Effectiveness of pulmonary rehabilitation and correlations in between functional parameters, extent of thoracic surgery and severity of post-operative complications: randomized clinical trial

Towards a common definition of surgical prehabilitation: a scoping review of randomised trials

BACKGROUND

There is no universally accepted definition for surgical prehabilitation. The objectives of this scoping review were to (1) identify how surgical prehabilitation is defined across randomised controlled trials and (2) propose a common definition.

METHODS

The final search was conducted in February 2023 using MEDLINE, Embase, PsycINFO, Web of Science, CINAHL, and Cochrane. We included randomised controlled trials (RCTs) of unimodal or multimodal prehabilitation interventions (nutrition, exercise, and psychological support) lasting at least 7 days in adults undergoing elective surgery. Qualitative data were analysed using summative content analysis.

RESULTS

We identified 76 prehabilitation trials of patients undergoing abdominal (n=26, 34%), orthopaedic (n=20, 26%), thoracic (n=14, 18%), cardiac (n=7, 9%), spinal (n=4, 5%), and other (n=5, 7%) surgeries. Surgical prehabilitation was explicitly defined in more than half of these RCTs (n=42, 55%). Our findings consolidated the following definition: 'Prehabilitation is a process from diagnosis to surgery, consisting of one or more preoperative interventions of exercise, nutrition, psychological strategies and respiratory training, that aims to enhance functional capacity and physiological reserve to allow patients to withstand surgical stressors, improve postoperative outcomes, and facilitate recovery.'

CONCLUSIONS

A common definition is the first step towards standardisation, which is needed to guide future high-quality research and advance the field of prehabilitation. The proposed definition should be further evaluated by international stakeholders to ensure that it is comprehensive and globally accepted.

Outcomes reported in randomised trials of surgical prehabilitation: a scoping review

BACKGROUND

Heterogeneity of reported outcomes can impact the certainty of evidence for prehabilitation. The objective of this scoping review was to systematically map outcomes and assessment tools used in trials of surgical prehabilitation.

METHODS

MEDLINE, EMBASE, PsychInfo, Web of Science, CINAHL, and Cochrane were searched in February 2023. Randomised controlled trials of unimodal or multimodal prehabilitation interventions (nutrition, exercise, psychological support) lasting at least 7 days in adults undergoing elective surgery were included. Reported outcomes were classified according to the International Society for Pharmacoeconomics and Outcomes Research framework.

RESULTS

We included 76 trials, mostly focused on abdominal or orthopaedic surgeries. A total of 50 different outcomes were identified, measured using 184 outcome assessment tools. Observer-reported outcomes were collected in 86% of trials (n=65), with hospital length of stay being most common. Performance outcomes were reported in 80% of trials (n=61), most commonly as exercise capacity assessed by cardiopulmonary exercise testing. Clinician-reported outcomes were included in 78% (n=59) of trials and most frequently included postoperative complications with Clavien-Dindo classification. Patient-reported outcomes were reported in 76% (n=58) of trials, with health-related quality of life using the 36- or 12-Item Short Form Survey being most prevalent. Biomarker outcomes were reported in 16% of trials (n=12) most commonly using inflammatory markers assessed with C-reactive protein.

CONCLUSIONS

There is substantial heterogeneity in the reporting of outcomes and assessment tools across surgical prehabilitation trials. Identification of meaningful outcomes, and agreement on appropriate assessment tools, could inform the development of a prehabilitation core outcomes set to harmonise outcome reporting and facilitate meta-analyses.

Optimizing cardiopulmonary rehabilitation duration for long COVID patients: an exercise physiology monitoring approach

The presence of prolonged symptoms after COVID infection worsens the workability and quality of life. 200 adults with long COVID syndrome were enrolled after medical, physical, and mental screening, and were divided into two groups based on their performance. The intervention group (n = 100) received supervised rehabilitation at Department of Pulmonology, Semmelweis University with the registration number 160/2021 between 01/APR/2021-31/DEC/2022, while an age-matched control group (n = 100) received a single check-up. To evaluate the long-term effects of the rehabilitation, the intervention group was involved in a 2- and 3-month follow-up, carrying out cardiopulmonary exercise test. Our study contributes understanding long COVID rehabilitation, emphasizing the potential benefits of structured cardiopulmonary rehabilitation in enhancing patient outcomes and well-being. Significant difference was found between intervention group and control group at baseline visit in pulmonary parameters, as forced vital capacity, forced expiratory volume, forced expiratory volume, transfer factor for carbon monoxide, transfer coefficient for carbon monoxide, and oxygen saturation (all p < 0.05). Our follow-up study proved that a 2-week long, patient-centered pulmonary rehabilitation program has a positive long-term effect on people with symptomatic long COVID syndrome. Our data showed significant improvement between two and three months in maximal oxygen consumption (p < 0.05). Multidisciplinary, individualized approach may be a key element of a successful cardiopulmonary rehabilitation in long COVID conditions, which improves workload, quality of life, respiratory function, and status of patients with long COVID syndrome.

