Preoperative pulmonary rehabilitation in lung cancer patients undergoing lung resection surgery

Programa Oficial de Doutoramento en Saúde, Discapacidade e Dependencia. 560V01[Abstract] INTRODUCTION: Lung resection surgery (LRS) remains the treatment of choice for early stages of lung cancer but significant morbidity is associated, especially among patients with poor preoperative status. Preoperative exercise training (PET) has been proposed as an effective way of optimizing patients’ condition before surgery and enhancing postoperative recovery. However, it remains unknown whether or not similar results can be achieved after video-assisted thoracic surgery (VATS). Therefore, the aim of this thesis is to determine the feasibility, safety and efficacy of a preoperative pulmonary rehabilitation program (PPRP) on the functional and postoperative outcomes on patients undergoing VATS. MATERIALS AND METHODS: This thesis was structured in three studies: 1) a systematic review and meta-analysis of the effects PET on the functional and postoperative outcomes after LRS; 2) a small pilot investigation to assess the feasibility, safety and preliminary effects of a PPRP in patients awaiting VATS; and 3) a randomized controlled trial examining the effects of the PPRP after VATS for lung cancer on selected postoperative and functional outcomes in comparison to the standard care. RESULTS: Results from the study #1 show that PET improves pulmonary function before surgery and hastens postoperative recovery by reducing postoperative complications and hospital length of stay. In study #2, we concluded that a PPRP is safe and feasible and can potentially improve functional fitness. Finally, study #3, confirmed that a PPRP significantly improves exercise capacity, muscle strength and health-related quality of life while minimizing the impact of LRS during the first 3 months after VATS. CONCLUSIONS: We conclude that preoperative exercise-based interventions in patients with lung cancer awaiting VATS are feasible, safe and can significantly improve exercise and functional performance and enhance postoperative recovery.[Resumen] INTRODUCCION: La cirugía de resección pulmonar (CRP) continúa siendo el tratamiento de elección en estadios iniciales del cáncer de pulmón pero la morbilidad asociada continúa siendo elevada, especialmente en pacientes con peor condición física. La Rehabilitación Pulmonar Preoperatoria (RPP) podría constituir una herramienta útil a la hora de disminuir el riesgo perioperatorio y optimizar la recuperación postoperatoria. Sin embargo, dichos programas no han sido probados en pacientes operados por videocirugía. Así pues, el objetivo de esta tesis es investigar la viabilidad, seguridad y eficacia de un programa de RPP en pacientes sometidos a resección pulmonar por videocirugía. MATERIAL Y METODOS: Esta tesis está estructurada en tres estudios: 1) revisión sistemática y meta-análisis sobre la eficacia del ejercicio preoperatorio en pacientes sometidos a CRP en cuanto a mejorar el estado funcional de los pacientes y acelerar la recuperación postoperatoria; 2) estudio piloto centrado en la viabilidad, seguridad y eficacia preliminar de la RPP en pacientes sometidos a videocirugia; y 3) un ensayo controlado aleatorizado sobre la eficacia de la RPP en los outcomes funcionales y postoperatorios en pacientes sometidos a videocirugia en comparación con el tratamiento estándar. RESULTADOS: Los resultados obtenidos en el estudio #1 muestran que el ejercicio preoperatorio mejora la función pulmonar y acelera la recuperación postoperatoria al reducir la estancia hospitalaria y el número de complicaciones; con el estudio #2 se comprobó que la RPP es viable, segura y potencialmente eficaz a la hora de incrementar la capacidad funcional, mientras que el estudio #3 corroboró los resultados anteriores demostrando que la RPP incrementa la tolerancia al esfuerzo, la fuerza muscular y la calidad de vida al tiempo que optimiza la recuperación postoperatoria los tres primeros meses tras videocirugia. CONCLUSION: La RPP en pacientes con cáncer de pulmón sometidos a videocirugia es viable, segura y eficaz a la hora de incrementar el estado funcional preoperatorio de los pacientes así como optimizar la recuperación postoperatoria.[Resumo] INTRODUCCION: A cirurxía de resección pulmonar (CRP) constitue o tratamiento de elección en pacientes con cancro de pulmón en estadios iniciáis pero a morbilidade asociada continua a ser elevada especialmente en pacientes con peor condición física de base. Neste contexto, a Rehabilitación Pulmonar Preoperatoria (PRP) podería considerarse como unha ferramenta útil para disminuir o risco quirúrxico e optimizar o estado funcional dos pacientes. Non obstante, desconecese o rol destos programas nos pacientes operados por videocirurxía. Así pois, o obxectivo desta tese de doutoramento e estudar a viabilidade, seguridade e eficacia da Rehabilitación Pulmonar Preoperatoria (RPP) en pacientes con cancro de pulmón sometidos a resección pulmonar por videocirurxía. MATERIAL E METODOS: Esta tese está estructurada en tres estudos: 1) revisión sistemática e meta-analice da efectividade da RPP en pacientes con cancro de pulmón sometidos a CRP para mellorar o estado funcional e acelerar a recuperación postoperatoria; 2) estudo piloto sobre a viabilidade, seguridade e eficacia preliminar da RPP en pacientes operados por videocirurxía e 3) ensaio clínico aleatorizado sobre o impacto da RPP sobre a tolerancia o esforzo, a capacidade funcional e a tolerancia o esforzo no postoperatorio de CRP en comparación co tratamento estándar. RESULTADOS: Os resultados obtidos no estudo #1 mostraron que o exercicio preoperatorio en pacientes sometidos a CRP mellora a función pulmonar e acelera a recuperación postoperatoria ao reducir o número de complicacións postoperatorias e a estadía hospitalaria; no estudo #2 quedo comprobada a viabilidade da intervención así como a ausencia de eventos adversos así como o potential da intervención para mellorar a funcionalidade dos pacientes; finalmente, o estudo #3 corroborou a efectividade da RPP para optimizar o estado funcional v | P a g e dos pacientes previo a cirurxía e disminuir o impacto ocasionado pola CRP durante os tres primeiros meses tras videocirurxía. CONCLUSIÓNS: A RPP en pacientes con cancro de pulmón sometidos a videocirurxía e viable, segura e eficaz para incrementar a tolerancia o estado funcional previo a cirurxía e optimizar a recuperación postoperatoria

