Pulmonary Rehabilitation Exercises Effectively Improve Chronic Cough After Surgery for Non-small Cell Lung Cancer

INTRODUCTION

Cough is a major complication after lung cancer surgery, potentially impacting lung function and quality of life. However, effective treatments for managing long-term persistent postoperative cough remain elusive. In this study, we investigated the potential of a pulmonary rehabilitation training program to effectively address this issue.

METHODS

Between January 2019 and December 2022, a retrospective review was conducted on patients with non-small cell lung cancer (NSCLC) who underwent lobectomy and lymph node dissection via video-assisted thoracoscopic surgery (VATS) at Daping hospital. Based on their postoperative rehabilitation methods, the patients were categorized into 2 groups: the traditional rehabilitation group and the pulmonary rehabilitation group. All patients underwent assessment using the Leicester cough questionnaire (LCQ) on the third postoperative day. Additionally, at the 6-month follow-up, patients' LCQ scores and lung function were re-evaluated to assess the long-term effects of the pulmonary rehabilitation training programs.

RESULTS

Among the 276 patients meeting the inclusion criteria, 195 (70.7%) were in the traditional rehabilitation group, while 81 (29.3%) participated in the pulmonary rehabilitation group. The pulmonary rehabilitation group showed a significantly lower incidence of cough on the third postoperative day (16.0% vs 29.7%, P = .018) and higher LCQ scores in the somatic dimension (5.09 ± .81 vs 4.15 ± 1.22, P = .007) as well as in the total score (16.44 ± 2.86 vs 15.11 ± 2.51, P = .018, whereas there were no significant differences in psychiatric and sociological dimensions. At the 6-month follow-up, the pulmonary rehabilitation group continued to have a lower cough incidence (3.7% vs 12.8%, P = .022) and higher LCQ scores across all dimensions: somatic (6.19 ± .11 vs 5.75 ± 1.20, P = .035), mental (6.37 ± 1.19 vs 5.85 ± 1.22, P = .002), sociological (6.76 ± 1.22 vs 5.62 ± 1.08, P < .001), and total (18.22 ± 2.37 vs 16.21 ± 2.53, P < .001). Additionally, lung function parameters including FVC, FVC%, FEV1, FEV1%, MVV, MVV%, DLCO SB, and DLCO% were all significantly higher in the pulmonary rehabilitation group compared to the traditional group.

CONCLUSION

Pulmonary rehabilitation exercises significantly reduced the incidence of postoperative cough and improved cough-related quality of life in patients undergoing lobectomy, with sustained benefits observed at the 6-month follow-up. Additionally, these exercises demonstrated superior lung function outcomes compared to traditional rehabilitation methods.

[Pulmonary function testing and prehabilitation in thoracic surgery]

Preoperative assessment should include spirometry and analysis of the diffusing capacity for carbon monoxide. If necessary, exercise tests can be performed. High risk patients can be revealed considering these data. These patients need for prehabilitation, i.e. preoperative measures increasing functional capacity. This review is devoted to preoperative assessment, principles of prehabilitation and perioperative nutritional support.

A Patient with GOLD Stage 3 COPD « cured » by One-Way Endobronchial Valves

Lung hyperinflation is a main determinant of dyspnoea in patients with chronic obstructive pulmonary disease (COPD). Surgical or bronchoscopic lung volume reduction are the most efficient therapeutic approaches for reducing hyperinflation in selected patients with emphysema. We here report the case of a 69-year old woman with COPD (GOLD stage 3-D) referred for lung volume reduction. She complained of persistent disabling dyspnoea despite appropriate therapy. Chest imaging showed marked emphysema heterogeneity as well as severe hyperinflation of the right lower lobe. She was deemed to be a good candidate for bronchoscopic treatment with one-way endobronchial valves. In the absence of interlobar collateral ventilation, 2 endobronchial valves were placed in the right lower lobe under general anaesthesia. The improvement observed 1 and 3 months after the procedure was such that the patient no longer met the pulmonary function criteria for COPD. The benefit persisted after 3 years.

Potentially modifiable factors contribute to limitation in physical activity following thoracotomy and lung resection: a prospective observational study

BACKGROUND

Early mobility is considered important in minimising pulmonary complication, length of stay (LOS) and enhancing recovery following major surgery. We aimed to observe and measure the reduction in early postoperative physical activity following major thoracic surgery, identifying any potentially limiting factors, and factors predictive of reduced activity.

METHODS

Patients undergoing thoracotomy and lung resection were prospectively observed for the purposes of this study. All patients were routinely assisted to mobilise by physiotherapists from postoperative day 1, and continued daily with exercise and progression of mobility as per usual practice. Physical activity was measured with SenseWear Pro 3 armband physiologic motion sensors between postoperative day 1-4. The motion sensors recorded step count, time spent in 'sedentary'/ 'moderate' activity, and energy expenditure. Frequency of postoperative pulmonary complication (PPC) and postoperative LOS were also observed. Multivariate analyses were performed using forward stepwise logistic regression; results are displayed as odds ratio (95% confidence intervals).