A qualitative evaluation of a multi-modal cancer prehabilitation programme for colorectal, head and neck and lung cancers patients

BACKGROUND

Growing evidence indicates patients' survivorship outcomes can be enhanced through active engagement in a multi-modal cancer prehabilitation programme (MCPP), although this intervention is not uniformly embedded as a standard of care. MCPP aims to optimise patients physiologically and psychologically for cancer treatments, shorten recovery time, reduce complications, promote healthier lifestyles and improve quality of life. South Eastern Health and Social Care Trust (SET) developed and evaluated a system-wide collaborative approach to MMCP across three tumour groups (colorectal, lung, head and neck cancer). Addressing the lack of qualitative evaluation of MCPPs, this novel paper explores mechanisms promoting feasibility and acceptability of MCPP from patients' and interdisciplinary professionals' perspectives.

METHODS

Semi-structured virtual one-to-one interviews were conducted with 24 interdisciplinary professionals and nine patients. Transcripts were recorded, transcribed verbatim and themes developed using Framework Analysis.

RESULTS

Analysis of findings identified three themes providing an in-depth understanding of key elements required to develop and promote system-wide delivery of a MCPP: 1) Equipping the team: Capability and capacity, 2) Timing of intervention and delivery timeframe and 3) Systems and processes.

CONCLUSION

The system-wide collaborative approach to developing a MCPP was deemed both feasible and acceptable. Success was attributed to visionary leadership, alongside a diverse group of interdisciplinary professionals being engaged, motivated and committed to intervention delivery in an effort to improve patient outcomes. Iterative, responsive troubleshooting during initial delivery is required to facilitate successful implementation. Further training is required for greater adherence to provision of prescriptive high intensity exercise within the programme, which may further promote enhanced patient outcomes. To enable sustainability of MCPP, ongoing training for professionals and funding is required.

Reporting quality of randomized controlled trials in prehabilitation: a scoping review

BACKGROUND

Inadequate study reporting precludes interpretation of findings, pooling of results in meta-analyses, and delays knowledge translation. While prehabilitation interventions aim to enhance candidacy for surgery, to our knowledge, a review of the quality of reporting in prehabilitation has yet to be conducted. Our objective was to determine the extent to which randomized controlled trials (RCTs) of prehabilitation are reported according to methodological and intervention reporting checklists.

METHODS

Eligibility criteria: RCTs of unimodal or multimodal prehabilitation interventions.

SOURCES OF EVIDENCE

search was conducted in March 2022 using MEDLINE, Embase, PsychINFO, Web of Science, CINAHL, and Cochrane.

CHARTING METHODS

identified studies were compared to CONSORT, CERT & Modified CERT, TIDieR, PRESENT, and CONSORT-SPI. An agreement ratio (AR) was defined to evaluate if applicable guideline items were correctly reported. Data were analyzed as frequency (n, %) and mean with standard deviation (SD).

RESULTS

We identified 935 unique articles and included 70 trials published from 1994 to 2022. Most prehabilitation programs comprised exercise-only interventions (n = 40, 57%) and were applied before oncologic surgery (n = 32, 46%). The overall mean AR was 57% (SD: 20.9%). The specific mean ARs were as follows: CONSORT: 71% (SD: 16.3%); TIDieR: 62% (SD:17.7%); CERT: 54% (SD: 16.6%); Modified-CERT: 40% (SD:17.8%); PRESENT: 78% (SD: 8.9); and CONSORT-SPI: 47% (SD: 22.1).

CONCLUSION

Altogether, existing prehabilitation trials report approximately half of the checklist items recommended by methodological and intervention reporting guidelines. Reporting practices may improve with the development of a reporting checklist specific to prehabilitation interventions.

International expert consensus on diagnosis and treatment of lung cancer complicated by chronic obstructive pulmonary disease

Background

Lung cancer combined by chronic obstructive pulmonary disease (LC-COPD) is a common comorbidity and their interaction with each other poses significant clinical challenges. However, there is a lack of well-established consensus on the diagnosis and treatment of LC-COPD.

