Preoperative pulmonary rehabilitation in patients undergoing lung resection for non-small cell lung cancer. Preoperative pulmonary rehabilitation before lung cancer resection: results from two randomized studies. Postoperative pulmonary complications following thoracic surgery: are there any modifiable risk factors? Preoperative inspiratory muscle training to prevent postoperative pulmonary complications in patients undergoing esophageal resection (PREPARE study): study protocol for a randomized controlled trial Assessment of pulmonary complications after lung resection. Long-term impact of developing a postoperative pulmonary complication after lung surgery Incentive spirometry does not enhance recovery after thoracic surgery Perioperative rehabilitation in operation for lung cancer (PROLUCA) – rationale and design Preoperative pulmonary rehabilitation versus chest physical therapy in patients undergoing lung cancer resection: a pilot randomized controlled trial. Short‐Term Preoperative High‐Intensity Interval Training in Patients Awaiting Lung Cancer Surgery: A Randomized Controlled Trial Randomised clinical trial of physiotherapy after open abdominal surgery in high risk patients. Preoperative Maximal Oxygen Uptake and Exercise-induced Changes in Pulse Oximetry Predict Early Postoperative Respiratory Complications in Lung Cancer Patients Preoperative physiotherapy for the prevention of respiratory complications after upper abdominal surgery: pragmatic, double blinded, multicentre randomised controlled trial Preoperative Exercise Vo2 Measurement for Lung Resection Candidates: Results of Cancer and Leukemia Group B Protocol 9238 Perioperative rehabilitation and physiotherapy for lung cancer patients with chronic obstructive pulmonary disease. Perioperative Rehabilitation in Operable Lung Cancer Patients (PROLUCA) The degree of oxidative stress is associated with major adverse effects after lung resection: a prospective study. Feasibility of preoperative inspiratory muscle training in patients undergoing coronary artery bypass surgery with a high risk of postoperative pulmonary complications: a randomized controlled pilot study Does physiotherapy reduce the incidence of postoperative pulmonary complications following pulmonary resection via open thoracotomy? A preliminary randomised single-blind clinical trial. Efficacy of breathing and coughing exercises in the prevention of pulmonary complications after coronary artery surgery. CPAP Increases 6-Minute Walk Distance After Lung Resection Surgery Preoperative intensive inspiratory muscle training to prevent postoperative pulmonary complications in high-risk patients undergoing CABG surgery: a randomized clinical trial. Comparable postoperative pulmonary atelectasis in patients given 30% or 80% oxygen during and 2 hours after colon resection.
BACKGROUND The impact of short-term preoperative pulmonary rehabilitation on exercise capacity of patients with chronic obstructive pulmonary disease undergoing lobectomy for non-small cell lung cancer is evaluated . METHODS A prospect i ve observational study was design ed . Inclusion criteria consisted of an indication to lung resection because of a clinical stage I or II non-small cell lung cancer and a chronic obstructive disease on preoperative pulmonary function test . In such conditions , maximal oxygen consumption by a cardio-pulmonary exercise test was evaluated ; when this result ed as being < or = 15 ml/kg/min a pulmonary rehabilitation programme lasting 4 weeks was considered . Twelve patients fulfilled inclusion criteria , completed the preoperative rehabilitation programme and underwent a new functional evaluation prior to surgery . The postoperative record of these patients was collected . RESULTS On completion of pulmonary rehabilitation , the resting pulmonary function test and diffuse lung capacity of patients was unchanged , whereas the exercise performance was found to have significantly improved ; the mean increase in maximal oxygen consumption proved to be at 2.8 ml/kg/min ( p<0.01 ) . Eleven patients underwent lobectomy ; no postoperative mortality was noted and mean hospital stay was 17 days . Postoperative pulmonary complication was recorded in 8 patients . CONCLUSIONS Short-term preoperative pulmonary rehabilitation could improve the exercise capacity of patients with chronic obstructive pulmonary disease who are c and i date s for lung resection for non-small cell lung cancer Complete surgical resection is the most effective curative treatment for lung cancer . However , many patients with lung cancer also have severe COPD which increases their risk of postoperative complications and their likelihood of being considered " inoperable . " Preoperative pulmonary rehabilitation ( PR ) has been proposed as an intervention to decrease surgical morbidity but there is no established protocol and no r and omized study has been published to date . We tested two preoperative PR interventions in patients undergoing lung cancer resection and with moderate-severe COPD in a r and omized single blinded design . Outcomes were length of hospital stay and postoperative complications . The first study tested 4 weeks of guideline -based PR vs. usual care : that study proved to be very difficult to recruit as patients and providers were reluctant to delay surgery . Nine patients were r and omized and no differences were found between arms . The second study tested ten preoperative PR sessions using a customized protocol with nonst and ard components ( exercise prescription based on self efficacy , inspiratory muscle training , and the practice of slow breathing ) ( n=10 ) vs. usual care ( n=9 ) . The PR arm had shorter length of hospital stay by 3 days ( p=0.058 ) , fewer prolonged chest tubes ( 11 % vs. 63 % , p=0.03 ) and fewer days needing a chest tube ( 8.8 vs. 4.3 days p=0.04 ) compared to the controlled arm . A ten-session preoperative PR intervention may improve post operative lung reexpansion evidence d by shorter chest tube times and decrease the length of hospital stay , a crude estimator of post operative morbidity and costs . Our results suggest the potential for short term preoperative pulmonary rehabilitation interventions in patients with moderate-severe COPD undergoing curative lung resection . 