Effect of pre-operative pulmonary rehabilitation in lung cancer patients

[Resumen] El cáncer de pulmón constituye una de las principales causas de muerte en los países desarrollados. Los tratamientos utilizados frecuentemente conducen a un deterioro en la calidad de vida y la capacidad funcional de los pacientes. Las principales bases de datos han sido revisadas entre febrero y marzo de 2012 para evaluar el papel que ejercen los programas de rehabilitación pulmonar (RP) en el preoperatorio de cirugía torácica y sus efectos sobre el postoperatorio inmediato. De los 425 artículos identificados, finalmente 9 cumplieron los criterios de inclusión establecidos. De los datos extraídos, podemos concluir que los programas de RP son efectivos para mejorar la tolerancia al esfuerzo en los pacientes, aunque son necesarios más estudios controlados para establecer diferencias significativas en otros aspectos como la función pulmonar o la calidad de vida.[Abstract] Lung cancer is considered as one of the leading causes of death in developed countries. The therapies used for the treatment often lead to a deterioration in the patient's quality of life and functional capacity. The main data bases were searched between February and March 2012 in order to evaluate the role of pulmonary rehabilitation (PR) programs during the thoracic surgery preoperative period and their effects on the immediate post-surgery period. Finally, 9 out of the 425 papers identified met the inclusion criteria. Based on the data obtained, we can conclude that the PR programs are effective to improve tolerance to exercise in lung cancer patients. However, more randomized controlled trials are needed to establish significant differences in other aspects such as lung function or quality of life

Preoperative exercise training prevents functional decline after lung resection surgery: a randomized, single-blind controlled trial

[Abstract] Objectives: To investigate the effects of a preoperative pulmonary rehabilitation programme in patients with lung cancer undergoing video-assisted thoracic surgery. Design: Randomized, single-blind controlled trial. Setting: Teaching hospital. Subjects: Patients with suspected or confirmed lung cancer undergoing video-assisted thoracic surgery. Intervention: Participants were randomized to either a prehabilitation group or a control group. Participants in the prehabilitation group underwent a combination of moderate endurance and resistance training plus breathing exercises three to five times per week. Main measures: The primary outcome of the study was exercise capacity. Secondary outcomes were muscle strength (Senior Fitness Test), health-related quality of life (Short-Form 36) and the postoperative outcomes. Patients were evaluated at baseline (before randomization), presurgery (only the prehabilitation group), after surgery and three months post-operatively. Results: A total of 40 patients were randomized and 22 finished the study (10 in the prehabilitation group and 12 in the control group). Three patients were lost to follow-up at three months. After the training, there was a statistically significant improvement in exercise tolerance (+397 seconds, p = 0.0001), the physical summary component of the SF-36 (+4.4 points, p = 0.008) and muscle strength (p < 0.01). There were no significant differences between groups after surgery. However, three months postoperatively, significant differences were found in the mean change of exercise capacity (p = 0.005), physical summary component (p = 0.001) and upper and lower body strength (p = 0.045 and p = 0.002). Conclusions: A pulmonary rehabilitation programme before video-assisted thoracic surgery seems to improve patients’ preoperative condition and may prevent functional decline after surger

