The role of physiotherapy in patients undergoing pulmonary surgery for lung cancer. A literature review

Assessment of dyspnea, ADL, and QOL in the perioperative period in lung cancer patients treated with minimally invasive surgery

OBJECTIVE

Patients with lung cancer generally undergo minimally invasive surgery, such as video-assisted thoracoscopic surgery (VATS). This study examined the changes in health conditions and symptoms of patients with lung cancer using the European Organization for Research and Treatment of Cancer-Quality of Life Questionnaire (EORTC QLQ) C-30 questionnaires after surgery.

METHODS

This was a longitudinal descriptive study. One hundred and three patients with lung cancer who underwent lung resection at Tokushima University Hospital between 2012 and 2021 were eligible. They completed EORTC QLQ-C30, QLQ-LC13, the Cancer Dyspnea scale (CDS), and pulmonary-ADL (P-ADL) before and 1, 3, and 6 months after surgery.

RESULTS

Regarding functional scale scores, impairments in physical and role functions persisted for 6 months after surgery. In symptom scale scores, fatigue, pain, dyspnea, and appetite loss continued for 6 months after surgery. In CDS, sense of effort, discomfort, and total dyspnea scale scores were elevated for 6 months after surgery. In P-ADL, most ADL were impaired 1 month after surgery, but recovered by 3 months. The dyspnea index of ADL was lower for 6 months after surgery.

CONCLUSIONS

Impairments in health conditions and symptoms persisted for 6 months after surgery despite its minimally invasive nature. J. Med. Invest. 70 : 388-402, August, 2023.

Perioperative respiratory muscle training improves respiratory muscle strength and physical activity of patients receiving lung surgery: A meta-analysis

BACKGROUND

The clinical role of perioperative respiratory muscle training (RMT), including inspiratory muscle training (IMT) and expiratory muscle training (EMT) in patients undergoing pulmonary surgery remains unclear up to now.

AIM

To evaluate whether perioperative RMT is effective in improving postoperative outcomes such as the respiratory muscle strength and physical activity level of patients receiving lung surgery.

METHODS

The PubMed, EMBASE (via OVID), Web of Science, Cochrane Library and Physiotherapy Evidence Database (PEDro) were systematically searched to obtain eligible randomized controlled trials (RCTs). Primary outcome was postoperative respiratory muscle strength expressed as the maximal inspiratory pressure (MIP) and maximal expiratory pressure (MEP). Secondary outcomes were physical activity, exercise capacity, including the 6-min walking distance and peak oxygen consumption during the cardio-pulmonary exercise test, pulmonary function and the quality of life.

RESULTS

Seven studies involving 240 participants were included in this systematic review and meta-analysis. Among them, four studies focused on IMT and the other three studies focused on RMT, one of which included IMT, EMT and also combined RMT (IMT-EMT-RMT). Three studies applied the intervention postoperative, one study preoperative and the other three studies included both pre- and postoperative training. For primary outcomes, the pooled results indicated that perioperative RMT improved the postoperative MIP (mean = 8.13 cmH₂O, 95%CI: 1.31 to 14.95, P = 0.02) and tended to increase MEP (mean = 13.51 cmH₂O, 95%CI: -4.47 to 31.48, P = 0.14). For secondary outcomes, perioperative RMT enhanced postoperative physical activity significantly (P = 0.006) and a trend of improved postoperative pulmonary function was observed.

CONCLUSION

Perioperative RMT enhanced postoperative respiratory muscle strength and physical activity level of patients receiving lung surgery. However, RCTs with large samples are needed to evaluate effects of perioperative RMT on postoperative outcomes in patients undergoing lung surgery.

Application of ERAS Protocol after VATS Surgery for Chronic Empyema in Immunocompromised Patients

