Using Inspiratory Muscle Training to Improve Respiratory Strength, Functional Capacity, Fatigue, and Stress in Breast Cancer Patients Undergoing Surgery

Purpose

The main aim of the trial was to assess the effectiveness of inspiratory muscle training on respiratory muscle strength, functional capacity, fatigue, and stress in post-surgical breast cancer survivors.

Methods

Forty-seven females who had undergone unilateral post-mastectomy were randomly assigned to an intervention group (IG; n = 24) and a control group (CG; n = 23). Both groups received aerobic exercise training. In addition, the intervention group received inspiratory muscle training 3 days a week for 8 weeks. Maximum inspiratory and expiratory pressure (Pimax) (Pemex), 6-minute walk test, Handgrip strength by hand-held dynamometer, Fatigue Assessment Scale (FAS), and Perceived Stress Scale pss 10 values were measured before the training and then at the eighth week for both groups.

Results

No differences were detected between the groups in terms of sample and clinical characteristics 8 weeks post-intervention. In favor of the intervention group, a significant difference with medium to high effect size was found in terms of Pimax, Pemax, FAS, PS, and 6MWT (p < 0.05). However, there was no difference in terms of handgrip strength (p-value: 0.072), with a medium effect size (0.070). Regarding within-group comparisons, IG exhibited substantial differences in all outcome measures (p < 0.05) compared to CG, with the exception of PImax and 6MWT.

Conclusion

In post-operative breast cancer survivors, respiratory muscle training combined with aerobic training increases respiratory muscle strength and functional ability while lowering stress and tiredness.

The effectiveness of prehabilitation interventions on biopsychosocial and service outcomes pre and post upper gastrointestinal surgery: a systematic review

PURPOSE

This review synthesised the evidence for the effect of prehabilitation interventions on biopsychosocial and service outcomes.

MATERIALS AND METHODS

A systematic review was conducted. 10 databases were searched to December 2023. Prospective experimental studies exploring prehabilitation interventions in adults undergoing upper gastrointestinal surgery were included. Prehabilitation was any preoperative intervention to improve physical or psychological outcomes. Included studies required a comparator group or alternative preoperative intervention as well as baseline, presurgical and postoperative assessment points. Study quality was assessed using the Cochrane risk of bias tool (v.2). Data synthesis was narrative (SWiM guidance).

RESULTS

6028 studies were screened, with 25 studies included. Prehabilitation interventions were: inspiratory muscle training (five studies n = 450); exercise (nine studies n = 683); psychological (one study n = 400); and nutritional (ten studies n = 487). High quality studies showed preoperative improvements in impairments directly targeted by the interventions. Generally, these did not translate into functional or postoperative improvements, but multimodal interventions were more promising.

CONCLUSION

Current evidence supports prehabilitation as safe to preserve or improve preoperative function. Heterogeneity in outcomes and variable study quality means definitive conclusions regarding interventions are not yet possible, limiting implementation. Agreement of clinical outcomes and cost effectiveness evaluation is required.

Efficacy of Respiratory Muscle Training in the Immediate Postoperative Period of Cardiac Surgery: A Systematic Review and Meta-Analysis

INTRODUCTION

This study aimed to evaluate the efficacy of respiratory muscle training during the immediate postoperative period of cardiac surgery on respiratory muscle strength, pulmonary function, functional capacity, and length of hospital stay.

METHODS

This is a systematic review and meta-analysis. A comprehensive search on PubMed®, Excerpta Medica Database (or Embase), Cumulative Index of Nursing and Allied Health Literature (or CINAHL), Latin American and Caribbean Health Sciences Literature (or LILACS), Scientific Electronic Library Online (or SciELO), Physiotherapy Evidence Database (or PEDro), and Cochrane Central Register of Controlled Trials databases was performed. A combination of free-text words and indexed terms referring to cardiac surgery, coronary artery bypass grafting, respiratory muscle training, and clinical trials was used. A total of 792 studies were identified; after careful selection, six studies were evaluated.

RESULTS

The studies found significant improvement after inspiratory muscle training (IMT) (n = 165, 95% confidence interval [CI] 9.68, 21.99) and expiratory muscle training (EMT) (n = 135, 95% CI 8.59, 27.07) of maximal inspiratory pressure and maximal expiratory pressure, respectively. Also, IMT increased significantly (95% CI 19.59, 349.82, n = 85) the tidal volume. However, no differences were found in the peak expiratory flow, functional capacity, and length of hospital stay after EMT and IMT.

CONCLUSION

IMT and EMT demonstrated efficacy in improving respiratory muscle strength during the immediate postoperative period of cardiac surgery. There was no evidence indicating the efficacy of IMT for pulmonary function and length of hospital stay and the efficacy of EMT for functional capacity.

Prehabilitation: a narrative review focused on exercise therapy for the prevention of postoperative pulmonary complications following lung resection

Extensive preventive strategies in the perioperative period are popular worldwide. Novel "prehabilitation" approaches are being defined for every individual surgical discipline. With intention to reduce perioperative morbidity, "prehabilitation" was developed to increase "physical wellness" considering exercise capacity, nutritional status, and psychological support. Thus, prehabilitation could be well-suited for patients undergoing lung cancer surgery. Theoretically, improving physical condition may increase the chances of having a better post-operative course, especially among frail patients. In this review, we describe the concept of prehabilitation with possible benefits, its role in the Enhanced Recovery After Surgery protocols, and its potential for the future.

Inspiratory muscle training to reduce risk of pulmonary complications after coronary artery bypass grafting: a systematic review and meta-analysis

BACKGROUND

Pulmonary complications occur in a substantial proportion of patients who undergo coronary artery bypass grafting. Inspiratory muscle training (IMT), a simple, well-tolerated physical therapy, has been proposed to reduce the risk of complications, but its efficacy remains controversial.