4 weeks of conventional preoperative PR seems non feasible Background Postoperative pulmonary complications ( PPC ) are the most frequently observed complications following lung resection , of which pneumonia and atelectasis are the most common . PPCs have a significant clinical and economic impact associated with increased observed number of deaths , morbidity , length of stay and associated cost . The aim of this study was to assess the incidence and impact of PPCs and to identify potentially modifiable independent risk factors . Methods A prospect i ve observational study was carried out on all patients following lung resection via thoracotomy in a regional thoracic centre over 13 months .  PPC was assessed using a scoring system based on chest x-ray , raised white cell count , fever , microbiology , purulent sputum and oxygen saturations . Results Thirty-four of 234 subjects ( 14.5 % ) had clinical evidence of PPC . The PPC patient group had a significantly longer length of stay ( LOS ) in hospital , high dependency unit ( HDU ) LOS , higher frequency of intensive care unit ( ITU ) admission and a higher number of hospital deaths . Older patients , body mass index ( BMI ) ≥30 kg/m2 , preoperative activity < 400 m , American Society of Anesthesiologists ( ASA ) score ≥3 , smoking history , chronic obstructive pulmonary disease ( COPD ) , lower preoperative forced expiratory volume in 1 s ( FEV1 ) and predicted postoperative ( PPO ) FEV1 were all significantly ( p<0.05 ) associated with PPC on univariate analysis . Multivariate analysis confirmed that age > 75 years , BMI ≥30 kg/m2 , ASA ≥3 , smoking history and COPD were significant independent risk factors in the development of PPC ( p<0.05 ) . Conclusion The clinical impact of PPCs is marked . Significant independent preoperative risk factors have been identified in current clinical practice . Potentially modifiable risk factors include BMI , smoking status and COPD . The impact of targeted therapy requires further evaluation Background Esophageal resection is associated with a high incidence of postoperative pneumonia . Respiratory complications account for almost half of the readmissions to the critical care unit . Postoperative complications can result in prolonged hospital stay and consequently increase healthcare costs . In cardiac surgery a preoperative inspiratory muscle training program has shown to prevent postoperative pneumonia and reduce length of hospital stay . While in some surgical centers inspiratory muscle training is already used in the preoperative phase in patients undergoing esophageal resection , the added value of this intervention on the reduction of pulmonary complications has not yet been investigated in large surgical population s other than cardiac surgery in a r and omized and controlled study design . Methods / Design The effect of a preoperative inspiratory muscle training program on the incidence of postoperative pneumonia in patients undergoing esophageal resection will be studied in a single blind multicenter r and omized controlled trial ( the PREPARE study ) . In total 248 patients ( age > 18 years ) undergoing esophageal resection for esophageal cancer will be included in this study . They are r and omized to either usual care or usual care with an additional inspiratory muscle training intervention according to a high-intensity protocol which is performed with a tapered flow resistive inspiratory loading device . Patients have to complete 30 dynamic inspiratory efforts twice daily for 7 days a week until surgery with a minimum of 2 weeks . The starting training load will be aim ed to be 60 % of maximal inspiratory pressure and will be increased based on the rate of perceived exertion . The main study endpoint is the incidence of postoperative pneumonia . Secondary objectives are to evaluate the effect of preoperative inspiratory muscle training on length of hospital stay , duration of mechanical ventilation , incidence of other postoperative ( pulmonary ) complications , quality of life , and on postoperative respiratory muscle function and lung function . Discussion The PREPARE study is the first multicenter r and omized controlled trial to evaluate the hypothesis that preoperative inspiratory muscle training leads to decreased pulmonary complications in patients undergoing esophageal resection . Trial registration NCT01893008 BACKGROUND We assessed the utility of maximum oxygen consumption during exercise ( MVO2 ) and diffusing capacity for carbon monoxide ( DL(CO ) ) in the prediction of postoperative pulmonary complications , and the effect of such complications on postoperative length of hospital stay and the cost of hospitalization . METHODS C and i date s for lung resection were prospect ively studied by preoperative measurement of DL(CO ) ( expressed as a percentage of predicted [ DL(CO)% ] ) and MVO2 .  Postoperative pulmonary complications , duration of postoperative hospitalization , and the cost of hospitalization were assessed . RESULTS Forty patients had lung resection with no operative mortality . The postoperative length of hospitalization was longer for the 13 patients who developed pulmonary complications compared with the 27 patients who did not ( 7.7+/-0.8 vs 5.0+/-0.4 days , respectively ; p = 0.007 ) , and the cost of hospitalization in the former group was higher ( $ 11,530+/-$1,959 vs $ 6,578+/-$406 , respectively ; p = 0.031 ) . Diffusing capacity was higher in patients without than in patients with pulmonary complications ( DL(CO)% 90.1+/-5.0 vs 65.3+/-5.9 ; p = 0.0034 ) . The mean MVO2 did not differ between the groups ( 17.8+/-0.9 vs 16.3+/-1.2 ) . DL(CO)% predicted pulmonary complications ( p = 0.006 ) . CONCLUSIONS DL(CO)% predicts the likelihood of pulmonary complications after major lung resection , which are associated with increased length of hospital stay and cost Introduction Postoperative pulmonary complications ( PPC ) such as atelectasis and pneumonia are common following lung resection . PPCs have a significant clinical impact on postoperative morbidity and mortality . We studied the long-term effects of PPCs and sought to identify independent risk factors . Methods A prospect i ve observational study involved all patients following lung resection in a regional thoracic centre over 4 years .  