Enhanced recovery after surgery protocols have shown improved clinical outcomes after lung resection surgery, but their application after empyema surgery is still limited. We retrospectively evaluated the outcomes of an adapted enhanced recovery after surgery (ERAS) protocol for immunocompromised patients who underwent video-assisted thoracoscopic surgery (VATS) surgery for chronic empyema between December 2013 and December 2021. The patients were divided into an ERAS group and a conventional treatment group. Peri-operative data were collected and compared between the two groups. The primary outcome was post-operative length of stay. Secondary outcomes were post-operative pain and post-operative complications (air leaks, atelectasis). A total of 86 patients, 45 in the ERAS group and 41 in the non-ERAS group, were considered. Chest tube duration (6.4 ± 2.3 vs. 13.6 ± 6.8 days) and post-operative length of stay (7.6 ± 1.6 vs. 16.9 ± 6.9 days) were significantly shorter in the ERAS group. The volume of chest drainage (103 ± 78 vs. 157 ± 89 mL/day) was significantly smaller in the ERAS group. There were no significant differences in operative time, blood loss, need for transfusion, tube reinsertion and median VAS score. The incidence of air leaks and atelectasis was significantly reduced in the ERAS group, as was the need for bronchoscopic aspiration. The application of an ERAS protocol after empyema VATS surgery for immunocompromised patients improved the surgical outcome, reducing the post-operative length of stay and rate of complications.

Effect of Electrical Impedance Tomography-Guided Early Mobilization in Patients After Major Upper Abdominal Surgery: Protocol for a Prospective Cohort Study

Background: Pulmonary complications are common in patients after upper abdominal surgery, resulting in poor clinical outcomes and increased costs of hospitalization. Enhanced Recovery After Surgery Guidelines strongly recommend early mobilization post-operatively; however, the quality of the evidence is poor, and indicators for quantifying the effectiveness of early mobilization are lacking. This study will evaluate the effectiveness of early mobilization in patients undergoing an upper abdominal surgery using electrical impedance tomography (EIT). Specifically, we will use EIT to assess and compare the lung ventilation distribution among various regions of interest (ROI) before and after mobilization in this patient population. Additionally, we will assess the temporal differences in the distribution of ventilation in various ROI during mobilization in an effort to develop personalized activity programs for this patient population.

Methods: In this prospective, single-center cohort study, we aim to recruit 50 patients after upper abdominal surgery between July 1, 2021 and June 30, 2022. This study will use EIT to quantify the ventilation distribution among different ROI. On post-operative day 1, the nurses will assist the patient to sit on the chair beside the bed. Patient's heart rate, blood pressure, oxygen saturation, respiratory rate, and ROI 1-4 will be recorded before the mobilization as baseline. These data will be recorded again at 15, 30, 60, 90, and 120 min after mobilization, and the changes in vital signs and ROI 1-4 values at each time point before and after mobilization will be compared.

Ethics and Dissemination: The study protocol has been approved by the Institutional Review Board of Liaocheng Cardiac Hospital (2020036). The trial is registered at chictr.org.cn with identifier ChiCTR2100042877, registered on January 31, 2021. The results of the study will be presented at relevant national and international conferences and submitted to international peer-reviewed journals. There are no plans to communicate results specifically to participants. Important protocol modifications, such as changes to eligibility criteria, outcomes, or analyses, will be communicated to all relevant parties (including investigators, Institutional Review Board, trial participants, trial registries, journals, and regulators) as needed via email or in-person communication.

The Effects of Manual Lung Hyperinflation on Pulmonary Function after Weaning from Mechanical Ventilation among Patients with Abdominal Surgeries: Randomized Clinical Trial

Introduction: After abdominal surgery, the patients who are separated from mechanical ventilation and provided with oxygen therapy via a T-piece are at risk for respiratory complications. Therefore, they need additional respiratory support. This study aimed to evaluate the effects of manual hyperinflation (MHI) on pulmonary function after weaning. Methods: This randomized clinical trial included 40 patients who had undergone abdominal surgery and were receiving oxygen via a T-piece. Patients were selected from the intensive care units (ICU) of two hospitals in Mashhad, Iran. The subjects were randomly allocated to intervention (MHI) and control groups. Patients in the MHI group were provided with three 20-minute MHI rounds using the Mapleson C, while the control group received routine cares. Tidal volume (Vt), Rapid Shallow Breathing Index (RSBI), and the ratio of arterial oxygen partial pressure to fractional inspired oxygen (P/F ratio) were measured before the intervention, as well as 5 and 20 minutes after the intervention. Atelectasis prevalence was assessed before and 24 hours after the intervention. Data were analysed by SPSS software version 13. Results: At baseline, there were no significant differences between the groups regarding Vt, RSBI, P/F ratio, and atelectasis rate. No significant difference was also found between the groups regarding atelectasis rate 24 hours after the intervention. However, at both posttests, Vt, RSBI, and P/F ratio in the MHI group were significantly better than the control group. Conclusion: In patients with artificial airway and spontaneous breathing, MHI improves pulmonary function.

