title: Preoperative pulmonary rehabilitation in patients with non-small cell lung cancer and chronic obstructive pulmonary disease Preoperative pulmonary rehabilitation in patients undergoing lung resection for non-small cell lung cancer. The efficacy of postoperative incentive spirometry is influenced by the device-specific imposed work of breathing. Postoperative pulmonary complications following thoracic surgery: are there any modifiable risk factors? Perioperative rehabilitation and physiotherapy for lung cancer patients with chronic obstructive pulmonary disease. Comparison of the effects of pulmonary rehabilitation with chest physical therapy on the levels of fibrinogen and albumin in patients with lung cancer awaiting lung resection: a randomized clinical trial Pulmonary rehabilitation programme for patients undergoing curative lung cancer surgery. Which field walking test should be used to assess functional exercise capacity in lung cancer? an observational study Newcastle-Ottawa Scale: comparing reviewers’ to authors’ assessments Multidisciplinary Team-Based Approach for Comprehensive Preoperative Pulmonary Rehabilitation Including Intensive Nutritional Support for Lung Cancer Patients Does physiotherapy reduce the incidence of postoperative pulmonary complications following pulmonary resection via open thoracotomy? A preliminary randomised single-blind clinical trial. Should we exclude elderly patients with chronic obstructive pulmonary disease from a long-time ambulatory pulmonary rehabilitation programme? Preoperative Exercise Vo2 Measurement for Lung Resection Candidates: Results of Cancer and Leukemia Group B Protocol 9238 The extent of lung parenchyma resection significantly impacts long-term quality of life in patients with non-small cell lung cancer. Preoperative pulmonary rehabilitation versus chest physical therapy in patients undergoing lung cancer resection: a pilot randomized controlled trial. The effects of preoperative short-term intense physical therapy in lung cancer patients: a randomized controlled trial. Effects of Presurgical Exercise Training on Quality of Life in Patients Undergoing Lung Resection for Suspected Malignancy: A Pilot Study Endurance training in patients with chronic obstructive pulmonary disease: a comparison of high versus moderate intensity. Preoperative pulmonary rehabilitation before lung cancer resection: results from two randomized studies. High-intensity training and cardiopulmonary exercise testing in patients with chronic obstructive pulmonary disease and non-small-cell lung cancer undergoing lobectomy. Effects of systematic rehabilitation programs on quality of life in patients undergoing lung resection. Outcomes after lobectomy using thoracoscopy vs thoracotomy: a comparative effectiveness analysis utilizing the Nationwide Inpatient Sample database. Pursed lips breathing Effects of presurgical exercise training on systemic inflammatory markers among patients with malignant lung lesions.
abstract: Introduction The aim of this study was to assess the effects of preoperative pulmonary rehabilitation ( PPR ) on preoperative clinical status changes in patients with chronic obstructive pulmonary disease ( COPD ) and non-small cell lung cancer ( NSCLC ) , and net effects of PPR and cancer resection on residual pulmonary function and functional capacity . Material and methods This prospect i ve single group study included 83 COPD patients ( 62 ±8 years , 85 % males , FEV1 = 1844 ±618 ml , Tiffeneau index = 54 ±9 % ) with NSCLC , on 2–4-week PPR , before resection . Pulmonary function , and functional and symptom status were evaluated by  spirometry , 6-minute walking distance ( 6MWD ) and Borg scale , on admission , after PPR and after surgery . Results Following PPR significant improvement was registered in the majority of spirometry parameters ( FEV1 by 374 ml , p < 0.001 ; VLC by 407 ml , p < 0.001 ; FEF50 by 3 % , p = 0.003 ) , 6MWD ( for 56 m , p < 0.001 ) and dyspnoeal symptoms ( by 1.0 Borg unit , p < 0.001 ) . A positive correlation was identified between preoperative increments of FEV1 and 6MWD ( r s = 0.503 , p = 0.001 ) . Negative correlations were found between basal FEV1 and its percentage increment ( r s = –0.479 , p = 0.001 ) and between basal 6MWD and its percentage change ( r s = –0.603 , p < 0.001 ) during PPR . Compared to basal values , after resection a significant reduction of most spirometry parameters and 6MWD were recorded , while Tiffeneau index , FEF25 and dyspnoea severity remained stable ( p = NS ) . Conclusions Preoperative pulmonary rehabilitation significantly enhances clinical status of COPD patients before NSCLC resection . Preoperative increase of exercise tolerance was the result of pulmonary function improvement during PPR . The beneficial effects of PPR were most emphasized in patients with initially the worst pulmonary function and the weakest functional capacity 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 STUDY OBJECTIVES The study evaluated the impact of the additional imposed work of breathing ( WBimp ) generated by two different spirometers on postoperative incentive spirometry performance in patients at high risk and moderate risk for postoperative pulmonary complications ( PPCs ) . Additionally , we investigated whether maximal inspiratory pressure ( PImax ) is an easy estimate of the WBimp imposed by incentive spirometers . DESIGN Prospect i ve , r and omized , single-blind clinical trial . SETTING ICU of a university hospital . INTERVENTIONS AND MEASUREMENTS Thirty male patients were assigned to a group at high risk for PPCs ( group A ; inspiratory capacity [ IC ] , < 1.6 L ) or to a group at moderate risk for PPCs ( group B ; IC , 1.6 to 2.5 L ) after upper-abdominal , thoracic , or two-cavity surgery . On the first or second postoperative day WBimp , IC , and PImax were recorded without spirometers ( baseline ) and during incentive spirometry