title: Preoperative pulmonary rehabilitation in patients undergoing lung resection for non-small cell lung cancer. Reduction of postoperative pulmonary complications after lung surgery using a fast track clinical pathway. Six sessions of sprint interval training increases muscle oxidative potential and cycle endurance capacity in humans. Effects of exercise training on exercise capacity in patients with non-small cell lung cancer receiving targeted therapy Perioperative rehabilitation and physiotherapy for lung cancer patients with chronic obstructive pulmonary disease. Effects of high-intensity interval training on pulmonary function Preoperative pulmonary rehabilitation before lung cancer resection: results from two randomized studies. A randomized trial comparing lung-volume-reduction surgery with medical therapy for severe emphysema. Short‐Term Preoperative High‐Intensity Interval Training in Patients Awaiting Lung Cancer Surgery: A Randomized Controlled Trial
abstract: BACKGROUND The impact of short-term preoperative pulmonary rehabilitation on exercise capacity of patients with chronic obstructive pulmonary disease undergoing lobectomy for non-small cell lung cancer is evaluated . METHODS A prospect i ve observational study was design ed . Inclusion criteria consisted of an indication to lung resection because of a clinical stage I or II non-small cell lung cancer and a chronic obstructive disease on preoperative pulmonary function test . In such conditions , maximal oxygen consumption by a cardio-pulmonary exercise test was evaluated ; when this result ed as being < or = 15 ml/kg/min a pulmonary rehabilitation programme lasting 4 weeks was considered . Twelve patients fulfilled inclusion criteria , completed the preoperative rehabilitation programme and underwent a new functional evaluation prior to surgery . The postoperative record of these patients was collected . RESULTS On completion of pulmonary rehabilitation , the resting pulmonary function test and diffuse lung capacity of patients was unchanged , whereas the exercise performance was found to have significantly improved ; the mean increase in maximal oxygen consumption proved to be at 2.8 ml/kg/min ( p<0.01 ) . Eleven patients underwent lobectomy ; no postoperative mortality was noted and mean hospital stay was 17 days . Postoperative pulmonary complication was recorded in 8 patients . CONCLUSIONS Short-term preoperative pulmonary rehabilitation could improve the exercise capacity of patients with chronic obstructive pulmonary disease who are c and i date s for lung resection for non-small cell lung cancer BACKGROUND Fast track programs , multimodal therapy strategies , have been introduced in many surgical fields to minimize postoperative morbidity and mortality . In terms of lung resections no r and omized controlled trials exist to evaluate such patient care programs . METHODS In a prospect i ve , r and omized controlled pilot study a conservative and fast track treatment regimen in patients undergoing lung resections was compared . Main differences between the two groups consisted in preoperative fasting ( 6h vs 2h ) and analgesia ( patient controlled analgesia vs patient controlled epidural analgesia ) . Study endpoints were pulmonary complications ( pneumonia , atelectasis , prolonged air leak ) , overall morbidity and mortality . Analysis was performed in an intention to treat . RESULTS Both study groups were similar in terms of age , sex , preoperative forced expiratory volume in one second ( FEV(1 ) ) , American Society of Anesthesiologists score and operations performed . The rate of postoperative pulmonary complications was 35 % in the conservative and 6.6 % in the fast track group ( p=0.009 ) . A subgroup of patients with reduced preoperative FEV(1 ) ( < 75 % of predicted value ) experienced less pulmonary complications in the fast track group ( 55 % vs 7 % , p=0.023 ) . Overall morbidity was not significantly different ( 46 % vs 26 % , p=0.172 ) , mortality was comparable in both groups ( 4 % vs 3 % ) . CONCLUSION We evaluated an optimized patient care program for patients undergoing lung resections in a prospect i ve r and omized pilot study . Using this fast track clinical pathway the rate of pulmonary complications could be significantly decreased as compared to a conservative treatment regimen ; our results support the implementation of an optimized perioperative treatment in lung surgery in order to reduce pulmonary complications after major lung surgery Parra et al. ( Acta Physiol . Sc and 169 : 157 - 165 , 2000 ) showed that 2 wk of daily sprint interval training ( SIT ) increased citrate synthase ( CS ) maximal activity but did not change " anaerobic " work capacity , possibly because of chronic fatigue induced by daily training . The effect of fewer SIT sessions on muscle oxidative