RESULTS

n = 99, median (interquartile range) steps 472 (908) over combined postoperative days 2/ 3, sedentary activity (< 3 METs) 99%. Less active subjects reported significantly more pain on day 2 and 3 (p = 0.013/ 0.00 respectively) (p < 0.001). On regression analysis age ≥ 75 years, predicted FEV1 <  70% and poor preoperative activity were predictive of lower postoperative activity. Factors limiting mobility on day 1 included pain and dizziness. Median LOS was longer (p = 0.013) (6 vs. 5 days) in less active patients and frequency of PPC was 20% vs 4% (p = 0.034).

CONCLUSION

Physical activity following major thoracic surgery is generally very limited, with less active patients demonstrating longer LOS. Factors limiting immediate postoperative mobility were largely modifiable, some of the factors predictive of lower activity were also possibly modifiable/amenable to physiotherapy or pulmonary rehabilitation. Prompt assessment and recognition of these factors is needed in future, with timely and effective management incorporated into care pathways to maximise each patients potential to mobilise postoperatively.

TRIAL REGISTRATION

ISRCTN52709424.

[Pneumonectomy and lobectomy]

Thoracic surgery developed remarkably in tandem with anesthetic management and post-operative intensive care since 1990. The innovations in these fields include wide spread use of one-lung ventilation, advances in clarification of pathophysiology of postoperative acute lung injury as well as its treatment, initiation of lung protective ventilation strategy, advancement of chest physiotherapy, and wide use of non-invasive ventilation in the last two decades. Current guidelines support strongly the use of lower tidal volume in patients with acute lung injury and acute respiratory distress syndrome. Under the influence of this new lung protective ventilation strategy, perioperative managements such as setting of tidal volume changed drastically in nearly ten years. The purpose of this article is to review the innovations and the transitions in anesthetic management and post-operative intensive care in thoracic surgery, and to propose up-to-date peri-operative respiratory strategies for patients undergoing thoracic surgery, especially pneumonectomy.

Continuous positive airway pressure (CPAP) after lung resection: a randomized clinical trial

CONTEXT AND OBJECTIVE

Noninvasive mechanical ventilation during the postoperative period (PO) following lung resection can restore residual functional capacity, improve oxygenation and spare the inspiratory muscles. The objective of this study was to assess the efficacy of continuous positive airway pressure (CPAP) associated with physiotherapy, compared with physiotherapy alone after lung resection.

DESIGN AND SETTING

Open randomized clinical trial conducted in the clinical hospital of Universidade Estadual de Campinas.

METHOD

Sessions were held in the immediate postoperative period (POi) and on the first and second postoperative days (PO1 and PO2), and the patients were reassessed on the discharge day. CPAP was applied for two hours and the pressure adjustment was set between 7 and 8.5 cmH2O. The oxygenation index (OI), Borg scale, pain scale and presence of thoracic drains and air losses were evaluated.

RESULTS

There was a significant increase in the OI in the CPAP group in the POi compared to the Chest Physiotherapy (CP) group, P = 0.024. In the CP group the OI was significantly lower on PO1 (P = 0,042), than CPAP group. The air losses were significantly greater in the CPAP group in the POi and on PO1 (P = 0.001, P = 0.028), but there was no significant difference between the groups on PO2 and PO3. There was a statistically significant difference between the groups regarding the Borg scale in the POi (P < 0.001), but there were no statistically significant differences between the groups regarding the pain score.

CONCLUSION

CPAP after lung resection is safe and improves oxygenation, without increasing the air losses through the drains.

CLINICAL TRIAL REGISTRATION

NCT01285648.

[Respiratory preparation before surgery in patients with chronic respiratory failure]

Scheduled and/or thoracic, abdominal surgeries increase the risk of respiratory postoperative complications. In patients with chronic respiratory failure, preoperative evaluation should be performed to evaluate respiratory function in aim to optimize perioperative management. Preoperative gas exchange abnormalities (hypoxemia or hypercapnia) are associated with respiratory postoperative complications. Respiratory physiotherapy and prophylactic non-invasive ventilation should be integrated in a global rehabilitation management for cardiothoracic or abdominal surgery procedures, which are at high risk of postoperative respiratory dysfunction. Stopping tobacco consummation should be benefit, but decease risk of postoperative complications is relevant only after a period for 6 to 8 weeks of cessation. Bronchodilatator aerosol therapy (beta-agonists and atropinics) and inhaled corticotherapy allow a rapid preparation for 24 to 48 h. Systematic preoperative antibiotherapy should not be recommended.

Chest physiotherapy revisited: evaluation of its influence on the pulmonary morbidity after pulmonary resection

OBJECTIVE

The study aimed to evaluate if perioperative chest physiotherapy modifies the risk of pulmonary morbidity after lobectomy for lung cancer.

METHODS

We have reviewed a prospectively recorded database of 784 lung cancer patients treated by scheduled lobectomy (361 operated after implementing a new physiotherapy program). No other changes were introduced in the patients' perioperative management during the study period. A propensity matching score was generated for all eligible patients and two logistic models were constructed and adjusted. The first one (model A) included age of the patient, forced expiratory volume in 1s (percent) (FEV1%) and predicted postoperative forced expiratory volume in 1s (percent) (ppoFEV1%); for the second model (model B); chest physiotherapy was added to the previous ones. Using each model, patients' individual probability of postoperative complication was calculated and maintained in the database as a new variable (risk A and risk B). Individual risks calculated by both models were plotted on a time series and presented in two different graphs.

