Pre-operative optimisation for chronic obstructive pulmonary disease: a narrative review

Clinicosocial determinants of hospital stay following cervical decompression: A public healthcare perspective and machine learning model

OBJECTIVE

Post-operative length of hospital stay (LOS) is a valuable measure for monitoring quality of care provision, patient recovery, and guiding hospital resource management. But the impact of patient ethnicity, socio-economic deprivation as measured by the indices of multiple deprivation (IMD), and pre-existing health conditions on LOS post-anterior cervical decompression and fusion (ACDF) is under-researched in public healthcare settings.

METHODS

From 2013 to 2023, a retrospective study at a single center reviewed all ACDF procedures. We analyzed 14 non-clinical predictors-including demographics, comorbidities, and socio-economic status-to forecast a categorized LOS: short (≤2 days), medium (2-3 days), or long (>3 days). Three machine learning (ML) models were developed and assessed for their prediction reliability.

RESULTS

2033 ACDF patients were analyzed; 79.44 % had a LOS ≤ 2 days. Significant predictors of LOS included patient sex (HR:0.81[0.74-0.88], p < 0.005), IMD decile (HR:1.38[1.24-1.53], p < 0.005), smoking (HR:1.24[1.12-1.38], p < 0.005), DM (HR:0.70[0.59-0.84], p < 0.005), and COPD (HR:0.66, p = 0.01). Asian patients had the highest mean LOS (p = 0.003). Testing on 407 patients, the XGBoost model achieved 80.95 % accuracy, 71.52 % sensitivity, 85.76 % specificity, 71.52 % positive predictive value, and a micro F1 score of 0.715. This model is available at: https://acdflos.streamlit.app.

CONCLUSIONS

Utilizing non-clinical pre-operative parameters such as patient ethnicity, socio-economic deprivation index, and baseline comorbidities, our ML model effectively predicts postoperative LOS for patient undergoing ACDF surgeries. Yet, as the healthcare landscape evolves, such tools will require further refinement to integrate peri and post-operative variables, ensuring a holistic decision support tool.

Effects of extracorporeal diaphragm pacing combined with inspiratory muscle training on respiratory function in people with stroke: a randomized controlled trial

OBJECTIVES

To evaluate the effect of external diaphragmatic pacing (EDP) combined with inspiratory muscle training on respiratory function in post-stroke patients.

METHODS

Patients with stroke were enrolled from the First Affiliated Hospital of Soochow University in China between 2021 and 2022. The patients were randomized into an EDP treatment group (control group) or an EDP treatment plus inspiratory muscle training group (experimental group). Each therapy was administered once a day for 6 days per week. The peak inspiratory flow (PIF), maximal inspiratory pressure (MIP), forced expiratory volume in 1 s (FEV1), forced vital capacity (FVC), FEV1/FVC% ratio, and diaphragm thickness and mobility were measured and compared between the two groups after 4 weeks.

RESULTS

After 4 weeks of intervention, respiratory muscle function indicators including PIF (95% CI: 0.21-1.28, p = 0.008) and MIP (95% CI: 6.92-25.44, p = 0.001) significantly improved in the experimental group. Diaphragmatic thickness also significantly increased in the experimental group (p < 0.05), while diaphragmatic excursion showed no significant difference between the two groups. Additionally, FVC (95% CI: 0.14-1.14, p = 0.013) and FEV1 (95% CI: 0.20-1.06, p = 0.005) demonstrated a significant increase in the experimental group, whereas FEV1/FVC% (95% CI: -0.84 to 9.36, p = 0.099) exhibited no significant group difference.

CONCLUSION

EDP combined with inspiratory muscle training in individuals with stroke provides greater benefits than EDP alone in terms of respiratory function recovery, except for the parameters of diaphragmatic excursion and FEV1/FVC%.