with the Mediflo spirometer ( Medimex ; Hamburg , Germany ) ( high WBimp ) and the Coach spirometer ( Kendall ; Neustadt , Germany ) ( low WBimp ) using a pneumotachograph . In group A , the baseline and the ICs for both spirometers only differed slightly . In group B , the IC was significantly reduced for the Mediflo ( p < 0.05 ) , which imposed a WBimp twice as high as the Coach ( p < 0.01 ) . PImax was significantly increased for both the Mediflo and the Coach ( p < 0.01 ) . PImax was positively correlated with WBimp ( r = 0.8 ) . CONCLUSIONS Incentive spirometers differ considerably in their additional Wbimp with a potential impact on the efficacy of postoperative incentive spirometry performance . PImax might be an easy clinical estimate for the WBimp during incentive spirometry . Incentive spirometers with low WBimp permit increased maximal sustained inspiration and , thus , enhanced incentive spirometry performance , and , therefore , it might be more suitable for use in postoperative respiratory care Background Postoperative pulmonary complications ( PPC ) are the most frequently observed complications following lung resection , of which pneumonia and atelectasis are the most common . PPCs have a significant clinical and economic impact associated with increased observed number of deaths , morbidity , length of stay and associated cost . The aim of this study was to assess the incidence and impact of PPCs and to identify potentially modifiable independent risk factors . Methods A prospect i ve observational study was carried out on all patients following lung resection via thoracotomy in a regional thoracic centre over 13 months .  PPC was assessed using a scoring system based on chest x-ray , raised white cell count , fever , microbiology , purulent sputum and oxygen saturations . Results Thirty-four of 234 subjects ( 14.5 % ) had clinical evidence of PPC . The PPC patient group had a significantly longer length of stay ( LOS ) in hospital , high dependency unit ( HDU ) LOS , higher frequency of intensive care unit ( ITU ) admission and a higher number of hospital deaths . Older patients , body mass index ( BMI ) ≥30 kg/m2 , preoperative activity < 400 m , American Society of Anesthesiologists ( ASA ) score ≥3 , smoking history , chronic obstructive pulmonary disease ( COPD ) , lower preoperative forced expiratory volume in 1 s ( FEV1 ) and predicted postoperative ( PPO ) FEV1 were all significantly ( p<0.05 ) associated with PPC on univariate analysis . Multivariate analysis confirmed that age > 75 years , BMI ≥30 kg/m2 , ASA ≥3 , smoking history and COPD were significant independent risk factors in the development of PPC ( p<0.05 ) . Conclusion The clinical impact of PPCs is marked . Significant independent preoperative risk factors have been identified in current clinical practice . Potentially modifiable risk factors include BMI , smoking status and COPD . The impact of targeted therapy requires further evaluation 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 Background Systemic inflammation plays an important role in the initiation , promotion , and progression of lung carcinogenesis . In patients with non-small cell lung cancer ( NSCLC ) , fibrinogen levels correlate with neoplasia . Here we compared the effects of pulmonary rehabilitation ( PR ) with chest physical therapy ( CPT ) on fibrinogen and albumin levels in patients with LC and previous inflammatory lung disease awaiting lung resection . Methods We conducted a r and omized clinical trial with 24 patients who were r and omly assigned to Pulmonary Rehabilitation ( PR ) and Chest Physical Therapy ( CPT ) groups . Each group underwent training 5 days weekly for 4 weeks . All patients were assessed before and after four weeks of training through clinical assessment , measurement of fibrinogen and albumin levels , spirometry , 6-minute Walk Test ( 6MWT ) , quality of life survey , and anxiety and depression scale . PR involved strength and endurance training , and CPT involved lung expansion techniques . Both groups attended educational classes . Results A mixed between-within subjects analysis of variance ( ANOVA ) revealed a significant interaction between time ( before and after intervention ) and group ( PR vs. CPT ) on fibrinogen levels ( F(1 , 22 ) = 0.57 , p < 0.0001 ) and a significant main effect of time ( F(1 , 22 ) = 0.68 , p = 0.004 ) . Changes in albumin levels were not statistically significant relative to the interaction effect between time and group ( F(1 , 22 ) = 0.96 , p = 0.37 ) nor the main effects of time ( F(1 , 22 ) = 1.00 , p = 1.00 ) and group ( F(1 , 22 ) = 0.59 , p = 0.45 ) . A mixed between-within subjects ANOVA revealed significant interaction effects between time and group for the peak work rate of the unsupported upper limb exercise ( F(1 , 22 ) = 0.77 , p = 0.02 ) , endurance time ( F(1 , 22 ) = 0.60 , p = 0.001 ) , levels of anxiety ( F(1 , 22 ) = 0.60 , p = 0.002 ) and depression ( F(1 , 22 ) = 0.74 , p = 0.02 ) , and the SF-36 physical component summary ( F(1 , 22 ) = 0.83 , p = 0.07 ) . Conclusion PR reduced serum fibrinogen levels , improved functional parameters , and quality of life of patients with LC and inflammatory lung disease awaiting lung resection . Trial registration Current Controlled Trials RBR-3nm5bv OBJECTIVES The aim of the study was to develop a multistr and ed pragmatic rehabilitation programme for operable lung cancer patients , that looks into feasibility , process indicators , outcome measures , local adaptability , compliance and potential cost benefit . METHODS An outpatient-based complex intervention , rehabilitation for operated lung cancer ( ROC ) programme , was developed to optimize physical status , prepare for the inpatient journey and support through recovery after surgery . It includes exercise classes , smoking cessation , dietary advice and patient education and was tested in an enriched cohort