RESULTS

Rates of pulmonary morbidity were 15.5% before the intensive physiotherapy program and 4.7% for patients included in the implemented program (p = 0.000). The propensity score identified 359 pairs of patients. Model A included age (p = 0.012), FEV1% (p = 0.000), and ppoFEV1% (p = 0.031) as prognostic variables. Model B included age (p = 0.012), FEV1% (p = 0.000), and physiotherapy (p = 0.000). On graphic representation, a great decrease of the estimated risk could be seen after the onset of the physiotherapy program.

CONCLUSIONS

Implementing a program of perioperative intensive chest physiotherapy reduced the overall pulmonary morbidity after lobectomy for lung cancer.

Pulmonary rehabilitation for patients who undergo lung-volume-reduction surgery or lung transplantation

Patients preparing for or recovering from lung-volume-reduction surgery (LVRS) or lung transplantation represent a selected group of patients with advanced chronic respiratory disease. Such patients typically have severe ventilatory limitation and disability and are at high risk of preoperative and postoperative complications. Pulmonary rehabilitation is an ideal setting in which to: address the patient's questions and knowledge-deficits regarding his or her disease and its treatment; ensure that the patient understands the nature, potential benefits, risks, and expected outcomes of the surgery relative to medical therapies, and; prepare physically and emotionally for the surgery. Pulmonary rehabilitation also may improve survival to and/or outcomes of LVRS and transplantation, at least in part by stabilizing and improving the patient's exercise tolerance and muscle function. Further work is needed to determine whether pulmonary rehabilitation can augment the benefits and outcomes of LVRS or lung transplantation, reduce postoperative complications, or improve patient survival to or following the surgery.

[Preoperative rehabilitation in the surgical treatment of lung cancer]

OBJECTIVE

The aim of this study is to evaluate the effect of preoperative rehabilitation on operability and postoperative outcome in patients with lung cancer.

METHODS

We studied retrospectively 27 patients who underwent respiratory rehabilitation for 4 weeks prior to lung cancer resection and 26 patients who were operated without previous rehabilitation (control group). Spirometry, arterial blood gases, and exercise tests with maximum oxygen consumption (VO2max) were assessed pre and postoperatively. Postoperative outcome was evaluated in terms of complications and survival.

RESULTS

Patients in the rehabilitation group had a more severe functional impairment (forced expiratory volume in 1 second FEV1 67,9% versus 79,3% and VO2max 60% versus 85,7% in the control group). The rehabilitation program increased FEV1 and VO2max by 4,3% and 8%, respectively, in patients who had had these parameters below 60%. Postoperative complications and survival were similar between the 2 groups.

CONCLUSIONS

Preoperative rehabilitation is beneficial in patients with borderline respiratory function, improving accessibility to intervention.

Pulmonary Rehabilitation in Patients Undergoing Lung-Volume Reduction Surgery

Chronic obstructive pulmonary disease (COPD) is the most common form of primary pulmonary disability. Few effective treatment options exist for it, but recently, lung-volume reduction surgery (LVRS) has been shown to be effective in selected patients with emphysema. Pulmonary rehabilitation is an integral part of the preparation for and recovery from the procedure and has significant benefit in helping to improve the quality of life and conditioning of patients with COPD who undergo LVRS.

OVERALL ARTICLE OBJECTIVES

(a) To describe the role of pulmonary rehabilitation in LVRS, (b) to understand the components of a comprehensive pulmonary rehabilitation program, and (c) to describe the effects of a pulmonary rehabilitation program.

The Value of Preoperative Pulmonary Rehabilitation

Although data are limited for preoperative pulmonary rehabilitation, benefit can be inferred largely from studies done on COPD and pulmonary rehabilitation because of the similarity of patient populations. Although underlying lung function is unchanged, patients who undergo preoperative pulmonary rehabilitation seem to experience an enhanced quality of life and increased functional capacity. Likewise, multidisciplinary rehabilitation programs can result in better patient compliance with medications and smoking cessation and decreased use of various health care resources. Although pulmonary rehabilitation works to benefit patients anticipating surgery, it also represents a valuable treatment alternative to patients who are poor surgical candidates. Pulmonary rehabilitation seems to be a cost-effective, benign intervention with no adverse effects and should remain an essential component of patient management before lung transplantation, LVRS, lung resection, and potentially any other elective thoracic surgical procedure.

The increase in body mass index observed after lung volume reduction may act as surrogate marker of improved health status

OBJECTIVE

To assess the effects of lung volume reduction surgery (LVRS) on body mass index (BMI).

METHODS

Prospective data was collected on a series of 63 patients undergoing LVRS (bilateral in 22 patients, unilateral in 41 patients). Median age was 58 (41-70) years. The peri-operative effects of LVRS on BMI, lung function and health status (assessed by SF 36 questionnaire) were recorded at 3, 6, 12 and 24 months.

