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

The Effect of Nursing-Based Enhanced Recovery After Surgery on Quality of Life in Lung Cancer Patients Receiving Surgery: A Systematic Review and Meta-Analysis

Enhanced recovery after surgery (ERAS) is an evidence-based, multidisciplinary protocol aimed at reducing surgical stress and expediting postoperative recovery. This meta-analysis will provide a comprehensive examination of the implications of ERAS care for the quality of life (QOL) of postoperative Lung cancer (LC) patients. The literature databases were searched to identify randomized controlled trials that implemented an ERAS program for adult patients with LC who underwent surgical treatment and reported QOL results. Thirty-one studies were included in the analysis. ERAS/FTS significantly improved the overall QOL of postoperative LC patients according to the Short Form-36 (SF-36) score (mean difference (MD): 8.58; 95% confidence interval (CI): 6.17, 11.00; p < 0.001). For physical functioning, the ERAS/FTS significantly improved the SF-36 score (MD: 10.45; 95% CI: 7.41, 13.50; p < 0.001). In the role-physical dimension, the ERAS/FTS nurse strategy had a significant advantage in improving the role-physical score on the SF-36 scale (MD: 10.06; 95% CI: 7.00, 13.13; p < 0.001). The ERAS has a highly positive impact on QOL in postoperative LC patients, especially in the physical functioning and role-physical dimensions.

Effect of pulmonary rehabilitation on lung cancer surgery outcomes: a matched-case analysis

Pulmonary rehabilitation programs for COPD patients are extensively accessible throughout the UK and have demonstrated efficacy in enhancing outcomes, including recovery from exacerbations. Numerous lung cancer surgery patients possess COPD, and the surgery may be regarded as a definitive aggravation of COPD. It is ambiguous in practical application whether referral to pulmonary rehabilitation programs enhances surgical and patient-reported results. We want to address this topic by conducting a propensity-score analysis (PSA) of participants in an enriched cohort trial. Methods An enriched cohort research was conducted, providing rehabilitation both pre- and post-surgery pragmatically through local pulmonary rehabilitation providers for patients undergoing lung cancer resection, and compared to a contemporaneous control group receiving standard treatment. The study enrolled 873 participants (pulmonary rehabilitation (PR) n = 135, non-intervention or control (NG) n = 738). Regression analyses for exposed and unexposed matching, effect estimation, and standard error estimations were conducted.Results A total of 114 participants were matched PR (n = 57) and NG (n = 57). The multivariate-linear regression indicated a reduction in length of stay (LOS) of 0.2 days of LOS compared to the usual care group (EE = - 0.20), and that reduction could potentially go up to 1.8 days (95% CI = - 1.8-1.6). The multivariate log-binomial regression revealed that PR had a reduction of 60% postoperative pulmonary complications (PPC) rate (EE = - 0.60, 95% CI = - 1.8-0.5). Lastly, the multivariate-linear regression showed an improvement in quality of life 6 weeks and 6 months after surgery (QoL) in patients in PR, especially in the physical functioning score in which an improvement of 6.6% was noted for the PR group compared to the NG group following surgery (EE = 6.6). Conclusion Participation in "real world" pulmonary rehabilitation prior to and following surgery seems to yield improved patient and clinical results post-lung cancer surgery. Nonetheless, prompt access to pulmonary rehabilitation may be a significant challenge following COVID.

Changes in the Glittre-ADL test in patients with non-small cell lung cancer: Pre- and postoperative analysis after home-based rehabilitation: A preliminary study

Background and objective

Postoperative pulmonary rehabilitation in non-small cell lung cancer (NSCLC) patients following thoracic surgery can be an important strategy for restoring functional exercise capacity. This study aimed to evaluate the changes in the Glittre-ADL test (TGlittre) in patients with NSCLC undergoing thoracic surgery and early home-based pulmonary rehabilitation and, subsequently, to assess the associations of the test results with muscle strength and quality of life (QoL).

Methods

This observational study evaluated 18 patients with NSCLC before and after home-based pulmonary rehabilitation. Before thoracic surgery and 3 months after pulmonary rehabilitation, the participants underwent the following assessments: St. George's Respiratory Questionnaire (SGRQ), spirometry, measurement of the diffusion capacity of the lung for carbon monoxide (DLCO), respiratory muscle strength, handgrip strength (HGS), quadriceps muscle strength, and TGlittre.