Construction and validation of a risk prediction model for postoperative ICU admission in patients with colorectal cancer: clinical prediction model study

BACKGROUND

Transfer to the ICU is common following non-cardiac surgeries, including radical colorectal cancer (CRC) resection. Understanding the judicious utilization of costly ICU medical resources and supportive postoperative care is crucial. This study aimed to construct and validate a nomogram for predicting the need for mandatory ICU admission immediately following radical CRC resection.

METHODS

Retrospective analysis was conducted on data from 1003 patients who underwent radical or palliative surgery for CRC at Ningxia Medical University General Hospital from August 2020 to April 2022. Patients were randomly assigned to training and validation cohorts in a 7:3 ratio. Independent predictors were identified using the least absolute shrinkage and selection operator (LASSO) and multivariate logistic regression in the training cohort to construct the nomogram. An online prediction tool was developed for clinical use. The nomogram's calibration and discriminative performance were assessed in both cohorts, and its clinical utility was evaluated through decision curve analysis (DCA).

RESULTS

The final predictive model comprised age (P = 0.003, odds ratio [OR] 3.623, 95% confidence interval [CI] 1.535-8.551); nutritional risk screening 2002 (NRS2002) (P = 0.000, OR 6.129, 95% CI 2.920-12.863); serum albumin (ALB) (P = 0.013, OR 0.921, 95% CI 0.863-0.982); atrial fibrillation (P = 0.000, OR 20.017, 95% CI 4.191-95.609); chronic obstructive pulmonary disease (COPD) (P = 0.009, OR 8.151, 95% CI 1.674-39.676); forced expiratory volume in 1 s / Forced vital capacity (FEV1/FVC) (P = 0.040, OR 0.966, 95% CI 0.935-0.998); and surgical method (P = 0.024, OR 0.425, 95% CI 0.202-0.891). The area under the curve was 0.865, and the consistency index was 0.367. The Hosmer-Lemeshow test indicated excellent model fit (P = 0.367). The calibration curve closely approximated the ideal diagonal line. DCA showed a significant net benefit of the predictive model for postoperative ICU admission.

CONCLUSION

Predictors of ICU admission following radical CRC resection include age, preoperative serum albumin level, nutritional risk screening, atrial fibrillation, COPD, FEV1/FVC, and surgical route. The predictive nomogram and online tool support clinical decision-making for postoperative ICU admission in patients undergoing radical CRC surgery.

TRIAL REGISTRATION

Despite the retrospective nature of this study, we have proactively registered it with the Chinese Clinical Trial Registry. The registration number is ChiCTR2200062210, and the date of registration is 29/07/2022.

Preoperative Spirometry in Patients With Known or Suspected Chronic Obstructive Pulmonary Disease Undergoing Major Surgery: The Prospective Observational PREDICT Study

BACKGROUND

Pulmonary function tests (PFTs) such as spirometry and blood gas analysis have been claimed to improve preoperative pulmonary risk assessment, but the scientific literature is conflicting. The Preoperative Diagnostic Tests for Pulmonary Risk Assessment in Chronic Obstructive Pulmonary Disease (PREDICT) study aimed to determine whether preoperative PFTs improve the prediction of postoperative pulmonary complications (PPCs) in patients with known or suspected chronic obstructive pulmonary disease (COPD) undergoing major surgery. A secondary aim was to determine whether the Global Initiative for Chronic Obstructive Lung Diseases (GOLD) classification of airflow limitation severity (grades I-IV) is associated with PPC.

METHODS

In this prospective, single-center study, patients with GOLD key indicators for COPD scheduled for major surgery received PFTs. Patients with confirmed COPD (forced expiratory volume in 1 second [FEV1]/forced vital capacity [FVC] ≤0.7) were included in the COPD cohort and compared with a reference cohort without COPD. We developed 3 multivariable risk prediction models and compared their ability to predict PPC: the "standard model" (medical preconditions, and sociodemographic and surgical data), the "COPD assessment model" (additional GOLD key indicators, pack-years, and poor exercise capacity), and the "PFT model" (additional PFT parameters selected by adaptive least absolute shrinkage and selection operator [LASSO] regression). Multiple LASSO regressions were used for cross-validation.