METHOD

Randomized controlled trials (RCTs) examining the influence of IMT on the risk of pulmonary complications after coronary artery bypass grafting were identified from PubMed, Embase, CENTRAL, CINAL, and Web of Science through March 2023. Data were meta-analyzed for the primary outcomes of pulmonary complications, defined as pneumonia, pleural effusion, and atelectasis; and in terms of the secondary outcomes of maximum inspiratory pressure, maximum expiratory pressure, length of hospitalization, 6 min walk test, and peak expiratory flow and other outcomes. Risk of bias and quality of evidence assessments were carried out using the RoB 2.0 and Grading of Recommendations Assessment, Development and Evaluation (GRADE) applied to primary outcomes of pulmonary complications.

RESULTS

Data from eight RCTs involving 755 patients were meta-analyzed. IMT was associated with a significantly lower risk of postoperative pneumonia [relative risk (RR) 0.39, 95% confidence interval (CI) 0.25-0.62, P < 0.0001] and atelectasis (RR 0.43, 95% CI 0.27-0.67, P = 0.0002), but not pleural effusion (RR 1.09, 95% CI 0.62-1.93, P = 0.76). IMT was associated with significantly better maximum inspiratory pressure (preoperative: mean difference (MD) 16.55 cmH2O, 95% CI 13.86-19.24, P < 0.00001; postoperative: mean difference (MD) 8.99 cmH2O, 95% CI 2.39-15.60, P = 0.008) and maximum expiratory pressure (MD 7.15 cmH2O, 95% CI: 1.52-12.79, P = 0.01), and with significantly shorter hospitalization (MD -1.71 days, 95% CI -2.56 to -0.87, P < 0.001). IMT did not significantly affect peak expiratory flow or distance traveled during the 6 min walk test.

CONCLUSIONS

The available evidence from medium and high quality trials suggests that IMT can significantly decrease the risk of pneumonia and atelectasis after coronary artery bypass grafting while shortening hospitalization and improving the strength of respiratory muscles.

SYSTEMATIC REVIEW REGISTRATION

https://www.crd.york.ac.uk/prospero/, identifier: CRD42023415817.

Inspiratory Muscle Training in Patients in the Postoperative Phase of Cardiac Surgery: A Systematic Review and Meta-Analysis

To review the evidence about inspiratory muscle training (IMT) in patients in postoperative of cardiac surgery. We conducted this systematic review used the databases Ovid, LILACS, CINAHL, PubMed, PEDro, and CENTRAL. Randomized clinical trials that addressed IMT after cardiac surgery were selected. The outcomes assessed were maximum inspiratory pressure (MIP), maximum expiratory pressure (MEP), tidal volume (TV), peak expiratory flow (PEF), functional capacity (6-minute walk test) and length of hospital stay. The mean difference between groups and the respective 95% confidence interval (CI) were calculated and used to quantify the effect of continuous outcomes. Seven studies were selected. The IMT was superior to the control over MIP 15.77 cmH2O (95% CI, 5.95-25.49), MEP 15.87 cmH2O (95% CI, 1.16-30.58), PEF 40.98 L/min (95% CI, 4.64-77.32), TV 184.75 mL (95% CI, 19.72-349.77), hospital stay -1.25 days (95% CI, -1.77 to -0.72), but without impact on functional capacity 29.93 m (95% CI, -27.59 to 87.45). Based on the results presented, IMT was beneficial as a form of treatment for patients after cardiac surgery.

The anesthesia management of totally thoracoscopic cardiac surgery: A single-center retrospective study

Anesthesia management of Totally thoracoscopic cardiac surgery (TTCS) has been the subject of much debate and discussion. In this single center retrospective study, we summarize the experience of clinical anesthesia management for TTCS by review the medical records of our medical center and look forward to its future development. In this retrospective study, 103 patients (49 male and 54 female) were enrolled, the mean age was 56.7 ± 14.4 years old. The participants underwent Mitral Valve Replacement (MVR) + Tricuspid Valve Annuloplasty (TVA) (42, 40.8%), Mitral Valve Annuloplasty (MVA) + TVA (38, 36.9%), MVA (21, 20.4%), and MVR (2, 1.9%)，respectively. Intraoperative hypoxemia, radiographic pulmonary infiltrates, and pneumonia were observed in 19 (18.4%), 84 (81.6%), and 13 (12.6%) patients, respectively. The LOS of ICU and POD were as follows: MVR + TVA (55.1 ± 25h, 9.9 ± 3.5 d), MVA + TVA (56.5 ± 28.4h, 9.4 ± 4.2d), MVA (37.9 ± 21.9h, 8.1 ± 2.3d) and MVR (48 ± 4.2h, 7.5 ± 2.1d). No reintubation, reoperations, postoperative cognitive dysfunction, 30-day mortality were observed in the present study. The present study demonstrated that applying this anesthesia management for TTCS associated with acceptable morbidity, intensive care unit and postoperative hospital lengths of stay. The finding from the present study might provide some new approach for Anesthesia management of TTCS.

Implementation of a perioperative care App in elective thoracic surgery

INTRODUCTION

The design and implementation inconsistency of perioperative care programs limits their universalization, and it is where e-Health can standardize these processes. The objective of the study is to create a Smartphone App with a perioperative care program, implement it in a group of patients scheduled for a thoracic surgical procedure, and evaluates its use.

METHODS

A prospective and descriptive study. We created a Smartphone app (Fissios App) which contains 40 perioperative recommendations and 10 chest physical exercises. Patients were recommended to use it before and after surgery; to measure its use, we created and applied a questionnaire. A descriptive analysis of patient variables and questionnaire responses was performed and their association evaluated.