Respiratory Physiotherapy in Post-COVID-19: A Decision-Making Algorithm for Clinical Practice

[Resumen] La pandemia causada por la enfermedad de la COVID-19 ha supuesto un gran reto para los profesionales del sistema sociosanitario, intensificándose con el manejo y atención de las manifestaciones clínicas que potencialmente pueden presentarse de manera persistente en las personas que han superado la enfermedad. Para ello, la fisioterapia respiratoria se presenta como piedra angular dentro del modelo de abordaje interdisciplinar que requiere esta población. Dado que la implementación de esta opción terapéutica continúa siendo limitada en España, es imprescindible realizar una evaluación integral y exhaustiva de la persona que nos permita establecer criterios de selección a fin de optimizar el uso de los recursos humanos y materiales existentes. Para ello, se propone un algoritmo de decisión terapéutica basado en pruebas de evaluación validadas y objetivas de las posibles manifestaciones clínicas del paciente. La aplicación de este algoritmo, en cualquier nivel asistencial (atención especializada y atención primaria/comunitaria) junto con la atención centrada en la persona, el impulso del uso de los espacios comunitarios verdes y azules de las ciudades y un adecuado uso de las tecnologías de la comunicación y la información, nos permitirá optimizar el modelo de atención de fisioterapia respiratoria en el contexto actual, marcado por la COVID-19.[Abstract] The outbreak of COVID-19 has posed a great challenge for the healthcare system which has been later aggravated by the need of managing clinical manifestations and potential sequelae in COVID-19 survivors. In this context, respiratory Physiotherapy emerges as a cornerstone in the interdisciplinary management warranted in this population. Given that the implementation and resources available for the interdisciplinary therapeutic interventions in Spain is scarce, it is essential to perform a comprehensive, exhaustive and personalised assessment. This will allow us to establish more accurate selection criteria in order to optimise the use of existing human and material resources. To this end, we propose here a decision-making algorithm for clinical practice to assess the clinical manifestations in people recovered from COVID-19 based on well-established, validated tests and assessment tools. This algorithm can be used at any clinical practice environment (primary care/community or hospital-based), combined with a patient-centered model and the use of community and e-Health resources and its application to improve the Physiotherapy care of these patients in the COVID-19 era

Pulmonary Rehabilitation: Time for an Upgrade

Pulmonary rehabilitation is a notoriously known but highly underused intervention aimed to restore or improve functional capacity, symptom management and health-related quality of life among patients with chronic respiratory diseases. Since early 1980s, pulmonary rehabilitation has been acknowledged as a comprehensive intervention with hundreds of studies being performed over the past thirty years demonstrating its benefits on multiple outcomes; nevertheless, there are still multiple unresolved challenges, and new ones are currently emerging, with the COVID-19 outbreak now in the spotlight. In this editorial, these issues are summarized and discussed, while presenting some of the latest findings in research and clinical practice, with the ultimate goal of raising awareness of the future of pulmonary rehabilitation in the post COVID-19 era

Changes in Muscle Contractile Properties after Cold- or Warm-Water Immersion Using Tensiomyography: A Cross-Over Randomised Trial

