Réhabilitation et VNI avant exérèse pulmonaire chez les patients à haut risque opératoire

Effect of Prehabilitation in Lung Cancer Patients Undergoing Lobectomy: A Review

Deaths from lung cancer are mostly caused by smoking. Cough, dyspnea, fatigue, weight loss, and Horner's syndrome are among the symptoms. Non-small cell lung cancer (NSCLC) and small cell lung cancer (SCLC) are the two categories into which lung cancer may be divided. Because of its effectiveness and lower death rates, lobectomy is the primary line of therapy for benign and early-stage lung illnesses. Pulmonary rehabilitation is a routine treatment for thoracic surgery individuals who are at a high risk to improve functional ability, avoid postoperative deterioration, avoid postoperative deterioration, and reduce complications and even hospital stays. Pulmonary rehabilitation is a multifaceted continuum of services intended to help individuals with pulmonary disease and their families reach and sustain their highest possible degree of independence and community functioning, typically provided by an interdisciplinary team of specialists.  The objective of this research was to gather preliminary information and assess the effects of pre-rehabilitation on those suffering from lung cancer and having lobectomy. The pre-rehabilitation program's outcomes include increased lung functional capacity, enhanced quality of life, patient independence in daily living activities, and a shorter hospital stay. Gradually increasing walking distance over time can build endurance, requiring consistency, pacing, proper hydration, nutrition, and regular breaks. This review analyzed the effect of pre-rehabilitation in lung cancer patients undergoing lobectomy. Pre-rehabilitation program for individuals with lung cancer improves both preoperative and postoperative health through various exercises. Pulmonary rehabilitation is a multidisciplinary approach that encourages physical activity, learning about disease, treatment options, and coping mechanisms. Instead of curing the illness, its goal is to lessen its symptoms and limitations. Patients with pulmonary diseases or undergoing thoracic surgery prefer pre-rehabilitation programs due to their non-traumatic nature and fewer resources required. Elastic resistance band exercises are beneficial for lung cancer patients' pre-rehabilitation by strengthening and stretching muscle groups, improving exercise capacity, and supporting white blood cell counts. These exercises can be customized to individual needs, making them a safe and effective addition to a patient's exercise routine. They have to be carried out at least three days a week. Pulmonary exercise, including the use of a tri-ball pulmonary exerciser or three-ball spirometer, can improve lung function, respiratory muscle strength, and exercise capacity in lung cancer patients. It involves breathing techniques, cough exercises, and inflating a balloon. Pulmonary rehabilitation has a positive impact on patient health. Improved lung vital capacity, shorter hospital stays, and fewer problems following surgery are all achieved with pulmonary rehabilitation. The pre-rehabilitation plan allows the patient to resume their daily routines.

[KINE PREOP pilot study: Prehabilitation in fast-track thoracic surgery protocol]

INTRODUCTION

Prehabilitation preceding oncological thoracic surgery according to a fast-track enhanced recovery after surgery (ERAS) protocol is in full expansion. Many recent studies have demonstrated the benefits of preoperative pulmonary rehabilitation as a means of reducing postoperative pulmonary complications. Unfortunately, it is rarely carried out by independent physiotherapists, and questions arise: is it feasible in private practice? Can it yield results similar to those achieved in institutional settings?

DESIGN

The study was non-interventional. The patients included had to be able to practice physical activities according to a standard ERAS approach. The endpoints were: postoperative pulmonary complications, physical condition (VO2max), and impact on the quality of life (SF-36 questionnaire). A statistical study was conducted to analyze the results with parametric and non-parametric tests.

RESULTS

Between June 2018 and January 2019, nine patients were included. From two to fifteen pulmonary rehabilitation sessions were carried out by six volunteering independent physiotherapists. Only two minor postoperative complications ensued. VO2max post rehabilitation increased on average by 2.4mL.kg -1.min-1. The SF-36 physical score increased significantly (+17.9%). The physical functioning (PF) (+28.9), physical restrictions (PR) (+11.1) and vitality (VT) (+16.7) sub-scores likewise improved.