potential is unknown , and aside from changes in peak oxygen uptake ( Vo(2 peak ) ) , no study has examined the effect of SIT on " aerobic " exercise capacity . We tested the hypothesis that six sessions of SIT , performed over 2 wk with 1 - 2 days rest between sessions to promote recovery , would increase CS maximal activity and endurance capacity during cycling at approximately 80 % Vo(2 peak ) . Eight recreationally active subjects [ age = 22 + /- 1 yr ; Vo(2 peak ) = 45 + /- 3 ml.kg(-1).min(-1 ) ( mean + /- SE ) ] were studied before and 3 days after SIT . Each training session consisted of four to seven " all-out " 30-s Wingate tests with 4 min of recovery . After SIT , CS maximal activity increased by 38 % ( 5.5 + /- 1.0 vs. 4.0 + /- 0.7 mmol.kg protein(-1).h(-1 ) ) and resting muscle glycogen content increased by 26 % ( 614 + /- 39 vs. 489 + /- 57 mmol/kg dry wt ) ( both P < 0.05 ) . Most strikingly , cycle endurance capacity increased by 100 % after SIT ( 51 + /- 11 vs. 26 + /- 5 min ; P < 0.05 ) , despite no change in Vo(2 peak ) . The coefficient of variation for the cycle test was 12.0 % , and a control group ( n = 8) showed no change in performance when tested approximately 2 wk apart without SIT . We conclude that short sprint interval training ( approximately 15 min of intense exercise over 2 wk ) increased muscle oxidative potential and doubled endurance capacity during intense aerobic cycling in recreationally active individuals Purpose Peak oxygen consumption ( VO2peak ) is an important predictive factor for long-term prognosis in patients with non-small cell lung cancer ( NSCLC ) . The purpose of this study was to investigate whether 8 weeks of exercise training improves exercise capacity , as assessed by VO2peak , and other related factors in patients with NSCLC receiving targeted therapy . Methods A total of 24 participants with adenocarcinoma were r and omly assigned to either the control group ( n = 11 ) or the exercise group ( n = 13 ) . Subjects in the exercise group participated in individualized , high-intensity aerobic interval training of exercise . The outcome measures assessed at baseline and after 8 weeks were as follows : VO2peak and the percentage of predicted VO2peak ( % predVO2peak ) , muscle strength and endurance of the right quadriceps , muscle oxygenation during exercise , insulin resistance as calculated by the homeostasis model , high-sensitivity C-reactive protein , and quality of life ( QoL ) question naire inventory . Results No exercise-related adverse events were reported . After exercise training , VO2peak and % predVO2peak increased by 1.6 mL kg−1 min−1 and 5.3 % ( p < 0.005 ) , respectively ; these changes were associated with improvements in circulatory , respiratory , and muscular functions at peak exercise ( all p = 0.001 ) . The exercise group also had less dyspnea ( p = 0.01 ) and favorably lower fatigue ( p = 0.05 ) than baseline . Conclusions Patients with NSCLC receiving targeted therapy have quite a low exercise capacity , even with a relatively high QoL. Exercise training appears to improve exercise capacity and alleviate some cancer-related symptoms OBJECTIVE The purpose of this study was to investigate the impact of pulmonary rehabilitation on surgical morbidity and lung function in lung cancer patients with chronic obstructive pulmonary disease ( COPD ) . METHODS Prospect ively , 22 lung cancer patients with COPD who underwent lobectomy between 2000 and 2003 were enrolled for this study as a rehabilitation group (  Rehab . Group ) . The criteria of COPD were preoperative forced expiratory volume in 1 second (FEV1)/forced vital capacity ( FVC ) < or = 70 % and more than 50 % of low attenuation area in a computed tomography . Preoperatively patients performed aggressive pulmonary exercise for two weeks and received chest physiotherapy postoperatively .  As a historical control , 60 patients with lung cancer who fulfilled the same criteria but did not receive rehabilitation between 1995 and 1999 ( control group ) were entered in this study . RESULTS Patient background s were all equivalent between the two groups . However , FEV1 and FEV1/FVC were significantly lower in the Rehab . Group ( p < 0.05 ) . Prolonged oxygen supplement and tracheostomy tended to be more frequent in the control group . The ratio of actual postoperative to predicted postoperative FEV1 was significantly better in the Rehab . Group ( p = 0.047 ) . Furthermore , postoperative hospital stay was significantly longer in the control group ( p = 0.0003 ) . CONCLUSION Despite lower FEV1 and FEV1/FVC in the Rehab . Group , postoperative pulmonary complications and long hospital stay could be effectively prevented and FEV1 was well preserved by rehabilitation and physiotherapy To determine whether high-intensity interval training ( HIT ) would