Muscle contractile properties in clinical practice are often measured using either subjective scales or high-cost, inaccessible equipment. In this randomised cross-over study, we aimed to explore the use of tensiomyography (TMG) to assess changes in muscle contractile properties after cold- and warm-water immersion. The muscle contractile properties of the biceps femoris (BF) were assessed using TMG in 12 healthy active men (mean age 23 +/- 3 years, Body Mass Index 22.9 +/- 1.3 kg/m(2)) before and after a 20-min warm- or cold-water immersion over a period of 40 min. Muscle displacement (Dm) and contraction time (Tc) were registered as the main variables of the study. There was a significant condition by time interaction for Dm (p < 0.01). Post hoc analysis showed that, compared to the baseline, there was an increase in Dm 40 min after warm-water immersion (p < 0.01) and a decrease at 10 min after cold-water immersion (p < 0.01). No significant effect was found for Tc. Our results indicate that muscle contractile properties are affected by water temperature and time after the immersion; therefore, these factors should be taken into account when water-immersion is used as a recovery strategy

Pulmonary function in patients with chronic stroke compared with a control group of healthy people matched by age and sex

[Abstract] Background: Effects of chronic stroke on pulmonary function are largely unknown. Aim: To compare lung volumes in people with chronic stroke with a control group of healthy people matched by age and sex, as well as to investigate the relationship between the lung volumes and functional capacity. Methods: A cross-sectional study involving people with chronic stroke. Cases were matched to a control group of healthy people. Lung function and the distance walked during the Six-Minute Walk Test (6MWD) were the main outcomes. Independent t-tests were used to compare pulmonary function between groups and the Pearson correlation coefficient was used to assess any relationship between lung volumes and the 6MWD in the stroke group. Results: Sixty-six participants (24 males in each group; 56.5 ± 15.5 years) were included. People with stroke presented significantly lower lung volumes when compared to the control group. The median of forced vital capacity (FVC) was 79% and peak expiratory flow was 64% of the reference value. The 6MWD was found to be weakly correlated with inspiratory reserve volume (r = 0.39, p = .03) and peak inspiratory flow (r = 0.35, p = .05). Conclusions: People with chronic stroke show decreased lung volumes when compared with healthy people and this likely impacts on their functional capacity

Changes in Muscle Contractile Properties after Cold- or Warm-Water Immersion Using Tensiomyography: A Cross-Over Randomised Trial

Muscle contractile properties in clinical practice are often measured using either subjective scales or high-cost, inaccessible equipment. In this randomised cross-over study, we aimed to explore the use of tensiomyography (TMG) to assess changes in muscle contractile properties after cold- and warm-water immersion. The muscle contractile properties of the biceps femoris (BF) were assessed using TMG in 12 healthy active men (mean age 23 &plusmn; 3 years, Body Mass Index 22.9 &plusmn; 1.3 kg/m2) before and after a 20-min warm- or cold-water immersion over a period of 40 min. Muscle displacement (Dm) and contraction time (Tc) were registered as the main variables of the study. There was a significant condition by time interaction for Dm (p &lt; 0.01). Post hoc analysis showed that, compared to the baseline, there was an increase in Dm 40 min after warm-water immersion (p &lt; 0.01) and a decrease at 10 min after cold-water immersion (p &lt; 0.01). No significant effect was found for Tc. Our results indicate that muscle contractile properties are affected by water temperature and time after the immersion; therefore, these factors should be taken into account when water-immersion is used as a recovery strategy

Impacto de un programa de rehabilitación pulmonar preoperatoria sobre el rendimiento funcional de pacientes sometidos a cirugía torácica asistida por vídeo debido a neoplasia maligna pulmonar

Also available in English : Impact of a pre-operative pulmonary rehabilitation program on functional performance in patients undergoing video-assisted thoracic surgery for lung cancer

Perioperative Nursing as the Guiding Thread of a Prehabilitation Program

Multimodal preoperative prehabilitation has been shown to be effective in improving the functional capacity of cancer patients, reducing postoperative complications and the length of hospital and ICU stay after surgery. The availability of prehabilitation units that gather all the professionals involved in patient care facilitates the development of integrated and patient-centered multimodal prehabilitation programs, as well as patient adherence. This article describes the process of creating a prehabilitation unit in our center and the role of perioperative nursing. Initially, the project was launched with the performance of a research study on prehabilitation for gastrointestinal cancer surgery. The results of this study encouraged us to continue the implementation of the unit. Progressively, multimodal prehabilitation programs focusing on each type of patient and surgery were developed. Currently, our prehabilitation unit is a care unit that has its own gym, which allows supervised training of cancer patients prior to surgery. Likewise, the evolution of perioperative nursing in the unit is described: from collaboration and assistance in the integral evaluation of the patient at the beginning to current work as a case manager; a task that has proven extremely important for the comprehensive and continuous care of the patient