RESULTS

A total of 31,714 patients were assessed for eligibility; 1271 individuals received PFTs. Three hundred twenty patients (240 with confirmed COPD: 78 GOLD I, 125 GOLD II, 28 GOLD III, 9 GOLD IV, and 80 without COPD) completed follow-up. The diagnostic performance was similar among the standard model (cross-validated area under the curve [cvAUC], 0.723; bias-corrected bootstrapped [bc-b] 95% confidence interval [CI], 0.663-0.775), COPD assessment model (cvAUC, 0.724; bc-b 95% CI, 0.662-0.777), and PFT model (cvAUC, 0.729; bc-b 95% CI, 0.668-0.782). Previously known COPD was an independent predictor in the standard and COPD assessment model. %FEV1 PRED was the only PFT parameter selected by LASSO regression and was an independent predictor in the PFT model (adjusted odds ratios [OR], 0.98; 95% CI, 0.967-.0.998; P = .030). The risk for PPC significantly increased with GOLD grades ( P < .001). COPD was newly diagnosed in 53.8% of the patients with confirmed COPD; however, these individuals were not at increased risk for PPC ( P = .338).

CONCLUSIONS

COPD is underdiagnosed in surgical patients. Patients with newly diagnosed COPD commonly presented with low GOLD severity grades and were not at higher risk for PPC. Neither a structured COPD-specific assessment nor preoperative PFTs added incremental diagnostic value to the standard clinical preassessment in patients with known or suspected COPD. Unnecessary postponement of surgery and undue health care costs can be avoided.

Stair-Climbing Tests or Self-Reported Functional Capacity for Preoperative Pulmonary Risk Assessment in Patients with Known or Suspected COPD-A Prospective Observational Study

BACKGROUND

This prospective study aims to determine whether preoperative stair-climbing tests (SCT) predict postoperative pulmonary complications (PPC) better than self-reported poor functional capacity (SR_PFC) in patients with known or suspected COPD.

METHODS

A total of 320 patients undergoing scheduled for major non-cardiac surgery, 240 with verified COPD and 80 with GOLD key indicators but disproved COPD, underwent preoperative SR_PFC and SCT and were analyzed. Least absolute shrinkage and selection operator (LASSO) regression was used for variable selection. Two multivariable regression models were fitted, the SR_PFC model (baseline variables such as sociodemographic, surgical and procedural characteristics, medical preconditions, and GOLD key indicators plus SR_PFC) and the SCT model (baseline variables plus SCT_PFC).

RESULTS

Within all stair-climbing variables, LASSO exclusively selected self-reported poor functional capacity. The cross-validated area under the receiver operating characteristic curve with bias-corrected bootstrapping 95% confidence interval (95% CI) did not differ between the SR_PFC and SCT models (0.71; 0.65-0.77 for both models). SR_PFC was an independent risk factor (adjusted odds ratio (OR) 5.45; 95% CI 1.04-28.60; p = 0.045 in the SR_PFC model) but SCT_PFC was not (adjusted OR 3.78; 95% CI 0.87-16.34; p = 0.075 in the SCT model).

CONCLUSIONS

Our findings indicate that preoperative SR_PFC adequately predicts PPC while additional preoperative SCTs are dispensable in patients with known or suspected COPD.

[Anatomical resection for non-small cell lung cancer: cardiopulmonary exercise testing in assessing the risk of respiratory complications]

OBJECTIVE

To assess the role of cardiopulmonary exercise testing in examination of patients with high risk of respiratory complications in anatomical resections for non-small cell lung cancer.

MATERIAL AND METHODS

A non-randomized retrospective single-center study was devoted to immediate results of surgical treatment of patients with NSCLC between December 2020 and April 2021. Median age of patients was 65 (84; 30) years, male-to-female ratio - 129 (57%)/98 (43%). All patients were examined according to a unified algorithm recommended by the American (ATS) and European (ESTS) societies of thoracic surgeons. At the first stage, we analyzed airflow rate and performed non-invasive exercise tests (6-minute walk and/or stair test). Resections of lungs were performed in 231 patients, anatomic lung resections - in 227 patients (lobectomy - 199, bilobectomy - 4, segmentectomy - 17, pneumonectomy - 7). We excluded 4 patients who underwent non-anatomic lung resections (marginal resections).