PPCs were assessed daily in hospital using the Melbourne group scale based on chest X-ray , white cell count , fever , purulent sputum , microbiology , oxygen saturations , physician diagnosis and intensive therapy unit (ITU)/high-dependency unit readmission . Follow-up included hospital length of stay ( LOS ) , 30-day readmissions , and mortality . Results 86 of 670 patients ( 13 % ) who had undergone a lung resection developed a PPC . Those patients had a significantly longer hospital LOS in days ( 13 , 95 % CI 10.5–14.9 vs 6.3 , 95 % CI 5.9 to 6.7 ; p<0.001 ) and higher rates of ITU admissions ( 28 % vs 1.9 % ; p<0.001 ) and 30-day hospital readmissions ( 20.7 % vs 11.9 % ; p<0.05 ) . Significant independent risk factors for development of PPCs were COPD and smoking ( p<0.05 ) , not age . Excluding early postoperative deaths , developing a PPC result ed in a significantly reduced overall survival in months ( 40 , 95 % CI 34 to 44 vs 46 , 95 % CI 44 to 47 ; p=0.006 ) . Those who developed a PPC had a higher rate of non-cancer-related deaths ( 11 % vs 5 % ; p=0.020 ) . PPC is a significant independent risk factor for late deaths in non-small cell lung cancer patients ( HR 2.0 , 95 % CI 1.9 to 3.2 ; p=0.006 ) . Conclusions Developing a PPC after thoracic surgery is common and is associated with a poorer long-term outcome Objective : To investigate the additional effect of incentive spirometry to chest physiotherapy to prevent postoperative pulmonary complications after thoracic surgery for lung and esophageal resections . Design : R and omized controlled trial . Setting : University hospital , intensive care unit , and surgical department . Patients : Sixty‐seven patients ( age , 59 ± 13 yrs ; forced expiratory volume in 1 sec , 93 % ± 22 % predicted ) undergoing elective thoracic surgery for lung ( n = 40 ) or esophagus ( n = 27 ) resection . Interventions : Physiotherapy ( breathing exercises , huffing , and coughing ) ( PT ) plus incentive spirometry ( IS ) was compared with PT alone . Measurements and Main Results : Lung function , body temperature , chest radiograph , white blood cell count , and number of hospital and intensive care unit days were all measured . Pulmonary function was significantly reduced after surgery ( 55 % of the initial value ) and improved significantly in the postoperative period in both groups . However , no differences were observed in the recovery of pulmonary function between the groups . The overall score of the chest radiograph , based on the presence of atelectasis , was similar in both treatment groups . Eight patients ( 12 % ) ( three patients with lobectomy and five with esophagus resection ) developed a pulmonary complication ( abnormal chest radiograph , elevated body temperature and white blood cell count ) , four in each treatment group . Adding IS to regular PT did not reduce hospital or intensive care unit stay . Conclusions : Pulmonary complications after lung and esophagus surgery were relatively low . The addition of IS to PT did not further reduce pulmonary complications or hospital stay . Although we can not rule out beneficial effects in a subgroup of high‐risk patients , routine use of IS after thoracic surgery seems to be ineffective Background The purpose of the PROLUCA study is to investigate the efficacy of preoperative and early postoperative rehabilitation in a non-hospital setting in patients with operable lung cancer with special focus on exercise . Methods Using a 2x2 factorial design with continuous effect endpoint ( Maximal Oxygen Uptake ( VO2peak ) ) , 380 patients with non-small cell lung cancer ( NSCLC ) stage I-IIIa referred for surgical resection will be r and omly assigned to one of four groups : ( 1 ) preoperative and early postoperative rehabilitation ( starting two weeks after surgery ) ; ( 2 ) preoperative and late postoperative rehabilitation ( starting six weeks after surgery ) ; ( 3 ) early postoperative rehabilitation alone ; ( 4 ) today ’s st and ard care which is postoperative rehabilitation initiated six weeks after surgery . The preoperative rehabilitation program consists of an individually design ed , 30-minute home-based exercise program performed daily . The postoperative rehabilitation program consists of a supervised group exercise program comprising cardiovascular and resistance training two-hour weekly for 12 weeks combined with individual counseling . The primary study endpoint is VO2peak and secondary endpoints include : Six-minute walk distance ( 6MWD ) , one-repetition-maximum ( 1RM ) , pulmonary function , patient-reported outcomes ( PROs ) on health-related quality of life ( HRQoL ) , symptoms and side effects of the cancer disease and the treatment of the disease , anxiety , depression , wellbeing , lifestyle , hospitalization time , sick leave , work status , postoperative complications ( up to 30 days after surgery ) and survival . Endpoints will be assessed at baseline , the day before surgery , pre-intervention , post-intervention , six months after surgery and one year after surgery . Discussion The results of the PROLUCA study may potentially contribute to the identification of the optimal perioperative rehabilitation for operable lung cancer patients focusing on exercise initiated immediately after diagnosis and rehabilitation shortly after surgery . Trial Registration OBJECTIVE To evaluate the effect of 4 weeks of pulmonary rehabilitation ( PR ) versus chest physical therapy ( CPT ) on the preoperative functional capacity and postoperative respiratory morbidity of patients undergoing lung cancer resection . DESIGN R and omized single-blinded study . SETTING A teaching hospital . PARTICIPANTS Patients undergoing lung cancer resection ( N=24 ) . INTERVENTIONS Patients were r and omly assigned to receive PR ( strength and endurance training ) versus CPT ( breathing exercises for lung expansion ) . Both groups received educational classes . MAIN OUTCOME MEASURES Functional parameters assessed before and after 4 weeks of PR