RESULTS

One hundred four patients were included, 60.3% were men with a median age of 62 years (51-71), and 26.72% had completed high school. The 89.3% of patients highlighted the ease of downloading and setting up the app. More than 90% of patients positively assessed clarity in explaining chest physical exercises and perioperative recommendations. One hundred four (79.4%) patients highlighted the contribution of the use of the app during the preoperative period to face the postoperative period.

CONCLUSIONS

We created a Smartphone app (Fissios App) with a perioperative care program and it was successfully implemented regardless of the age or educational level of patients. The tool clearly explains the information contained and the patients reported that its use before surgery helped them to face the postoperative period, with an appropriate level of physical demand and time of use.

The effect of Preoperative threshold inspiratory muscle training in adults undergoing cardiac surgery on postoperative hospital stay: a systematic review

BACKGROUND

Systematic reviews have reported benefits of preoperative inspiratory muscle training in adults undergoing cardiac surgery, however there have been inconsistencies with the devices used. Threshold devices generate a constant inspiratory load independent of respiratory rate.

OBJECTIVE

To assess the effect of preoperative inspiratory muscle training using threshold devices in adults undergoing cardiac surgery.

METHODS

A literature search was conducted across five electronic databases. Seven randomized controlled trials met the inclusion criteria and were critically appraised. The primary outcome was length of hospital stay. Secondary outcomes included postoperative pulmonary complications, quality of life and mortality.

RESULTS

Seven eligible randomized controlled trials were identified with a total of 642 participants. One study was a post hoc analysis of one of the included studies. Three out of five studies reported a decrease in length of postoperative hospital stay (p < 0.05). A significant reduction in postoperative pulmonary complications was reported by three studies (p < 0.05). There were concerns with bias across all papers.

CONCLUSIONS

Preoperative threshold inspiratory muscle training has potential to reduce postoperative length of hospital stay and pulmonary complications after cardiac surgery. The evidence on quality of life and mortality is inconclusive. The overall evidence for these conclusions may be influenced by bias.

Effectiveness of Nonpharmacological Interventions in the Field of Ventilation: An Umbrella Review

This umbrella review aimed to determine the effectiveness of nonpharmacological interventions in pulmonary ventilation and their impact on respiratory function. An individual with impaired ventilation displays visible variations manifested in their respiratory frequency, breathing rhythm ratio (I:E), thoracic symmetry, use of accessory muscles, dyspnea (feeling short of breath), oxygen saturation, diaphragm mobility, minute ventilation, peak flow, walking test, spirometry, Pimax/Pemax, diffusion, and respiratory muscle strength. Any variation in these markers demands the need for interventions in order to duly manage the signs and symptoms and to improve ventilation.

METHOD

Systematic reviews of the literature published in English, Spanish, French, and Portuguese were used, which included studies in which nonpharmacological interventions were used as a response to impaired ventilation in adults in any given context of the clinical practice. The recommendations given by the Joanna Briggs Institute (JBI) for umbrella reviews were followed. This research took place in several databases such as MEDLINE, CINAHL Complete, CINHAL, MedicLatina, ERIC, Cochrane Reviews (Embase), and PubMed. The Joanna Briggs critical analysis verification list was used for the systematic review. The data extraction was performed independently by two investigators based on the data extraction tools of the Joanna Briggs Institute, and the data were presented in a summary table alongside the support text.

RESULTS

Forty-four systematic reviews, thirty randomized clinical essays, and fourteen observational studies were included in this review. The number of participants varied between n = 103 and n = 13,370. Fifteen systematic revisions evaluated the effect of isolated respiratory muscular training; six systematic revisions evaluated, in isolation, breathing control (relaxed breathing, pursed-lip breathing, and diaphragmatic breathing exercises) and thoracic expansion exercises; and one systematic review evaluated, in isolation, the positions that optimize ventilation. Nineteen systematic reviews with combined interventions that reinforced the role of education and capacitation while also aiming for their success were considered. The articles analyzed isolated interventions and presented their efficacy. The interventions based on respiratory exercises and respiratory muscular training were the most common, and one article mentioned the efficacy of positioning in the compromisation of ventilation. Combined interventions in which the educational component was included were found to be effective in improving pulmonary function, diffusion, oxygenation, and functional capacity. The outcomes used in each study were variable, leading to a more difficult analysis of the data.

CONCLUSIONS

The interventions that were the focus of the review were duly mapped. The results suggest that nonpharmacological interventions used to optimize ventilation are effective, with a moderate to high level of evidence. There is a strong foundation for the use of the chosen interventions. The lack of studies on the intervention of "positioning to optimize ventilation" points out the need for a deeper analysis of its effects and for studies with a clear focus. This study supports the decisions and recommendations for the prescription of these interventions to patients with impaired ventilation.

Pneumonia After Cardiovascular Surgery: Incidence, Risk Factors and Interventions

Postoperative pneumonia (POP) is prevalent in patients undergoing cardiovascular surgery, associated with poor clinical outcomes, prolonged hospital stay and increased medical costs. This article aims to clarify the incidence, risk factors, and interventions for POP after cardiovascular surgery. A comprehensive literature search was performed to identify previous reports involving POP after cardiovascular surgery. Current situation, predictors and preventive measures on the development of POP were collected and summarized. Many studies showed that POP was prevalent in various cardiovascular surgical types, and predictors varied in different studies, including advanced age, smoking, chronic lung disease, chronic kidney disease, cardiac surgery history, cardiac function, anemia, body mass index, diabetes mellitus, surgical types, cardiopulmonary bypass time, blood transfusion, duration of mechanical ventilation, repeated endotracheal intubation, and some other risk factors. At the same time, several targeted interventions have been widely reported to be effective to reduce the risk of POP and improve prognosis, including preoperative respiratory physiotherapy, oral care and subglottic secretion drainage. Through the review of the current status, risk factors and intervention measures, this article may play an important role in clinical prevention and treatment of POP after cardiovascular surgery.