A randomized trial comparing inspiratory training and positive pressure training in immediate lung recovery after minor pleuro-pulmonary surgery

Background

Two respiratory physiotherapy modalities were compared in a randomized controlled trial on patients undergoing minor pleuro-pulmonary surgery.

Methods

Forty-five patients were randomly allocated into positive expiratory pressure (PEP) therapy (n=23) and inspiratory muscle training (IMT) groups (n=22). Individualized group specific physiotherapeutic guidance was administered preoperatively, and once a day postoperatively. Patients also performed independent exercises and kept a logbook. Pain was assessed on a numerical reference scale (NRS). Volumetric pulmonary function values and walking distance were recorded preoperatively, and on first (POD1) and second postoperative days (POD2). Pre- and postoperative values were compared using two-way repeated measures analysis of variance.

Results

Patient characteristics and pleuro-pulmonary interventions were similar between the groups. Thoracotomy was performed in 14/45 and video assisted surgery (VATS) in 31/45 of cases. Preoperative volumetric pulmonary functions were normal or slightly decreased in 29/45, and fell significantly (P<0.001) on the first postoperative day (POD1) and improved but remained significantly lower on the second postoperative day. The recovery of mean FEV1, FIV1 and FIVC values was greater in the IMT than in the PEP group between POD1 and POD2, but without significant difference. The corresponding relative to preoperative values were higher in the IMT group, with a significant difference in FEV1 (P=0.045). Also relative PEF and FIV1 values seemed to be slightly higher in the IMT compared to the PEP group, but not significantly. Average NRS values for pain were lower in the IMT group (P=0.010) but only on POD1. Air leak was noted in 4/45 patients, two in each group, on POD1, and two in PEP groups and one in IMT group on POD2. Mean measured walking distances between groups did not differ. Mean hospital stay was 4 days in the PEP group and 3 days in the IMT group. There was no hospital mortality.

Conclusions

Pulmonary function values decreased significantly after minor lung resections, supporting rehabilitative respiratory physiotherapy to avoid postoperative pulmonary complications (PPCs). Both PEP and IMT training were well tolerated and equally efficient when comparing spirometry values at three time points. IMT appeared advantageous regarding relative FEV1 recovery and immediate postoperative pain.

Drug Regimen for Patients after a Pneumonectomy

Pneumonectomy is an entire lung removal and is indicated for both malignant and benign diseases. Due to its invasiveness and postoperative complications, pneumonectomy is still associated with high mortality and morbidity. Appropriate postoperative management is crucial in pneumonectomy patients to improve quality of life and overall survival rates. Diverse drug regimens are under development to be used in adjuvant chemotherapy or to improve respiratory health after a pneumonectomy. The most common causes for a pneumonectomy are non-small cell lung cancer, malignant pleural mesothelioma, and tuberculosis; thus, an appropriate drug regimen is necessary. The uncommon incidence of pneumonectomy cases remains the major obstacle in studies of postoperative drug regimens. As the majority of current studies include post-lobectomy and post-segmentectomy patients, it is highly recommended that further research of postoperative drug regimens be focused on post-pneumonectomy patients.

Inspiratory training and immediate lung recovery after resective pulmonary surgery: a randomized clinical trial

Background

Prompt and uneventful recovery after resective pulmonary surgery benefits patients by decreasing length and total costs of hospital stay. Postoperative physiotherapy has been shown to be advantageous for patient recovery in several studies and lately inspiratory muscle training (IMT) physiotherapy has been used also in thoracic patients. This randomized controlled trial intended to evaluate whether IMT is an efficient and feasible method of physiotherapy compared to water bottle positive expiratory physiotherapy (PEP) immediately after lung resections.

Methods

Forty-two patients were randomly allocated into two intervention groups: water bottle PEP (n=20) and IMT group (n=22). Patients were given physiotherapeutic guidance once a day and patients were also instructed to do independent exercises. Measurements of pulmonary function were compared between the treatment groups according to intention to treat by using two-way repeated measures analysis of variances at three time points (preoperative, first postoperative day, and second postoperative day). Walking distance was measured at first and second postoperative day and similarly, evaluation of postoperative air leak during exercises was performed. Physiotherapy was modified or temporarily interrupted, if necessary, because of the air leak.