study within a regional thoracic unit over 18 months . RESULTS A multistr and ed pragmatic rehabilitation programme pre- and post-surgery is feasible . Fifty-eight patients received the intervention and 305 received st and ard care . Both groups were matched for age , lung function comorbidity and type of surgery . Patients in the intervention group attended exercise classes twice a week until surgery , which was not delayed . Patients attended four sessions presurgery ( range 1 - 15 ) , result ing in an improvement of 20 m ( range -73 - 195 , P = 0.001 ) in a 6-min walk test and 0.66 l in forced expiratory volume in 1 s ( range -1.85 from 1.11 , P = 0.009 ) from baseline to presurgery . Fifty-four percentage of smokers in the intervention group stopped smoking . Sixteen percentage of patients were identified as being at risk of malnourishment and received nutritional intervention . There was a trend in patients in the intervention group towards experiencing fewer postoperative pulmonary complications than those in the non-intervention group ( 9 vs 16 % , respectively , P = 0.21 ) and fewer readmissions to hospital because of complications ( 5 vs 14 % respectively , P = 0.12 ) . CONCLUSION Chronic obstructive pulmonary disease-type pulmonary rehabilitation before and after lung cancer surgery is viable , and preliminary results suggest improvement in physical measures . A multicentre , r and omized controlled trial is warranted to confirm clinical efficacy . IS RCT N REGISTRATION NUMBER IS RCT N00061628 Background There is emerging evidence regarding the efficacy of exercise training to improve exercise capacity for individuals with non-small cell lung cancer ( NSCLC ) .  Cardiopulmonary exercise testing ( CPET ) is the gold st and ard measure of exercise capacity ; however this laboratory test has limitations for use in research and clinical practice . Alternative field walking tests are the six-minute walk test ( 6MWT ) , incremental-shuttle walk test ( ISWT ) and endurance-shuttle walk test ( ESWT ) ; however there is limited information about their clinimetric properties in NSCLC . Aims : In NSCLC to determine the 1 ) criterion validity of the 6MWT , ISWT and ESWT against CPET ; 2 ) construct validity of the 6MWT , ISWT and ESWT against measures of function , strength , respiratory function and health-related quality of life ( HRQoL ) ; and 3 ) clinical applicability of the tests . Methods Twenty participants ( 40 % male , mean ± SD age 66.1 ± 6.5 years ) with stage I-IIIb NSCLC completed the 6MWT , ISWT , ESWT and CPET within six months of treatment . Testing order was r and omised . Additional measures included Eastern Cooperative Oncology Group Performance-Status ( ECOG-PS , function ) , respiratory function , h and -grip dynamometry and HRQoL. Correlations and regression analyses were used to assess relationships . Results The ISWT demonstrated criterion validity with a moderate relationship between ISWT distance and CPET peak oxygen consumption ( r = 0.61 , p = 0.007 ) . Relationships between CPET and six minute walk distance ( 6MWD ) ( r = 0.24 , p = 0.329 ) or ESWT time ( r = 0.02 , p = 0.942 ) were poor . Moderate construct validity existed for the 6MWD and respiratory function ( forced vital capacity % predicted r = 0.53 , p = 0.019 ; forced expiratory volume in the first second % predicted r = 0.55 , p = 0.015 ) . There were no relationships between the walking tests and measures of function , strength or HRQoL. The ESWT had a ceiling effect with 18 % reaching maximum time . No floor effects were seen in the tests . The mean ± SD time required to perform the individual 6MWT , ISWT and ESWT was 12.8 ± 2.5 , 14.7 ± 3.7 and 16.3 ± 5.0 min respectively ; in comparison to CPET which was 51.2 ± 12.7 min . Only one assessor was required to perform all field walking tests and no adverse events occurred . Conclusions The ISWT is a promising measure of functional exercise capacity in lung cancer . Findings need to be confirmed in a larger sample prior to translation into practice Background Lack of appropriate reporting of method ological details has previously been shown to distort risk of bias assessment s in r and omized controlled trials . The same might be true for observational studies . The goal of this study was to compare the Newcastle-Ottawa Scale ( NOS ) assessment for risk of bias between review ers and authors of cohort studies included in a published systematic review on risk factors for severe outcomes in patients infected with influenza . Methods Cohort studies included in the systematic review and published between 2008–2011 were included . The corresponding or first authors completed a survey covering all NOS items . Results were compared with the NOS assessment applied by review ers of the systematic review . Inter-rater reliability was calculated using kappa ( K ) statistics . Results Authors of 65/182 ( 36 % ) studies completed the survey . The overall NOS score was significantly higher ( p < 0.001 ) in the review ers ’ assessment ( median = 6 ; interquartile range [ IQR ] 6–6 ) compared with those by authors ( median = 5 , IQR 4–6 ) . Inter-rater reliability by item ranged from slight ( K = 0.15 , 95 % confidence interval [ CI ] = −0.19 , 0.48 ) to poor ( K = −0.06 , 95 % CI = −0.22 , 0.10 ) . Reliability for the overall score was poor ( K = −0.004 , 95 % CI = −0.11 , 0.11 ) . Conclusions Differences in assessment and low agreement between review ers and authors suggest the need to contact authors for information not published in studies when applying the NOS in systematic review Background To decrease the risk of postoperative complication , improving general and pulmonary conditioning preoperatively should be considered essential for patients scheduled to undergo lung surgery . Objective The aim of this study is to develop a short-term beneficial program of preoperative pulmonary rehabilitation for lung cancer patients . Methods From June 2009 , comprehensive preoperative pulmonary rehabilitation ( CHPR ) including intensive nutritional support was performed prospect ively using a multidisciplinary team-based approach . Postoperative complication rate and the transitions of pulmonary function in CHPR were compared with historical data of conventional preoperative pulmonary rehabilitation ( CVPR ) conducted since June 2006 . The study population was limited to patients who underwent st and ard lobectomy .  