Incentive spirometry performance. A reliable indicator of pulmonary function in the early postoperative period after lobectomy?

Predictors of delayed extubation following lung resection: Focusing on preoperative pulmonary function and incentive spirometry

BACKGROUND

Delayed extubation is one of postoperative pulmonary complications (PPCs). Preoperative pulmonary function test (PFT) is an important assessment for patients undergoing lung resection. Volume-oriented incentive spirometry (IS) is one of physiotherapies to prevent PPCs. Preoperative PFT and IS volume (IS-v) can reflect the physiologic conditions of respiratory system in patients planning to undergo lung resection. However, the relationship between preoperative PFT/IS-v and delayed extubation in patients undergoing lung resection remains unclear. The study investigated the risk factors and impact of delayed extubation after lung resection. We aimed to achieve early recognition of patients being at a higher risk for developing postoperative delayed extubation after lung resection.

METHODS

This retrospective observational 4-year cohort study was conducted in a medical center, Taiwan. A total of 353 enrolled patients receiving thoracic surgery for lung resection were further categorized into the delayed extubation (n = 142, 40%) and non-delayed extubation (n = 211, 60%) groups.

RESULTS

In multivariate logistic regression analyses, age >65 years (adjusted odds ratio [AOR]: 2.60; 95% confidence interval [CI], 1.52-4.45), American Society of Anesthesiologists score >2 (AOR: 1.72; 95% CI, 1.05-2.82), anesthesia time >6hrs (AOR: 1.80; 95% CI, 1.13-2.88), pneumonectomy (AOR: 5.58; 95% CI, 1.62-19.19), and IS-v/inspiratory capacity (IC) ratio (AOR: 2.07; 95% CI, 1.16-3.68) were associated with delayed extubation after lung resection (all p < 0.05). Patients with delayed extubation were significantly associated with a higher proportion of other pulmonary complications, reintubation, mortality, and prolonged intensive care unit and hospital stays.

CONCLUSION

Older age, poor general health status, longer anesthesia time, pneumonectomy, and IS-v/IC ratio could be the independent factors predictive for delayed extubation after lung resection, which was in turn associated with worse outcomes. Preoperative PFT and IS-v were valuable for early recognition of patients being at a higher risk for developing postoperative delayed extubation after lung resection.

A randomized-controlled trial of sugammadex versus neostigmine: impact on early postoperative strength

BACKGROUND

Residual neuromuscular blockade after surgery is associated with airway obstruction, hypoxia, and respiratory complications. Compared with neostigmine, sugammadex reverses neuromuscular blockade to a train-of-four ratio > 0.9 more rapidly. It is unknown, however, whether the superior reversal profile of sugammadex improves clinically relevant measures of strength in the early postoperative period.

METHODS

Patients undergoing general, gynecological, or urologic surgery were randomized to receive either neostigmine (70 µg·kg^-1, maximum 5 mg) or sugammadex (2 or 4 mg·kg^-1) to reverse neuromuscular blockade. The primary outcome was the ability to breathe deeply measured by incentive spirometry at 30, 60, and 120 min after reversal.

RESULTS

We randomized 62 patients to either a neostigmine (n = 31) or sugammadex (n = 31) group. The incentive spirometry volume recovery trajectory was not different between the two groups (P = 0.35). Median spirometry volumes at baseline, 30, 60, and 120 min postoperatively were 2650 vs 2500 mL, 1775 vs 1750 mL, 1375 vs 2000 mL, and 1800 vs 1950 mL for the sugammadex and neostigmine groups, respectively. Postoperative incentive spirometry decrease from baseline was not different between the two groups. Hand grip strength, the ability to sit unaided, train-of-four ratio on postanesthesia care unit (PACU) admission, time to extubation, time to PACU discharge readiness, and Quality of Recovery-15 scores were also not different between the groups.

CONCLUSIONS

Measures of postoperative strength, such as incentive spirometry, hand group strength, and the ability to sit up in the early postoperative period were not different in patients who received neostigmine or sugammadex for the reversal of neuromuscular blockade.

TRIAL REGISTRATION

www.clinicaltrials.gov (NCT02909439); registered: 21 September, 2016.