Methods

A panel of experts, comprising specialists in oncology, respiratory medicine, radiology, interventional medicine, and thoracic surgery, was convened. The panel was presented with a comprehensive review of the current evidence pertaining to LC-COPD. After thorough discussions, the panel reached a consensus on 17 recommendations with over 70% agreement in voting to enhance the management of LC-COPD and optimize the care of these patients.

Results

The 17 statements focused on pathogenic mechanisms (n=2), general strategies (n=4), and clinical application in COPD (n=2) and lung cancer (n=9) were developed and modified. These statements provide guidance on early screening and treatment selection of LC-COPD, the interplay of lung cancer and COPD on treatment, and considerations during treatment. This consensus also emphasizes patient-centered and personalized treatment in the management of LC-COPD.

Conclusions

The consensus highlights the need for concurrent treatment for both lung cancer and COPD in LC-COPD patients, while being mindful of the mutual influence of the two conditions on treatment and monitoring for adverse reactions.

Pulmonary prehabilitation and smoking cessation

PURPOSE OF REVIEW

This review aims to summarize the current literature on pulmonary prehabilitation programs, their effects on postoperative pulmonary complications, and the financial implications of implementing these programs. Additionally, this review has discussed the current trends in pulmonary prehabilitation programs, techniques for improving rates of perioperative smoking cessation, and the optimal timing of these interventions.

RECENT FINDINGS

Prehabilitation is a series of personalized multimodal interventions tailored to individual needs, including lifestyle and behavioral measures. Pulmonary prehabilitation has shown to reduce postoperative pulmonary complications (PPCs).

SUMMARY

The implications of clinical practice and research findings regarding PPCs are an increased burden of postoperative complications and financial cost to both patients and hospital systems. There is convincing evidence that pulmonary prehabilitation based on endurance training should be started 8-12 weeks prior to major surgery; however, similar rates of improved postoperative outcomes are observed with high-intensity interval training (HIIT) for 1-2 weeks. This shorter interval of prehabilitation may be more appropriate for patients awaiting thoracic surgery, especially for cancer resection. Additionally, costs associated with creating and maintaining a prehabilitation program are mitigated by shortened lengths of stay and reduced PPCs. Please see Video Abstract, http://links.lww.com/COAN/A90.

Cardiovascular effects of exercise induced dynamic hyperinflation in COPD patients-Dynamically hyperinflated and non-hyperinflated subgroups

INTRODUCTION

An increase in respiratory rate and expiratory flow limitation can facilitate dynamic hyperinflation (DH), which may cause an element of the intrathoracic pressure in connection with the worsening of venous return, with negative effect on stroke volume (SV) and cardiac output (CO). It has been unclassified, whether poor circulatory adaptation to exercise can be attributed to DH or poor cardio-vascular performance itself in COPD. Only a subset of COPD patients exhibit dynamic hyperinflation during exercise.

PATIENTS AND METHODS

We designed a study to show how lung mechanical and cardiovascular parameters change in hyperinflated and non-hyperinflated COPD patients during exercise with a new experimental set-up. Thirty-three COPD patients with similar severity of COPD and left ventricular performance (20 men, 13 women, mean±SD age: 65,36±6,95 years) participated. We measured the cardiovascular parameters with a non-invasive device (Finometer-pro) including the left ventricular ejection time index (LVETi) and estimated the change of DH with inspiratory capacity (IC) manoeuvres during exercise.

RESULTS

Twenty-one subjects exhibited DH (DH group) and 12 did not (non-DH group). The measurement results were given in mean ± SD and difference between the values measured during maximal load and rest also (ΔX = Xmax.load-Xrest). ΔSV and ΔCO were significantly higher in non-DH vs. DH patients (ΔSV: non-DH 9,7 ± 13,22 ml vs. DH -3,6 ± 14,34 ml, p = 0.0142; ΔCO: non-DH 2,26 ± 1,46 l/min vs. DH 0,88 ± 1,35 l/min, p = 0.0024). LVETi was not different between the two groups. Calculated oxygen delivery (DO2) during maximal load was significantly higher in non-DH group.

CONCLUSION

We concluded that worse cardiovascular adaptation to exercise of COPD patients can be associated with exercise-induced DH in a similar cardiovascular aged COPD group.