RESULTS

We found an overall increase in BMI after LVRS, which was significant up to 2 years. These changes correlated with the changes in FEV1 (R = 0.3, P < 0.01 6 months after LVRS) and diffusing capacity for carbon monoxide (DLCO) (R = 0.5, P < 0.01 6 months after LVRS). At 6 months, when the best results in health status were found, the patients were divided in a responders group (improved SF 36 score) and a non-responders group (same or worse SF 36 score) for each of the 8 domains of the SF 36. In 6 domains the non-responders showed no increase in BMI. In 6 domains the responders showed a significant increase in BMI.

CONCLUSION

LVRS significantly improves postoperative BMI, which correlates with improvements in DLCO and reflects changes in health status.

Predicting length of stay out of hospital following lung resection using preoperative health status measures

Studies evaluating predictors of operative outcome for lung resection have focused on physiological measures of cardiorespiratory impairment, but these have proved inadequate. This study evaluated the predictive abilities of six preoperative variables: the global quality of life (QL), social function (SF), and emotional function (EF) scales of the European Organization for the Research and Treatment of Cancer's (EORTC) QLQ-C30 questionnaire, 6-min walk distance (6MWD), forced expiratory volume (FEV1), and diffusion capacity (DLCO). Operative outcome was represented by the surrogate measure length of stay, out of hospital within the first 30 days (LOSOH). A single-centre prospective cohort study evaluating 70 subjects was conducted using multiple regression. LOSOH was bimodally distributed, therefore analysis was undertaken for the entire sample and for two separate groups (A and B). Group B (n = 4) experienced severe complications (LOSOH = 0-5 days) and was too small for statistical analysis. Group A (n = 66) suffered fewer and less severe complications (LOSOH = 14-26 days). For the entire sample, age was the sole predictor of LOSOH (R2 = 0.123, p = 0.003). In Group A, the strongest predictors of LOSOH were global QL score and 6MWD (R2 = 0.224, p < 0.001). LOSOH was inversely correlated with complications. While it remains difficult to predict severe complications in this population, within Group A, health status measures demonstrated a limited ability to predict LOSOH.

The long-term health status improvements seen after lung volume reduction surgery☆

OBJECTIVES

To correlate the long-term changes in respiratory physiology, body mass index (BMI) and health status after lung volume reduction surgery (LVRS).

PATIENTS/METHODS

From 1995 to 2002 77 patients; 48 male: 29 female, median age 59 (41-72) years, have undergone LVRS (simultaneous bilateral in 27; staged bilateral in 3; unilateral in 47). FEV(1), total lung capacity (TLC), residual volume (RV) and RV/TLC ratio were measured preoperatively and at 3 months, 6 months, 1 year, 2 years, 3 years and 4 years post surgery. At the same time interval health status was assessed by Euroquol and Short Form 36 (SF 36) questionnaires. Seventeen patients have died within 4 years of their operation (30 day mortality 5%).

RESULTS

The changes in FEV(1) are only significantly improved for 1 year post LVRS, while the improvements in TLC and RV remain significant up to 3 years postoperatively. The improvements in BMI also persist for 3 years. The best scores in Euroquol and SF 36 are obtained 6 months after LVRS but are only significantly improved up to 1 year.

CONCLUSION

The physiological effects of volume LVRS are lasting but initial improvements in health status decline more rapidly.

[New technique designed for the evaluating of respiratory function]

New models of the matrix of sensors and devices operating in the meter-range are presented for use in the medical diagnostics. A technique of a remotely controllable analysis of respiratory volumes and a method for the functional visualization of respiration were worked out. The possibilities of using the DU and FD-P pulmonology computer systems in medicine were studied.

Utilization of the walking oximetry test to allow safe ambulation after pulmonary resection

Supplemental oxygen therapy after pulmonary resection can generally be tapered according to arterial blood gases at rest or pulse oximetry (SpO2). However, detecting exercise-induced oxygen desaturation can be difficult. We developed the walking oximetry test (WOT) so that thoracotomy patients could be rehabilitated without the risk of undetected ambulatory hypoxemia. The subjects were 58 patients who had undergone pulmonary resection and could walk at the bedside, with oxygen at 3 l/min via a nasal cannula. Patients with a value of more than 100 torr were allowed to walk with assistance for 6 min in the corridor. The oxygen flow rate was kept at 3 l/min and the walking pace was less than 50 m/min. SpO2 was determined using a wristwatch pulse oximeter. The test was stopped if the SpO2 fell below 90% or there was a score of 5 or more on the Borg scale (range 1-10). Oxygen desaturation occurred in six patients (10%) during the WOT. These patients underwent ambulatory training with sufficient oxygen supplementation and were then tested again. Patients whose SpO2 values remained higher than 90% and who showed no more than 5% desaturation were permitted to walk in the corridor with oxygen at 3 l/min via a nasal cannula. All these patients had a Borg score of 4 or lower. The WOT is a reliable, nonvasive method for detecting exercise-induced oxygen desaturation during ambulation after pulmonary resection.