Guidelines on enhanced recovery after cardiac surgery under cardiopulmonary bypass or off-pump

OBJECTIVE

To provide recommendations for enhanced recovery after cardiac surgery (ERACS) based on a multimodal perioperative medicine approach in adult cardiac surgery patients with the aim of improving patient satisfaction, reducing postoperative mortality and morbidity, and reducing the length of hospital stay.

DESIGN

A consensus committee of 20 experts from the French Society of Anaesthesia and Intensive Care Medicine (Société française d'anesthésie et de réanimation, SFAR) and the French Society of Thoracic and Cardiovascular Surgery (Société française de chirurgie thoracique et cardio-vasculaire, SFCTCV) was convened. A formal conflict-of-interest policy was developed at the onset of the process and enforced throughout. The entire guideline process was conducted independently of any industry funding. The authors were advised to follow the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to guide the assessment of the quality of evidence.

METHODS

Six fields were defined: (1) selection of the patient pathway and its information; (2) preoperative management and rehabilitation; (3) anaesthesia and analgesia for cardiac surgery; (4) surgical strategy for cardiac surgery and bypass management; (5) patient blood management; and (6) postoperative enhanced recovery. For each field, the objective of the recommendations was to answer questions formulated according to the PICO model (Population, Intervention, Comparison, Outcome). Based on these questions, an extensive bibliographic search was carried out and analyses were performed using the GRADE approach. The recommendations were formulated according to the GRADE methodology and then voted on by all the experts according to the GRADE grid method.

RESULTS

The SFAR/SFCTCV guideline panel provided 33 recommendations on the management of patients undergoing cardiac surgery under cardiopulmonary bypass or off-pump. After three rounds of voting and several amendments, a strong agreement was reached for the 33 recommendations. Of these recommendations, 10 have a high level of evidence (7 GRADE 1+ and 3 GRADE 1-); 19 have a moderate level of evidence (15 GRADE 2+ and 4 GRADE 2-); and 4 are expert opinions. Finally, no recommendations were provided for 3 questions.

CONCLUSIONS

Strong agreement existed among the experts to provide recommendations to optimise the complete perioperative management of patients undergoing cardiac surgery.

Cardiac surgery in the morbidly obese

BACKGROUND

Obesity rates globally continue to rise and in turn the body mass index (BMI) of patients undergoing cardiac surgery is set to mirror this. Patients who are Class III obese (BMI ≥ 40) pose significant challenges to the surgical teams responsible for their care and are also at high risk of complications from surgery and even death. To improve outcomes in this population, interventions carried out in the preoperative, operative, and postoperative periods have shown promise. Despite this, there are no defined best practice national guidelines for perioperative management of obese patients undergoing cardiac surgery.

AIM

This review is aimed at clinicians and researchers in the field of cardiac surgery and aims to form a basis for the future development of clinical guidelines for the management of obese cardiac surgery patients.

METHODS

The PubMed database was utilized to identify relevant literature and strategies employed at various stages of the surgical journey were analyzed.

CONCLUSIONS

Data presented identified the benefits of preoperative respiratory muscle training, off-pump coronary artery bypass grafting where possible, and early extubation. Further randomized controlled trials are required to identify optimal operative and perioperative management strategies before the introduction of such guidance into clinical practice.

Postoperative exercise training improves the quality of life in patients receiving pulmonary resection: A systematic review and meta-analysis based on randomized controlled trials

PURPOSE

To evaluate whether postoperative exercise training is effective in improving clinical outcomes such as the quality of life (QoL), exercise capacity and respiratory function of patients receiving pulmonary resection.

DATA SOURCES

The PubMed, EMBASE, Web of Science and PEDro electronic databases were comprehensively searched to identify eligible randomized controlled trials (RCTs).

METHODS

The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines were followed. The primary outcome was postoperative QoL and secondary outcomes were exercise capacity and respiratory function.

RESULTS

A total of eight studies involving 691 participants were enrolled in this systematic review and meta-analysis. For the postoperative QoL measured by 36-Item Short Form Health Survey (SF-36), the pooled results demonstrated that postoperative exercise training could significantly improve the SF-36 physical domain score [weighted mean difference (WMD) = 5.87, 95% confidence interval (CI): 3.96 to 7.78, P＜0.001] and SF-36 mental domain score (WMD = 8.15, 95% CI: 0.13 to 16.16, P = 0.05). The results of further analysis for the eight dimensions of SF-36 were similar to the overall results. However, for secondary outcomes, no significant effects of postoperative exercise training on exercise capacity and respiratory function were observed.

CONCLUSION

Postoperative exercise training could significantly improve the QoL of patients undergoing lung surgery. However, more RCTs with large samples are still needed to verify the effects of postoperative exercise rehabilitation on clinical outcomes of patients who receive pulmonary resection.

Effectiveness of Inspiratory Muscle Training on Respiratory Muscle Strength in Patients Undergoing Cardiac Surgeries: A Systematic Review With Meta-Analysis

To determine the effect of inspiratory muscle training (IMT) on pulmonary function, respiratory muscle strength (RMS), and functional capacity in patients undergoing cardiac surgery. The PubMed, PEDro, CINAHL, Web of Science, CENTRAL, and EMBASE databases were searched from inception to June 2020. Randomized controlled trials (RCTs) that evaluated patients who underwent cardiac surgery were included in this review. Meta-analysis performed using a random-effects model showed that the mean difference in forced vital capacity, forced expiratory volume in 1 second, 6-minute walk distance, and RMS was 3.47% (95% confidence interval [CI], 0.57 to 6.36), 5.80% (95% CI, 2.03 to 9.56), 78.05 m (95% CI, 60.92 to 95.18), and 4.8 cmH2O (95% CI, -4.00 to 13.4), respectively. There is strong evidence that IMT improves inspiratory muscle strength, pulmonary function, and functional capacity, and reduces the length of hospital stay in patients undergoing cardiac surgery.

