Postoperative Respiratory Exercises Reduce the Risk of Developing Pulmonary Complications in Patients Undergoing Lobectomy

The effectiveness of pre- and post-operative rehabilitation for lung cancer: A systematic review and meta-analysis on postoperative pulmonary complications and length of hospital stay

OBJECTIVE

To investigate the effects of rehabilitation either before or after operation for lung cancer on postoperative pulmonary complications and the length of hospital stay.

DATA SOURCES

MEDLINE, Cochrane Central Register of Controlled Trials, Web of Science, CINAHL Plus, SPORTDiscus, PsycInfo and Embase were searched from inception until June 2021.

REVIEW METHODS

Inclusion criteria were patients scheduled to undergo or had undergone operation for lung cancer, randomised controlled trials comparing rehabilitative interventions initiated before hospital discharge to usual care control. Two reviewers independently assessed eligibility, extracted data and risks of bias. Pooled odds ratios (ORs) or standardised mean differences (SMDs) with 95% Confidence Intervals (CI) were estimated using random-effects meta-analyses.

RESULTS

Twenty-three studies were included (12 preoperative, 10 postoperative and 1 perioperative), with 2068 participants. The pooled postoperative pulmonary complication risk and length of hospital stay were reduced after preoperative interventions (OR = 0.32; 95% CI = 0.22, 0.47; I² = 0.0% and SMD = -1.68 days, 95% CI = -2.23, -1.13; I² = 77.8%, respectively). Interventions delivered during the immediate postoperative period did not have any significant effects on either postoperative pulmonary complication or length of hospital stay (OR = 0.85; 95% CI = 0.56, 1.29; I² = 0.0% and SMD = -0.23 days, 95% CI = -1.08, 0.63; I² = 64.6%, respectively). Meta-regression showed an association between a higher number of supervised sessions and shorter hospital length of stay in preoperative studies (β = -0.17, 95% CI = -0.29, -0.05).

CONCLUSION

Preoperative rehabilitation is effective in reducing postoperative pulmonary complications and length of hospital stay associated with lung cancer surgery. Short-term postoperative rehabilitation in inpatient settings is probably ineffective.

Tailored anaesthesia for thoracoscopic surgery promoting enhanced recovery: The state of the art

PURPOSE OF THE REVIEW

The current review focuses on precise anaesthesia for video-assisted thoracoscopic surgery (VATS) with the goal of enhanced recovery. The main aim of an enhanced recovery program after thoracic surgery is to reduce postoperative stress response, protect from postoperative pulmonary complications, give hospitals a better financial option and improve overall patient outcome. This can ultimately reduce hospital stay and increase patient satisfaction. With advances in endoscopic, robotic and endovascular techniques, video-assisted thoracoscopic surgery (VATS) can be performed in a minimally invasive way in managing most pulmonary, pleural and mediastinal diseases. As a minimally invasive technique, video-assisted thoracoscopic surgery (VATS) represents an important element of enhanced recovery program in thoracic surgery as it can achieve most of its goals. Anaesthetic management during preoperative, intraoperative and postoperative period is essential for the establishment of a successful enhanced recovery program. In the era of enhanced recovery protocols, non-intubated thoracoscopic procedures present a step forward. This article focuses on the key anaesthetic elements of the enhanced recovery program during all phases of thoracoscopic surgery. Having reviewed recent literature, a systematic review of literature will highlight successful ERAS protocols published for thoracoscopic surgery.

Is respiratory physiotherapy effective on pulmonary complications after lobectomy for lung cancer?

Background

The aim of this study was to investigate the effects of a postoperative respiratory physiotherapy program on pulmonary complications, length of hospital stay, and hospital cost after lobectomy for lung cancer.

Methods

A total of 90 patients (75 males, 15 females; mean age 63.1±10.4 years; range, 30 to 82 years) who underwent elective lobectomy through thoracotomy due to lung cancer between June 2014 and December 2019 were retrospectively analyzed. The patients were divided into two groups as Group S who received standard postoperative care (n=50) and Group P who received postoperative respiratory physiotherapy in addition to standard care (n=40). Both groups were compared in terms of postoperative pulmonary complications, 30-day mortality, length of hospital stay, and hospital cost.