Health-related quality of life and pulmonary function in lung cancer patients undergoing medical rehabilitation treatment

Treatment for lung cancer results in reduced Quality of Life (QoL) and limited lung function are well-known. Yet, there are no results available concerning the interaction of objective lung function tests and QoL parameters for lung cancer patients during in-patient cancer rehabilitation. This is also true for outcome parameters in medical rehabilitation. The aim was to study the impact of lung and cardiopulmonary function on QoL (EORTC-QLQ C-30 and SF-36 Health Survey) and to identify possible outcome parameters for a rehab program. 56 lung cancer patients participated. Inpatient rehabilitation consisted of individual aerobic exercise and physical, psychological, social, educational and recreational components and only led to a gain of QoL by SF-36 Health Survey sub scales "Vitality" and "Mental Health". Lung function parameters improved; yet the correlation between lung function and health-related QoL questionnaires was not significant. Multivariate analysis for groups with high and low performance in lung functioning showed differences in the SF-36 Health Survey "Vitality" and "Mental Health" sub-scales. However, patients with high and low functional performance of the lungs did not differ in their QoL over time. Health-related QoL and pulmonary function therefore seem to be independent dimensions. Thus, for judging the outcome and success of medical rehabilitation of lung cancer patients, both, QoL and pulmonary function have to be taken into account.

Cardiopulmonary rehabilitation and cancer rehabilitation. 3. Pulmonary rehabilitation

This self-directed learning module highlights assessment and therapeutic options in the rehabilitation of patients with pulmonary diseases and in the pulmonary management of neurologic disorders. It is part of the chapter on cardiovascular, pulmonary, and cancer rehabilitation in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation. Topics reviewed in the rehabilitation of pulmonary diseases include interdisciplinary programming for patients with chronic obstructive pulmonary disease, the role of rehabilitation in lung transplantation and lung volume reduction surgery, and chest physiotherapy and other rehabilitation strategies for patients with cystic fibrosis. The pulmonary management of several neuromuscular disorders is discussed, with attention to the recognition of early pulmonary dysfunction, the role of ventilatory muscle training, and the indications and options for assisted ventilation.

OVERALL ARTICLE OBJECTIVE

(a) To review the assessment and therapeutic options in the rehabilitation of patients with pulmonary diseases and (b) to describe the pulmonary management of neurologic disorders.

Lung volume reduction surgery (LVRS) for emphysema: initial experience at the University Hospital Gasthuisberg. Leuven LVRS Group

Emphysema is a disabling disease, for which there is no curative therapy available today. Lung transplantation offers a valuable option for a very selected number of patients, however, due to the enormous organ shortage, only few patients can be offered such a therapy. Recently there has been important resurgence of interest in lung volume reduction surgery and as a consequence, we have embarked in such a program since may 1997. We have now performed unilateral lung volume reduction surgery in 29 emphysema patients (25 on the right and 4 on the left side). Twenty-four patients were already discharged home. There has been no perioperative mortality. The mean hospital stay was 19.8 +/- 11.4 days (range, 8-47 d). Twenty patients of whom we already have follow-up data during 6 months (m) form the further basis of this report. Six weeks after the procedure the FEV1 increased from 0.82 +/- 0.28 L (28 +/- 8%) to 1.05 +/- 0.39 L, a mean increase of 28%. There was a further increase of the FEV1 to a maximum of 1.06 +/- 0.42 L at 6 m, a mean maximum increase of 29% (p = 0.0046, ANOVA). Similarly, the FVC increased from 2.80 +/- 1.10 L to 3.15 +/- 1.00 L, a mean increase of 12.5%. A further increase was also obtained at 6 m and was 19.6% (3.35 +/- 1.05 L, p = 0.014, ANOVA). The maximum decrease in RV was obtained at 3 m (from 5.91 +/- 1.37 L to 4.37 +/- 0.85 L (p = 0.0001, ANOVA), a mean decrease of 26%. The maximum TLC decrease was demonstrated at 3 m (from 8.71 +/- 1.71 L to 7.60 +/- 1.56 L (p = 0.002, ANOVA), a mean decrease of 12.8%. Afterwards there was again a gradual raise of the TLC. The six minute walking distance increased from 231 +/- 31 m to 272 +/- 34 m (p = NS) after pulmonary rehabilitation and to 416 +/- 77 m at 3 m and 415 +/- 18 m at 6 m (p = 0.0002, ANOVA) after the operation. The quality of life (measured with a standardized questionnaire, the Nottingham Health Profile) improved significantly in several domains (e.g. mobility, pain, energy, emotions and social) at 3 m postoperatively. There was one late death (at 6 m) due to an unknown cause. The actuarial survival rate was therefore 100% at 3 m and 95% at 12 m. In conclusion, unilateral thoracoscopic lung volume reduction surgery is a new and safe treatment modality for patients suffering from severe end-stage emphysema. The objective and subjective improvement is marked and the mortality is very low. Rigid selection criteria are, however, necessary to be able to guarantee an optimal result.

