For patients undergoing thoracic surgery for conditions such as chronic obstructive pulmonary disease (COPD) and lung cancer, the risk of perioperative complications is increased by many factors, including impaired functional capacity, smoking, and lack of physical activity.1 These issues can often be addressed through pulmonary rehabilitation, which has been found to improve cardiovascular and lung function, metabolism, exercise capacity, and more.
“The incidence of pulmonary complications after noncardiac surgery is greater than the incidence of cardiovascular complications; however, they are frequently underappreciated,” according to Jochen Steppan, MD, assistant professor of anesthesiology and critical care medicine at John Hopkins University School of Medicine in Baltimore, Maryland. “Perioperative pulmonary rehab in conjunction with physiotherapy can improve pulmonary reserve, exercise tolerance, and quality of life,” Dr Steppan said in an interview with Pulmonology Advisor.
Patients who tend to benefit most from a structured pulmonary rehabilitation program are patients with the highest risk of perioperative pulmonary complications, including patients who smoke and patients with COPD and other types of lung disease, as well as patients undergoing thoracic or abdominal surgery. “Periperative pulmonary rehab and physiotherapy should be used in a multimodal fashion, incorporating early mobilization, respiratory muscle training, incentive spirometry, and smoking cessation,” said Dr Steppan.
In a recent study published in the Journal of Thoracic Disease, researchers examined the effects of perioperative pulmonary rehabilitation, including smoking cessation and respiratory training techniques, in patients with COPD (72% had primary lung cancer).1 One group of patients (n=68) completed preoperative rehabilitation only, while another group (n=72) participated in both pre- and postoperative rehabilitation, and a third group (n=68) completed postoperative rehabilitation only.
Significant improvements were observed in forced expiratory volume in 1 second (FEV1): 64±16 vs 67±16 %pred in group 1, 60±13 vs 66±13 %pred presurgery and 48±13 vs 52±13 %pred postsurgery in group 2, and 56±16 vs 61±14 %pred in group 3 (all P <.05). There were also improvements in the 6-minute walk distance (6MWD): 403±87 m vs 452±86 m in group 1, 388±86 m vs 439±83 m presurgery and 337±111 m vs 397±105 m postsurgery in group 2, and 362±89 vs 434±94 m in group 3 (P <.0001). Pulmonary rehabilitation was further associated with increases in forced vital capacity (FVC), grip strength, and quality of life scores.
In a study published in 2014, patients with COPD undergoing resection of non-small cell lung cancer also demonstrated significant improvements after preoperative pulmonary rehabilitation: FEV1 by 374 ml, P <.001); vital lung capacity by 407 ml, (P <.001); forced expiratory flow by 3%, P =.003; 6MWD (for 56 m, P <.001); and dyspnoeal symptoms (by 1.0 Borg unit, P <.001).2
More recently, the same researchers found that preoperative physiotherapy was linked to postoperative preservation of static lung volumes and increased exercise tolerance, although no significant effects were observed for most parameters of pulmonary function.3
Findings reported in 2011 showed that patients treated with a physiotherapy protocol before and after coronary artery bypass graft surgery (CABG) had lower reductions in postoperative pulmonary function than reported in other studies.4 Patients had a 33% decrease in postoperative pulmonary function on day 3 and a 23% decrease on day 6, whereas earlier results indicate that reductions in FVC remained up to 3 weeks postsurgery in a set of participants who underwent CABG without physiotherapy.5 “We can attribute this difference to the physiotherapy that our subjects received up to postoperative day 6,” the researchers from the 2011 study concluded.
Additional Benefits and Clinical Considerations
In addition to the benefits for postoperative outcomes, patients with “severe deconditioning due to respiratory disease that would otherwise preclude surgery may be able to improve enough to be considered surgical candidates after pulmonary rehab,” noted Daniel J. Dorgan, MD, assistant professor of clinical medicine in pulmonary medicine at the University of Pennsylvania Perelman School of Medicine in Philadelphia, and associate program director of the Adult Cystic Fibrosis Program. “Another factor to consider is that preoperative pulmonary rehab can provide an opportunity to educate patients about aspects of postoperative care, which may facilitate postoperative management,” he told Pulmonology Advisor.
