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  • Although preoperative rehabilitation may have a strong

    2019-04-15

    Although preoperative rehabilitation may have a strong impact on survival if additional patients are qualified for curative resection, yet strong evidence remains lacking to support the regimens for patients who have lung cancer. This may be due to, in part, the relatively brief purchase abk of time between cancer diagnosis and surgery, which does not typically allow a 4–8 weeks rehabilitation program. This issue may hinder the translation of evidence supporting prehabilitation into clinical practice. Furthermore, it is currently recommended for already operable patients not to delay surgery in order to undertake prehabilitation, but instead use the time waiting to deliver prehabilitation. The European Respiratory Society and the European Society of Thoracic Surgeons have published evidence-based guidelines on the use of physical therapy programs in lung cancer patients. The suggestions were that exercise training may improve surgical risk and/or recovery, symptom control, and possibly, risk of dying following a lung cancer diagnosis.
    Perioperative rehabilitation Rehabilitation in the immediate postoperative period aims to reduce PPCs, prevent deconditioning and facilitate early and safe discharge. A PPC is defined as any pulmonary sequelae occurring during the post-operative period and resulting in significant dysfunction, adversely affecting the clinical course. The problems that were encountered included pneumonia, atelectasis, acute respiratory failure, need for reintubation, pulmonary edema, bronchospasm, pneumothorax and prolonged air leaks. Currently, the known independent risk factors for PPC are age ≥75 years, body mass index ≥30 kg/m2, Anesthesia Physical Classification System scored 3, smoking history and COPD. Despite the improvement in surgical techniques and perioperative management, PPCs still occur in 3.9%–32.5% of patients with lung cancer who have undergone surgical resection. PPCs are a major cause of morbidity, mortality, prolonged hospital stay, and the increased cost of care. One study examined the feasibility of high frequency chest wall oscillation therapy immediately after pulmonary lobectomy in lung cancer patients compared to conventional chest physiotherapy. The chest wall oscillation group had a better and quicker recovery of pulmonary function (including FEV1 and oxygenation) than the conventional chest physiotherapy group. No unexpected complications, such as hemodynamic deterioration, bleeding or chest tube or wound problems associated with oscillation therapy were detected. A quasi-experimental study attempted to evaluate the effects of an intensive postoperative respiratory exercise in patients undergoing lobectomy; 90% of the 208 participants had lung cancer. The control group received standard care and the experimental group received an additional daily physiotherapy program that focused on respiratory exercises until discharge. A significant improvement in terms of PPCs was detected in both the control (20.6%) and experimental group (6.6%), with a median LOS of 14 and 12 days in control and experimental groups, respectively. In addition, both the physiotherapy program and percentage of FEV1 were identified as protective factors for the development of PPCs in lobectomy procedure according to the logistic regression model. Another randomized single-blind clinical trial found that no difference was apparent in the PPC rate or LOS for patients treated with prophylactic targeted respiratory physiotherapy (deep breathing and coughing, mobilization, progressive shoulder/thoracic mobility exercises) plus the usual care compared to usual care alone. The usual care included a clinical pathway with early mobilization. However, the study was conducted in a single hospital in New Zealand. The results cannot be extrapolated for the entire population, thus execution of this treatment should be used with caution. A systematic review investigated the efficacy of perioperative respiratory physiotherapy in patients undergoing pulmonary resection for lung cancer in terms of PPC incidence, postoperative recovery of pulmonary function and LOS. Studies were included if they were randomized controlled trials, compared two or more perioperative physiotherapy interventions or compared one intervention with no intervention. Two studies investigated the efficacy of interventions that started preoperatively and then continued after surgery; four studies assessed postoperative interventions only. The rehabilitation program includes incentive spirometry, breathing and coughing exercises, sustained maximal inspirations, active cycle of breathing techniques, intermittent positive pressure breathing, flutter, positive pressure devices and shoulder/thoracic cage exercise. The authors found that pre-surgical interventions based on moderate-to-intense aerobic exercise in patients undergoing lung resection improved functional capacity and reduced postoperative morbidity, whereas interventions performed only during the postoperative period did not seem to reduce PPCs or LOS. However, it was noted that the results of the substantial heterogeneity in the interventions across the studies were inconsistent. Recent improvements in pain management and the increasing use of video-assisted thoracic surgery changed the postoperative clinical pathways. There is a lack of strong evidence to support the routine use of prophylactic targeted pulmonary rehabilitation interventions immediately after lung resection surgery.