or CPT ( phase 1 ) , and pulmonary complications assessed after lung cancer resection ( phase 2 ) . RESULTS Twelve patients were r and omly assigned to the PR arm and 12 to the CPT arm . Three patients in the CPT arm were not su bmi tted to lung resection because of inoperable cancer . During phase 1 evaluation , most functional parameters in the PR group improved from baseline to 1 month : forced vital capacity ( FVC ) ( 1.47L [ 1.27 - 2.33L ] vs 1.71L [ 1.65 - 2.80L ] , respectively ; P=.02 ) ; percentage of predicted FVC ( FVC% ; 62.5 % [ 49%-71 % ] vs 76 % [ 65%-79.7 % ] , respectively ; P<.05 ) ; 6-minute walk test ( 425.5±85.3 m vs 475±86.5 m , respectively ; P<.05 ) ; maximal inspiratory pressure ( 90±45.9cmH(2)O vs 117.5±36.5cmH(2)O , respectively ; P<.05 ) ; and maximal expiratory pressure ( 79.7±17.1cmH(2)O vs 92.9±21.4cmH(2)O , respectively ; P<.05 ) . During phase 2 evaluation , the PR group had a lower incidence of postoperative respiratory morbidity ( P=.01 ) , a shorter length of postoperative stay ( 12.2±3.6d vs 7.8±4.8d , respectively ; P=.04 ) , and required a chest tube for fewer days ( 7.4±2.6d vs 4.5±2.9d , respectively ; P=.03 ) compared with the CPT arm . CONCLUSIONS These findings suggest that 4 weeks of PR before lung cancer resection improves preoperative functional capacity and decreases the postoperative respiratory morbidity Introduction : Impairment in aerobic fitness is a potential modifiable risk factor for postoperative complications . In this r and omized controlled trial , we hypothesized that a high‐intensity interval training ( HIIT ) program enhances cardiorespiratory fitness before lung cancer surgery and therefore reduces the risk of postoperative complications . Methods : Patients with operable lung cancer were r and omly assigned to usual care ( UC ) ( n = 77 ) or preoperative rehabilitation based on HIIT ( Rehab ) ( n = 74 ) .  Maximal cardiopulmonary exercise testing and the 6‐minute walk test were performed twice before surgery . The primary outcome measure was a composite of death and in‐hospital postoperative complications . Results : The groups were well balanced in terms of patient characteristics . During the preoperative waiting period ( median 25 days ) , the peak oxygen consumption and the 6‐minute walking distance increased ( median + 15 % , interquartile range , 25th to 75 percentile [ IQR25%–75 % , % ] = + 9 % to + 22 % , p = 0.003 and + 15 % , IQR25%–75 % = + 8 % to + 28 % , p < 0.001 , respectively ) in the Rehab group , whereas peak oxygen consumption declined in the UC group ( median –8 % , IQR25%–75 % = –16 % to 0 % ] , p = 0.005 ) . The primary end point did not differ significantly between the two groups : at least one postoperative complication developed in 27 of the 74 patients ( 35.5 % ) in the Rehab group and 39 of 77 patients ( 50.6 % ) in the UC group ( p = 0.080 ) . Notably , the incidence of pulmonary complications was lower in the Rehab compared with in the UC group ( 23 % versus 44 % , p = 0.018 ) , owing to a significant reduction in atelectasis ( 12.2 % versus 36.4 % , p < 0.001 ) , and this decrease was accompanied by a shorter length of stay in the postanesthesia care unit ( median –7 hours , IQR25%–75 % = –4 to –10 ) . Conclusions : In this r and omized controlled trial , preoperative HIIT result ed in significant improvement in aerobic performances but failed to reduce early complications after lung cancer resection Postoperative physiotherapy has been shown to reduce the incidence of postoperative pulmonary complications after open abdominal surgery . This study aim ed to determine if the addition of deep breathing exercises and secretion clearing techniques to a st and ardised physiotherapist-directed program of early mobilisation improved clinical outcomes in patients undergoing open abdominal surgery . Fifty-six patients undergoing open abdominal surgery , at high risk of developing postoperative pulmonary complications , were r and omised before operation to an early mobilisation-only group or an early mobilisation-plus-deep breathing and coughing group .  Mobility duration , frequency and intensity of breathing interventions were quantified for both groups . All outcomes were assessed by a blinded outcomes research er using a st and ardised outcomes measurement tool developed specifically for this population . Outcomes included incidence of clinical ly significant postoperative pulmonary complications , fever , length of stay , and restoration of mobility . There were no significant differences between groups in mean age , anaesthetic time , perioperative morbidity , or postoperative mobility . Outcome data were available for 89 % of enrolled subjects . Overall incidence of postoperative pulmonary complications was 16 % . The incidence of postoperative pulmonary complications in the non-deep breathing and coughing group was 14 % , and the incidence of postoperative pulmonary complications in the deep breathing and coughing group was 17 % , ( absolute risk reduction -3 % , 95 % C1 -22 to 19 % ) . There was no significant difference between groups in the incidence of fever , physiotherapist time , or the number of treatments . This study suggests that , in this clinical setting , the addition of deep breathing and coughing exercises to a physiotherapist-directed program of early mobilisation does not significantly reduce the incidence of clinical ly significant postoperative pulmonary complications in high risk open abdominal surgery subjects Background : Postoperative respiratory complications often arise in lung cancer patients after lung resection , although these are often difficult to predict . We sought to identify reliable predictors of early-onset postoperative respiratory complications in lung cancer patients who had moderate-to-severe preoperative respiratory impairment . Methods : This was a prospect i ve observational study that included 107 consecutive lung cancer patients with forced expiratory volume in 1 s < 60 % of predicted who were scheduled for thoracotomy and lung resection .  