increase respiratory muscle strength and expiratory flow rates more than endurance training ( ET ) , 15 physically active , healthy subjects ( untrained ) were r and omly assigned to an ET group ( n = 7 ) or a HIT group ( n = 8) . All subjects performed an incremental test to exhaustion ( VO2max ) on a cycle ergometer before and after training . St and ard pulmonary function tests , maximum inspiratory pressure ( PImax ) , maximum expiratory pressure ( PEmax ) , and maximal flow volume loops were performed pre training and after each week of training . HIT subjects performed a 4-week training program , 3 days a week , on a cycle ergometer at 90 % of their VO2max final workload , while the ET subjects performed exercise at 60–70 % VO2max . The HIT group performed five 1-min bouts with 3-min recovery periods and the ET group cycled for 45 min continuously . A five-mile time trial ( TT ) was performed prior to , after 2 weeks , and after completion of training . Both groups showed improvements ( P < 0.05 ) in VO2max ( ~8–10 % ) and TT ( HIT 6.5 ± 1.3 % , ET 4.4 ± 1.8 % ) following training with no difference ( P > 0.05 ) between groups . Both groups increased ( P < 0.05 ) PImax post training ( ET ~ 25 % , HIT ~ 43 % ) with values significantly higher for HIT than ET . There was no change ( P > 0.05 ) in expiratory flow rates with training in either group . These data suggest that both whole-body exercise training and HIT are effective in increasing inspiratory muscle strength with HIT offering a time-efficient alternative to ET in improving aerobic capacity and performance Complete surgical resection is the most effective curative treatment for lung cancer . However , many patients with lung cancer also have severe COPD which increases their risk of postoperative complications and their likelihood of being considered " inoperable . " Preoperative pulmonary rehabilitation ( PR ) has been proposed as an intervention to decrease surgical morbidity but there is no established protocol and no r and omized study has been published to date . We tested two preoperative PR interventions in patients undergoing lung cancer resection and with moderate-severe COPD in a r and omized single blinded design . Outcomes were length of hospital stay and postoperative complications . The first study tested 4 weeks of guideline -based PR vs. usual care : that study proved to be very difficult to recruit as patients and providers were reluctant to delay surgery . Nine patients were r and omized and no differences were found between arms . The second study tested ten preoperative PR sessions using a customized protocol with nonst and ard components ( exercise prescription based on self efficacy , inspiratory muscle training , and the practice of slow breathing ) ( n=10 ) vs. usual care ( n=9 ) . The PR arm had shorter length of hospital stay by 3 days ( p=0.058 ) , fewer prolonged chest tubes ( 11 % vs. 63 % , p=0.03 ) and fewer days needing a chest tube ( 8.8 vs. 4.3 days p=0.04 ) compared to the controlled arm . A ten-session preoperative PR intervention may improve post operative lung reexpansion evidence d by shorter chest tube times and decrease the length of hospital stay , a crude estimator of post operative morbidity and costs . Our results suggest the potential for short term preoperative pulmonary rehabilitation interventions in patients with moderate-severe COPD undergoing curative lung resection . 4 weeks of conventional preoperative PR seems non feasible BACKGROUND Lung-volume-reduction surgery has been proposed as a palliative treatment for severe emphysema . Effects on mortality , the magnitude and durability of benefits , and criteria for the selection of patients have not been established . METHODS A total of 1218 patients with severe emphysema underwent pulmonary rehabilitation  and were r and omly assigned to undergo lung-volume-reduction surgery or to receive continued medical treatment . RESULTS Overall mortality was 0.11 death per person-year in both treatment groups ( risk ratio for death in the surgery group , 1.01 ; P=0.90 ) . After 24 months , exercise capacity had improved by more than 10 W in 15 percent of the patients in the surgery group , as compared with 3 percent of patients in the medical-therapy group ( P<0.001 ) . With the exclusion of a subgroup of 140 patients at high risk for death from surgery according to an interim analysis , overall mortality in the surgery group was 0.09 death per person-year , as compared with 0.10 death per person-year in the medical-therapy group ( risk ratio , 0.89 ; P=0.31 ) ; exercise capacity after 24 months had improved by more than 10 W in 16 percent of patients in the surgery group , as compared with 3 percent of patients in the medical-therapy group ( P<0.001 ) . Among patients with predominantly upper-lobe emphysema and low