Impact of serratus plane block on pain scores and incentive spirometry volumes after chest trauma

Background: Adequate pain control is difficult to achieve in patients with multiple rib fractures (MRF). Serratus plane block (SPB) is a novel technique for alleviating rib fracture pain. Several published case reports support this hypothesis. Purpose: The purpose of this study was to evaluate the use of SPB in MRF at our level 1 trauma center. Methods: Our hospital's Regional Anesthesia Registry was queried for all trauma patients with MRF who underwent SPB between August 2014 and January 2018. Data were compared in each patient as a matched pair for the time periods before and after undergoing SPB. Thirty-four patients with similar baseline characteristics were enrolled. Results: The median number of rib fractures was 7. Ordinal pain scores were found to be improved 4 hrs after SPB from median 7/10 to 3/10 (P<0.001). Incentive spirometry (IS) volumes recorded 4 and 24 hrs postserratus plane block showed a median increase of 150 and 175 mL from baseline, respectively (P<0.001). IS volumes recorded at 48 hrs showed a median increase of 300 mL from baseline (P<0.001). Respiratory rate decreased from a median value of 24.5 to 16 breaths/min (P<0.001). SpO₂ was improved at 24 hrs from median 96% to 99% (P<0.001). Conclusion: SPB improves pain scores and IS volumes in MRF. Because it is not limited by patient positioning or anticoagulation and has a better safety profile, it may offer a viable alternative to neuraxial techniques. Additional studies are necessary to evaluate its efficacy compared to neuraxial techniques.

Is incentive spirometry beneficial for patients with lung cancer receiving video-assisted thoracic surgery?

Background

The effectiveness of Incentive spirometry (IS) in patients undergoing video-assisted thoracic surgery (VATS) remains lacking. We conducted a population-based study to investigate the effectiveness of IS on patients with lung cancers following VATS.

Methods

We identified patients newly diagnosed with lung cancer who underwent surgical resection by VATS or thoracotomy from the years 2000 to 2008 in the Longitudinal Health Insurance Database. Exposure variable was the use of IS during admission for surgical resection by VATS or thoracotomy. Primary outcomes included hospitalization cost, incidence of pneumonia, and length of hospital stay. Secondary outcomes included the frequency of emergency department (ED) visits and hospitalizations at 3-month, 6-month, and 12-month follow-ups after thoracic surgery.

Results

We analyzed 7549 patients with lung cancer undergoing surgical resection by VATS and thoracotomy. The proportion of patients who were subjected to IS was significantly higher in those who underwent thoracotomy than in those who underwent VATS (68.4% vs. 53.1%, P < 0.0001). After we controlled for potential covariates, the IS group significantly reduced hospitalization costs (− 524.5 USD, 95% confidence interval [CI] = − 982.6 USD – -66.4 USD) and the risk of pneumonia (odds ratio = 0.55, 95% CI = 0.32–0.95) compared to the non-IS group following VATS. No difference in ED visit frequency and hospitalization frequency at 3-month, 6-month, and 1-year follow-up was noted between the IS and the non-IS groups following VATS.

Conclusions

The use of IS in patients with lung cancers undergoing VATS may reduce hospitalization cost and the risk of pneumonia.

Sufentanil sublingual tablet system (Zalviso®) as an effective analgesic option after thoracic surgery: An observational study

Introduction

Sufentanil sublingual tablet system (SSTS) (Zalviso^®) is a sublingual system for patient controlled analgesia, demonstrated to be an effective strategy for pain control after major abdominal and orthopedic surgery. We present a prospective observational study on the use of SSTS for the management of postoperative pain after thoracic surgery. The aim of this study was to assess the efficacy of Zalviso^® in reducing pain scores and increasing respiratory ability during postoperative period.

Materials and Methods

There were about 40 patients underwent video assisted thoracoscopy were included in the study. All the enrolled patients signed the informed consent were educated to the use of the device. Pain numeric rating scale values (NRS) were recorded at awakening from anesthesia (T0) and during the next hours, both at rest and with cough. We evaluate the time to obtain a mean NRS value ≤3 and difference in pain scores between first and subsequent measurements as the primary outcomes. The ability to use incentive spirometer and eventual drug adverse effect were evaluated as secondary outcomes.