Preoperative functional assessment s included pulmonary function testing by spirometry , single breath diffusion capacity of lung for carbon monoxide , and cardiopulmonary exercise testing . Risk factors for early-onset postoperative respiratory complications that occurred within 30 days postoperatively were sought from among these pulmonary function testing and cardiopulmonary exercise testing results . Results : By multivariable logistic regression , peak oxygen uptake ( V′O2max% ; p < 0.001 ) and the transcutaneous pulse oxygen saturation difference during load exercise ( ΔSPO2 % ; p < 0.001 ) were independent predictors of postoperative respiratory complications . A receiver operating characteristic curve had an area under the curve of 0.846 for the combination of V′O2max% and ΔSPO2 % , while the area under the curve with V′O2max% only was 0.726 . From this , the probability of postoperative respiratory complications was P complication = e ( 2 . 58 − 0 . 08 V ′ O 2 max % + 0 . 56 Δ SP O 2 % ) / [ 1 + e ( 2 . 58 − 0 . 08 V ′ O 2 max % + 0 . 56 Δ SP O 2 % ) ] . Pcomplication ≥ 0.202 for postoperative respiratory complications had a sensitivity of 80.8 % and a specificity of 81.5 % . Conclusions : For lung cancer patients with forced expiratory volume in 1 s < 60 % of predicted , in addition to common preoperative tests , V′O2max% and ΔSPO2 % may be an aid for predicting early-onset postoperative respiratory complications Abstract Objective To assess the efficacy of a single preoperative physiotherapy session to reduce  postoperative pulmonary complications ( PPCs )  after upper abdominal surgery . Design Prospect i ve , pragmatic , multicentre , patient and assessor blinded , parallel group , r and omised placebo controlled superiority trial . Setting Multidisciplinary preadmission clinics at three tertiary public hospitals in Australia and New Zeal and . Participants 441 adults aged 18 years or older who were within six weeks of elective major open upper abdominal surgery were r and omly assigned through concealed allocation to receive either an information booklet ( n=219 ; control ) or preoperative physiotherapy ( n=222 ; intervention ) and followed for 12 months . 432 completed the trial . Interventions Preoperatively , participants received an information booklet ( control ) or an additional 30 minute physiotherapy education and breathing exercise training session ( intervention ) . Education focused on PPCs and their prevention through early ambulation and self directed breathing exercises to be initiated immediately on regaining consciousness after surgery . Postoperatively , all participants received st and ardised early ambulation , and no additional respiratory physiotherapy was provided . Main outcome measures The primary outcome was a PPC within 14 postoperative hospital days assessed daily using the Melbourne group score . Secondary outcomes were hospital acquired pneumonia , length of hospital stay , utilisation of intensive care unit services , and hospital costs . Patient reported health related quality of life , physical function , and post-discharge complications were measured at six weeks , and all cause mortality was measured to 12 months . Results The incidence of PPCs within 14 postoperative hospital days , including hospital acquired pneumonia , was halved ( adjusted hazard ratio 0.48 , 95 % confidence interval 0.30 to 0.75 , P=0.001 ) in the intervention group compared with the control group , with an absolute risk reduction of 15 % ( 95 % confidence interval 7 % to 22 % ) and a number needed to treat of 7 ( 95 % confidence interval 5 to 14 ) . No significant differences in other secondary outcomes were detected . Conclusion In a general population of patients listed for elective upper abdominal surgery , a 30 minute preoperative physiotherapy session provided within existing hospital multidisciplinary preadmission clinics halves the incidence of PPCs and specifically hospital acquired pneumonia . Further research is required to investigate benefits to mortality and length of stay . Trial registration Australian New Zeal and Clinical Trials Registry ANZCTR 12613000664741 Introduction : A stepwise approach to the functional assessment of lung resection c and i date s is widely accepted , and this approach incorporates the measurement of exercise peak Vo2 when spirometry and radionuclear studies suggest medical inoperability . A new functional operability ( FO ) algorithm incorporates peak exercise Vo2 earlier in the preoperative assessment to determine which patients require preoperative radionuclear studies . This algorithm has not been studied in a multicenter study . Methods : The CALGB ( Cancer and Leukemia Group B ) performed a prospect i ve multi-institutional study to investigate the use of primary exercise Vo2 measurement for the prediction of surgical risk . Patients with known or suspected resectable non-small cell lung cancer ( NSCLC ) were eligible .  Exercise testing including measurement of peak oxygen uptake ( Vo2 ) , spirometry , and single breath diffusion capacity ( DLCO ) was performed on each patient . Nuclear perfusion scans were obtained on selected high-risk patients . After surgery , morbidity and mortality data were collected and correlated with preoperative data . Mortality and morbidity were retrospectively compared by algorithm-based risk groups . Results : Three hundred forty-six patients with suspected lung cancer from nine institutions underwent thoracotomy with or without resection ; 57 study patients did not undergo thoracotomy .  