[The correction of the immune status at the postoperative rehabilitative stage in lung cancer patients by using millimeter-wave resonance therapy]

Results are submitted of study into effects of microwave resonance therapy (MRT) on parameters characterizing cell immunity in those lung cancer patients having undergone a radical operation. This study comprised 58 patients as the main group, with 31 patients being controls. Indices for cell immunity were also studied in 20 donors. There was a rise in T-lymphocytes after MRT in the postoperative period. MRT contributed to prolongation of patients' lives, reduction of the incidence of chemotherapy-related dyspeptic complications and that of leukopenia cases by 8 and 9 percent respectively.

Recombinant human growth hormone for reconditioning of respiratory muscle after lung volume reduction surgery

OBJECTIVE

To investigate the effects of recombinant human growth hormone (rHGH) as a "rescue treatment" in an end-stage chronic obstructive pulmonary disease patient after prolonged weaning failure.

DESIGN

Descriptive case report.

SETTING

Fifteen-bed intensive care unit in a university hospital.

PATIENT

A 62-year-old man with end-stage chronic obstructive pulmonary disease and pulmonary emphysema after lung reduction surgery and prolonged weaning failure after long-term mechanical ventilation.

INTERVENTIONS

After 42 days of unsuccessful weaning from the respirator, rHGH (27 IU/day, 0.3 IU/kg body weight/day) was administered for 20 days through a subcutaneous injection in addition to standard intensive care.

MEASUREMENTS AND MAIN RESULTS

In addition to daily routine laboratory studies, the visceral proteins prealbumin, retinol-binding protein, and transferrin, and nitrogen balance were measured twice a week, as were the thyroid hormones triiodothyronine, thyroxine, and thyroid-stimulating hormone, plasma insulin levels, and the insulin-like growth factor (IGF)-1 binding proteins IGF-BP1 and IGF-BP3. IGF-1 was measured from day 1 to day 4 of rHGH administration. Nutritional support was guided by indirect calorimetry. Additionally, weaning variables such as peak expiratory flow rate and expiratory tidal volume were measured noninvasively. T-piece weaning trials were carried out daily until respiratory muscle fatigue occurred. IGF-1 increased in response to rHGH stimulation, from 103 to 230 microg/mL, within 4 days. The carrier protein IGF-BP3 increased from 126 to 283 mg/L at the end of the study period, and the inhibiting IGF-BP1 decreased initially from 19 to 14 mg/L and then increased until the end of the study to 31 mg/L. Nitrogen balance increased initially from 4.6 to 13.6 g/24 hrs and thereafter decreased until the end of rHGH treatment to 8.3 g/24 hrs. Resting energy expenditure increased from 1800 to 2300 kcal/24 hrs. Peak expiratory flow rate increased from 0.69 to 0.88 L/sec. The expiratory tidal volume showed a slight increase during the study period during the daily decrease of pressure support on the ventilator setting. Respiratory muscular strength increased beginning 10 days after rHGH therapy was started. From this point, T-piece weaning trials could be prolonged almost daily. The patient was extubated successfully on postoperative day 75.

CONCLUSIONS

This case report shows that after a prolonged catabolic state and long-term mechanical ventilation, administration of rHGH not only enhances the response of protein metabolism but improves respiratory muscular strength. Therefore, it may reduce the duration of mechanical ventilation in selected patients.

Fixed maximal stroke index in patients after pneumonectomy

Patients who have undergone pneumonectomy (PNX) show limited exercise capacity, partly attributable to an impaired stroke index (SI). To determine whether this limitation is due to deconditioning, we assessed exercise performance and cardiopulmonary function in seven patients after PNX (age: 59 +/- 2 yr, mean +/- SEM) and eight normal, healthy nonsmokers (52 +/- 3 yr) before and after an ergometer exercise training program for 30 min per day, 5 d per week, for 8 wk at 65% of measured maximal O2 uptake. Lung volume, diffusing capacity of carbon dioxide (DL(CO)) and cardiac index (CI) were determined during steady-state exercise by a rebreathing method. Exercise endurance was measured at 80% of maximal power. As compared with normal subjects, patients who had had PNX showed diminished maximal oxygen uptake (VO2max), as well as diminished lung volumes, ventilatory capacities, and maximal cardiac and stroke indexes. After training, VO2max, endurance, and peripheral O2 extraction improved in both groups. However, maximal cardiac and stroke indexes increased only in normal subjects and not in patients. We conclude that an irreversibly fixed maximal SI is a major source of exercise limitation after PNX, probably because of pulmonary arterial hypertension and/or mechanical distortion of the cardiac fossa. Ventilatory impairment after PNX did not prevent a training-induced increase in VO2max. Exercise training confers significant functional benefit on postpneumonectomy patients by enhancing peripheral O2 extraction.

One-day admission for lung lobectomy: an incidental result of a clinical pathway

BACKGROUND

Most complications after lung lobectomy are related to pain, narcotic analgesia, and inactivity. When the operation is performed with the goal of minimizing postoperative pain, and when rapid restoration of activity and patient independence can be achieved, most postoperative complications can be obviated and early discharge can be attained.

