Preoperative Maximal Oxygen Uptake and Exercise-induced Changes in Pulse Oximetry Predict Early Postoperative Respiratory Complications in Lung Cancer Patients

The association between cardiopulmonary exercise testing and postoperative outcomes in patients with lung cancer undergoing lung resection surgery: A systematic review and meta-analysis

BACKGROUND

Exercise capacity should be determined in all patients undergoing lung resection for lung cancer surgery and cardiopulmonary exercise testing (CPET) remains the gold standard. The purpose of this study was to investigate associations between preoperative CPET and postoperative outcomes in patients undergoing lung resection surgery for lung cancer through a review of the existing literature.

METHODS

A search was conducted on PubMed, Scopus, Cochrane Library and CINAHL from inception until December 2022. Studies investigating associations between preoperative CPET and postoperative outcomes were included. Risk of bias was assessed using the QUIPS tool. A random effect model meta-analysis was performed. I2 > 40% indicated a high level of heterogeneity.

RESULTS

Thirty-seven studies were included with 6450 patients. Twenty-eight studies had low risk of bias. [Formula: see text] peak is the oxygen consumption at peak exercise and serves as a marker of cardiopulmonary fitness. Higher estimates of [Formula: see text] peak, measured and as a percentagege of predicted, showed significant associations with a lower risk of mortality [MD: 3.66, 95% CI: 0.88; 6.43 and MD: 16.49, 95% CI: 6.92; 26.07] and fewer complications [MD: 2.06, 95% CI: 1.12; 3.00 and MD: 9.82, 95% CI: 5.88; 13.76]. Using a previously defined cutoff value of > 15mL/kg/min for [Formula: see text] peak, showed evidence of decreased odds of mortality [OR: 0.55, 95% CI: 0.28-0.81] and but not decreased odds of postoperative morbidity [OR: 0.82, 95% CI: 0.64-1.00]. There was no relationship between [Formula: see text] slope, which depicts ventilatory efficiency, with mortality [MD: -9.60, 95% CI: -27.74; 8.54] however, patients without postoperative complications had a lower preoperative [Formula: see text] [MD: -2.36, 95% CI: -3.01; -1.71]. Exercise load and anaerobic threshold did not correlate with morbidity or mortality. There was significant heterogeneity between studies.

CONCLUSIONS

Estimates of cardiopulmonary fitness as evidenced by higher [Formula: see text] peak, measured and as a percentage of predicted, were associated with decreased morbidity and mortality. A cutoff value of [Formula: see text] peak > 15mL/kg/min was consistent with improved survival but not with fewer complications. Ventilatory efficiency was associated with decreased postoperative morbidity but not with improved survival. The heterogeneity in literature could be remedied with large scale, prospective, blinded, standardised research to improve preoperative risk stratification in patients with lung cancer scheduled for lung resection surgery.

Exercise testing and postoperative complications after minimally invasive lung resection: A cohort study

Background: Peak oxygen uptake (V˙O2) during cardiospulmonary exercise testing (CPET) is used to stratify postoperative risk following lung cancer resection but peak V˙O2 thresholds to predict post-operative mortality and morbidity were derived mostly from patients who underwent thoracotomy.

Objectives: We evaluated whether peak V˙O2 or other CPET-derived variables predict post-operative mortality and cardiopulmonary morbidity after minimally invasive video-assisted thoracoscopic surgery (VATS) for lung cancer resection.

Methods: A retrospective analysis of patients who underwent VATS lung resection between 2002 and 2019 and in whom CPET was performed. Logistic regression models were used to determine predictors of postoperative outcomes until 30 days after surgery. The ability of peak V˙O2 to discriminate between patients with and without post-operative complications was evaluated using Receiver operating characteristic (ROC) analysis.

Results: Among the 593 patients, postoperative cardiopulmonary complications occurred in 92 (15.5%) individuals, including three deaths. Mean peak V˙O2 was 18.8 ml⋅kg⁻¹⋅min⁻¹, ranging from 7.0 to 36.4 ml⋅kg⁻¹⋅min⁻¹. Best predictors of postoperative morbidity and mortality were peripheral arterial disease, bilobectomy or pneumonectomy (versus sublobar resection), preoperative FEV₁, peak V˙O2 , and peak V˙E/V˙CO2. The proportion of patients with peak V˙O2 of < 15 ml⋅kg⁻¹⋅min⁻¹, 15 to < 20 ml⋅kg⁻¹⋅min⁻¹ and ≥ 20 ml⋅kg⁻¹⋅min⁻¹ experiencing at least one postoperative complication was 23.8, 16.3 and 10.4%, respectively. The area under the ROC curve for peak V˙O2 was 0.63 (95% CI: 0.57–0.69).

Conclusion: Although lower peak V˙O2 was a predictor of postoperative complications following VATS lung cancer resection, its ability to discriminate patients with or without complications was limited.