Results Postoperative complication rate in the CVPR ( n = 29 ) and CHPR ( n = 21 ) were 48.3 % and 28.6 % ( p = 0.2428 ) , respectively . Those in patients with Charlson Comorbidity Index scores ≥2 were 68.8 % ( n = 16 ) and 27.3 % ( n = 11 ) , respectively ( p = 0.0341 ) and those in patients with preoperative risk score in Estimation of Physiologic Ability and Surgical Stress scores > 0.3 were 57.9 % ( n = 19 ) and 21.4 % ( n = 14 ) , respectively ( p = 0.0362 ) . Vital capacities of pre- and post intervention before surgery in the CHPR group were 2.63±0.65 L and 2.75±0.63 L ( p = 0.0043 ) , respectively ; however , their transition in the CVPR group was not statistically significant ( p = 0.6815 ) . Forced expiratory volumes in one second of pre- and post intervention before surgery in the CHPR group were 1.73±0.46 L and 1.87±0.46 L ( p = 0.0012 ) , respectively ; however , their transition in the CVPR group was not statistically significant ( p = 0.6424 ) . Conclusions CHPR appeared to be a beneficial and effective short-term preoperative rehabilitation protocol , especially in patients with poor preoperative conditions OBJECTIVE This study investigates whether targeted postoperative respiratory physiotherapy decreased the incidence of postoperative pulmonary complications and length of stay for patients undergoing elective pulmonary resection via open thoracotomy . METHODS Seventy-six patients participated in a prospect i ve , single-blind , parallel-group , r and omised trial with concealed allocation , assessor blinding and intention-to-treat analysis . Treatment group participants received daily respiratory physiotherapy interventions until discharge . Control group participants received st and ard medical/nursing care involving a clinical pathway . The presence of postoperative pulmonary complications was assessed on a daily basis during hospitalisation using a st and ardised diagnostic tool . Length of stay was recorded . RESULTS Postoperative pulmonary complications developed in two participants ( 4.8 % ) in the treatment group and in one participant ( 2.9 % ) in the control group ; the difference ( treatment minus control ) was 1.8 % ( 95 % confidence interval ( CI ) -10.6 % to 13.1 % ) ( p=1.00 ) . No significant difference was found between groups for length of stay ( treatment group , median 6.0 days ; control group 6.0 days ) ( p=0.87 ) . A preoperative forced expiratory volume in 1s of 1.5l or less ( p=0.005 ) and a history of chronic obstructive pulmonary disease ( p=0.008 ) were associated with a greater number of criteria for a postoperative pulmonary complication being met . CONCLUSIONS In this patient population , given the low incidence of postoperative pulmonary complications , targeted respiratory physiotherapy may not be required in addition to st and ard care involving a clinical pathway following pulmonary resection via open thoracotomy . These results should be extrapolated with caution to those patients undergoing pulmonary resection with poor preoperative lung function OBJECTIVE To assess the outcomes of a 6-month comprehensive multidisciplinary outpatient pulmonary rehabilitation programme in patients with chronic obstructive pulmonary disease according to age . DESIGN Prospect i ve cohort study . PATIENTS A total of 140 patients with chronic obstructive pulmonary disease ( Global Initiative for Chronic Obstructive Lung Disease ( GOLD ) 3 - 4 ) admitted to our centre for pulmonary rehabilitation . METHODS Patients were divided into 3 groups : group A ( < 65 years ) , group B ( 65 - 74 years ) and group C ( ≥ 75 years ) . All the patients received an education and individualized training programme . Pulmonary rehabilitation  efficacy was evaluated at 6 months of treatment and 12 months post-treatment . RESULTS A total of 116 patients completed the pulmonary rehabilitation programme  : 59 in group A ( 85.5 % ) , 40 in group B ( 80 % ) and 17 in group C ( 80.9 % ) . All the parameters studied ( number of sessions , 6-min walking distance , isometric quadriceps strength , health-related quality of life , maximal load , peak oxygen uptake , maximal inspiratory and expiratory pressures ) were significantly improved in each of the groups at 3 and 6 months compared with baseline . Moreover , percentage changes from baseline at 6 months for all of the parameters studied were not significantly different between age-groups . CONCLUSION Pulmonary rehabilitation is efficient in elderly patients with severe and very severe chronic obstructive pulmonary disease , and their compliance with pulmonary rehabilitation was similar to that seen in younger groups . Therefore , elderly patients with chronic obstructive pulmonary disease should not be denied pulmonary rehabilitation Introduction : A stepwise approach to the functional assessment of lung resection c and i date s is widely accepted , and this approach incorporates the measurement of exercise peak Vo2 when spirometry and radionuclear studies suggest medical inoperability . A new functional operability ( FO ) algorithm incorporates peak exercise Vo2 earlier in the preoperative assessment to determine which patients require preoperative radionuclear studies . This algorithm has not been studied in a multicenter study . Methods : The CALGB ( Cancer and Leukemia Group B ) performed a prospect i ve multi-institutional study to investigate the use of primary exercise Vo2 measurement for the prediction of surgical risk . Patients with known or suspected resectable non-small cell lung cancer ( NSCLC ) were eligible .  