Results

Postoperative pulmonary function tests were equal between the intervention groups. Air leak was relatively common after lung resections: 31% of all patients had mild or moderate/severe air leak at first postoperative day and 14% of all patients had mild to severe air leak at second postoperative day respectively. There were no statistically significant differences in occurrence of air leak between intervention groups, but water resistance had to be reduced or physiotherapy discontinued significantly more often among the water bottle PEP group patients (P=0.01). Walking distance improved slightly faster in the IMT group between the first and the second postoperative day when compared to the water bottle PEP group, but the difference between the groups was not statistically significant.

Conclusions

IMT physiotherapy is equally effective to water bottle PEP training in postoperative physiotherapy after lung resection surgery evaluated with pulmonary function tests and walking distance. In addition, IMT physiotherapy is safe and more feasible form of physiotherapy during postoperative air leak compared to water bottle PEP.

Recommendations from the Italian intersociety consensus on Perioperative Anesthesa Care in Thoracic surgery (PACTS) part 2: intraoperative and postoperative care

Introduction

Anesthetic care in patients undergoing thoracic surgery presents specific challenges that require a multidisciplinary approach to management. There remains a need for standardized, evidence-based, continuously updated guidelines for perioperative care in these patients.

Methods

A multidisciplinary expert group, the Perioperative Anesthesia in Thoracic Surgery (PACTS) group, was established to develop recommendations for anesthesia practice in patients undergoing elective lung resection for lung cancer. The project addressed three key areas: preoperative patient assessment and preparation, intraoperative management (surgical and anesthesiologic care), and postoperative care and discharge. A series of clinical questions was developed, and literature searches were performed to inform discussions around these areas, leading to the development of 69 recommendations. The quality of evidence and strength of recommendations were graded using the United States Preventive Services Task Force criteria.

Results

Recommendations for intraoperative care focus on airway management, and monitoring of vital signs, hemodynamics, blood gases, neuromuscular blockade, and depth of anesthesia. Recommendations for postoperative care focus on the provision of multimodal analgesia, intensive care unit (ICU) care, and specific measures such as chest drainage, mobilization, noninvasive ventilation, and atrial fibrillation prophylaxis.

Conclusions

These recommendations should help clinicians to improve intraoperative and postoperative management, and thereby achieve better postoperative outcomes in thoracic surgery patients. Further refinement of the recommendations can be anticipated as the literature continues to evolve.

Essentials of Physiotherapy after Thoracic Surgery: What Physiotherapists Need to Know. A Narrative Review

Physiotherapy has recently become an essential part of enhanced recovery protocols after thoracic surgery. The evidence-based practice of physiotherapy is essential for the effective management of postoperative patients. Unfortunately, only a small body of literature has discussed the rationale of the physiotherapy interventions that are routinely implemented following thoracic surgery. Nonetheless, we can integrate the available knowledge into our practice until new evidence emerges. Therefore, in this review, the principles of physiotherapy after thoracic surgery are presented, along with a detailed description of physiotherapy interventions, with the goals of enhancing the knowledge and practical skills of physiotherapists in postoperative care units and helping them to re-evaluate and justify their traditional practices.

Inspiratory Muscle Training in High-Risk Patients Following Lung Resection May Prevent a Postoperative Decline in Physical Activity Level

Objectives. To describe postoperative self-reported physical activity (PA) level and assess the effects of 2 weeks of postoperative inspiratory muscle training (IMT) in patients at high risk for postoperative pulmonary complications following lung resection. Methods. This is a descriptive study reporting supplementary data from a randomized controlled trial that included 68 patients (mean age = 70 ± 8 years), randomized to an intervention group (IG; n = 34) or a control group (CG; n = 34). The IG underwent 2 weeks of postoperative IMT added to a standard postoperative physiotherapy given to both groups. The standard physiotherapy consisted of breathing exercises, coughing techniques, and early mobilization. We evaluated self-reported physical activity (Physical Activity Scale 2.1 questionnaire) and health status (EuroQol EQ-5D-5L questionnaire), assessed the day before surgery and 2 weeks postoperatively. Results. A significant percentage of the patients in the IG reported less sedentary activity 2 weeks postoperatively when compared with the CG (sedentary 6% vs 22%, low activity 56% vs 66%, moderate activity 38% vs 12%, respectively; P = .006). The mean difference in EQ-5D-5L between the IG and CG 2 weeks postoperatively was nonsignificant (P = .80). The overall preoperative EQ-5D-5L index score for the study population was comparable to a reference population. Conclusion. Postoperative IMT seems to prevent a decline in PA level 2 weeks postoperatively in high-risk patients undergoing lung resection. More research is needed to confirm these findings.