Low-technology exercise test in the preoperative evaluation of lung resection candidates

Quality of life between home-based and outpatient pulmonary rehabilitation in patients after surgical resection for lung cancer: protocol for a prospective, single-blind, randomised controlled trial

INTRODUCTION

Lung cancer remains a highly fatal disease. Surgical resection has been proven to be the most effective treatment for early-stage lung cancer. The conventional hospital-based pulmonary rehabilitation (PR) is shown to reduce symptoms, improve exercise capacity and impact the quality of life (QoL) for lung cancer patients. To date, scientific evidence on the effectiveness of home-based PR for patients with lung cancer following surgery is scarce. We aim to explore if home-based PR is non-inferior to outpatient PR for patients with lung cancer following surgical resection.

METHODS AND ANALYSIS

This study is a two-arm, parallel-group, assessor-blind, single-centre, randomised controlled trial. Participants will be recruited from West China Hospital, Sichuan University and randomly allocated to either an outpatient group or a home-based group at a ratio of 1:1. The PR programme involves self-management and exercises. The exercise includes warm-up (10 min), aerobic training (20 min), resistance training (15 min) and cool-down (10 min), lasting 4 weeks, with two sessions per week either at home or in the outpatient setting. The intensity will be adjusted according to the modified Borg rating of perceived exertion and heart rate before and after each exercise session. The primary outcome is QoL measured by EORTC QLQ-C30 & LC 13 after an intervention. Secondary outcomes include physical fitness measured by a 6 min walk test and stair-climbing test and symptom severity measured by patient-reported questionnaires and pulmonary function. The main hypothesis is that home-based PR is non-inferior to outpatient PR for patients with lung cancer following surgical resection.

ETHICS AND DISSEMINATION

The trial has been approved by the Ethical Committee of West China Hospital and is also registered with the Chinese Clinical Trial Registry. The results of this study will be disseminated through peer-reviewed publications and presentations at national and international conferences.

TRIAL REGISTRATION NUMBER

ChiCTR2100053714.

Performance at stair-climbing test is associated with postoperative complications after lung resection: a systematic review and meta-analysis

Background

Thoracic surgery is the optimal treatment for early-stage lung cancer, but there is a high risk of postoperative morbidity. Therefore, it is necessary to evaluate patients’ preoperative general condition and cardiorespiratory capacity to determine the risk of postoperative complications. The objective of this study was to assess whether the stair-climbing test could be used in the preoperative evaluation of lung resection patients to predict postoperative morbidity following thoracic surgery.

Methods

We performed a systematic review and a meta-analysis on the association between stair-climbing test result and morbidity/mortality after thoracic surgery. We analysed all articles published until May 2020 in the following databases: Pubmed/Medline, Pedro, The Cochrane library, Embase and CINAHL. The risk of bias was assessed using the Quality in Prognosis Studies tool. This meta-analysis is registered as PROSPERO CRD42019121348.

Results

13 articles were included in the systematic review for a total of 2038 patients and 6 in the meta-analysis. There were multiple test evaluation criteria: rise time, height, desaturation and heart rate change. For the meta-analysis, we were able to pool data on the height of rise at a variable threshold: risk ratio 2.34 (95% CI 1.59 to 3.43) with I²=53% (p=0.06). The threshold for occurrence of complications was estimated at a 10 m climb.

Conclusions

Our results indicate that the stair-climbing test could be used as a first-line functional screening test to predict postoperative morbidity following thoracic surgery and that patients with a poor test result (<10 m) should be referred to formal cardiopulmonary exercise testing.

Performance in the shuttle walk test is associated with cardiopulmonary complications after lung resections

BACKGROUND

The current functional guidelines recommend the shuttle walk test (SWT) as an initial screening tool to identify candidates for lung resection without requiring cardiopulmonary exercise testing. This study aims to: (I) assess the use of the SWT in predicting postoperative cardiopulmonary complications; and (II) determine whether the recommended 400 m cut-off is an appropriate distance.

METHODS

We retrospectively analysed 101 patients that had performed a SWT prior to surgery. Univariate and multivariate regression analyses were used to test associations between patient variables [demographics, pre-existing conditions, pulmonary function, oxygen desaturation during the SWT, shuttle walk distance (SWD)] and post-operative cardiopulmonary complications.

RESULTS

Patients without cardiopulmonary complications walked longer distance compared to those with complication (417.3 vs. 348.6 m, P=0.01. Fifty two patients walked less than 400 m and 16 less than 250 m. Only 10% of patients who walked at least 400 m had cardiopulmonary complications compared to 33% of those who did not reach this distance (P=0.008). Half of the patients who walked less than 400 m and desaturated during the exercise developed cardiopulmonary complications. A SWD shorter than 400 m remained the only factor significantly associated with cardiopulmonary complications (P=0.009, OR: 4.3) after logistic regression analysis.

CONCLUSIONS

Our results support the use of the SWT as an initial screening tool in all patients prior to lung resection. Patients walking longer than 400 m experienced very low incidence of complications and would not need further testing prior to proceed to lung resection.

Pulmonary function tests in the preoperative evaluation of lung cancer surgery candidates. A review of guidelines

Before planned surgical treatment of lung cancer, the patient's respiratory system function should be evaluated. According to the current guidelines, the assessment should start with measurements of FEV₁ (forced expiratory volume in 1 second) and DLco (carbon monoxide lung diffusion capacity). Pneumonectomy is possible when FEV₁ and DLco are > 80% of the predicted value (p.v.). If either of these parameters is < 80%, an exercise test with VO₂ max (oxygen consumption during maximal exercise) measurement should be performed. When VO₂ max is < 35 % p.v. or < 10 ml/kg/min, resection is associated with high risk. If VO₂ max is in the range of 35-75% p.v. or 10-20 ml/kg/min, the postoperative values of FEV₁ and DLco (ppoFEV₁, ppoDLco) should be determined. The exercise test with VO₂ max measurement may be replaced with other tests such as the shuttle walk test and the stair climbing test. The distance covered during the shuttle walk test should be > 400 m. Patients considered for lobectomy should be able to climb 3 flights of stairs (12 m) and for pneumonectomy 5 flights of stairs (22 m).