RESULTS

Among 236 patients referred for anatomical lung resections, 34 (14.4%) ones were selected for cardiopulmonary testing. Selection was based on low exercise tolerance and/or severe decrease in predictive respiratory parameters (FEV<50%). Patients were divided into 4 groups depending on peak oxygen consumption. There were 5 (2%), 10 (29.4%), 11 (32.3%) and 8 (23.5%) patients with extremely high, high, moderate and low risk of respiratory complications, respectively. Surgeries were performed for IA1 (n=6), IA2 (n=50), IA3 (n=37), IB (n=31), IIA (n=19), IIB (n=37), IIIA (n=25) and IIIB (n=4) stages. The overall incidence of postoperative complications was 23% (95% CI: 18-28.8). Complications Clavien-Dindo grade I, IIIA, IIIB, IVA, IVB and V prevailed in both groups. Median postoperative hospital-stay (6 (6; 8) vs. 7 (6; 8) days) and time of pleural drainage (4 (2; 5) vs. 3 (3; 4) days) were similar. Organ-sparing procedures prevailed in the main group (5 (26%) out of 19 (95% CI: 11.81-48.8) vs. 12 (6.7%) out of 180 (95% CI: 3.8-11.3)). Overall mortality (n=231) was 1.7% (95% CI: 0.7-4.4). Mortality throughout the first postoperative year was 24% (95% CI: 12.2-42.1) and 7.4% (95% CI: 4.2-11.3), respectively.

CONCLUSION

Cardiopulmonary exercise testing makes it possible to objectively assess exercise tolerance and identify high-risk patients for respiratory complications. These data are valuable when planning the treatment of patients with non-small cell lung cancer.

Risk Factor-Driven Prehabilitation Prior to Abdominal Wall Reconstruction to Improve Postoperative Outcome. A Narrative Review

All abdominal wall reconstructions find themselves on a scale, varying between simple to highly complex procedures. The level of complexity depends on many factors that are divided into patient comorbidities, hernia characteristics, and wound characteristics. Preoperative identification of modifiable risk factors provides the opportunity for patient optimization. Because this so called prehabilitation greatly improves postoperative outcome, reconstructive surgery should not be scheduled before all modifiable risk factors are optimized to a point where no further improvement can be expected. In this review, we discuss the importance of preoperative risk factor recognition, identify modifiable risk factors, and utilize options for patient prehabilitation, all aiming to improve postoperative outcome and therewith long-term success of the reconstruction.

Clinical Observation of General Anesthesia Combined with Spinal Anesthesia in Elderly Patients with Chronic Obstructive Pulmonary Disease

Objective

This work is aimed at evaluating the efficacy and safety of general anesthesia (GA) combined with spinal anesthesia (SA) (GA+SA) in elderly patients with chronic obstructive pulmonary disease (COPD). Methods and Material. 50 elderly COPD patients were rolled randomly into a control group (simple GA) and observation group (GA+SA). The differences in operation time, postoperative recovery time (PRT), language expression time (LET), anesthetic dosage (AD), catheter extubation time (CET), respiratory circulation indicators (mean arterial pressure (MAP), heart rate (HR), SaO2, and PaO2), postoperative VRS score, pulmonary function (forced vital capacity (FVC)), forced expiratory volume in 1 s (FEV1)/FVC and forced expiratory flow (FEF 25%~75%), serum inflammatory factors (IL-6, IL-8, and TNF-α), Short Portable Mental Status Questionnaire (SPMSQ) score, and the incidence of respiratory system events were analyzed.