CONCLUSION

Based on a literature review and on comparisons, our results seem promising. While further investigations are needed, it would seem that prehabilitation by independent physiotherapists leads to results similar to those achieved in inpatient prehabilitation.

The key questions in rehabilitation in thoracic surgery

Enhancing the recovery of patients undergoing Thoracic Surgery is the raison d'être of a pulmonary rehabilitation (PR) process. Benefits of a PR program have been shown to include reduced postoperative complications, hospital length of stay (LOS) and improved exercise and lung function parameters. Identifying which groups of patients benefit most and the constituency of the perfect PR program is subject to ongoing research. Providing PR to patients in a manner acceptable to their lifestyle and disease timeline within economic limitations is the challenge.

Impact of prehabilitation on morbidity and mortality after pulmonary lobectomy by minimally invasive surgery: a cohort study

Background

Thoracic surgery is currently the optimal treatment for non-small cell lung cancer (NSCLC). However, it may be responsible for numerous postoperative complications and is often used in patients with multi co morbidities. In recent years, the optimization of a patient's physical capacity before surgery has been the subject of several studies. The objective of this study was to determine whether participation in a prehabilitation program would improve outcomes after surgery and lower morbidity according to the Clavien-Dindo classification.

Methods

This retrospective cohort study was performed between 1st January 2014 and 31st January 2016 at Rouen University Hospital. All adult patients with NSCLC (IIIa or <) who had pulmonary lobectomy by minimally invasive surgery and cardiopulmonary exercise testing [CPET (VO2max ≤20 mL/min/kg)] were included.

Results

The cohort included 38 patients. Two groups were formed: one group with prehabilitation (n=19) and one group without prehabilitation (n=19). Four patients were not included leaving 34 patients for the final analysis. Most patients with a Clavien-Dindo grade of ≤2 had received prehabilitation compared to patients who had not received prehabilitation, respectively 17/19 vs. 8/15; P=0.0252. Patients who had received prehabilitation had fewer postoperative complications than patients who had not received prehabilitation, respectively 8/19 vs. 12/15; P=0.0382.

Conclusions

We have shown that prehabilitation has a positive impact on the occurrence and severity of postoperative complications after pulmonary lobectomy by minimally invasive surgery. Further studies conducted in larger populations are warranted to confirm these results.

Preoperative pulmonary rehabilitation for marginal-function lung cancer patients

Background This study aimed to evaluate the impact of preoperative pulmonary rehabilitation in lung cancer patients undergoing pulmonary resection surgery with marginal lung function. Methods Short-term outcomes of 42 patients with forced expiratory volume in 1 s < 1.6 L who underwent lung resection between 01/2006 and 12/2010 were reviewed retrospectively. They were divided into group A (no preoperative pulmonary rehabilitation) and group B (receiving pulmonary rehabilitation). In group B, a second set of pulmonary function tests was obtained. Results There were no significant differences in terms of sex, age, race, pathologic stage, operative procedure, or smoking years. Mean forced expiratory volume in 1 s and diffusing capacity for carbon monoxide in group A was 1.40 ± 0.22 L and 10.28 ± 2.64 g∙dL^-1 vs. 1.39 ± 0.13 L and 10.75 ± 2.08 g∙dL^-1 in group B. Group B showed significant improvement in forced expiratory volume in 1 s from 1.39 ± 0.13 to 1.55 ± 0.06 L ( p = 0.02). Mean intensive care unit stay was 6 ± 5 days in group A vs. 9 ± 9 days in group B ( p = 0.22). Mean hospital stay was 10 ± 4 days in group A vs. 14 ± 9 days in group B ( p = 0.31). There was no significant difference in morbidity or mortality between groups. Conclusion Preoperative pulmonary rehabilitation can significantly improve forced expiratory volume in 1 s in some marginal patients undergoing lung cancer resection. However, it does not improve length of stay, morbidity, or mortality.