Results

When comparing the preoperative and postpulmonary rehabilitation periods, there was a significant increase in HGS [21.6 (19-29) vs. 28.5 (26-33) kgf, p = 0.011] with preservation of TGlittre time [3.6 (3.2-4) vs. 3.6 (3-4.1) min, p = 0.87]. In addition, there was a significant decrease in lung function and SGRQ scores. Preoperative TGlittre time significantly correlated with maximum inspiratory pressure (MIP, r s  = -0.491, p = 0.038) and DLCO (r s  = -0.621, p = 0.006). TGlittre time measured in postpulmonary rehabilitation was significantly correlated with HGS (r s  = -0.664, p = 0.002) and the MIP (r s  = -0.478, p = 0.045).

Conclusion

In patients with NSCLC undergoing thoracic surgery and pulmonary rehabilitation, there was an increase in muscle strength and preservation of functional exercise capacity, although there was a decrease in lung function and QoL. There were interrelations of TGlittre time with MIP and pulmonary diffusion in the preoperative period and of TGlittre time with HGS and MIP following the home-based pulmonary rehabilitation. Although the results are promising, additional studies with a larger number of patients and a control group are needed to further support these findings.

Effectiveness and Feasibility of Digital Pulmonary Rehabilitation in Patients Undergoing Lung Cancer Surgery: Systematic Review and Meta-Analysis

BACKGROUND

Pulmonary rehabilitation (PR) has been shown to effectively support postsurgical recovery in patients with lung cancer (LC) at various stages. While digital PR programs offer a potential solution to traditional challenges, such as time and space constraints, their efficacy and feasibility for patients undergoing LC surgery remain unclear.

OBJECTIVE

This systematic review aims to assess the feasibility and effectiveness of digital PR programs for individuals undergoing LC surgery.

METHODS

A systematic review was conducted, retrieving data from 6 English and 4 Chinese databases from their inception to January 1, 2024. References in related studies were also manually reviewed. The primary outcomes assessed were physical capacity, lung function, and the incidence of postoperative pulmonary complications (PPCs). The secondary outcomes were compliance, hospital stay, chest tube duration, anxiety, depression, and quality of life. Where applicable, recruitment and withdrawal rates were also evaluated. Meta-analysis and descriptive analysis were used to assess the outcomes.

RESULTS

A total of 5 randomized controlled trials and 6 quasi-experimental studies (n=1063) were included, with 4 studies being included in the meta-analyses. Our meta-analyses revealed that digital PR reduced the decline in 6-minute walk distance (6-MWD) by an average of 15 m compared with routine PR programs from admission to discharge, demonstrating a clinically significant improvement in physical capacity (mean difference -15.00, 95% CI -25.65 to -4.34, P=.006). Additionally, digital PR was associated with a reduction (26/58, 45%) in the likelihood of PPCs (risk ratio 0.45, 95% CI 0.30-0.66, P<.001) and a reduction of 1.53 days in chest tube duration (mean difference -1.53, 95% CI -2.95 to -0.12, P=.03), without a statistically significant effect on postoperative hospital stay (mean difference -1.42, 95% CI -3.45 to 0.62, P=.17). Descriptive analyses suggested that digital PR has the potential to improve knowledge, lung function, quality of life, and self-efficacy, while reducing depression and anxiety. Notably, digital PR was found to be a safe, feasible, and acceptable supplementary intervention. Despite challenges with low recruitment, digital PR enhanced exercise compliance, increased patient satisfaction, and lowered dropout rates.

CONCLUSIONS

This systematic review is the first comprehensive analysis to suggest that digital PR is a safe, feasible, acceptable, and effective intervention for promoting recovery in patients with LC after surgery. Digital PR has the potential to be a valuable supplement, expanding access to traditional PR programs. Future research should prioritize the development of interactive and inclusive digital solutions tailored to diverse age groups and educational backgrounds. Rigorous studies, including large-scale, high-quality randomized controlled trials with detailed protocols and robust methodologies, are needed to assess the short-, medium-, and long-term efficacy of digital PR, ensuring reproducibility in future research.

TRIAL REGISTRATION

PROSPERO CRD42023430271; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=430271.