Effect of pulmonary rehabilitation in patients with chronic obstructive pulmonary disease: a systematic review and meta-analysis of randomized controlled trials

OBJECTIVE

The present systematic review and meta-analysis of randomized clinical trials (RCTs) aimed to investigate the effects of pulmonary rehabilitation in individuals with chronic obstructive pulmonary disease (COPD).

METHODS

The RCTs of pulmonary rehabilitation programs published between 1999 and 2021 were retrieved from electronic databases (PubMed, Cochrane Library, and Embase). Two reviewers independently assessed the topical relevance and trial quality and extracted data for meta-analysis using the Stata software version 14.0.

RESULTS

A total of 39 trials involving 2,397 participants with COPD were evaluated. We found that patients who received pulmonary rehabilitation program had significant improvement in the 6-min walk test (6MWT), St. George Respiratory Questionnaire score, and the modified British Medical Research Council score as compared to those who received usual care. Yoga and Tai Chi showed significant improvement in the forced expiratory volume (FEV1)% in 1 s predicted value. However, no significant difference was detected in the modified Borg score, forced vital capacity (FVC), and FEV1/FVC predicted value between the pulmonary rehabilitation and usual care groups.

CONCLUSION

Yoga and Tai Chi showed a significant improvement in the FEV1% predicted value. Also, pulmonary rehabilitation program improved the exercise capacity, the quality of life, and dyspnoea in patients with COPD.Key messagesA total of 39 trials involving 2,397 participants with COPD were evaluated.We found that patients who received pulmonary rehabilitation program had significant improvement in the 6MWT, St. George Respiratory Questionnaire score, and the modified British Medical Research Council score as compared to those who received usual care.Yoga and Tai Chi showed significant improvement in the FEV1% predicted value.No significant difference was detected in the modified Borg score, FVC, and FEV1/FVC predicted value between the pulmonary rehabilitation and usual care groups.

Freedive Training Gives Additional Physiological Effect Compared to Pulmonary Rehabilitation in COPD

INTRODUCTION

Pulmonary rehabilitation (PR) is beneficial for lung mechanics, chest kinematics, metabolism, and inspiratory and peripheral muscle function. Freediving training (FD) can be effective in sportsmen and can improve breath-holding time.

AIMS

We sought to determine the effectiveness of freediving training in the pulmonary rehabilitation of COPD patients.

PATIENTS AND METHODS

Twenty-three COPD patients (15 men and 8 women; median age 63 years; FEV1: 41% pred; BMI: 28 kg/m²) participated in the FD + PR group (3 weeks PR and 3 weeks FD + PR) and 46 patients with COPD (25 men and 21 women; median age 66 years; FEV1: 43% pred; BMI: 27 kg/m²) participated in an inpatient PR program (6 weeks). Patients performed comfort zone breath holding for 30 min/day. Patients increased their breath-holding time within their comfort zone for 30 min. We detected lung function, chest expansion (CWE), inspiratory muscle pressure (MIP), peripheral muscle function (GS), and exercise capacity (6MWD), and we included breath-holding time (BHT), quality of life score (COPD Assessment Test (CAT)), modified Medical Research Dyspnea Scale (mMRC) score, and the severity of the disease assessed by the BODE index (FEV1, BMI, 6MWD, and mMRC) and an alternative scale (FEV1, BMI, 6MWD, and CAT).

RESULT

There were significant differences in the characteristics of the two groups. Significant improvement was detected in all functional and quality of life parameters except lung function in both groups. Significantly higher improvement was detected in CWE, GS, 6MWD, BHT, CAT, mMRC, alternative scale, and MIP. The improvement in forced vital capacity (FVC) was not significant. There were no side effects of FD training.

CONCLUSION

The FD method can potentiate the effect of PR, improving not only BHT but also other parameters.

TRIAL REGISTRATION

ISRCTN ISRCTN13019180. Registered 19 December 2017.

Rapid Recovery of Postoperative Pulmonary Function in Patients With Lung Cancer and Influencing Factors

Among malignant tumors, lung cancer has the highest morbidity and mortality worldwide. Surgery is the first-line treatment for early-stage lung cancers, and has gradually advanced from conventional open-chest surgery to video-assisted thoracic surgery (VATS). Additionally, increasingly smaller surgical incisions and less surgical trauma have resulted in reduced pulmonary function damage. Previous studies have found that the level of pulmonary function loss and recovery is significantly correlated with postoperative complications and the quality of life. Thus, an accurate assessment of the preoperative pulmonary function and effective rehabilitation of postoperative pulmonary function are highly important for patients undergoing lung surgery. In addition, pulmonary function assessment after pulmonary rehabilitation serves as an objective indicator of the postoperative pulmonary rehabilitation status and is crucial to facilitating pulmonary function recovery. Furthermore, a complete preoperative assessment and effective rehabilitation are especially critical in elderly patients with pulmonary tumors, poor basic physiological functions, comorbid lung diseases, and other underlying diseases. In this review, we summarize the clinical significance of pulmonary function assessment in patients undergoing lung cancer surgery, postoperative changes in pulmonary function, effective pulmonary function rehabilitation, and the influencing factors of pulmonary function rehabilitation.