Results

The preoperative and surgical characteristics of the groups were similar. Group P had a lower incidence of postoperative pulmonary complications (10% vs. 38%, respectively; p=0.002) than Group S. The median length of stay in the hospital was six (range, 4 to 12) days in Group P and seven (range, 4 to 40) days in Group S (p=0.001). The drug cost (639.70 vs. 1,211.46 Turkish Liras, respectively; p=0.001) and the total hospital cost (2,031.10 vs. 3,778.68 Turkish Liras, respectively; p=0.001) of the patients in Group P were significantly lower. The multivariate logistic regression analysis showed that respiratory physiotherapy had a protective effect on the development of postoperative pulmonary complications (odds ratio =0.063, 95% confidence interval: 0.010-0.401, p=0.003).

Conclusion

An intensive physiotherapy program focusing on respiratory exercises is a cost-effective practice which reduces the risk of development of postoperative pulmonary complications in patients undergoing lobectomy for lung cancer.

Anesthetic considerations for lung resection: preoperative assessment, intraoperative challenges and postoperative analgesia

This article is intended to provide a general overview of the anesthetic management for lung resection surgery including the preoperative evaluation of the patient, factors influencing the intraoperative anesthetic management and options for postoperative analgesia. Lung cancer is the leading cause of death among cancer patients in the United States. In patients undergoing lung resection, perioperative pulmonary complications are the major etiology of morbidity and mortality. Risk stratification of patients should be part of the preoperative assessment to predict their risk of short-term vs. long-term pulmonary complications. Improvements in surgical technique and equipment have made video assisted thoracoscopy and robotically assisted thoracoscopy the procedures of choice for thoracic surgeries. General anesthesia including lung isolation has become essential for optimizing visualization of the operative lung but may itself contribute to pulmonary complications. Protective lung ventilation strategies may not prevent acute lung injury from one-lung ventilation, but it may decrease the amount of overall lung injury by using small tidal volumes, positive end expiratory pressure, low peak and plateau airway pressures and low inspired oxygen fraction, as well as by keeping surgical time as short as possible. Because of the high incidence of chronic post-thoracotomy pain syndrome following thoracic surgery, which can impact a patient's normal daily activities for months to years after surgery, postoperative analgesia is a necessary part of the anesthetic plan. Multiple options such as thoracic epidural analgesia, intravenous narcotics and several nerve blocks can be considered in order to prevent or attenuate chronic pain syndromes. Enhanced recovery after thoracic surgery is a relatively new topic with many elements taken from the experience with colorectal surgery. The goal of enhanced recovery is to improve patient outcome by improving organ function and decreasing postoperative complications, and therefore decreasing length of hospital stay.

Physiotherapy management of patients undergoing thoracotomy procedure: A survey of current practice in Gauteng

BACKGROUND

Physiotherapy is included in the management of patients undergoing thoracic surgery. The aim of this study was to describe physiotherapy practice in the management of patients who undergo an open thoracotomy.

METHODS

A cross-sectional study using convenience sampling was undertaken. An electronic self-administered questionnaire was distributed via SurveyMonkey to 1389 physiotherapists registered with the South African Society of Physiotherapy in Gauteng. The data collection period was August and September 2014 and data were analysed descriptively.

RESULTS

A total of 323 physiotherapists (23.3%) responded to the survey and 141 (10.2%) indicated that they treated patients with open thoracotomies. Preoperative treatment was done by 65 (41.6%) and consisted of teaching supported coughing (92.3%; n = 60), sustained maximal inspiration (70.8%; n = 46) and the active cycle of breathing technique (69.2%; n = 45). One hundred and sixteen (82.3%) respondents treated patients during their hospital stay. Deep breathing exercises (97.6%; n = 83), coughing (95.3%; n = 81), early mobilisation (95.3%; n = 81), upper limb mobility exercises (91.8%; n = 78), chest wall vibrations (88.2%; n = 75) and trunk mobility exercises (85.9%; n = 73) were done frequently. Pain management modalities were less common, for example transcutaneous electrical nerve stimulation (12.9%; n = 11). Post hospital physiotherapy management was uncommon (32.6%; n = 46).

CONCLUSION

Physiotherapy related to early mobilisation in hospital is in line with evidence-based practice, but further education is needed regarding the need for physiotherapy post hospital discharge and pain management.