Patients who underwent surgery had a median survival time of 30.9 months , whereas patients who did not undergo surgery had a median survival time of 15.6 months . Among the 346 patients who underwent thoracotomy , 15 patients died postoperatively ( 4 % ) , and 138 patients ( 39 % ) exhibited at least one cardiorespiratory complication postoperatively . We found that patients who had a peak exercise Vo2 of < 65 % of predicted ( or a peak Vo2/kg < 16 ml/min/kg ) were more likely to suffer complications ( p = 0.0001 ) and were also more likely to have a poor outcome ( respiratory failure or death ) if the peak Vo2 was < 15 ml/min/kg ( p = 0.0356 ) . We also found a subset of 58 patients who did not meet FO algorithm criteria for operability , but who still tolerated lung resection with a 2 % mortality rate . Conclusions : Our data provide multicenter validation for the use of exercise Vo2 for preoperative assessment of lung cancer patients , and we encourage an aggressive approach when evaluating these patients for surgery OBJECTIVE The purpose of this study was to investigate the impact of pulmonary rehabilitation on surgical morbidity and lung function in lung cancer patients with chronic obstructive pulmonary disease ( COPD ) . METHODS Prospect ively , 22 lung cancer patients with COPD who underwent lobectomy between 2000 and 2003 were enrolled for this study as a rehabilitation group (  Rehab . Group ) . The criteria of COPD were preoperative forced expiratory volume in 1 second (FEV1)/forced vital capacity ( FVC ) < or = 70 % and more than 50 % of low attenuation area in a computed tomography . Preoperatively patients performed aggressive pulmonary exercise for two weeks and received chest physiotherapy postoperatively .  As a historical control , 60 patients with lung cancer who fulfilled the same criteria but did not receive rehabilitation between 1995 and 1999 ( control group ) were entered in this study . RESULTS Patient background s were all equivalent between the two groups . However , FEV1 and FEV1/FVC were significantly lower in the Rehab . Group ( p < 0.05 ) . Prolonged oxygen supplement and tracheostomy tended to be more frequent in the control group . The ratio of actual postoperative to predicted postoperative FEV1 was significantly better in the Rehab . Group ( p = 0.047 ) . Furthermore , postoperative hospital stay was significantly longer in the control group ( p = 0.0003 ) . CONCLUSION Despite lower FEV1 and FEV1/FVC in the Rehab . Group , postoperative pulmonary complications and long hospital stay could be effectively prevented and FEV1 was well preserved by rehabilitation and physiotherapy Introduction . Surgical resection in patients with non – small cell lung cancer ( NSCLC ) may be associated with significant morbidity , functional limitations , and decreased quality of life . Objectives . The safety and feasibility of a preoperative and early postoperative rehabilitation program in patients operated for NSCLC was determined in a nonhospital setting , with focus on high-intensity interval exercise . Methods . Forty patients with biopsy-proven NSCLC stages I to IIIa referred for surgical resection at the Department of Cardiothoracic Surgery RT , Rigshospitalet , University of Copenhagen , were r and omly assigned to 1 of 4 groups ( 3 intervention groups and 1 control group ) . The preoperative intervention consisted of a home-based exercise program , while the postoperative exercise program comprised a supervised group exercise program involving resistance and high-intensity interval cardiorespiratory exercise 2 hours weekly for 12 weeks combined with individual counseling . The study endpoints were inclusion rate , adherence , and number of adverse events . Results . Forty patients ( of 124 screened ; 32 % ) were included and r and omized into the 4 groups . The postoperative exercise was completed by 73 % of the patients r and omized to this intervention . No adverse events were observed , indicating that the early postoperative exercise program is safe . The preoperative home-based exercise program was not feasible due to interfering diagnostic procedures and fast-track surgery that left only 1 to 2 weeks between diagnosis and surgery . Conclusion . The early postoperative exercise program for patients with NSCLC was safe and feasible , but in a fast-track set up , a preoperative home-based exercise program was not feasible for this population OBJECTIVE This prospect i ve r and omized study was conducted in order to define the contribution of the generated oxygen and nitrogen reactive species on postlobectomy morbidity and mortality . PATIENTS AND METHODS Between 2001 and 2003 , 132 patients with non-small cell lung cancer ( NSCLC ) were prospect ively studied . The patients were grouped according to one-lung ventilation ( OLV ) use or not and to the duration of lung 's atelectasis . Group A included 50 patients with confirmed non-small cell lung cancer who were subjected to lobectomy without one-lung ventilation .  Group B included 30 patients subjected to 60 min OLV . Group C included 30 patients subjected to 90 min OLV . Group D included 22 patients subjected to 120 min OLV . Preoperative , intraoperative and postoperative strict blood sampling protocol was followed . Malondialdehyde ( MDA ) plasma levels were measured . The groups were statistically compared for the occurrence of postoperative complications . OLV ( groups B-D ) along with other clinical parameters were entered in multivariate analysis as risk factors for complication development . MEASUREMENTS AND RESULTS Comparison of group A with groups B-D ( OLV ) documented significant increase ( p<0.001 ) of MDA levels during lung reexpansion . The magnitude of oxidative stress was related to OLV duration ( group D > group C > group B , all p<0.001 ) . Univariate analysis disclosed a higher incidence of acute respiratory failure , cardiac arrhythmias and pulmonary hypertension in group D. Multivariate analysis revealed OLV as an independent risk factor for postoperative development of cardiac arrhythmias and pulmonary hypertension . CONCLUSION Protracted ( > 1h ) OLV should be considered a potential cause for cardiovascular complications through the generation of severe oxidative stress due to lung reexpansion Objective : To determine in a pilot study the feasibility and effects of preoperative inspiratory muscle training in patients at high risk of postoperative pulmonary complications who were scheduled for coronary artery bypass graft surgery . Design : Single-blind , r and omized controlled pilot study . Setting : University Medical Centre Utrecht , the Netherl and s. Subjects : Twenty-six patients at high risk of postoperative pulmonary complications were selected . Intervention : The intervention group ( N = 14 ) received 2 - 4 weeks of preoperative inspiratory muscle training on top of the usual care received by the patients in the control group . Main measures : Primary outcome variables