Effectiveness of Perioperative Cardiopulmonary Rehabilitation in Patients With Lung Cancer Undergoing Video-Assisted Thoracic Surgery

Objectives

Patients with lung cancer pose a high risk of morbidity and mortality after lung resection. Those who receive perioperative cardiopulmonary rehabilitation (PRCR) have better prognosis. Peak oxygen consumption (peak VO₂), VO₂ at the ventilatory threshold (VO₂ at VT), and slope of minute ventilation to carbon dioxide production (V_E/V_CO2 slope) measured during pre-surgical cardiopulmonary exercise testing (CPET) have prognostic values after lung resection. We aimed to investigate the influence of individualized PRCR on postoperative complications in patients undergoing video-assisted thoracic surgery (VATS) for lung cancer with different pre-surgical risks.

Methods

This was a retrospective study. We recruited 125 patients who underwent VATS for lung cancer between 2017 and 2021. CPET was administered before surgery to evaluate the risk level and PRCR was performed based on the individual risk level defined by peak VO2, VO2 at VT, and VE/VCO2 slope, respectively. The primary outcomes were intensive care unit (ICU) and hospital lengths of stay, endotracheal intubation time (ETT), and chest tube insertion time (CTT). The secondary outcomes were postoperative complications (PPCs), including subcutaneous emphysema, pneumothorax, pleural effusion, atelectasis, infection, and empyema.

Results

Three intergroup comparisons based on the risk level by peak VO2 (3 groups), VO2 at VT (2 groups), and VE/VCO2 slope (3 groups) were done. All of the comparisons showed no significant differences in both the primary and secondary outcomes (p = 0.061–0.910).

Conclusion

Patients with different risk levels showed comparable prognosis and PPCs after undergoing CPET-guided PRCR. PRCR should be encouraged in patients undergoing VATS for lung cancer.

Telerehabilitation physical exercise for patients with lung cancer through the course of their disease: A systematic review

BACKGROUND AND OBJECTIVE

Evidence is shown for the benefits of physical activity, for patients with lung cancer, at different times through the course of the disease. Telerehabilitation can overcome some of barriers often met by patients to practice physical activity. The objective of this systematic review is to assess feasibility and safety of telerehabilitation for patients with lung cancer, its effects on physical capacity, quality of life, symptoms severity, depression and anxiety, survival, lung function, post-operative outcomes, dyspnoea and body composition. Secondary aim was to distinguish the telerehabilitation efficacy between the different phases of the disease.

DATA SOURCE AND SELECTION CRITERIA

Pubmed, PEDro, Scopus, ScienceDirect, randomized controlled trials and non-randomized controlled trials, written in French or English, of telerehabilitation among patients with lung cancer.

RESULTS

Eight studies were included. Telerehabilitation is safe but was characterized by a low recruitment and attendance rate (<70%). It enhances quality of life, muscle mass, depression and anxiety but it does not improve physical capacity (except in preoperative period), symptoms severity, survival, lung function or dyspnoea. After surgery, it ameliorates quality of life, depression and anxiety. During systemic treatments of lung cancer, it improves quality of life, symptoms severity and muscle mass.

CONCLUSION

Telerehabilitation could be proposed in patients with lung cancer as a complementary intervention of hospital-based programme to increase physical activity volume, compliance and self-efficacy. In case the classic programmes are not possible, it could also be an alternative approach for patients unable to participate to a hospital or community-based training programme.

Preoperative Cardiopulmonary Exercise Test Associated with Postoperative Outcomes in Patients Undergoing Cancer Surgery: A Systematic Review and Meta-Analyses

BACKGROUNDS

There is mixed evidence on the value of preoperative cardiorespiratory exercise test (CPET) to predict postoperative outcomes in patients undergoing a cancer surgical procedure. The purpose of this review was to investigate the association between preoperative CPET variables and postoperative complications, length of hospital stay, and quality of life in patients undergoing cancer surgery.

METHODS

A search was conducted on MEDLINE, Embase, AMED, and Web of science from inception to April 2020. Cohort studies investigating the association between preoperative CPET variables, including peak oxygen uptake (peak VO₂), anaerobic threshold (AT), or ventilatory equivalent for carbon dioxide (V_E/V_CO2), and postoperative outcomes (complications, length of stay, and quality of life) were included. Risk of bias was assessed using the QUIPS tool. A random-effect model meta-analysis was performed whenever possible.

RESULTS

Fifty-two unique studies, including 10,030 patients were included. Overall, most studies were rated as having low risk of bias. Higher preoperative peak VO₂ was associated with absence of postoperative complications (mean difference [MD]: 2.28; 95% confidence interval [CI]: 1.26-3.29) and no pulmonary complication (MD: 1.47; 95% CI: 0.49-2.45). Preoperative AT and V_E/V_CO2 also demonstrated some positive trends. None of the included studies reported a negative trend.

CONCLUSIONS

This systematic review and meta-analysis demonstrated a significant association between superior preoperative CPET values, especially peak VO₂, and better postoperative outcomes. The assessment of preoperative functional capacity in patients undergoing cancer surgery has the potential to facilitate treatment decision making.