Exercise testing including measurement of peak oxygen uptake ( Vo2 ) , spirometry , and single breath diffusion capacity ( DLCO ) was performed on each patient . Nuclear perfusion scans were obtained on selected high-risk patients . After surgery , morbidity and mortality data were collected and correlated with preoperative data . Mortality and morbidity were retrospectively compared by algorithm-based risk groups . Results : Three hundred forty-six patients with suspected lung cancer from nine institutions underwent thoracotomy with or without resection ; 57 study patients did not undergo thoracotomy .  Patients who underwent surgery had a median survival time of 30.9 months , whereas patients who did not undergo surgery had a median survival time of 15.6 months . Among the 346 patients who underwent thoracotomy , 15 patients died postoperatively ( 4 % ) , and 138 patients ( 39 % ) exhibited at least one cardiorespiratory complication postoperatively . We found that patients who had a peak exercise Vo2 of < 65 % of predicted ( or a peak Vo2/kg < 16 ml/min/kg ) were more likely to suffer complications ( p = 0.0001 ) and were also more likely to have a poor outcome ( respiratory failure or death ) if the peak Vo2 was < 15 ml/min/kg ( p = 0.0356 ) . We also found a subset of 58 patients who did not meet FO algorithm criteria for operability , but who still tolerated lung resection with a 2 % mortality rate . Conclusions : Our data provide multicenter validation for the use of exercise Vo2 for preoperative assessment of lung cancer patients , and we encourage an aggressive approach when evaluating these patients for surgery BACKGROUND Secondary to clinical outcome , health-related quality of life ( QOL ) after resection of non-small cell lung cancer ( NSCLC ) is of particular interest . However , few studies have explored QOL following lung resection . METHODS Between January 1998 and December 2004 , a total of 159 patients with NSCLC underwent surgical resection and were enrolled in this prospect i ve study . QOL and clinical data were assessed prior to resection and for up to 24 months after surgery by applying the European Organization for Research and Treatment of Cancer core question naire and the lung-specific question naire , the European Organization for Research and Treatment of Cancer lung-specific module . QOL was calculated , and QOL following bilobectomy/lobectomy was compared with QOL after pneumonectomy . RESULTS Overall , the 5-year survival rate was 42 % . Mean survival of the pneumonectomy group was slightly lower than that of the bilobectomy/lobectomy group , although the difference was not statistically significant ( p = 0.058 ) . The rate of complications was not significantly different between the two groups . After a postoperative drop , most QOL indicators remained near baseline for up to 24 months , with the exception of physical function ( p < 0.001 ) , pain ( p = 0.034 ) , and dyspnoea ( p < 0.001 ) , which remained significantly impaired . QOL was significantly better ( difference > 10 points ) after bilobectomy/lobectomy than after pneumonectomy . However , differences were statistically significant only with regards to physical function ( at 3 months ) , social function ( at 3 and 6 months ) , role function ( at 3 , 6 , and 12 months ) , global health ( at 3 and 6 months ) , and pain ( at 6 months ) . CONCLUSIONS Patients who underwent lung resection for NSCLC failed to make a complete recovery after 24 months . Patients who underwent pneumonectomy had significantly worse QOL values and a decreased tendency to recover , compared with patients who underwent bilobectomy/lobectomy . Therefore , major lung resection has a much more serious impact on the QOL of affected patients than does major visceral surgery OBJECTIVE To evaluate the effect of 4 weeks of pulmonary rehabilitation ( PR ) versus chest physical therapy ( CPT ) on the preoperative functional capacity and postoperative respiratory morbidity of patients undergoing lung cancer resection . DESIGN R and omized single-blinded study . SETTING A teaching hospital . PARTICIPANTS Patients undergoing lung cancer resection ( N=24 ) . INTERVENTIONS Patients were r and omly assigned to receive PR ( strength and endurance training ) versus CPT ( breathing exercises for lung expansion ) . Both groups received educational classes . MAIN OUTCOME MEASURES Functional parameters assessed before and after 4 weeks of PR or CPT ( phase 1 ) , and pulmonary complications assessed after lung cancer resection ( phase 2 ) . RESULTS Twelve patients were r and omly assigned to the PR arm and 12 to the CPT arm . Three patients in the CPT arm were not su bmi tted to lung resection because of inoperable cancer . During phase 1 evaluation , most functional parameters in the PR group improved from baseline to 1 month : forced vital capacity ( FVC ) ( 1.47L [ 1.27 - 2.33L ] vs 1.71L [ 1.65 - 2.80L ] , respectively ; P=.02 ) ; percentage of predicted FVC ( FVC% ; 62.5 % [ 49%-71 % ] vs 76 % [ 65%-79.7 % ] , respectively ; P<.05 ) ; 6-minute walk test ( 425.5±85.3 m vs 475±86.5 m , respectively ; P<.05 ) ; maximal inspiratory pressure ( 90±45.9cmH(2)O vs 117.5±36.5cmH(2)O , respectively ; P<.05 ) ; and maximal expiratory pressure ( 79.7±17.1cmH(2)O vs 92.9±21.4cmH(2)O , respectively ; P<.05 ) . During phase 2 evaluation , the PR group had a lower incidence of postoperative respiratory morbidity ( P=.01 ) , a shorter length of postoperative stay ( 12.2±3.6d vs 7.8±4.8d , respectively ; P=.04 ) , and required a chest tube for fewer days ( 7.4±2.6d vs 4.5±2.9d , respectively ; P=.03 ) compared with the CPT arm . CONCLUSIONS These findings suggest that 4 weeks of PR before lung cancer resection improves preoperative functional capacity and decreases the postoperative respiratory