Results

All patients in recovery room experienced moderate to severe pain. Pain score at rest and coughing decreased to a mean NRS value ≤3 (mild pain) respectively after 2 and 6 hours and the pain score difference continued to increase significantly after repeated measurements. 67.5% of patients resumed the original spirometric ability in pod 1; 9.5% in pod 2; 12% in pod 3. Only three patients out of forty (7,5%) experienced nausea; one patient (2,5%) had a vomiting episode.

Conclusion

Our study showed SSTS as an effective option for postoperative pain management in thoracic surgery, improving pain scores and respiratory ability.

Do simple beside lung function tests predict morbidity after rib fractures?

BACKGROUND

We evaluated if incentive spirometry volume (ISV) and peak expiratory flow rate (PEFR) could predict acute respiratory failure (ARF) in patients with rib fractures.

METHODS

Normotensive, co-operative patients were enrolled prospectively. ISV and PEFR were measured on admission, at 24 h and at 48 h by taking the best of three readings each time. The primary outcome, ARF, was defined as requiring invasive or noninvasive positive pressure ventilation.

RESULTS

99 patients were enrolled (median age, 77 years). ARF occurred in 9%. Of the lung function tests, only a low median ISV at admission was associated with ARF (500 ml vs 1250 ml, p = 0.04). Three of 69 patients with ISV of ≥1000 ml versus six of 30 with ISV <1000 ml developed ARF (p = 0.01). Other significant factors were: number of rib fractures, tube thoracostomy, any lower-third rib fracture, flail segment.

CONCLUSION

PEFR did not predict ARF. Admission ISV may have value in predicting ARF.

Changes in Simple Spirometric Parameters After Lobectomy for Bronchial Carcinoma

Introduction: The purpose of this study was to describe the postoperative changes in lung function after pure open lobectomy for lung carcinoma.

Methods: 30 patients (mean age 64 ± 7 years old, 16 men and 14 women) underwent a left or right lobectomy. They underwent spirometric pulmonary tests preoperatively, and at 1 and 6 months after the operation.

Results: The average preoperative forced expiratory volume in 1 second (FEV1) was 2.55±0.62lt and the mean postoperative FEV1 at 1 and 6 months was 1.97 ± 0.59 L and 2.15±0.66 L respectively. The percentage losses for FEV1 were 22.7% and 15.4% after 1 and 6 months respectively. An average percentage increase of 9.4% for FEV1 was estimated at the time of 6 months in comparison with this of 1 month after the operation. The average preoperative forced vital capacity (FVC) was 3.17 ± 0.81 L and the mean postoperative FVC at 1 and 6 months after the operation was 2.50 ± 0.63 L and 2.72 ± 0.67 L respectively. The percentage losses for FVC were 21.1% and 14.2% after 1 and 6 months respectively. An average percentage increase of 8.7% was observed at the time period of 6 months in comparison with this of 1 month after the operation.

Conclusion: Although, we observed a significant decrease in FEV1 and FVC after the operation, all patients were in excellent clinical status. FEV1 and FVC of 6 months were increased in comparison with the respective values of 1 month after the operation, but did not reach the preoperative values in any patient.

Effect of magnesium infusion on thoracic epidural analgesia

INTRODUCTION

Patients of lung volume reduction surgery (LVRS) having an ASA status III or more are likely to be further downgraded by surgery to critical levels of pulmonary function.

AIM

To compare the efficacy of thoracic epidural block with (0.125%) bupivacaine, fentanyl combination and (0.125%) bupivacaine, fentanyl combination with adjunctive intravenous magnesium infusion for the relief of postoperative pain in patients undergoing LVRS.

METHODS

Patients were operated under general anesthesia. Thirty minutes before the anticipated completion of skin closure in both groups, (Group A and Group B) 7 ml of (0.125%) bupivacaine calculated as 1.5 ml/thoracic segment space for achieving analgesia in dermatomes of T4, T5, T6, T7, and T8 segments, along with fentanyl 50 μg (0.5 ml), was administered through the catheter, activating the epidural block, and the time was noted. Thereafter, in patients of Group A, magnesium sulfate injection 30 mg/kg i.v. bolus was followed by infusion of magnesium sulfate at 10 mg/kg/hr and continued up to 24 hours. Group B was treated as control.