exercise capacity , mortality was lower in the surgery group than in the medical-therapy group ( risk ratio for death , 0.47 ; P=0.005 ) . Among patients with non-upper-lobe emphysema and high exercise capacity , mortality was higher in the surgery group than in the medical-therapy group ( risk ratio , 2.06 ; P=0.02 ) . CONCLUSIONS Overall , lung-volume-reduction surgery increases the chance of improved exercise capacity but does not confer a survival advantage over medical therapy . It does yield a survival advantage for patients with both predominantly upper-lobe emphysema and low base-line exercise capacity . Patients previously reported to be at high risk and those with non-upper-lobe emphysema and high base-line exercise capacity are poor c and i date s for lung-volume-reduction surgery , because of increased mortality and negligible functional gain Introduction : Impairment in aerobic fitness is a potential modifiable risk factor for postoperative complications . In this r and omized controlled trial , we hypothesized that a high‐intensity interval training ( HIIT ) program enhances cardiorespiratory fitness before lung cancer surgery and therefore reduces the risk of postoperative complications . Methods : Patients with operable lung cancer were r and omly assigned to usual care ( UC ) ( n = 77 ) or preoperative rehabilitation based on HIIT ( Rehab ) ( n = 74 ) .  Maximal cardiopulmonary exercise testing and the 6‐minute walk test were performed twice before surgery . The primary outcome measure was a composite of death and in‐hospital postoperative complications . Results : The groups were well balanced in terms of patient characteristics . During the preoperative waiting period ( median 25 days ) , the peak oxygen consumption and the 6‐minute walking distance increased ( median + 15 % , interquartile range , 25th to 75 percentile [ IQR25%–75 % , % ] = + 9 % to + 22 % , p = 0.003 and + 15 % , IQR25%–75 % = + 8 % to + 28 % , p < 0.001 , respectively ) in the Rehab group , whereas peak oxygen consumption declined in the UC group ( median –8 % , IQR25%–75 % = –16 % to 0 % ] , p = 0.005 ) . The primary end point did not differ significantly between the two groups : at least one postoperative complication developed in 27 of the 74 patients ( 35.5 % ) in the Rehab group and 39 of 77 patients ( 50.6 % ) in the UC group ( p = 0.080 ) . Notably , the incidence of pulmonary complications was lower in the Rehab compared with in the UC group ( 23 % versus 44 % , p = 0.018 ) , owing to a significant reduction in atelectasis ( 12.2 % versus 36.4 % , p < 0.001 ) , and this decrease was accompanied by a shorter length of stay in the postanesthesia care unit ( median –7 hours , IQR25%–75 % = –4 to –10 ) . Conclusions : In this r and omized controlled trial , preoperative HIIT result ed in significant improvement in aerobic performances but failed to reduce early complications after lung cancer resection
target: High-intensity interval training ( HIT ) with duration of 2 to 6 weeks seems to be the best exercise programme in a prehabilitation intervention but it exists heterogeneity in terms of intensity and duration .
  Prehabilitation increase exercise capacity and significantly enhances pulmonary function .
  But the reduction of postoperative complication and mortality has not been clearly demonstrated .
  It seems that not all patients can benefit from prehabilitation and it could be indicated only in patients with impaired lung function .
  Meanwhile , safety of prehabilitation and good results of some studies support this intervention in high-risk patients
background: Surgical resection remains the best treatment option for patients with early stage of non-small cell lung cancer ( NSCLC ) .
  However , it may be responsible of postoperative complication and mortality , especially in patients with impaired pulmonary function .
  Enhanced recovery after surgery ( ERAS ) programs have been focused mainly in minimal invasive surgery approach during lung resection and respiratory rehabilitation after surgery .
  Preoperative exercise-based intervention ( prehabilitation ) has demonstrated reduction of morbi-mortality in other surgeries but in thoracic surgery continues to be under discussion .
  Cardio-pulmonary exercise test ( CPET ) is the gold st and ard technique to predict postoperative morbi-mortality .
  The implementation of a preoperative respiratory rehabilitation could optimize patient 's physical capacity before surgery and improve outcomes and enhance recovery .
  The aim of this systematic review of the literature is to identify the effectiveness and safety of prehabilitation programs in thoracic surgery , the type of exercise and its duration , and the group of patients with best benefit .
  Prehabilitation is a safe intervention without side effects in patients .