- Dr Dorgan offered the following clinical considerations regarding pulmonary rehabilitation.
- Disease severity is one factor that affects decisions about the necessity of pulmonary rehabilitation, as patients with a high functional capacity and few respiratory symptoms may not derive a meaningful benefit.
- Contraindications to pulmonary rehabilitation include conditions that increase health risks associated with exercise, such as uncontrolled cardiac disease. Severe pain, cognitive limitations, or neurologic dysfunction may impair a patient’s ability to fully participate in pulmonary rehabilitation.
- The urgency of a necessary surgical procedure clearly has a significant impact on the timing of pulmonary rehabilitation. Clearly, it is not possible to complete pulmonary rehabilitation before an urgent or emergent procedure.
- It is important to optimize other therapies based on an individual patient’s needs, such as inhaled or oral medications, supplemental oxygen, and nocturnal noninvasive ventilation as appropriate, both to improve surgical outcomes and to facilitate optimal participation in pulmonary rehabilitation.
- Many patients may face barriers to care that need to be addressed in order to facilitate their participation in pulmonary rehabilitation, such as difficulty traveling to a pulmonary rehabilitation site, conflicting personal obligations, and lack of insurance coverage.
- A pulmonary rehabilitation program should be tailored to a patient’s specific needs as determined during assessments of exercise capacity to maximize the impact for a given patient. There are many modes of exercise that can be used in pulmonary rehabilitation, including endurance, interval, strength, respiratory muscle, and flexibility training.
- It is also worthwhile to note that prior participation in pulmonary rehabilitation does not preclude future pulmonary rehabilitation. The benefits of pulmonary rehabilitation have been shown to decline over time after completion of a rehabilitation program, but studies have shown that repeating pulmonary rehabilitation can lead to further benefits.
Dr Steppan noted that future research efforts should include a large multicenter trial to explore the optimal timing, duration, and most beneficial set of interventions. Dr Dorgan added that there is a need for more data on the impact of perioperative pulmonary rehabilitation in patients with pulmonary disease undergoing nonthoracic surgery.
- Vagvolgyi A, Rozgonyi Z, Kerti M, Vadasz P, Varga J. Effectiveness of perioperative pulmonary rehabilitation in thoracic surgery. J Thorac Dis. 2017;9(6):1584-1591. doi:10.21037/jtd.2017.05.49
- Mujovic N, Mujovic N, Subotic D, et al. Preoperative pulmonary rehabilitation in patients with non-small cell lung cancer and chronic obstructive pulmonary disease. Arch Med Sci. 2014;10(1):68-75. doi:10.5114/aoms.2013.32806
- Mujovic N, Mujovic N, Subotic D, et al. Influence of pulmonary rehabilitation on lung function changes after the lung resection for primary lung cancer in patients with chronic obstructive pulmonary disease. Aging Dis. 2015;6(6):466-477. doi:10.14336/AD.2015.0503
- Moreno AM, Castro RRT, Sorares PPS, Sant’ Anna M, Cravo SLD, Nóbrega ACL. Longitudinal evaluation the pulmonary function of the pre and postoperative periods in the coronary artery bypass graft surgery of patients treated with a physiotherapy protocol. J Cardiothorac Surg. 2011;6:62. doi:10.1186/1749-8090-6-62
- Shenkman Z, Shir Y, Weiss YG, Bleiberg B, Gross D. The effects of cardiac surgery on early and late pulmonary functions. Acta Anaesthesiol Scand. 1997;41(9):1193-1199. doi:10.1111/j.1399-6576.1997.tb04865.x