Effect of postoperative high load long duration inspiratory muscle training on pulmonary function and functional capacity after mitral valve replacement surgery: A randomized controlled trial with follow-up

Objectives

Although, pre-operative inspiratory muscle training has been investigated and reported to be an effective strategy to reduce postoperative pulmonary complications, the efficacy of postoperative inspiratory muscle training as well as the proper load, frequency, and duration necessary to reduce the postoperative pulmonary complications has not been fully investigated. This study was designed to investigate the effect of postoperative high-load long-duration inspiratory muscle training on pulmonary function, inspiratory muscle strength, and functional capacity after mitral valve replacement surgeries.

Design

Prospective randomized controlled trial.

Methods

A total of one hundred patients (mean age 38.3±3.29years) underwent mitral valve replacement surgery were randomized into experimental (n = 50) and control (n = 50) groups. The control group received conventional physiotherapy care, while experimental group received conventional care in addition to inspiratory muscle training, with 40% of the baseline maximal inspiratory pressure targeting a load of 80% by the end of the 8 weeks intervention protocol. Inspiratory muscle training started on the patient’s first day in the inpatient ward. Lung functions, inspiratory muscle strength, and functional capacity were evaluated using a computer-based spirometry system, maximal inspiratory pressure measurement and 6MWT respectively at 5 time points and a follow-up assessment was performed 6 months after surgery. Repeated measure ANOVA and post-hoc analyses were used (p <0.05).

Results

Group-time interactions were detected for all the studied variables (p<0.001). Between-group analysis revealed statistically significant postoperative improvements in all studied variables in the experimental group compared to the control group (p <0.001) with large effect size of η² ˃0.14. Within-group analysis indicated substantial improvements in lung function, inspiratory pressure and functional capacity in the experimental group (p <0.05) over time, and these improvements were maintained at follow-up.

Conclusion

High intensity, long-duration postoperative inspiratory muscle training is highly effective in improving lung function, inspiratory muscle strength, and functional capacity after mitral valve replacement surgeries.

Changes and prognostic value of cardiopulmonary exercise testing parameters in elderly patients undergoing cardiac rehabilitation: The EU-CaRE observational study

Objective

We aimed 1) to test the applicability of the previously suggested prognostic value of CPET to elderly cardiac rehabilitation patients and 2) to explore the underlying mechanism of the greater improvement in exercise capacity (peak oxygen consumption, VO₂) after CR in surgical compared to non-surgical cardiac patients.

Methods

Elderly patients (≥65 years) commencing CR after coronary artery bypass grafting, surgical valve replacement (surgery-group), percutaneous coronary intervention, percutaneous valve replacement or without revascularisation (non-surgery group) were included in the prospective multi-center EU-CaRE study. CPETs were performed at start of CR, end of CR and 1-year-follow-up. Logistic models and receiver operating characteristics were used to determine prognostic values of CPET parameters for major adverse cardiac events (MACE). Linear models were performed for change in peak VO₂ (start to follow-up) and parameters accounting for the difference between surgery and non-surgery patients were sought.

Results

1421 out of 1633 EU-CaRE patients performed a valid CPET at start of CR (age 73±5.4, 81% male). No CPET parameter further improved the receiver operation characteristics significantly beyond the model with only clinical parameters. The higher improvement in peak VO₂ (25% vs. 7%) in the surgical group disappeared when adjusted for changes in peak tidal volume and haemoglobin.

Conclusion

CPET did not improve the prediction of MACE in elderly CR patients. The higher improvement of exercise capacity in surgery patients was mainly driven by restoration of haemoglobin levels and improvement in respiratory function after sternotomy.

Trial registration

Netherlands Trial Register, Trial NL5166.

Evaluation of respiratory and peripheral muscle training in individuals undergoing myocardial revascularization

OBJECTIVES

To investigate the effect of peripheral muscle strength training (PMT) and respiratory muscle strength training (RMT) muscle strength training associated with conventional physical therapy on the respiratory muscle strength, functional capacity, and quality of life in the immediate postoperative period of patients undergoing coronary artery bypass graft (CABG).

METHODS

This was a randomized controlled trial. Eighty-three patients undergoing CABG were divided into two groups: Intervention group, patients that received PMT and RMT associated with conventional physical therapy, one session a day for 5 days; control group, patients that received conventional physical therapy, one session a day for 5 days. All patients had respiratory muscle strength, peripheral muscle strength, functional capacity, and quality of life evaluated by manovacuometry, dynamometry, 6-min walking test, and 36-item Short-Form Health Survey Questionnaire, respectively, before and 5 days after CABG.

RESULTS

Both groups showed a significantly reduced respiratory muscle strength after CABG; however, in the intervention group, the inspiratory muscle strength reduction was lower (confidence interval [CI] 95%: 2.29 [1.9; 27.54]). The quality of live domains for pain (CI 95%: 3.08 [5.21; 24.97]) and vitality perception (CI 95%: 2.51 [2.12; 19.53]) worsened in the control and improved in the intervention group (pain: CI 95%: 1.19 [-3.38; 13.09]; vitality CI 95%: 0.07 [-6.55; 7.04]). Both groups showed reduced functional capacity and expiratory muscle strength after CABG.

CONCLUSION

Conventional physical therapy combined with PMT and RMT may reduce inspiratory muscle strength loss and improve pain and vitality perception in the immediate postoperative period after CABG.

Inspiratory Muscle Weakness is Related to Poor Short-Term Outcomes for Heart Transplantation

INTRODUCTION

In heart transplantation (HT) recipients, several factors are critical to promptly adopting appropriate rehabilitation strategies and may be important to predict outcomes way after surgery. This study aimed to determine preoperative patient-related risk factors that could adversely affect the postoperative clinical course of patients undergoing HT.