Outcomes of pulmonary rehabilitation after lung resection in patients with lung cancer

BACKGROUND

In this study, we aimed to examine the effectiveness of pulmonary rehabilitation applied after resection in patients with lung cancer.

METHODS

Between October 2017 and December 2019, a total of 66 patients (53 males, 13 females; median age: 65 years; range, 58 to 70 years) who underwent lung resection for non-small cell lung cancer and who were not administered any chemotherapy or radiotherapy regimen were included in the study. An eight-week comprehensive outpatient pulmonary rehabilitation program was applied to half of the patients, while the other half received respiratory exercise training. After the intervention, the results of both groups were compared.

RESULTS

In the pulmonary rehabilitation group, forced vital capacity value (p=0.011), six-minute walking distance (p<0.001), and Short Form-36 physical function, mental health, vitality scores increased significantly, while all scores of St. George's Respiratory Questionnaire, dyspnea (p<0.001) and anxiety score (p=0.041) significantly decreased. In the group given breathing exercise training, only dyspnea (p=0.046) and St. George's Respiratory Questionnaire symptom scores (p=0.038) were decreased. When the changes in the groups after pulmonary rehabilitation were compared, the decrease in dyspnea perception was significantly higher in the pulmonary rehabilitation group (p<0.001).

CONCLUSION

Pulmonary rehabilitation program applied after lung resection in patients with non-small cell lung cancer reduces dyspnea and psychological symptoms, increases exercise capacity, and improves quality of life. It should be ensured that patients with lung cancer who have undergone lung resection are directed to the pulmonary rehabilitation program and benefit from this program.

Effects of Prehabilitation on Functional Capacity in Aged Patients Undergoing Cardiothoracic Surgeries: A Systematic Review

Background: an increasing number of advanced age patients are considered for cardiothoracic surgeries. Prehabilitation optimizes the patients’ functional capacity and physiological reserve. However, the effectiveness of prehabilitation on physical functioning and postoperative recovery in the scope of cardiothoracic surgery is still uncertain. Objective: to assess the effectiveness of prehabilitation on pre- and/or postoperative functional capacity and physiological reserve in aged patients that are considered for cardiothoracic surgeries. Methods: this systematic review was registered in PROSPERO (CRD42021247117). The searches were conducted in PubMed, Web of Science, Scopus, and Cochrane CENTRAL until 18 April 2021. Randomized clinical trials that compared different prehabilitation strategies with usual care on the pre- and-postoperative results in aged patients undergoing cardiothoracic surgeries were included. Methodological quality was assessed by means of the Jadad scale, and the effectiveness of the interventions according to the Consensus on Therapeutic Exercise Training. Results: nine studies with 876 participants aged from 64 to 71.5 years old were included. Risk of bias was moderate due to the absence of double-blinding. The content of the interventions (multimodal prehabilitation n = 3; based on physical exercises n = 6) and the result measures presented wide variation, which hindered comparison across the studies. In general, the trials with better therapeutic quality (n = 6) reported more significant improvements in physical functioning, cardiorespiratory capacity, and in the postoperative results in the participants under-going prehabilitation. Conclusions: prehabilitation seems to improve functional capacity and postoperative recovery in aged patients undergoing cardiothoracic surgeries. However, due to the significant heterogeneity and questionable quality of the trials, both the effectiveness of prehabilitation and the optimum content are still to be determined.

Repeated measures correlation between functional capacity, pulmonary function and chest expansion in children undergoing open abdominal surgery: Secondary analysis from randomized clinical trial

PURPOSE

Six minute walk test (6MWT), Spirometry and chest expansion are used regularly to investigate the status of functional capacity and pulmonary function pre and post operatively. We assessed whether Functional capacity Ten meter walk test (10mWT), Nine stair climbing test (9SCT), pulmonary function [Spirometry parameters (FVC, FEV1, FEV1/FVC ratio and PEFR)] and chest expansion have correlation in children undergoing open abdominal surgery.