of feasibility were the occurrence of adverse events , and patient satisfaction and motivation . Secondary outcome variables were postoperative pulmonary complications and length of hospital stay . Results : The feasibility of inspiratory muscle training was good and no adverse events were observed . Treatment satisfaction and motivation , scored on 10-point scales , were 7.9 ( ± 0.7 ) and 8.2 ( ± 1.0 ) , respectively . Postoperative atelectasis occurred in significantly fewer patients in the intervention group than in the control group ( ϰ2 DF1 = 3.85 ; P = 0.05 ) : Length of hospital stay was 7.93 ( ± 1.94 ) days in the intervention group and 9.92 ( ± 5.78 ) days in the control group ( P = 0.24 ) . Conclusion : Inspiratory muscle training for 2 - 4 weeks before coronary artery bypass graft surgery was well tolerated by patients at risk of postoperative pulmonary complications and prevented the occurrence of atelectasis in these patients . A larger r and omized clinical trial is warranted OBJECTIVE This study investigates whether targeted postoperative respiratory physiotherapy decreased the incidence of postoperative pulmonary complications and length of stay for patients undergoing elective pulmonary resection via open thoracotomy . METHODS Seventy-six patients participated in a prospect i ve , single-blind , parallel-group , r and omised trial with concealed allocation , assessor blinding and intention-to-treat analysis . Treatment group participants received daily respiratory physiotherapy interventions until discharge . Control group participants received st and ard medical/nursing care involving a clinical pathway . The presence of postoperative pulmonary complications was assessed on a daily basis during hospitalisation using a st and ardised diagnostic tool . Length of stay was recorded . RESULTS Postoperative pulmonary complications developed in two participants ( 4.8 % ) in the treatment group and in one participant ( 2.9 % ) in the control group ; the difference ( treatment minus control ) was 1.8 % ( 95 % confidence interval ( CI ) -10.6 % to 13.1 % ) ( p=1.00 ) . No significant difference was found between groups for length of stay ( treatment group , median 6.0 days ; control group 6.0 days ) ( p=0.87 ) . A preoperative forced expiratory volume in 1s of 1.5l or less ( p=0.005 ) and a history of chronic obstructive pulmonary disease ( p=0.008 ) were associated with a greater number of criteria for a postoperative pulmonary complication being met . CONCLUSIONS In this patient population , given the low incidence of postoperative pulmonary complications , targeted respiratory physiotherapy may not be required in addition to st and ard care involving a clinical pathway following pulmonary resection via open thoracotomy . These results should be extrapolated with caution to those patients undergoing pulmonary resection with poor preoperative lung function One hundred twenty patients undergoing coronary artery surgery completed a r and omized controlled study design ed to investigate whether prophylactic chest physiotherapy affected the incidence of postoperative pulmonary complications . Group 1 patients received no preoperative or postoperative chest physiotherapy . Group 2 patients received preoperative education and instruction in breathing and coughing exercises and postoperative supervision and assistance in performing the same . These exercises were supervised by a physiotherapist twice per day on the first 2 postoperative days and once per day on the 3rd and 4th postoperative days . Physiotherapy for group 3 patients was the same as for group 2 patients except that patients were seen by a physiotherapist 4 times per day on the first 2 postoperative days and twice per day on the 3rd and 4th postoperative days . Group 2 and 3 patients were instructed to practice breathing and coughing exercises every hour . Overall , an incidence of clinical ly significant postoperative pulmonary complications of 7.5 percent was demonstrated . In general , these patients demonstrated lower levels of preoperative pulmonary function and very low early postoperative oxygenation compared with those who did not develop pulmonary complications . There was no indication that the incidence or severity of fever , hypoxemia , chest roentgenologic abnormalities or clinical ly significant postoperative pulmonary complications was different between groups . These results suggest that the necessity for prophylactic chest physiotherapy after routine coronary artery surgery should be review ed BACKGROUND : The application of CPAP has been used to minimize postoperative pulmonary complications after lung resection surgery . The aim of this study was to quantify both the CPAP effects upon lung function and functional capacity in early postoperative lung resection , as well as to evaluate if CPAP prolongs air leak through the chest drain . METHODS : Thirty patients in the postoperative period of lung resection were allocated into 2 groups : an experimental group , consisting of 15 patients who underwent a 10 cm H2O CPAP  , and a  15 patient control group  , who performed breathing exercises . Arterial blood gas analysis , peak expiratory flow ( PEF ) , respiratory muscle strength , spirometry , and 6-min walk test ( 6MWT ) were assessed in the preoperative period , and repeated postoperatively on the first and on the seventh day ( 6MWT was repeated only on the seventh day ) . RESULTS : Significant increases in PEF , muscle strength , and FEV1 between the first and seventh postoperative day were observed , both in the experimental and in the control group , whereas FVC and PaO2 increased significantly between the first and seventh postoperative day only in the experimental group . The average loss in 6-min walk distance ( 6MWD ) from preoperative to postoperative day 7 in the experimental group was significantly lower than in control group . When comparing the 2 groups , only 6MWD was statistically different ( P < .001 ) . There was no air leakage increase through the drain with the early use of CPAP . CONCLUSION : When compared to breathing exercises , CPAP increases the 6MWD in postoperative lung resection patients , without prolonging