Effect of Exercise and Pulmonary Rehabilitation in Pre- and Post-Surgical Patients with Lung Cancer: Systematic Review and Meta-Analysis

Background and objectives: Lung cancer is a common cancer, and its impact on public health is not only reflected in the 1 million deaths it causes annually but also in the significant implications it has on daily activities and quality of life, resulting in a considerable burden on healthcare systems. This review aims to determine the effects of pulmonary rehabilitation and pre- or post-surgical exercise in patients with lung cancer. Materials and methods: A systematic review with a meta-analysis of randomized controlled trials published between 2010 and 2024 was conducted; the search was carried out in PubMed, Cochrane Clinical Trial, SCOPUS, Science Direct, Web of Science, Scielo, and LILAC. Results: Pulmonary rehabilitation or exercise before surgery was associated with a greater 6 min walking distance (MD: 37.42, 95% CI: 9.68-65.1; p = 0.008); however, it had no implications on hospital stay (MD: -0.91, 95% CI: -1.88-0.055; p = 0.06). When the intervention was performed post-surgery, higher FEV1 (SMD: 0.62, 95% CI: 0.32-0.92; p = 0.0001) and improved 6 min walking distances (60.8, 95% CI: 20.96-100.6; p = 0.0033) were found compared to standard management. Conclusions: This review suggests that, depending on the timing of implementation, pulmonary rehabilitation or exercise could produce positive effects on certain clinical variables in lung cancer patients.

Impact of pulmonary rehabilitation on exercise capacity, health-related quality of life, and cardiopulmonary function in lung surgery patients: a retrospective propensity score-matched analysis

Background

Pulmonary rehabilitation is considered beneficial for patients undergoing lung surgery, yet its specific impacts on exercise capacity, health-related quality of life (HRQL), and cardiopulmonary function require further elucidation. This study aimed to evaluate the effect of PR on these outcomes in patients undergoing lung surgery using a retrospective propensity score-matched analysis.

Methods

We retrospectively analyzed 420 patients with non-small cell lung cancer (NSCLC) who underwent lung surgery from January 2022 to May 2024. Among these, 84 patients received PR while 336 did not (control group). Propensity score matching (PSM) at a 1:1 ratio yielded 46 patients in each group. Baseline characteristics, spirometry, cardiopulmonary exercise testing, respiratory muscle strength, HRQL, and muscle measurements were assessed pre-and post-surgery.

Results

Before PSM, significant differences existed between groups, with the PR group being older and having different pulmonary function baselines. After PSM, groups were well-balanced. Postoperatively, the PR group showed significant improvements in FEV1/FVC (64.17% vs. 50.87%, p < 0.001), FEV1 (2.31 L/min vs. 1.75 L/min, p < 0.001), and predicted FVC percentage (88.75% vs. 68.30%, p < 0.001). Cardiovascular responses showed a lower CI during exercise in the PR group post-PSM (6.24 L/min/m2 vs. 7.87 L/min/m2, p < 0.001). In terms of exercise capacity, the PR group had higher maximal WR percentage (104.76% vs. 90.00%, p = 0.017) and peak VO2 (1150.70 mL/min vs. 1004.74 mL/min, p = 0.009). PR also resulted in less leg soreness and lower total CAT scores postoperatively. Muscle measurements indicated significantly smaller reductions in ΔHUESMCSA and percentage change in the PR group.

Conclusion

Pulmonary rehabilitation significantly enhances exercise capacity, HRQL, and cardiopulmonary function in patients undergoing lung surgery. It also mitigates postoperative muscle loss, underscoring its importance in the postoperative management of lung surgery patients.

The effect of a hybrid structured pulmonary rehabilitation education program for patients with lung cancer with a high risk of postoperative pulmonary complications: A quasi-experimental study

PURPOSE

The absence of standardized protocols and education are the main obstacles to perioperative pulmonary rehabilitation (PR), especially for patients with high-risk factors of postoperative pulmonary complications (PPCs). We aimed to explore the effect of a hybrid structured pulmonary rehabilitation education program (SPREP) on patients with lung cancer at high risk of PPCs.

METHODS

A quasi-experimental trial with a pre-post test design was conducted. The control group (n = 53) adopted routine perioperative pulmonary rehabilitation, while the intervention group (n = 53) received SPREP. Respiratory function, 6-min walk distance, Borg dyspnea scale, quality of life, anxiety-depression scores at admission, discharge, 2 weeks and 3 months post-discharge, and incidence of PPCs were compared between the two groups.

RESULTS

There were no significant differences on the 6-min walk distance and Borg Dyspnoea Scale at discharge between the two groups (P > 0.05), whereas the intervention group showed improved performance at the remaining time points (P < 0.05). In addition, the intervention group had improved exercise capacity, pulmonary function and quality of life, reduced levels of anxiety and depression at discharge, 2 weeks post-discharge and 3 months post-discharge (P < 0.05). In addition, incidence of PPCs was significantly reduced in the intervention group, especially postoperative pneumonia.

CONCLUSIONS

The SPREP could show significant benefits in enhancing exercise capacity, lung function, and quality of life, while diminishing the occurrence of PPCs and mitigating the levels of anxiety and depression, future large RCT need to further explore the efficacy.