METHODS

Total 18 children aged 5-17 years old undergoing open abdominal surgery participated in the study. The study follows secondary analysis from randomized clinical trial. 6MWT, Spirometry parameters (FVC, FEV1, FEV1/FVC ratio and PEFR), 10mWT, 9SCT, and Chest expansion measures were taken before [Preoperative day (Pre-OP)] and after open abdominal surgery [postoperative day one (POD1) and postoperative day five (POD5)].

RESULTS

Bivariate analysis showed no correlation (r_s <0.25; p>0.05) between Functional capacity and pulmonary function preoperatively, on POD1, and on POD5. 9SCT (Functional capacity) showed moderate to good correlation (r_s= 0.742; p<0.05) with pulmonary function at the Pre-OP. Chest expansion parameters also showed moderate to good correlation (r_s = 0.50-0.75; p<0.05) with the pulmonary function on Pre-OP, POD1, and POD5.

CONCLUSION

There is moderate correlation exists between pulmonary function and chest expansion, but poor correlation of functional capacity with pulmonary function and chest expansion. Hence, all the outcome measures (6MWT, 10Mwt, 9SCT, Spirometry, and Chest expansion) are having individual importance.

Usefulness of Pulmonary Rehabilitation in Non-small Cell Lung Cancer Patients Based on Pulmonary Function Tests and Muscle Analysis Using Computed Tomography Images

Purpose

The usefulness of rehabilitation in patients with reduced lung function before lung surgery remains unclear, and there is no adequate method for evaluating the effect of rehabilitation. We aimed to evaluate the usefulness of rehabilitation in patients with non–small cell lung cancer (NSCLC) undergoing lung cancer surgery.

Materials and Methods

We retrospectively analyzed the medical records of NSCLC patients at Korea University Guro Hospital between 2018 and 2020. Patients were divided into two groups depending on whether they underwent rehabilitation. Pulmonary function test data and muscle determined using chest computed tomography images were analyzed. Because the baseline characteristics were different between the two groups, propensity score matching was performed.

Results

Of 325 patients, 75 (23.1%) and 250 (76.9%) were included in the rehabilitation and non-rehabilitation (control) groups, respectively. The rehabilitation group had a worse general condition at baseline. After propensity score matching, 45 patients remained in each group. Pulmonary function (forced expiratory volume in 1 second, %) (p=0.001) and the Hounsfield unit of erector spinae muscle (p=0.001) were better preserved in the rehabilitation group. Muscle loss of 3.4% and 0.6% was observed in the control and rehabilitation groups, respectively (p=0.003). In addition, the incidence of embolic events was lower in the rehabilitation group (p=0.044).

Conclusion

Pulmonary rehabilitation is useful in patients with NSCLC undergoing lung surgery. Pulmonary rehabilitation preserves lung function, muscle and reduces embolic events after surgery. Pulmonary rehabilitation is recommended for patients with NSCLC undergoing surgery.

The Clinical Value of Pulmonary Rehabilitation in Reducing Postoperative Complications and Mortality of Lung Cancer Resection: A Systematic Review and Meta-Analysis

Background: Pulmonary rehabilitation is one meaningful way of improving exercise tolerance and pulmonary function. Thus, it may reduce the postoperative complications and mortality of pulmonary resection. Hence, we refreshed the data and conducted this systemic analysis.

Method: We searched Pubmed, Web of Science, and EMBASE using “lung OR pulmonary” AND “operation OR resection OR surgery” AND “rehabilitation or exercise.” The cut-off date was September 30, 2020. The publications were filtrated, and data were extracted from all selected studies by two reviewers. Review Manger 5.1 and the fixed or random regression model were used for calculating the pooled odds ratio (OR).

Result: Finally, 13 publications were enrolled in this study. Among them, five publications reported mortality, nine reported postoperative complications, and seven reported postoperative pulmonary complications. The pooled OR of mortality was 1.32 [95% confidence interval (CI): 0.54–3.23] for the pulmonary rehabilitation group, the pooled OR of postoperative complications was 0.62 (95% CI: 0.49–0.79) for the pulmonary rehabilitation group, and the pooled OR of postoperative pulmonary complications was 0.39 (95% CI: 0.27–0.56) for the pulmonary rehabilitation group. Subgroup analysis revealed the perioperative pulmonary rehabilitation was the most important part.

