (LAB). However, the advantage of preoperative bronchodilator treatment for patients with OLD remains unclear. The aim of this study is to elucidate the effect of preoperative LAB treatment in patients with untreated OLD on postoperative outcomes. In this propensity-matched cohort study, we included patients who were referred to the pulmonologists for untreated OLD. The patients were either treated with LAB or left untreated. The primary outcome was the incidence of prolonged oxygen therapy (>3days) in the postoperative period. We evaluated patients' characteristics with and without the use of LAB using propensity score (PS) matching weight. Subsequently, the outcomes in the two groups were compared. We analysed 614 patients; 132 patients were part of the LAB group and 482 were included in the control group. In the crude analysis, the incidence of prolonged oxygen therapy was higher in the LAB group than in the control group (odds ratio [OR]=1.35; P=0.04). However, after PS matching weight, no statistically significant differences in prolonged oxygen therapy (OR=1.15), incidence of prolonged intensive care unit stay, endotracheal re-intubation postoperatively and in-hospital death between the groups were identified. There is a limited benefit of preoperative treatment with inhaled LAB for the reduction of PPC in patients with untreated OLD.

Does prehabilitation improve outcomes in cardiac surgical patients?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was: does prehabilitation improve outcomes in cardiac surgical patients? Altogether more than 483 papers were found using the reported search, of which 10 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. Four meta-analyses concluded that prehabilitation reduced postoperative pulmonary complications (PPCs). The 6 randomized controlled trials (RCT) included, differed significantly in the type of prehabilitation delivered. There was replication of some RCTs across the meta-analyses. The consensus across the meta-analyses was a reduction in PPCs and 3 of 4 meta-analyses finding a reduction in length of stay (LOS). There were no adverse events or difference in mortality found. Two small RCTs showed feasibility and modest improvements in physiological parameters. Three RCTs demonstrated a reduction in LOS and a reduction in PPCs. One RCT found no difference in quality of life scores, LOS or postoperative atrial fibrillation. None of the RCTs found negative evidence of prehabilitation interventions. We conclude that the prehabilitation is a positive preoperative intervention, most favourably in older patients and in those who are at risk of PPCs. Specifically inspiratory muscle training is the intervention with most favourable evidence.

A Systematic Review and Meta-analysis of Physical Exercise Prehabilitation in Major Abdominal Surgery (PROSPERO 2017 CRD42017080366)

BackgroundPhysical exercise prehabilitation has been proposed to improve postoperative outcomes in patients undergoing major abdominal surgery. The aim of this systematic review was to investigate the effect of preoperative exercise training compared with standard care on postoperative outcomes in major abdominal surgery. MethodsRandomized controlled trials (RCT) comparing prehabilitation with standard care were identified by a systematic literature search of MEDLINE and CENTRAL. Qualitative and quantitative analyses of perioperative outcome data were conducted. Meta-analyses were performed wherever possible and meaningful. ResultsA total of eight trials including 442 patients met the inclusion criteria. These trials investigated the effect of prehabilitation in patient cohorts undergoing major liver, colorectal, gastroesophageal, and general abdominal surgery. Quantitative analyses of all included trials showed a significant reduction in postoperative pulmonary complications (OR 0.37; 0.20 to 0.67; p = 0.001) as well as in postoperative overall morbidity (OR 0.52; 0.30 to 0.88; p = 0.01) in the prehabilitation group compared with standard care. The length of hospital stay showed no significant differences between the groups (MD − 0.58; − 1.28 to 0.13; p = 0.11). Risk of bias and methodological quality varied substantially among the trials, most of which were small single-center studies. ConclusionPrehabilitation including a physical exercise intervention may lead to a reduction of postoperative pulmonary complications as well as less overall morbidity compared with standard care in patients undergoing major abdominal surgery. Further, well-designed RCT are needed to evaluate these potential positive effects in more detail and to identify suitable target populations. Protocol RegistrationPROSPERO 2017 CRD42017080366

Maximum inspiratory pressure of the patients after open-heart surgery following physiotherapy