TRIAL REGISTRATION

This study was registered with the China Clinical Trial Registration Center (ChiCTR) under the Clinical Trial Registration Number [ChiCTR2200066698].

Effectiveness of preoperative and perioperative pulmonary rehabilitation nursing program for the management of patients undergoing thoracic surgery: A systematic review and meta-analysis

Background & Objective

Several studies have investigated the effectiveness of preoperative or perioperative pulmonary rehabilitation in thoracic surgery patients, but the results are inconsistent and inconclusive. This study attempts to summarize the existing data on the effect of the preoperative and perioperative pulmonary rehabilitation nursing program for the management of patients undergoing thoracic surgery.

Methods

Systematic search was done in PubMed Central, SCOPUS, EMBASE, MEDLINE, Google Scholar, and ScienceDirect for papers published until December 2022 and reporting data of postoperative complications and pulmonary health status in patients undergoing thoracic surgery and receiving preoperative or perioperative pulmonary rehabilitation nursing intervention or standard care. Meta-analysis was done by random-effects model and pooled standardised mean differences (SMD) or odds ratios (OR) along with 95% confidence intervals (CIs) were reported.

Results

Eighteen studies were included and analysed. Pooled SMD was 0.44 (95%CI: -0.21 to 1.08) for forced expiratory volume (FEV-1), -0.34 (95%CI: -0.94 to 0.26) for peak expiratory flow (PEF), 0.61 (95%CI: -0.60 to 1.81) for forced vital capacity (FVC), 0.42 (95%CI: -0.13 to 0.98) for diffusing capacity of carbon monoxide (DLCO). Pooled SMD for length of hospital stay was -0.64 (95%CI: -1.09 to -0.19). Pooled OR was 0.87 [95%CI: 0.32 to 2.37] for all-cause mortality, 0.35 [95%CI: 0.25 to 0.50] for postoperative pulmonary complications, 0.98 [95%CI: 0.45 to 2.12] for respiratory failure, 0.52 [95%CI: 0.38 to 0.78] for pneumonia and 0.50 [95%CI: 0.33 to 0.76] for atelectasis.

Conclusion

Perioperative pulmonary rehabilitation nursing program is effective in reducing the postoperative lung complications and shortening the length of hospital stay in patients undergoing thoracic surgery.

The effect of incentive spirometry in perioperative patients with lung cancer-a systematic review and meta-analysis

BACKGROUND

Incentive spirometry (IS) as a routine respiratory therapy during the perioperative period has been widely used in clinical practice. However, the impact of IS on patients with perioperative lung cancer remains controversial. This review aimed to evaluate the efficacy of IS in perioperative pulmonary rehabilitation for patients with lung cancer.

METHODS

Cochrane Library, PubMed, Web of Science, Ovid, CINAHL, Chinese National Knowledge Infrastructure, Weipu, and Wanfang Databases were searched from inception to 30 November 2023. Only randomized controlled trials were included in this systematic review. The PRISMA checklist served as the guidance for conducting this review. The quality assessment of the included studies was assessed by the Cochrane risk-of-bias tool. The meta-analysis was carried out utilizing Review Manager 5.4. Furthermore, sensitivity analysis and subgroup analysis were also performed.

RESULTS

Nine studies recruited 1209 patients met our inclusion criteria. IS combined with other respiratory therapy techniques was observed to reduce the incidence of postoperative pulmonary complications, enhance pulmonary function, curtail the length of hospital stay, and lower the Borg score. Nevertheless, no improvements were found in the six-minute walk distance or quality of life score.

CONCLUSIONS

Although IS demonstrates benefits as a component of comprehensive intervention measures for perioperative patients with lung cancer, it proves challenging to determine the precise impact of IS as a standalone component within the comprehensive intervention measures. Therefore, further researches are required to better understand the effectiveness of IS isolation and its interactions when integrated with additional respiratory therapies for these patients.

CLINICAL TRIAL REGISTRATION

PROSPERO, https://www.crd.york.ac.uk/prospero/ , registry number: CRD42022321044.

The effectiveness of postoperative rehabilitation interventions that include breathing exercises to prevent pulmonary atelectasis in lung cancer resection patients: a systematic review and meta-analysis

BACKGROUND

The main aim of this systematic review was to determine the effectiveness of postoperative rehabilitation interventions that include breathing exercises as a component to prevent atelectasis in lung cancer resection patients.