METHODS

Twenty-one hospitalized patients with heart failure undergoing HT were evaluated according to respiratory muscle strength and functional capacity before HT. Mechanical ventilation (MV) time, reintubation rate, and intensive care unit (ICU) length of stay were recorded, and assessed postoperatively.

RESULTS

Inspiratory muscle strength as absolute and percentpredicted values were strongly correlated with MV time (r=-0.61 and r=-0.70, respectively, at P<0.001). Concerning ICU length of stay, only maximal inspiratory pressure (MIP) absolute and percent-predicted values were significantly associated. The absolute |MIP| was significantly negatively correlated with ICU length of stay (r=-0.58 at P=0.006) and the percent-predicted MIP was also significantly negatively correlated with ICU length of stay (r=-0.68 at P=0.0007). No associations were observed between preoperative functional capacity, age, sex, and clinical characteristics and MV time and ICU length of stay in the cohort included in this study. Patients with respiratory muscle weakness had a higher prevalence of prolonged MV, reintubation, and delayed ICU length of stay.

CONCLUSION

An impairment of preoperative MIP was associated with poorer short-term outcomes following HT. As such, inspiratory muscle strength is an important clinical preoperative marker in patients undergoing HT.

The Safety and Efficacy of Inspiratory Muscle Training for Patients With Acute Myocardial Infarction Undergoing Percutaneous Coronary Intervention: Study Protocol for a Randomized Controlled Trial

Background: Uncommonly high rates of pneumonia in patients with acute myocardial infarction (AMI) undergoing primary percutaneous coronary intervention (PCI) have been observed during recent years. Inspiratory muscle training (IMT) could reduce pneumonia in patients undergoing coronary artery bypass grafting and other cardiac surgeries. The relationship between IMT and AMI is unknown. Here, we describe the feasibility and potential benefit of IMT in patients at high risk for pneumonia with AMI who have undergone primary PCI.

Methods: Our study is a prospective, randomized, controlled, single-center clinical trial. A total of 60 participants will be randomized into an IMT group and control group with 30 participants in each group. Participants in the IMT group will undergo training for 15 min per session, twice a day, from 12 to 24 h after primary PCI, until 30 days post-randomization; usual care will be provided for the control group. The primary endpoint is the change in inspiratory muscle strength, the secondary endpoint included feasibility, pneumonia, major adverse cardiovascular events, length of stay, pulmonary function tests measure, and quality of life.

Discussion: Our study is designed to evaluate the feasibility of IMT and its effectiveness in improving inspiratory muscle strength in participants with AMI who have undergone primary PCI.

Clinical Trial Registration:www.ClinicalTrials.gov, identifier: NCT04491760.

A six-week inspiratory muscle training and aerobic exercise improves respiratory muscle strength and exercise capacity in lung cancer patients after video-assisted thoracoscopic surgery: A randomized controlled trial

OBJECTIVE

To compare the postoperative outcomes of inspiratory muscle training and aerobic exercise, along with standard care, on lung cancer patients undergoing video-assisted thoracoscopic surgery (VATS).

DESIGN

A parallel-group, single-blind randomized clinical trial.

SETTING

Thoracic surgery ward and outpatient clinic in a teaching hospital.

SUBJECTS

Overall 63 patients underwent VATS were randomly assigned to a triaging (TG, n = 32) or control group (CG, n = 31). A total of 54 patients (TG, n = 26; CG, n = 28) completed the study.

INTERVENTION

TG: six-week threshold inspiratory muscle training and aerobic exercise. CG: standard care.

MAIN MEASURES

Maximum inspiratory pressure (PImax), maximum expiratory pressure (PEmax) lung expansion volume, and 6-min walking test (6MWT) were performed on the day of chest tube removal (baseline), and 2, 6, and 12 weeks postoperatively.

RESULTS

The TG showed significant improvement in PImax at week 6 (71.6 ± 34.9 vs. 94.3 ± 32.8 cmH₂O, P = 0.018), PEmax at week 2 (70.9 ± 24.3 vs. 90.9 ± 28.2 cmH₂O, P = 0.015) and week 12 (76.1 ± 20.2 vs. 98.6 ± 35.3 cmH₂O, P = 0.012), the lung expansion volume at week 2 (1080 ± 433 vs 1457 ± 624 mL, P = 0.02) and week 12 (1200 ± 387 vs 1885 ± 678 mL, P < 0.001), in addition to the 6MWT at week 2 (332 ± 78 vs 412 ± 74 m, P = 0.002), week 6 (360 ± 70 vs 419 ± 60 m, P = 0.007) and week 12 (360 ± 58 vs 402 ± 65 m, P = 0.036).

CONCLUSION

A six weeks of inspiratory muscle training and aerobic exercise had improved respiratory muscle strength and aerobic exercise postoperatively in lung cancer patients after VATS as early as 2 weeks.

EFFECT OF PREOPERATIVE RESPIRATORY REHABILITATION IN PATIENTS UNDERGOING CARDIAC SURGERY

The aim of the study was to evaluate the effects of preoperative respiratory rehabilitation on functional capacity, length of stay in intensive care unit (ICU), duration of mechanical ventilation (MV) and total hospitalization, as well as to estimate arterial blood gas (ABG) values in patients undergoing cardiac surgery. Nineteen patients were included in the randomized observational study, divided into two groups: group A (intervention) and B (control). Preoperative and postoperative rehabilitation was performed in group A, and only postoperative rehabilitation in group B. Rehabilitation was carried out according to a predefined protocol. We used ABG to evaluate respiratory function, two-minute walk test (2MWT) and sit-to-stand test to assess functional capacity. The following data were obtained from medical documentation: duration of MV, length of stay at ICU, occurrence of postoperative pulmonary complications, and length of total hospitalization in both groups. Significant between-group difference was found for the length of total hospitalization and duration of MV (p<0.05 both). Analysis of the mean values of 2MWT on the last day of hospitalization (p=0.005), sit-to-stand test before surgery (p=0.022) and on the last day of hospitalization (p=0.008) showed statistically significant differences. The length of hospital stay significantly correlated with preoperative rehabilitation in group A (r=0.885; p<0.0001). There was no difference in ABG parameters between the groups. The study showed that preoperative respiratory rehabilitation had an effect on reducing duration of MV and length of total hospitalization, and improved functional capacity.