METHODS

Since March 1996, we have performed 10 consecutive elective major lung resections (8 lobectomies and 2 bilobectomies) for neoplastic (n = 8) and benign inflammatory (n = 2) lesions. Of the 10 patients, 4 were men and 6 were women ranging in age from 58 to 77 years (mean age, 66 years). Extensive preoperative patient and family education was provided in the surgeon's office. Same-day admission was followed by an oblique muscle-sparing minithoracotomy to access the chest cavity. A meticulous operation, with special attention to minimizing air leak and postoperative discomfort, was performed. Intercostal nerve cryolysis was used as the main method of analgesia.

RESULTS

All patients underwent the planned operation through a minithoracotomy and were extubated in the operating room. All patients exhibited normal ipsilateral shoulder girdle mobility in the recovery room and none required intravenous narcotics after leaving this unit. All patients were out of bed the day of the operation. The chest tube was removed the night of the operation in 2 patients, the morning after the operation in 6 patients, and on the second postoperative day in 1 patient. One patient who was discharged with a Heimlich valve had this device removed in the office 4 days after the operation. After the chest tubes were removed, there were no instances of pneumothorax. All 10 patients were able to ambulate independently on the first postoperative day. Eight patients were discharged home the morning after the operation and 2 on the second postoperative day. None of the patients have required readmission related to their operation or have exhibited evidence of postthoracotomy pain syndrome.

CONCLUSIONS

We have developed a clinical pathway based on patient education, meticulous minimally invasive operation, cryoanalgesia, and quick resumption of physical activity. Our preliminary experience with this approach has shown minimal morbidity, rapid restoration to preoperative status, and, for most patients, a 1-day hospital stay after major lung resection.

Pulmonary rehabilitation in the surgical patient. Lung transplantation and lung volume reduction surgery

Prior to lung transplantation or lung volume reduction surgery, patients complete a comprehensive pulmonary rehabilitation program. The program aids physicians in the selection of appropriate surgical candidates and prepares patients physically and psychologically for the stress of surgery. Because lung transplantation often involves relocation and prolonged waiting, stress levels can be particularly high. Rehabilitation continues through the perioperative and postoperative period to facilitate recovery and bring patients to the highest possible level of function. Studies of lung transplant recipients suggest that most patients who survive to hospital discharge enjoy a significant improvement in pulmonary function and many resume work and household responsibilities. Initial experiences with lung volume reduction surgery also suggest that many patients experience improved dyspnea symptoms and functional status after the procedure. As lung transplantation and lung volume reduction surgery emerge as viable therapeutic options for many patients with end-stage lung disease, comprehensive pulmonary rehabilitation programs are essential to address the complex medical, surgical, and psychological issues that surround these procedures and to produce optimal therapeutic outcomes.

Pulmonary rehabilitation of the patient with nonobstructive lung disease

Disability from chronic lung disease is usually associated with COPD and pulmonary rehabilitation programs are designed to address this population. There are a number of chronic nonobstructive lung diseases, however, that can produce disability and that also may benefit from pulmonary rehabilitation. This article discusses how to classify nonobstructive lung disease patients and examines their evaluation, rehabilitation, and outcomes.

[Effects of bilateral lung volume reduction surgery in a patient with severe pulmonary emphysema]

A 61-year-old man suffering from severe pulmonary emphysema underwent lung volume reduction surgery on both upper lobes. By one year after surgery functional residual capacity had decreased by 2.5 L and FEV1 had increased by a factor of 2.4. Diaphragm excursion, as assessed by dynamic magnetic resonance imaging, had increased and ventilation and pulmonary gas exchange had improved. Performance on a 6-minute-walk test and exercise tolerance measured on a bicycle ergometer improved, and both peak VE and VO2 increased. Before surgery, pulmonary artery pressure Ppa and pulmonary capillary wedge pressure Pewp during exercise were abnormally high, but 6 months after the operation the increases in Ppa and Pcwp during exercise were markedly reduced.

Use of pleura, azygos vein, pericardium, and muscle flaps in tracheobronchial surgery

Desmoplastic reactions secondary to adjuvant chemotherapy and radiation in stage IIIA lung cancer, plus advances in complex tracheobronchial surgery, have rejuvenated an interest for augmenting bronchial stump coverage and suture line reinforcement. We present the techniques and applications of harvesting pleural, azygos vein, pericardial flaps, and fat pad grafts, and intrathoracic transposition of chest wall muscle flaps.

[Evaluation of the exercise capacity recovery process after lung cancer surgery by exercise test and expire gas analysis]

This study was conducted to evaluate the numerical changes and the recovery process in exercise capacity over time, and to establish new criteria that will objectively evaluate the recovery in exercise capacity after lung surgery using an expired gas analysis incorporating an exercise test. The subjects consisted of 47 patients that underwent curative resection (only lobectomy) for lung cancer in the four years from 1989 to 1992 that were able to undergo expired gas analysis incorporating an exercise test before and after surgery. The expired gas analysis were performed within one week prior to surgery and over a period from 14 to 449 days after surgery, maximum oxygen consumption (VO2max) and anaerobic threshold (AT) measured, and the VO2max/m2 and AT/m2 were calculated as an index by dividing by the body surface area (m2). In addition, in order to examine the changes in exercise capacity after surgery, the presurgical values were used as 100, and the rate of change after surgery found. These rate were divided into the following measuring times, and the postsurgical changes over time analyzed. The postsurgical measuring times were divided into five groups from 14-30 days (n = 11), from 31-90 days (n = 25), from 91-180 days (n = 8), from 181-270 days (n = 19), and greater than 271 days (n = 8) after surgery.(ABSTRACT TRUNCATED AT 250 WORDS)