METHODS

In this review, we systematically and comprehensively searched the Cochrane Library, PubMed, EMBASE, and Web of Science in English and CNKI and Wanfang in Chinese from 2012 to 2022. The review included any randomized controlled trials focusing on the effectiveness of postoperative rehabilitation interventions that include breathing exercises to prevent pulmonary atelectasis in lung cancer patients. Participants who underwent anatomic pulmonary resection and received postoperative rehabilitation interventions that included breathing exercises as a component were included in this review. The study quality and risks of bias were measured with the GRADE and Cochrane Collaboration tools, and statistical analysis was performed utilizing RevMan 5.3 software.

RESULTS

The incidence of atelectasis was significantly lower in the postoperative rehabilitation intervention group (OR = 0.35; 95% CI, 0.18 to 0.67; I2 = 0%; P = 0.67) than in the control group. The patients who underwent the postoperative rehabilitation program that included breathing exercises (intervention group) had higher forced vital capacity (FVC) scores (MD = 0.24; 95% CI, 0.07 to 0.41; I² = 73%; P = 0.02), forced expiratory volume in one second (FEV1) scores (MD = 0.31; 95% CI, 0.03 to 0.60; I² = 98%; P < 0.01) and FEV1/FVC ratios (MD = 9.09; 95% CI, 1.50 to 16.67; I² = 94%; P < 0.01).

CONCLUSION

Postoperative rehabilitation interventions that included breathing exercises decreased the incidence rate of atelectasis and improved lung function by increasing the FVC, FEV1, and FEV1/FVC ratio.

Closing the Gap between Inpatient and Outpatient Settings: Integrating Pulmonary Rehabilitation and Technological Advances in the Comprehensive Management of Frail Patients

Pulmonary rehabilitation (PR) is a well-established intervention supported by strong evidence that is used to treat patients affected by chronic respiratory diseases. However, several barriers still affect its spreading in rehabilitation clinical practices. Although chronic respiratory diseases are common age-related disorders, there is still a gap of knowledge regarding the implementation of sustainable strategies integrating PR in the rehabilitation management of frail patients at high risk of respiratory complications. Therefore, in the present study, we characterized the effects of PR in frail patients, highlighting the evidence supporting its role in improving the complex rehabilitative management of these patients. Moreover, we propose a novel organizational model promoting PR programs for frail patients in both inpatient and outpatient settings. Our model emphasizes the role of interdisciplinary care, specifically tailored to patients and environmental characteristics. In this scenario, cutting-edge technology and telemedicine solutions might be implemented as safe and sustainable strategies filling the gap between inpatient and outpatient settings. Future research should focus on large-scale sustainable interventions to improve the quality of life and global health of frail patients. Moreover, evidence-based therapeutic paths should be promoted and taught in training courses promoting multiprofessional PR knowledge to increase awareness and better address its delivery in frail patients.

Effects of enhanced recovery after surgery plus pulmonary rehabilitation on complications after video-assisted lung cancer surgery: a multicentre randomised controlled trial

BACKGROUND

Lung cancer surgery is associated with a high incidence of postoperative pulmonary complications (PPCs). We evaluated whether enhanced recovery after surgery plus pulmonary rehabilitation was superior over enhanced recovery after surgery alone in reducing the incidence of postoperative PPCs and length of hospital stay.

METHODS

In this pragmatic multicentre, randomised controlled, parallel-group clinical trial, eligible patients scheduled for video-assisted lung cancer surgery were randomly assigned (1:1) to either a newly developed programme that integrated preoperative and postoperative pulmonary rehabilitation components into a generic thoracic enhanced recovery after surgery pathway, or routine thoracic enhanced recovery after surgery. Primary outcome was the overall occurrence of PPCs within 2 weeks after surgery. Secondary outcomes were the occurrence of specific complications, time to removal of chest drain, and length of hospital stay (LOS).

RESULTS

Of 428 patients scheduled for lung cancer surgery, 374 were randomised with 187 allocated to the experimental programme and 187 to control. Incidence of PPCs at 14 Days was 18.7% (35/187) in the experimental group and 33.2% (62/187) in the control group (intention-to-treat, unadjusted HR 0.524, 95% CI 0.347 to 0.792, p=0.002). Particularly, significant risk reduction was observed regarding pleural effusion, pneumonia and atelectasis. Time to removal of chest drain and LOS were not significantly reduced in the experimental group.

CONCLUSIONS

Adding pulmonary rehabilitation to enhanced recovery after surgery appears to be effective in reducing the incidence of PPCs, but not LOS. Standard integration of pulmonary rehabilitation into thoracic enhanced recovery after surgery is a promising approach to PPC prophylaxis.

TRIAL REGISTRATION NUMBER

ChiCTR1900024646.