Conclusion: Pulmonary rehabilitation may not affect the mortality of pulmonary resection patients, however, it could decrease the number of postoperative complications, especially pulmonary complications. Perioperative pulmonary rehabilitation was the most important part of the program.

Pre-admission interventions (prehabilitation) to improve outcome after major elective surgery: a systematic review and meta-analysis

OBJECTIVE

To determine the benefits and harms of pre-admission interventions (prehabilitation) on postoperative outcomes in patients undergoing major elective surgery.

DESIGN

Systematic review and meta-analysis of randomised controlled trials (RCTs) (published or unpublished). We searched Medline, Embase, CENTRAL, DARE, HTA and NHS EED, The Cochrane Library, CINAHL, PsychINFO and ISI Web of Science (June 2020).

SETTING

Secondary care.

PARTICIPANTS

Patients (≥18 years) undergoing major elective surgery (curative or palliative).

INTERVENTIONS

Any intervention administered in the preoperative period with the aim of improving postoperative outcomes.

OUTCOMES AND MEASURES

Primary outcomes were 30-day mortality, hospital length of stay (LoS) and postoperative complications. Secondary outcomes included LoS in intensive care unit or high dependency unit, perioperative morbidity, hospital readmission, postoperative pain, heath-related quality of life, outcomes specific to the intervention, intervention-specific adverse events and resource use.

REVIEW METHODS

Two authors independently extracted data from eligible RCTs and assessed risk of bias and the certainty of evidence using Grading of Recommendations, Assessment, Development and Evaluation. Random-effects meta-analyses were used to pool data across trials.

RESULTS

178 RCTs including eight types of intervention were included. Inspiratory muscle training (IMT), immunonutrition and multimodal interventions reduced hospital LoS (mean difference vs usual care: -1.81 days, 95% CI -2.31 to -1.31; -2.11 days, 95% CI -3.07 to -1.15; -1.67 days, 95% CI -2.31 to -1.03, respectively). Immunonutrition reduced infective complications (risk ratio (RR) 0.64 95% CI 0.40 to 1.01) and IMT, and exercise reduced postoperative pulmonary complications (RR 0.55, 95% CI 0.38 to 0.80, and RR 0.54, 95% CI 0.39 to 0.75, respectively). Smoking cessation interventions reduced wound infections (RR 0.28, 95% CI 0.12 to 0.64).

CONCLUSIONS

Some prehabilitation interventions may reduce postoperative LoS and complications but the quality of the evidence was low.

PROSPERO REGISTRATION NUMBER

CRD42015019191.

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.

Assessment and Rehabilitation of the Compromised Patient Prior to Thoracotomy

Patients for whom pulmonary resection is anticipated often have compromised pulmonary function and decreased exercise tolerance. To avoid major morbidity and reduce mortality, identification of the high-risk patient becomes extremely important. The means of identification include rather simple testing modalities as well as those that are more complex, which report specific physiologic data. This article develops a schematic for a logical progression through the assessment of prethoracotomy patients in order that those facing a significant surgical risk might undergo pulmonary rehabilitation to improve exercise performance followed by reassessment prior to surgery.

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.

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

Chronic obstructive pulmonary disease is a condition commonly present in older people undergoing surgery and confers an increased risk of postoperative complications and mortality. Although predominantly a respiratory disease, it frequently has extra-pulmonary manifestations and typically occurs in the context of other long-term conditions. Patients experience a range of symptoms that affect their quality of life, functional ability and clinical outcomes. In this review, we discuss the evidence for techniques to optimise the care of people with chronic obstructive pulmonary disease in the peri-operative period, and address potential new interventions to improve outcomes. The article centres on pulmonary rehabilitation, widely available for the treatment of stable chronic obstructive pulmonary disease, but less often used in a peri-operative setting. Current evidence is largely at high risk of bias, however. Before surgery it is important to ensure that what have been called the 'five fundamentals' of chronic obstructive pulmonary disease treatment are achieved: smoking cessation; pulmonary rehabilitation; vaccination; self-management; and identification and optimisation of co-morbidities. Pharmacological treatment should also be optimised, and some patients may benefit from lung volume reduction surgery. Psychological and behavioural factors are important, but are currently poorly understood in the peri-operative period. Considerations of the risk and benefits of delaying surgery to ensure the recommended measures are delivered depends on patient characteristics and the nature and urgency of the planned intervention.