Inspiratory Muscle Training Based on Anaerobic Threshold on the Functional Capacity of Patients After Coronary Artery Bypass Grafting: Clinical Trial

INTRODUCTION

Coronary artery bypass grafting (CABG) is associated with reduced ventilatory muscle strength and consequent worsening of functional capacity (FC). Inspiratory Muscle Training (IMT) can be indicated, but there is still a lack of knowledge about the use of the anaerobic threshold (AT) as a basis for prescription. The objective of this study is to evaluate if IMT based on AT modifies FC and inspiratory muscle strength of patients submitted to CABG.

METHODS

This is a clinical trial. On the first postoperative day, the patients were divided into two groups: the conventional group (IMT-C), which performed IMT based on 40% of maximal inspiratory pressure (MIP), and the IMT-AT group, which performed IMT based on AT. All patients underwent preoperative and postoperative assessment of MIP and performed a six-minute walk test (6MWT).

RESULTS

Forty-two patients were evaluated, 21 in each group. Their mean age was 61.4±10 years and 27 (64%) of them were male. There was a reduction of inspiratory muscle strength with a delta of 23±13 cmH2O in the IMT-C group vs. 11±10 cmH2O in the IMT-AT group (P<0.01) and of the walking distance with a delta of 94±34 meters in the IMT-C group vs. 57±30 meters in the IMT-AT group (P=0.04).

CONCLUSION

IMT based on AT minimized the loss of FC and inspiratory muscle strength of patients submitted to CABG.

Coronary Artery Bypass Grafting Among Older Adults: Patterns, Outcomes, and Trends

INTRODUCTION

Although the numbers of older adults in the US are rapidly increasing, there is sparse recent data on the use and outcomes of coronary artery bypass grafting (CABG) among this population. We aimed to evaluate the characteristics and outcomes of older adults undergoing CABG and to measure temporal trends.

MATERIALS AND METHODS

Using data from the National Inpatient Sample (2005-2014), patients aged 85 y and older who underwent CABG were selected. Demographic, clinical, and hospital characteristics were extracted. Outcomes measured were hospital mortality, hospital length of stay, discharge home, and operative complications. Patients were grouped by 2-year increments. Differences in clinical characteristics and outcomes over time were evaluated using trend analyses.

RESULTS

There were 60,124 patients included in the cohort. The mean age was 86.8 y with majority being men (61%), white (88%), and treated in teaching hospitals (61%). Over the study period, the annual surgical volume decreased from 6689 in 2005/06 to 5150 in 2013/14. Mortality decreased from 8.5% to 5.5% (P-trend <0.001) and mean hospital length of stay decreased from 13.9 d to 12.0 d (P-trend <0.001), whereas the rate of discharge home remained stable (14.1% versus 11.6%, P-trend = 0.056). Compared with patients in 2005/06, those in 2013/14 had higher comorbidities [diabetes: 27.6% versus 17.3%; chronic kidney disease: 29.8% versus 9.2%; peripheral artery disease: 7.5% versus 6.0%; and hypertension: 83.7% versus 64.5% (all P-trend <0.001)].

CONCLUSIONS

CABG volumes are decreasing among older adults, and comorbidity burden is increasing, but outcomes are improving. These data may indicate improved preoperative optimization and better perioperative care processes.

Preoperative Treatment of Malnutrition and Sarcopenia in Cardiac Surgery: New Frontiers

Cardiac surgery is performed more often in a population with an increasing number of comorbidities. Although these surgeries can be lifesaving, they disturb homeostasis and may induce a temporary overall loss of physiologic function. The required postoperative intensive care unit and hospital stay often lead to a mid- to long-term decline of nutritional and physical status, mental health, and health-related quality of life. Prehabilitation before elective surgery might be an opportunity to optimize the state of the patient. This article discusses current evidence and potential effects of preoperative optimization of nutrition and physical status before cardiac surgery.

The effects of five days of intensive preoperative inspiratory muscle training on postoperative complications and outcome in patients having cardiac surgery: a randomized controlled trial

OBJECTIVE

To determine the prophylactic efficacy of short-term intensive preoperative inspiratory muscle training on the incidence of postoperative pulmonary complications in patients scheduled for cardiac surgery.

DESIGN

Single-blind, randomized controlled pilot study.

SETTING

TEDA International Cardiovascular Hospital, China.

SUBJECTS

In total, 197 subjects aged ⩾50 years scheduled for cardiac surgery were selected.

INTERVENTION

The intervention group ( n = 98) received five days of preoperative inspiratory muscle training on top of the usual care received by the patients in the control group ( n = 99).

MAIN MEASURES

The primary outcome variable was the occurrence of postoperative pulmonary complications. The secondary outcome variables were inspiratory muscle strength, lung function and length of hospitalization.

RESULTS

After cardiac surgery, a total of 10 (10.2%) of the 98 patients in the intervention group and 27 (27.3%) of 99 patients in the control group had postoperative pulmonary complications (risk ratio, 0.23; 95% confidence interval (CI), 0.09-0.58, P = 0.002). The study revealed that, compared with the control group, the intervention group had a significant increase in inspiratory muscle strength (by 10.48 cm H₂O, P < 0.001), forced expiratory volume in the first second of expiration (FEV1) %predicted (by 3.75%, P = 0.030), forced vital capacity (FVC) %predicted (by 4.15%, P = 0.008) and maximal voluntary ventilation (MVV) %predicted (by 6.44%, P = 0.034). Length of hospital stay was 7.51 (2.83) days in the intervention group and 9.38 (3.10) days in the control group ( P = 0.039).