air leak through the chest drain CONTEXT Postoperative pulmonary complications ( PPCs ) after coronary artery bypass graft ( CABG ) surgery are a major source of morbidity and mortality , and increase length of hospital stay and re source utilization . The prehospitalization period before CABG surgery may be used to improve a patient 's pulmonary condition . The efficacy of preoperative inspiratory muscle training ( IMT ) in reducing the incidence of PPCs in high-risk patients undergoing CABG surgery has not yet been determined . OBJECTIVE To evaluate the prophylactic efficacy of preoperative IMT on the incidence of PPCs in high-risk patients scheduled for elective CABG surgery . DESIGN , SETTING , AND PATIENTS A single-blind , r and omized clinical trial conducted at the University Medical Center Utrecht , Utrecht , the Netherl and s , with enrollment between July 2002 and August 2005 . Of 655 patients referred for elective CABG surgery , 299 ( 45.6 % ) met criteria for high risk of developing PPCs , of whom 279 were enrolled and followed up until discharge from hospital . INTERVENTION Patients were r and omly assigned to receive either preoperative IMT ( n = 140 ) or usual care ( n = 139 ) . Both groups received the same postoperative physical therapy . MAIN OUTCOME MEASURES Incidence of PPCs , especially pneumonia , and duration of postoperative hospitalization . RESULTS Both groups were comparable at baseline . After CABG surgery , PPCs were present in 25 ( 18.0 % ) of 139 patients in the IMT group and 48 ( 35.0 % ) of 137 patients in the usual care group ( odds ratio [ OR ] , 0.52 ; 95 % confidence interval [ CI ] , 0.30 - 0.92 ) . Pneumonia occurred in 9 ( 6.5 % ) of 139 patients in the IMT group and in 22 ( 16.1 % ) of 137 patients in the usual care group ( OR , 0.40 ; 95 % CI , 0.19 - 0.84 ) . Median duration of postoperative hospitalization was 7 days ( range , 5 - 41 days ) in the IMT group vs 8 days ( range , 6 - 70 days ) in the usual care group by Mann-Whitney U statistic ( z = -2.42 ; P = .02 ) . CONCLUSION Preoperative IMT reduced the incidence of PPCs and duration of postoperative hospitalization in patients at high risk of developing a pulmonary complication undergoing CABG surgery . TRIAL REGISTRATION is rct n.org Identifier : IS RCT N17691887 BACKGROUND High concentrations of inspired oxygen are associated with pulmonary atelectasis but also provide recognized advantages . Consequently , the appropriate inspired oxygen concentration for general surgical use remains controversial . The authors tested the hypothesis that atelectasis and pulmonary dysfunction on the first postoperative day are comparable in patients given 30 % or 80 % perioperative oxygen . METHODS Thirty patients aged 18 - 65 yr were anesthetized with isoflurane and r and omly assigned  to 30 % or 80 % oxygen during and for 2 h after colon resection .  Chest radiographs and pulmonary function tests ( forced vital capacity and forced expiratory volume ) were obtained preoperatively and on the first postoperative day . Arterial blood gas measurements were obtained intraoperatively , after 2 h of recovery , and on the first postoperative day . Computed tomography scans of the chest were also obtained on the first postoperative day . RESULTS Postoperative pulmonary mechanical function was significantly reduced compared with preoperative values , but there was no difference between the groups at either time . Arterial gas partial pressures and the alveolar-arterial oxygen difference were also comparable in the two groups . All preoperative chest radiographs were normal . Postoperative radiographs showed atelectasis in 36 % of the patients in the 30%-oxygen group and in 44 % of those in the 80%-oxygen group . Relatively small amounts of pulmonary atelectasis ( expressed as a percentage of total lung volume ) were observed on the computed tomography scans , and the percentages ( mean + /- SD ) did not differ significantly in the patients given 30 % oxygen ( 2.5 % + /- 3.2 % ) or 80 % oxygen ( 3.0 % + /- 1.8 % ) . These data provided a 99 % chance of detecting a 2 % difference in atelectasis volume at an alpha level of 0.05 . CONCLUSIONS Lung volumes , the incidence and severity of atelectasis , and alveolar gas exchange were comparable in patients given 30 % and 80 % perioperative oxygen . The authors conclude that administration of 80 % oxygen in the perioperative period does not worsen lung function . Therefore , patients who may benefit from generous oxygen partial pressures should not be denied supplemental perioperative oxygen for fear of causing atelectasis
Preoperative exercise training may reduce the risk of developing a postoperative pulmonary complication , the duration of intercostal catheter use , postoperative length of hospital stay , and improve both exercise capacity and FVC in people undergoing lung resection for NSCLC .
BACKGROUND Surgical resection for early stage non-small cell lung cancer ( NSCLC ) offers the best chance of cure , but is associated with a risk of postoperative pulmonary complications ( i.e. pneumonia ( new infiltrate coupled with either fever ( > 38º C ) and purulent secretions , or fever and white cell count > 11,000 ) , bronchopleural fistula , severe atelectasis that requires chest physiotherapy or bronchoscopy , and prolonged mechanical ventilation ( > 48 hours ) ) .
It is currently unclear if preoperative exercise training , and the potential result ant improvement in exercise capacity , may also improve postoperative outcomes , such as the risk of developing postoperative pulmonary complications , the length of postoperative intercostal drainage , or the length of hospital stay .
OBJECTIVES The primary aims of this study were to determine the effect of preoperative exercise training on postoperative outcomes , such as risk of developing a postoperative pulmonary complication , and postoperative duration of intercostal catheter use in adults scheduled to undergo lung resection for NSCLC .
The secondary aims of this study were to determine the effect of preoperative exercise training  on length of hospital stay , fatigue , dyspnoea , exercise capacity , lung function , and postoperative mortality .