Results

The results showed that the PRT, LET, AD, and CET of the observation group were all shorter (P < 0.05). The postoperative MAP, HR, SaO2, and PaO2 levels of patients who received GA+SA were much higher than those who received simple GA (P < 0.05). The postoperative VRS score of the observation group was better than that of the controls (P < 0.05). The postoperative pulmonary function of patients in the observation group was better compared with that in the control group (P < 0.05). The postoperative serum inflammatory factors in the observation group were lower in contrast to the patients who received simple GA (P < 0.05). The postoperative cognitive function SPMSQ score of patients who received GA+SA was lower compared with the score of patients who received simple GA (P < 0.05). However, the probability of respiratory system events in the observation group was lower (P < 0.05).

Conclusion

In conclusion, GA+SA could significantly shorten the PRT and improve the recovery quality of elderly COPD patients. It can also reduce the postoperative inflammatory response and strengthen the pulmonary function and cognitive function. It also enhances the analgesic which is beneficial to patients' postoperative recovery. Therefore, GA+SA was a highly effective and safe anesthesia method for elderly patients with COPD, and it was worthy of clinical application.

Pulmonary Function Tests for the Prediction of Postoperative Pulmonary Complications–a Systematic Review

BACKGROUND

Pulmonary function tests (PFTs) such as spirometry and blood gas analysis have been claimed to improve preoperative risk assessment. This systematic review summarizes the available scientific literature regarding the ability of PFTs to predict postoperative pulmonary complications (PPC) in nonthoracic surgery.

METHODS

We systematically searched MEDLINE, CINAHL, and the Cochrane Library for pertinent original research articles (PROSPERO CRD42020215502), framed by the PIT-criteria (PIT, participants, index test, target conditions), respecting the PRISMA-DTA recommendations (DTA, diagnostic test accuracy).

RESULTS

46 original research studies were identified that used PFT-findings as index tests and PPC as target condition. QUADAS-2 quality assessment revealed a high risk of bias regarding patient selection, blinding, and outcome definitions. Qualitative synthesis of prospective studies revealed inconclusive study findings: 65% argue for and 35% against preoperative spirometry, and 43% argue for blood gas analysis. A (post-hoc) subgroup analysis in prospective studies with low-risk of selection bias identified a possible benefit in upper abdominal surgery (three studies with 959 participants argued for and one study with 60 participants against spirometry).

CONCLUSION

As the existing literature is inconclusive it is currently unknown if PFTs improve risk assessment before nonthoracic surgery. Spirometry should be considered in individuals with key indicators for chronic obstructive pulmonary disease (COPD) scheduling for upper abdominal surgery.

Chronic obstructive pulmonary disease is an independent risk factor for postoperative complications following operative treatment of distal radius fracture

PURPOSE

This study aimed to investigate the relationship between chronic obstructive pulmonary disease (COPD) and postoperative complications for patients receiving distal radius fracture (DRF) open reduction internal fixation (ORIF).

METHODS

From 2007 to 2018, patients undergoing operative treatment for distal radius fracture were identified in the National Surgical Quality Improvement Program database. Patients were separated into 2 cohorts: non-COPD and COPD patients. In this analysis, thirty-day postoperative complications evaluated included wound, cardiac, pulmonary, renal, thromboembolic, sepsis, mortality, urinary tract infections, postoperative transfusion, extended length of stay, reoperation, and readmission. Bivariate and multivariate analyses were performed.

RESULTS

Of 12,424 total patients who underwent operative treatment for distal radius fracture, 11,957 patients (96.2%) did not have a diagnosis of COPD and 467 (3.8%) had COPD. Following adjustment, compared to patients who did not have COPD, those with COPD had an increased risk of any postoperative complications (OR 2.160; p = 0.010), postoperative transfusion requirement (OR 17.437; p = 0.001), extended length of hospital stay greater than 3 days (OR 1.564; p = 0.038), and readmission (OR 2.515; p < 0.001).

CONCLUSION

COPD is an independent risk factor for any postoperative complication including transfusions, extended length of stay, and readmission for patients receiving DRF ORIF. Pulmonary evaluation would be a critical step in preoperative management and counseling of these patients before DRF ORIF.