morbidity BACKGROUND We planned to investigate the effect of preoperative short period intensive physical therapy on lung functions , gas-exchange , and capacity of diffusion , and ventilation-perfusion distribution of patients with non-small cell lung cancer . METHODS Sixty patients with lung cancer , who were deemed operable , were r and omly allocated into two groups . Intensive physical therapy was performed in patients in the study group before operation . Both groups received routine physical therapy after operation . RESULTS There was no difference in pulmonary function tests between the two groups . Intensive physical therapy statistically significantly increased peripheral blood oxygen saturation . At least one complication was noted in 5 patients ( 16.7 % ) in the control group , and 2 ( 6.7 % ) , in the study group . However , there was no statistically significant difference ( p = 0,4 ) . The hospital stay has been found to be statistically significantly shortened by intensive physical therapy ( p < 0.001 ) . Ventilation-perfusion distribution was found to be significantly effected by intensive physical therapy . The change was prominent in the the contralateral lung ( p < 0.001 ) . CONCLUSIONS Intensive physical therapy appeared to increase oxygen saturation , reduce hospital stay , and change the ventilation/perfusion distribution . It had a significant , positive effect on the exercise capacity of patients The aim of this study was to explore the effects of presurgical exercise training on quality of life ( QOL ) in patients with malignant lung lesions . Using a single-group prospect i ve design , patients were enrolled in supervised aerobic exercise training for the duration of surgical wait time ( mean 59.7 days ) . Participants completed assessment s of cardiorespiratory fitness ( peak oxygen consumption ) and QOL using the Functional Assessment of Cancer Therapy-Lung scales , including the trial outcome index ( TOI ) and the lung cancer subscale ( LCS ) at baseline , immediately presurgery , and postsurgery ( mean , 57 days ) . 9 participants provided complete data . Repeated- measures analysis indicated a significant effect for time on TOI ( P = .006 ) and LCS ( P = .009 ) . Paired analysis revealed that QOL was unchanged after exercise training ( ie , baseline to presurgery ) , but there were significant and clinical ly meaningful declines from presurgery to postsurgery in the LCS ( −3.6 , P = .021 ) and TOI ( −8.3 , P = .018 ) . Change in peak oxygen consumption from presurgery to postsurgery was significantly associated with change in the LCS ( r = 0.70 , P = .036 ) and TOI ( r = 0.70 , P = .035 ) . Exercise training did not improve QOL from baseline to presurgery . Significant declines in QOL after surgery seem to be related to declines in cardiorespiratory fitness . A r and omized controlled trial is needed to further investigate these relationships PURPOSE To create a maximum tolerated 45-minute aerobic training program for patients with chronic obstructive pulmonary disease ( COPD ) and to compare its outcomes with those of commonly prescribed moderate exercise . DESIGN Prospect i ve , r and omized trial . SETTING A work physiology laboratory . PATIENTS AND METHODS The maximum exercise intensities that 7 COPD patients could sustain for 45 minutes were determined on a bilevel exercise ergometer . The patients then exercised 45 minutes daily , 5 days a week for 6 weeks , working 2.03+/-0.4 kJ/kg per session . They were matched with 6 COPD patients who pushed an O2 cart for 45 minutes daily , 5 days a week for 6 weeks , working 1.44+/-.35 kJ/kg per session . RESULTS A 45 minute maximal regimen was established by alternating 1-minute peak exercise at peak VO2-levels with 4 minutes at the ventilatory anaerobic threshold or at 40 % of peak VO2 . Maximal bilevel training significantly decreased dyspnea at rest ( p < or = .01 ) and the blood lactate level during submaximal exercise ( p<.001 ) , and increased peak VO2 and total physical work ( p<.01 ) , maximum inspiratory and expiratory pressures ( p<.01 ) , and grip and forearm strength and endurance ( p<.01 ) . The training also increased maximum voluntary ventilation while decreasing the ventilatory equivalent during exercise ( p<.001 ) . The O2 cart pushers significantly improved only on the 12-minute walk ( p<.05 ) . CONCLUSIONS A maximally intense anaerobic exercise program can be created for most COPD patients that can significantly improve both skeletal and respiratory muscle strength and endurance as well as dyspnea and physiologic parameters 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 OBJECTIVES Peak VO2 , as measure of physical performance is central to a correct preoperative evaluation in patients with both non-small-cell lung cancer ( NSCLC ) and chronic obstructive pulmonary disease ( COPD ) because it is closely related both to operability criteria and the rate of postoperative complications . Strategies to improve peak VO2 , as a preoperative pulmonary rehabilitation programme ( PRP ) , should be considered favourably in these patients . In order to clarify the role of pulmonary rehabilitation , we have evaluated the effects of 3-week preoperative high-intensity training on physical performance and respiratory function in a group of patients with both NSCLC and COPD who underwent lobectomy . METHODS We studied 40 patients with both NSCLC and COPD , age < 75 years , TNM stages I-II , who underwent lobectomy . Patients were r and omly divided into two groups ( R and S ) : Group R underwent an intensive preoperative PRP , while Group S underwent only lobectomy . We evaluated peak VO2 in all patients at Time 0 ( T0 ) , after PRP/before surgery in Group R/S ( T1 ) and 60 days after surgery , respectively , in both groups ( T2 ) . RESULTS There was no difference between groups in peak VO2 at T0 , while a significant difference was observed both at T1 and T2 . In