Implementing a system-wide cancer prehabilitation programme: The journey of Greater Manchester's 'Prehab4cancer'

Patients undergoing major cancer interventions such as major surgical resection, chemotherapy, radiotherapy, and immunotherapy are prone to the adverse effects of their cancer, as well as to the side effects of the treatments designed to cure them. The Prehabilitation process supports cancer patients in preparing for the physiological challenges of their cancer treatments, whilst aiming to shorten recovery time, reduce peri-operative complications and improve compliance with non-surgical treatments. Prehabilitation will be most useful in older patients. Greater Manchester Integrated Care system is the first regional system in the UK to introduce delivery of system-wide, large scale physical activity supported multi-modal prehabilitation and recovery programme, Prehab4Cancer as a standard of care for cancer patients. It builds upon the successful implementation of Enhanced Recovery After Surgery + programme to improve surgical care in Greater Manchester. During this review we describe the journey to develop a system wide prehabilitation model for patients with cancer. Prehab4Cancer to date has focused on robust co-design, development, and implementation of an effective service model with attention paid to stakeholder engagement. This has led to receipt of high numbers of referrals from across Greater Manchester for the all the cancer groups involved. The successful implementation of the P4C pathway in GM presents a best practice model that might be adopted by other local and combined authority areas nationally.

Is it possible to reverse frailty in patients with chronic obstructive pulmonary disease?

In recent years, frailty has attracted increasing attention from clinicians and health care workers. The influence of frailty on the elderly, especially those with chronic diseases of the respiratory system, is highly significant. Frailty is particularly more common in patients with chronic obstructive pulmonary disease (COPD). Frailty and COPD share many risk factors and pathophysiological mechanisms. As a comprehensive interventional method for chronic respiratory diseases, pulmonary rehabilitation is an important basic measure for the management of patients with COPD. Frailty in these patients can be reversed using pulmonary rehabilitation by targeting five components of the frailty phenotype at the entry point. The present review discusses the benefits of pulmonary rehabilitation in patients with COPD complicated by frailty and provides a theoretical basis for pulmonary rehabilitation treatment in this population. In addition, the timing of pulmonary rehabilitation is also addressed, with the prefrail stage being the "golden" period. The implementation of pulmonary rehabilitation must vary among individuals, and individualized treatment strategies will help maximize benefits.

Effectiveness of pulmonary rehabilitation in elderly patients with COPD: A systematic review and meta-analysis of randomized controlled trials

AIM

The review aimed to evaluate the effects of pulmonary rehabilitation in elderly patients with chronic obstructive pulmonary disease (COPD).

BACKGROUND

With an increase in published reports on pulmonary rehabilitation, there is a need for a meta-analysis to measure the effects of pulmonary rehabilitation in elderly COPD patients.

DESIGN

A systematic review and meta-analysis.

DATA SOURCES

The Cochrane library (Issue 4, 2018), Web of Science (1975 to April 2018), Embase (1974 to April 2018), Pubmed (1966 to April 2018), CINAHL (1982 to April 2018), JBI (The Joanna Briggs Institute) (1996 to April 2018), CNKI (China National Knowledge Infrastructure) (1979 to April 2018), CBM (SinoMed) (1982 to April 2018), and Wanfang Data (1900 to April 2018) were searched.

REVIEW METHODS

Six outcome indicators were utilized for the effects of pulmonary rehabilitation. Two reviewers selected trials, evaluated the quality, and extracted data. Meta-analysis was performed by using the RevMan 5.3 software.

RESULTS

Eight studies recruited 414 elderly patients. Pulmonary rehabilitation resulted in significantly improved exercise capacity and quality of life in elderly people but with no influence on oxygen saturation compared with the control group.

CONCLUSION

There is a need to provide more detailed pulmonary rehabilitation programs for elderly patients with COPD.

Smoking and pulmonary complications: respiratory prehabilitation

The severity of the clinical condition and co-morbidities of the patients for esophagectomy require a complex assessment and risk stratification before the operation, and most of the cases need complex management. We did a literature search and considered the data on risk stratification and complex management of patients who undergo thoracic surgery. Smoking cessation programs can protect against complications, which is related to the respiratory system, the heart and the convalescence of the wounds in postoperative condition, but the timing is critical due to the operation. A complex team of physicians and healthcare professionals, as well as respiratory prehabilitation, can help to improve the clinical condition, chest kinematics, lung mechanics, peripheral and respiratory muscle function, metabolism and quality of life of this type of patients. We need to consider a complex risk stratification before esophagectomy and require complex management for these patients, including smoking cessation and respiratory prehabilitation, to improve the post-operative complications.