Background: After open-heart surgery, various complications require specific care, especially in the respiratory system. To reestablish it, several strategies should be used, such as respiratory muscle training, which aims to improve respiratory muscle strength, leading to a reduction in post-operative pulmonary complications in patients undergoing cardiac surgery. Aims and Objectives: The objective of the study was to measure and compare maximum inspiratory pressure (MIP) in open-heart surgery patients following conventional physiotherapy group and conventional physiotherapy plus inspiratory muscle training (IMT) group. Materials and Methods: The study was an experimental design and it was a prospective randomized control study where participants were taken from cardiac hospital using balance block computer-generated randomization method. Fifty participants were divided into two groups of 25 each. Group A received conventional physiotherapy and Group B received conventional plus inspiratory muscle exercise (B) by pressure threshold IMT instrument. Physiotherapy treatment was delivered by qualified physiotherapy, twice a day preoperatively and after extubation, 4–5 sessions per day were given until they discharged. The pre-operative, at discharge, and at the 1st follow-up, patient MIP was measured. Results: There was no statistically significant change in inspiratory muscle strength in patients exposed to an IMT program compared to the control group (P > 0.05). Conclusion: There was no difference in MIP in conventional physiotherapy and conventional plus inspiratory muscle trainer group in “pre-operative,” “discharged,” and “1st follow-up” in open-heart surgery patient.

Short-term inpatient-based high-intensive pulmonary rehabilitation for lung cancer patients: is it feasible and effective?

This study was conducted to develop a preoperative in-hospital short-term rehabilitation program for surgical lung cancer patients, and investigate its feasibility, potential cost benefit and effectiveness on outcome measures including reduction of postoperative pulmonary complications (PPCs) and postoperative length of stay. A 7-day inpatient-based high-intensive rehabilitation regimen was performed between March 01, 2014 and June 30, 2015. It was combined with inspiratory muscles training (IMT) and aerobic endurance training and was tested in an enriched cohort study with 939 lung cancer patients undergoing lobectomy in a regional thoracic unit. Finally, 939 patients were divided into pulmonary rehabilitation (PR) group (n=197) and non-PR (NPR) group (n=742), according to whether they received the 7-day preoperative in-hospital systematic rehabilitation. The PR group had a shorter total length of stay (14.7±4.0 vs. 16.7±6.2 days, P<0.001) as well as postoperative length of stay (6.2±3.3 vs. 8.3±5.6 days, P<0.001) than the NPR group. Lower incidences of total PPCs (18.3%, 36/197 vs. 26.1%, 194/742, P=0.022), pneumonia (11.2%, 22/197 vs. 17.3%, 128/742, P=0.024) and atelectasis (6.6%, 13/197 vs. 12.3%, 91/742, P=0.038) were found in the PR group compared with NPR group. Meanwhile, a multivariable analysis of risk to PPCs, atelectasis and pneumonia, revealed that the PR intervention was the independent risk factor of the occurrence of the PPCs (OR =0.57, 95% CI: 0.47 to 0.93, P=0.033) and atelectasis (OR =0.49, 95% CI: 0.26 to 0.91, P=0.024). The study showed the effectiveness of this systematic and high-intensive PR combining IMT and aerobic exercise in reductions of the length of stay and occurrence of PPCs without increase in in-hospital cost, suggesting the potential of this rehabilitation pattern as a practicable strategy performed preoperatively in surgical lung cancer patients.

Fast track in thoracic surgery and anaesthesia

Update of key elements on enhanced recovery after thoracic anaesthesia and surgery. Pathways to enhance recovery after thoracic surgery ('fast-track') aim to improve response to lung surgery, reduction of postoperative pulmonary complications, and restore patient's vital function. Uncomplicated recovery after lung surgery reduces morbidity, hospital stay, and costs. Video-assisted thoracoscopic surgery is a major part of enhanced recovery minimizing tissue injury and stress response. Maintaining patient's physiology throughout perioperative processes by optimized anaesthesiological management and effective pain control present a crucial role in improving outcome. The concept of enhanced recovery ('fast-track') after thoracic surgery and anaesthesia was developed in recent years making allowance to the increased number of video-assisted parenchymal lung resections in managing primary lung cancer. Current studies promote the benefit in thoracic surgical patients, if an established departmental protocol-based algorithm is implemented.

Alveolar recruitment maneuver and perioperative ventilatory support in obese patients undergoing abdominal surgery

The development of abdominal surgery represents an alternative therapy for the morbidly obese; however, patients undergoing this surgical procedure often experience postoperative pulmonary complications. The use of alveolar recruitment maneuvers and/or perioperative ventilatory strategies is a possible alternative to reduce these complications, focusing on the reduction of postoperative pulmonary complications. In this review, the benefits of perioperative ventilatory strategies and the implementation of alveolar recruitment maneuvers in obese patients undergoing abdominal surgery are described.