Group R , peak VO2 improves significantly from T0 to T1 : 14.9 ± 2.3 - 17.8 ± 2.1 ml/kg/min ± st and ard deviation ( SD ) , P < 0.001 ( 64.5 ± 16.5 - 76.1 ± 14.9 % predicted ± SD , P < 0.05 ) and deteriorates from T1 to T2 : 17.8 ± 2.1 - 15.1 ± 2.4 , P < 0.001 ( 76.1 ± 14.9 - 64.6 ± 15.5 , P < 0.05 ) , reverting to a similar value to that at T0 , while in Group S peak VO2 did not change from T0 to T1 and significantly deteriorates from T1 to T2 : 14.5 ± 1.2 - 11.4 ± 1.2 ml/kg/min ± SD , P < 0.00001 ( 60.6 ± 8.4 - 47.4 ± 6.9 % predicted ± SD , P < 0.00001 ) . CONCLUSIONS PRP was a valid preoperative strategy to improve physical performance in patients with  both NSCLC and COPD and this advantage was also maintained after surgery The aim of this study was to investigate the effects of systematic rehabilitation programs on the quality of life ( QOL ) in patients undergoing lung resection of malignant lung lesions . In this prospect i ve population -based cohort study , QOL in patients prior to , as well as 3 and 6 months after surgery , was investigated . Using a single-group design , 48 patients ( 7 females and 41 males ) with suspected operable lung cancer were included in this study . The demographic characteristics and the clinical history of the patients were recorded . QOL [ assessed using the European Organization for Research and Treatment of Cancer Quality of Life Question naire Core 3.0 ( EORTC QLQ-C30 ) ] was evaluated at baseline ( immediately before ) , and 3 and 6 months after surgical resection . The systematic rehabilitation program , including breathing control , breathing exercises , relaxation training , upper and lower extremity exercises , mobilization and additional incorporating physiotherapy programs , was design ed to meet each patient 's individual needs . The χ2 and Fisher 's tests showed no statistically significant difference in the two groups in terms of age , gender , behavior , clinical stage , adjuvant therapy and Karnofsky scores . QOL analysis of baseline was homogeneous between the experimental and control groups . Three months after the rehabilitation process , the experimental group demonstrated an increase in the general QOL functional scales and a decrease of symptom scales compared to the control group . These changes were statistically significant in the functional scales of global health ( P<0.01 ) , physical function ( P<0.01 ) , role function ( P<0.01 ) , emotional function ( P<0.05 ) , symptom scales of fatigue ( P<0.01 ) and appetite loss ( P=0.001 ) . Six months after the intervention , the outcome was the same as 3 months after the intervention in functional scale domains . However , in the symptom scales , the symptoms in the experimental group were improved compared to the control group . The domains had been significant in the scales of fatigue ( P<0.001 ) , dyspnea ( P<0.001 ) , pain ( P<0.001 ) , insomnia ( P<0.001 ) , appetite loss ( P<0.001 ) and constipation ( P<0.001 ) . Therefore , the two groups demonstrated a statistically significant difference in 10 domains . In addition , the experimental group demonstrated a significant recovery . In conclusion , systematic rehabilitation programs may be beneficial for lung cancer patients by reducing respiratory symptoms , pain , and improving health-related QOL . Consequently , the findings of this study suggest that systematic rehabilitation programs , prepared by taking into consideration the individual requirements of lung cancer patients , should be incorporated into lung cancer treatment OBJECTIVES We examined the Nationwide Inpatient Sample ( NIS ) data base to compare short-term postoperative outcomes following  open and thoracoscopic lobectomy . Thoracoscopic ( video-assisted thoracic surgery ) lobectomy has been demonstrated to be associated with fewer postoperative complications compared with open thoracotomy lobectomy in several large case series . However , as no r and omized trial has been performed , there are many who question this . METHODS We examined the NIS data base for all patients undergoing lobectomy as their principal procedure either via thoracoscopic or open thoracotomy from 2007 to 08 . We compared the postoperative outcomes of these two groups of patients after propensity matching these groups based on several preoperative variables . RESULTS Over a 2-year-period , 68 350 patients underwent a lobectomy by either thoracoscopy [ n = 10 554 ( 15 % ) ] or thoracotomy [ n = 57 796(85 % ) ] . Thirty-two percent of thoracoscopic lobectomies ( n = 3421 ) were performed in either rural or non-teaching urban centres . Although in propensity-matched cohorts there was no difference in operative mortality , thoracoscopic lobectomy was associated with a lower incidence of postoperative complications [ n = 4146 ( 40.8 % ) vs n = 13 913 ( 45.1 % ) , P < 0.001 ] and shorter length of stay ( 5.0 vs 7.0 days ; P < 0.001 ) compared with open lobectomy . Specifically , the incidences of supraventricular arrhythmias , myocardial infa rct ion , pulmonary embolism and empyema were lower . CONCLUSIONS This large national data base study demonstrates that thoracoscopic lobectomy is associated with fewer in-hospital postoperative complications compared with open lobectomy . Thoracoscopic lobectomy appears to be applicable to the wider general thoracic surgical community It is pleasing to see increased research activity that focuses on therapeutic management of dyspnoea and , in particular , greater recognition of the important role that breathing techniques can provide in the amelioration of symptoms associated with Chronic Obstructive Pulmonary Disease ( COPD ) . For many years , the concept of breathing exercises has been poorly understood and , therefore , treatments underutilised . Pursed lip breathing ( PLB ) sits within that poorly defined toolbox termed ‘ breathing exercises ’ . Traditionally , breathing exercises are insufficiently described , the terminology used is at best , arbitrary , and frequently the same name is given to different interventions . Generally , there is little attempt to st and ardise the therapy delivered or the breathing technique performed . The American Thoracic Society guidelines describe the technique of PLB as involving ‘ a nasal inspiration followed by expiratory blowing against partially closed lips , avoiding forceful exhalation ’ . Bhatt et al. in the article published in this edition of Chronic Respiratory Disease ‘ Volitional pursed lips breathing in stable COPD patients improves exercise ’ make the further distinction that ‘ exhalation should continue slowly over 4 to 6 seconds without cheek puffing or forced exhalation ’ . This description of PLB enables better st and ardisation of a technique that has been the focus of debate for many years . The primary contention surrounding PLB is not so much whether it is effective ; over a decade ago , there was sufficient evidence to say that PLB reduces respiratory rate , minute ventilation , and carbon dioxide level ; increases tidal volume , arterial oxygen pressure , and oxygen saturation ; and we ourselves showed positive effects on respiratory rate and time to recovery post exercise . As such , many people with COPD spontaneously adopt this technique ; the contention around PLB concerns its use in people with COPD who do not naturally perform the technique and whether reductions in respiratory rate and oxygen saturation translate into improved exercise tolerance and perception of dyspnoea . Bhatt ’s article addresses this question nicely . Giving patients adequate training in the technique and excluding any subjects who used it automatically ( none did ) they performed , in a r and omised order , two 6-minute walk tests ( 6MWT ) , including an earlier practice test , with and without the use of PLB . These were patients with severe lung impairment ( mean FEV1 38 % predicted ) . Interestingly , the population was , on average , relatively young ( mean age 53 years ) with a fairly short duration of symptoms for such impairment suggesting that these may be patients who have not had sufficient time , or experience , to develop additional coping strategies such as PLB .  One memorable patient from our clinic , when asked why he used PLB , told us it was because he was taught it by another patient in the rehabilitation class and finding it helpful he had continued to use it . Clinical ly we see patients adopting PLB during periods of acute illness , and the use of PLB at rest is an indicator of increased work of breathing . In Bhatt ’s article , use of PLB in this group of patients with severe COPD , unaccustomed to the technique , result ed in a small but statistically significant improvement in a 6-minutewalk distance ( 6MWD ) ; the improvement however just failed to reach the lower confidence interval of the minimally clinical ly important difference in 6MWD . Whether these effects are accompanied by improvements in the perception of dyspnoea are as yet unknown . Furthermore , since oxygen saturation was not recorded , we can not make a comment on the role of PLB in patients who show exercise desaturation .  In this study , as in others , there was no Systemic inflammation plays an important role in the initiation , promotion , and progression of lung carcinogenesis . The effects of interventions to lower inflammation have not been explored . Accordingly , we conducted a pilot study to explore the effects of exercise training on changes in biomarkers of systemic inflammation among patients with malignant lung lesions . Using a single-group design , 12 patients with suspected operable lung cancer were provided with structured exercise training until surgical resection . Participants underwent cardiopulmonary exercise testing , 6 min walk testing , pulmonary function testing , and blood collection at baseline and immediately prior to surgical resection . Systemic inflammatory markers included intracellular adhesion molecule (ICAM)-1 , macrophage inflammatory protein-1alpha , interleukin (IL)-6 , IL-8 , monocyte chemotactic protein-1 , C-reactive protein , and tumor necrosis factor-alpha . The overall exercise adherence rate was 78 % , with patients completing a mean of 30 + /- 25 sessions . Mean peak oxygen consumption increased 2.9 mL.kg-1.min-1 from baseline to presurgery ( p = 0.016 ) . Results indicate that exercise training result ed in a significant reduction in ICAM-1 ( p = 0.041 ) . Changes in other inflammatory markers did not reach statistical significance . Change in cardiorespiratory fitness was not associated with change in systemic inflammatory markers . This exploratory study provides an initial step for future studies to eluci date the potential role of exercise , as well as identify the underlying mechanisms of action , as a means of modulating the relationship between inflammation and cancer pathogenesis
target: In conclusion , preoperative exercise-based training improves pulmonary function before surgery and reduces in-hospital length of stay and postoperative complications after lung resection surgery for lung cancer
background: Lung cancer is the leading cause of cancer-related death worldwide .
  For early stages of the disease , lung resection surgery remains the best treatment with curative intent , but significant morbidity is associated , especially among patients with poor pulmonary function and cardiorespiratory fitness .
  In those cases , the implementation of a preoperative exercise-based intervention could optimize patient 's functional status before surgery and improve postoperative outcomes and enhance recovery .
  The aim of this systematic review is to provide the current body of knowledge regarding the effectiveness of a preoperative exercise-based intervention on postoperative and functional outcomes in patients with lung cancer su bmi tted to lung resection surgery .