RESULTS AND ANALYSIS

A significant increase in the mean and maximum duration of analgesia in Group A in comparison with Group B (P<0.05) was observed. Total epidural dose of fentanyl and bupivacaine required in Group A was significantly lower in comparison with Group B in 24 hours.

DISCUSSION

Requirement of total doses of local anesthetics along with opioids could be minimized by magnesium infusion; therefore, the further downgradation of patients of LVRS may be prevented.

CONCLUSION

Intravenous magnesium can prolong opioid-induced analgesia while minimizing nausea, pruritus, and somnolence.

Função pulmonar em mulheres com câncer de mama submetidas à radioterapia: um estudo piloto

O câncer de mama é a forma de câncer que mais causa mortes entre mulheres no Brasil. O tratamento consiste em intervenção cirúrgica, quimioterapia, hormonioterapia e radioterapia, esta última responsável por uma significativa diminuição na taxa de recorrência local do câncer, mas que pode afetar a função pulmonar. O objetivo deste estudo foi detectar alterações pulmonares funcionais decorrentes da radioterapia no tratamento do câncer de mama. Participaram do estudo 10 mulheres submetidas a tratamento do câncer de mama, avaliadas quanto à função pulmonar antes e após a radioterapia. Foram mensuradas capacidade inspiratória e capacidade vital forçada, por espirômetro de incentivo, e pressões inspiratória e expiratória máximas, por manovacuômetro. Embora tenha havido redução, em vários casos, dos valores medidos antes e depois da radioterapia, não foi encontrada diferença estatisticamente significativa. Nas pacientes avaliadas, pois, a radioterapia não parece ter prejudicado a função pulmonar.

[Evolution of the early respiratory function after lung resection for cancer]

The assessment of the postoperative risk in lung resection is a major challenge for pneumologists and thoracic surgeons. Restrictive syndromes have been observed along with a disproportionate decrease of FEV1 in lobectomies. The purpose of the present study is to describe the early response of pulmonary function after thoracotomy and resection for lung cancer. In a prospective study, the authors included 31 patients (19 lobectomy patients: mean age 59+/-10 years and 12 pneumonectomy patients: mean age 56+/-9 years) without postoperative complications. Pulmonary function tests were performed before and after surgery on Days 1, 5 (D5), 10 and within the fourth month. The main aspect of the ventilation was an unexpected similarity in subgroups during the early perioperative period up to D5. When compared with the preoperative value, about a 50% decrease in the vital capacity and total lung capacity was observed. In both subgroups about a 40% decrease was noted in the inspiratory and expiratory reserve volume. In the lobectomy sub-group, the change in the forced expiratory volume in one second over forced vital capacity (FEV/FVC) ratio was found to be higher than predicted (52+/-16% at D5 versus 67+/-14% predicted). However, the FEV/FVC ratio did not change, attesting to major restrictive ventilation. Partial recovery of the FEV was dependant on the mobile volume and especially the inspiratory volume. These findings should have implications in patient management.

Lung function after lobectomy: a randomized, double-blinded trial comparing thoracic epidural ropivacaine/sufentanil and intravenous morphine for patient-controlled analgesia

BACKGROUND

Although thoracic epidural analgesia (TEA) is considered superior to IV opioids for postoperative analgesia after thoracic surgery, a few studies clearly demonstrate an improvement in pulmonary function attributable to TEA using a local anesthetic in combination with an opioid.

METHODS

In this prospective, randomized, double-blind study, we compared the effects of TEA with ropivacaine and sufentanil (TEA group) to IV morphine (IV group), as they affected pain and pulmonary function after lobectomy in 68 patients. Pain intensity, forced vital capacity (FVC), forced expiratory volume in 1 s (FEV1), FEV1/FVC ratio, forced expiratory flows, and sniff nasal inspiratory pressure as a marker of inspiratory muscle strength were measured from the first to the fourth postoperative day.

RESULTS

Pain relief was better in the TEA group at rest and on coughing (P < 0.001). The impairment of FVC and FEV1 was less in the TEA group when compared with that in the IV group (P < 0.001 and P = 0.003, respectively). Sniff nasal inspiratory pressure, FEV1/FVC ratio, and expiratory flow values decreased similarly in both groups. In-hospital mortality, as well as postoperative pulmonary complications, was not different between groups.