CONCLUSION

A five-day intensive pattern of preoperative inspiratory muscle training reduced the incidence of postoperative pulmonary complications and duration of postoperative hospitalization in patients undergoing cardiac surgery.

Combination of preoperative pulmonary and nutritional preparation for esophagectomy

PURPOSE

To compare pulmonary and nutritional parameters before and after inspiratory muscle training (IMT) and enteral feeding support in patients with esophageal disease undergoing preoperative outpatient follow-up.

METHODS

Thirty patients with a mean age of 55.83 years, 16 men and 14 women, were included. Pulmonary assessment consisted of the measurement of MIP, MEP, and spirometry. Anthropometric measurements and laboratory tests were performed for nutritional assessment. After preoperative evaluation, inspiratory muscle training and enteral nutrition support were started. A p<0.05 was considered statistically significant.

RESULTS

After an outpatient follow-up period of 4 weeks, a significant increase in MIP (-62.20 ± 25.78 to -81.53 ± 23.09), MEP (73.4 ± 31.95 to 90.33 ± 28.39), and FVC (94.86 ± 16.77 to 98.56 ± 17.44) was observed. Regarding the anthropometric variables, a significant increase was also observed in BMI (20.18 ± 5.04 to 20.40 ± 4.69), arm circumference (23.38 ± 3.28 to 25.08 ± 4.55), arm muscle circumference (21.48 ± 3.00 to 22.07 ± 3.36), and triceps skinfold thickness (5.62 ± 2.68 to 8.33 ± 6.59).

CONCLUSION

Pulmonary and nutritional preparation can improve respiratory muscle strength, FVC and anthropometric parameters. However, further studies are needed to confirm the effectiveness of this preoperative preparation.

Multicentre randomized clinical trial of inspiratory muscle training versus usual care before surgery for oesophageal cancer

Background

Up to 40 per cent of patients undergoing oesophagectomy develop pneumonia. The aim of this study was to assess whether preoperative inspiratory muscle training (IMT) reduces the rate of pneumonia after oesophagectomy.

Methods

Patients with oesophageal cancer were randomized to a home-based IMT programme before surgery or usual care. IMT included the use of a flow-resistive inspiratory loading device, and patients were instructed to train twice a day at high intensity (more than 60 per cent of maximum inspiratory muscle strength) for 2 weeks or longer until surgery. The primary outcome was postoperative pneumonia; secondary outcomes were inspiratory muscle function, lung function, postoperative complications, duration of mechanical ventilation, length of hospital stay and physical functioning.

Results

Postoperative pneumonia was diagnosed in 47 (39·2 per cent) of 120 patients in the IMT group and in 43 (35·5 per cent) of 121 patients in the control group (relative risk 1·10, 95 per cent c.i. 0·79 to 1·53; P = 0·561). There was no statistically significant difference in postoperative outcomes between the groups. Mean(s.d.) maximal inspiratory muscle strength increased from 76·2(26·4) to 89·0(29·4) cmH2O (P &lt; 0·001) in the intervention group and from 74·0(30·2) to 80·0(30·1) cmH2O in the control group (P &lt; 0·001). Preoperative inspiratory muscle endurance increased from 4 min 14 s to 7 min 17 s in the intervention group (P &lt; 0·001) and from 4 min 20 s to 5 min 5 s in the control group (P = 0·007). The increases were highest in the intervention group (P &lt; 0·050).

Conclusion

Despite an increase in preoperative inspiratory muscle function, home-based preoperative IMT did not lead to a decreased rate of pneumonia after oesophagectomy. Registration number: NCT01893008 (https://www.clinicaltrials.gov).

Safety and efficacy of inspiratory muscle training for preventing adverse outcomes in patients at risk of prolonged hospitalisation

Background

The early institution of inspiratory muscle training on hospitalised patients with no established respiratory deficits could prevent in-hospital adverse outcomes that are directly or indirectly associated to the loss of respiratory muscle mass inherent to a prolonged hospital stay. The objective of the clinical trial is to assess the impact of inspiratory muscle training on hospital inpatient complications.

Methods

This is a double-blind randomised controlled trial. Subjects in the intervention group underwent an inspiratory muscle training loaded with 50% maximum inspiratory pressure twice daily for 4 weeks from study enrolment. Patients were randomly assigned to an inspiratory muscle training group or a sham inspiratory muscle training group. All patients received conventional physiotherapy interventions. Baseline and post-intervention respiratory and peripheral muscle strength, functionality (performance of activities of daily living), length of hospital stay, and death were evaluated. Clinical outcomes were assessed until hospital discharge. This study was approved by the Institutional Hospital Ethics Committee (03/2014).

Results

Thirty-one patients assigned to the inspiratory muscle training group and 34 to the sham inspiratory muscle training group were analysed. Patients in the inspiratory muscle training group had a shorter mean length of hospital stay (35.3 ± 2.7 vs. 41.8 ± 3.5 days, p < 0.01) and a lower risk of endotracheal intubation (relative risk (RR) = 0.36; 95% confidence interval (CI) 0.27–0.97; p = 0.03) as well as muscle weakness (RR = 0.36; 95% CI 0.19–0.98; p = 0.02) and mortality (RR = 0.23; 95% CI 0.2–0.94; p = 0.04). The risk of adverse events did not differ significantly between groups.

Conclusion

Inspiratory muscle training was a protective factor against endotracheal intubation, muscle weakness, and mortality.

Trial registration

ClinicalTrials.gov, ID: NCT02459444. Registered on 19 May 2015.