Associations between pretreatment physical performance tests and treatment complications in patients with non-small cell lung cancer: A systematic review

This systematic review evaluated which outcome variables and cut-off values of pretreatment exercise tests are associated with treatment complications in patients with stage I-III non-small cell lung cancer (NSCLC). PRISMA and Cochrane guidelines were followed. A total of 38 studies with adult patients undergoing treatment for stage I-III NSCLC who completed pretreatment exercise tests, and of whom treatment-related complications were recorded were included. A lower oxygen uptake at peak exercise amongst several other variables on the cardiopulmonary exercise test and a lower performance on field tests, such as the incremental shuttle walk test, stair-climb test, and 6-minute walk test, were associated with a higher risk for postoperative complications and/or postoperative mortality. Cut-off values were reported in a limited number of studies and were inconsistent. Due to the variety in outcomes, further research is needed to evaluate which outcomes and cut-off values of physical exercise tests are most clinically relevant.

Preoperative Peak Oxygen Consumption: A Predictor of Survival in Resected Lung Cancer

The peak oxygen consumption (VO₂ peak) serves as a prognostic factor in cardio-respiratory diseases and plays an important role in cancer patients. The long-term prognostic relevance of VO₂ peak in lung cancer patients has not been investigated extensively. The aim of this study was to evaluate the impact of the preoperative VO₂ peak on the postoperative long-term survival in patients with operated lung cancer. Retrospective analysis of 342 patients with curatively resected non-small-cell lung cancer using a multivariate Cox proportional hazard model. Results: Preoperative VO₂ peak ranged from 10.2 to 51.8 mL/kg/min (mean: 18.3 ± 4.6), VO₂ peak % of predicted ranged from 32 to 172% (mean: 65.2 ± 18.0%). Overall 10-year survival was 23%. A Log-rank test comparing predicted VO₂ peak ≥ 60% with predicted VO₂ peak < 60% showed overall survival of 30% and 17%, respectively (p < 0.001) and non-tumour-related survival of 71% and 51% (p = 0.001) at 10 years. In multivariable Cox analysis, overall 10-year survival correlated with a high predicted VO₂ peak% (p = 0.001) and low N-stage corresponding to N0 and N1 (p < 0.001). Non-tumour-related death correlated with low VO₂ peak% of predicted (p = 0.001), and age (p < 0.001). Low preoperative VO₂ peak was associated with both decreased postoperative overall survival and decreased non-tumour-related survival during the 10-year follow-up.

Impact of preoperative exercise therapy on surgical outcomes in lung cancer patients with or without COPD: a systematic review and meta-analysis

Objectives

This meta-analysis aimed to demonstrate the impact of preoperative exercise therapy on surgical outcomes in patients with lung cancer and COPD. Pulmonary function and muscle capacity were investigated to explore their potential links with outcome improvements after exercise.

Methods

Articles were searched from PubMed, Embase, and the Cochrane Library with criteria of lung cancer patients with or without COPD, undergoing resection, and receiving preoperative exercise training. Key outcomes were analyzed using meta-analysis.

Results

Seven studies containing 404 participants were included. Patients receiving preoperative exercise training had a lower incidence of postoperative pulmonary complications (PPCs; OR 0.44, 95% CI 0.27-0.71) and shorter length of hospital stay (standardized mean difference -4.23 days, 95% CI -6.14 to -2.32 days). Exceptionally, pneumonia incidence remained unchanged. Patients with COPD could not obviously benefit from exercise training to reduce PPCs (OR 0.44, 95% CI 0.18-1.08), but still might achieve faster recovery. No significant difference in pulmonary function was observed between the two groups. However, 6MWD and VO₂ peak were significantly improved after exercise training.

Conclusion

Preoperative exercise training may reduce PPCs for lung cancer patients. However, for patients with COPD undergoing lung cancer resection, the role of exercise is uncertain, due to limited data, which calls for more prospective trials on this topic. Rehabilitation exercise strengthens muscle capacity, but does not improve impaired pulmonary function, which emphasizes the possible mechanism of the protocol design.

The Utility of Exercise Testing in Patients with Lung Cancer

The harm associated with lung cancer treatment include perioperative morbidity and mortality and therapy-induced toxicities in various organs, including the heart and lungs. Optimal treatment therefore entails a need for risk assessment to weigh the probabilities of benefits versus harm. Exercise testing offers an opportunity to evaluate a patient's physical fitness/exercise capacity objectively. In lung cancer, it is most often used to risk-stratify patients undergoing evaluation for lung cancer resection. In recent years, its use outside this context has been described, including in nonsurgical candidates and lung cancer survivors. In this article we review the physiology of exercise testing and lung cancer. Then, we assess the utility of exercise testing in patients with lung cancer in four contexts (preoperative evaluation for lung cancer resection, after lung cancer resection, lung cancer prognosis, and assessment of efficiency of exercise training programs) after systematically identifying original studies involving the most common forms of exercise tests in this patient population: laboratory cardiopulmonary exercise testing and simple field testing with the 6-minute walk test, shuttle walk test, and/or stair-climbing test. Lastly, we propose a conceptual framework for risk assessment of patients with lung cancer who are being considered for therapy and identify areas for further studies in this patient population.