CONCLUSION

After lobectomy, TEA enables a significant increase in pulmonary function concomitant with better pain relief than systemic morphine, although a modest intercostal motor block may occur.

Adding ketamine to morphine for patient-controlled analgesia after thoracic surgery: influence on morphine consumption, respiratory function, and nocturnal desaturation

BACKGROUND

I.V. patient-controlled analgesia (PCA) with morphine is often used for postoperative analgesia after thoracic surgery, but the required doses may increase postoperative respiratory disorders. Adjunction of ketamine could reduce both doses and related respiratory side-effects.

METHODS

The main objective of this prospective, randomized double-blinded study was to evaluate the influence of adding ketamine to PCA on morphine consumption and postoperative respiratory disorders. Consecutive patients undergoing lobectomy (n = 50) were randomly assigned to receive, during the postoperative period, either i.v. morphine 1 mg ml(-1) or morphine with ketamine 1 mg ml(-1) for each. Morphine consumption was evaluated by cumulative doses every 12 h for the three postoperative days. Postoperative respiratory disorders were assessed by spirometric evaluation and recording of nocturnal desaturation.

RESULTS

The adjunction of ketamine resulted in a significant reduction in cumulative morphine consumption as early as the 36th postoperative hour [43 (SD 18) vs 32 (14) mg, P = 0.03] with a similar visual analogue scale. In the morphine group, the percentage of time with desaturation < 90% was higher during the three nights [1.80 (0.21-6.37) vs 0.02 (0-0.13), P < 0.001; 2.15 (0.35-8.65) vs 0.50 (0.01-1.30), P = 0.02; 2.46 (0.57-5.51) vs 0.55 (0.21-1.00), P = 0.02]. The decrease in forced expiratory volume in 1 s was less marked in the ketamine group at the first postoperative day [1.04 (0.68-1.22) litre vs 1.21 (1.10-0.70) litre, P = 0.039].

CONCLUSIONS

Adding small doses of ketamine to morphine in PCA devices decreases the morphine consumption and may improve respiratory disorders after thoracic surgery.

Optimizing preoperative lung function

The exacerbation of chronic lung disease, bronchospasm, atelectasis, pneumonia, and respiratory failure with prolonged mechanical ventilation are considered to be clinically relevant postoperative pulmonary complications associated with increased morbidity and mortality. Careful history taking and a thorough physical examination are the most sensitive ways to identify patients at risk. Lung function tests serve as management tools for optimizing preoperative therapy and to assess postoperative lung function and individual risk in lung resection candidates. Additional cardiopulmonary exercise testing provides valuable information in borderline cases. The cessation of smoking, optimizing nutritional status and physiotherapy serve to prevent postoperative pulmonary complications. Moreover, medical therapy is recommended, especially for patients with obstructive airway diseases. In the absence of controlled clinical trials, medical therapy along the respective guidelines, with the primary goals of minimizing symptoms and improving lung function to the optimum seems to be a reasonable approach.

Preoperative assessment of pulmonary risk

STUDY OBJECTIVES

A summary of current modalities for and the utility of preoperative assessment of pulmonary risk.

DESIGN

Review of recent literature published in the English language.

SETTING

Not applicable.

PATIENTS OR PARTICIPANTS

Patients who undergo elective cardiothoracic or abdominal operations.

INTERVENTIONS

Not applicable.

MEASUREMENTS AND RESULTS

Postoperative pulmonary complications occur after 25 to 50% of major surgical procedures. The accuracy of the preoperative assessment of the risk of such complications is only fair. The routine assessment for all preoperative patients includes age, general physiologic status, and the nature of the planned operation. Specific tests such as measurement of spirometric values and diffusing capacity are indicated routinely only for patients who are candidates for major lung resection or esophagectomy.

CONCLUSIONS

Pulmonary complications are an important form of postoperative morbidity after major cardiothoracic and abdominal operations. The appropriate preoperative assessment of the risk of such complications is well defined for lung resection and esophagectomy operations, but it requires refinement for general surgical and cardiovascular operations.