Respiratory muscle limitation in patients after pneumonectomy

Exercise capacity is significantly impaired in postpneumonectomy patients who have relatively normal remaining lungs. Our objectives are to determine (1) the nature and extent of mechanical ventilatory abnormalities and oxygen cost of breathing in such patients, and (2) the efficacy of a selective respiratory muscle training program in improving ventilatory and exercise performance. A group of eight postpneumonectomy and eight normal subjects (mean ages 59 and 50 yr, respectively) were studied during steady-state exercise and resting voluntary hyperventilation. Ventilation, work of breathing, cardiac output, and oxygen costs of breathing were determined. Four postpneumonectomy and five normal subjects were studied before and after a respiratory muscle training program. In patients after pneumonectomy compared with normal control subjects, maximal oxygen uptake (VO2) was 56% lower (p < 0.001). Work of breathing was significantly higher at a given ventilation. Mechanical efficiency of ventilation was lower by 44% (p < 0.05). Near maximal VO2, 48% of any additional increment of total-body VO2 was required to sustain the associated increment in ventilatory work, compared with 28% in normal subjects (p < 0.05), suggesting that competition between respiratory and nonrespiratory muscles for oxygen delivery is a significant factor limiting exercise after pneumonectomy. After respiratory muscle training, maximal respiratory pressures improved but maximal sustained ventilation and maximal VO2 did not improve significantly, suggesting that selective respiratory muscle training is of limited utility in postpneumonectomy patients.

Imaging of the expanded polytetrafluoroethylene prosthetic diaphragm following extrapleural pneumonectomy for mesothelioma

Extrapleural pneumonectomy, which usually requires placement of a prosthetic hemidiaphragm, can be offered to approximately 24% of patients with malignant mesothelioma. Expanded polytetrafluoroethylene (Gore-Tex) has superior physical characteristics for diaphragmatic grafting and is the material of choice at the authors' institutions. This article describes conventional radiography and computed tomography findings in three patients who underwent extrapleural pneumonectomy. A freshly placed Gore-Tex prosthetic diaphragm appears as a radiolucent crescent-shaped band at the inferior border of the hemithorax and could be confused with a pneumoperitoneum. With time, the lucent crescent becomes thinner and eventually becomes radiopaque; it may be confused with a calcified diaphragm.

Right pneumonectomy syndrome in infancy treated with an expandable prosthesis

Severe respiratory distress developed in a 5-month-old infant approximately ten days after pneumonectomy for complete sequestration of the right lung. Right pneumonectomy syndrome was diagnosed by bronchography, which revealed thinning and obstruction of the left main bronchus during expiration. A right thoracotomy was then performed, and an inflatable tissue expander with a subcutaneous injection port was inserted into the right chest cavity to prevent recurrence of the mediastinal shift and to allow for future growth. The patient has done well, requiring reinjection of the prosthesis with additional volume on one occasion in a 20-month period of follow-up.

[Disability of patients with lung cancer after surgical treatment]

Invalidity of 149 patients subjected to surgical treatment of lung cancer was studied. More than half of all the patients and 84.1% of those directed to the commission were pronounced invalids of the I or II groups. Only 40.0% of the invalids had positive dynamics of invalidity. Stability of invalidity was due to coming the pension age, an anatomical defect arising after pneumonectomy and the presence of a severe concomitant pathology. One of the methods to reduce invalidity in patients with lung cancer after a radical treatment in the presence of indications is thought to be prolongation of temporary disablement during the first examination of the commission.

[Medical-work capacity examination of patients with chronic empyema of the pleura after pulmonectomy]

Treatment and analysis of immediate results were described in 269 patients with chronic empyema of the pleura as well as their long-term results in 207 of them. Under consideration were main criteria of the examination of labor capacity in such patients. It was shown that the establishment of the phase of "compensation at the limit" (IIa degree of pulmonary insufficiency) and subcompensation (IIb degree of pulmonary insufficiency) allowed more exact evaluation of the degree of compensatory processes of respiratory organs in patients after operation and the degree of loss of their working capacity.

[Respiratory care for pulmonary resection in geriatric patients with bronchogenic carcinoma]

In patients aged over 70 years with bronchogenic carcinoma, respiratory failure following pulmonary resection is the most common cause of death. Before August 1982, 23 patients over 70 were treated surgically at the National Defense Medical College Hospital. Of these 23 patients, 4 died from postoperative respiratory failure, 2 of them dying within 30 postoperative days. Since August 1982, 35 pulmonary resections have been performed in patients over 70 who have been managed with pulmonary rehabilitation, resulting in no deaths from respiratory failure. Pulmonary rehabilitation has also provided a shorter duration of atelectasis and a reduced need for bronchoscopic aspiration. We therefore consider that pulmonary rehabilitation is the respiratory care of choice in elderly patients undergoing pulmonary resection.