Effect of prehabilitation on ventilatory efficiency in non–small cell lung cancer patients: A cohort study

Abstract

Objective: Cardiopulmonary exercise testing (CPET) for patients awaiting lung resection for non-small cell lung cancer (NSCLC) has developed considerably in recent years. Pulmonary rehabilitation before surgery (prehabilitation) improves postoperative risk factors such as forced expiratory volume in 1 second and peak oxygen consumption (VO 2peak ). Ventilatory inefficiency assessed according to the linear regression of the ratio between the increase in minute ventilation and the expired carbon dioxide flow during CPET (VE/VCO 2 slope) >35, is a highrisk factor for postoperative complications. Our objective was to assess the effect of prehabilitation on VE/VCO2 slope, and its relationship with VO 2peak .Methods: This retrospective cohort study was performed between January 1, 2014 and December 31, 2017 at Rouen University Hospital. One hundred fiftytwo patients with NSCLC awaiting lung surgery who underwent CPET were screened. A total of 50 patients who underwent CPET before and after prehabilitation were included.Results: VE/VCO 2 slope did not change significantly after prehabilitation (median, 37.1 [25th-75th percentile, 33.8-43.4] vs median, 35.4 [25th-75th percentile, 31.1-40.5]; P ¼ .09), whereas VO 2peak increased significantly (from a median of 13.2 [25th-75th percentile, 11.9-14.7] to a median of 14.8 [25th-75th percentile, 13.1-16.4] mL/kg/min). The number of patients with a high risk of postoperative complications (ie, VE/VCO 2 slope>35) did not change significantly after prehabilitation. Cardiorespiratory parameters improved significantly more in patients who underwent at least 15 sessions of ambulatory prehabilitation.Conclusions: VE/VCO 2 slope, a known predictor of favorable surgical outcomes in patients with NSCLC, did not change with the prehabilitation program used in this study, despite clear improvements in VO 2peak and other CPET measures. Larger, prospective studies are needed to confirm the results of this study.

The Role of Surgery in Lung Cancer Treatment: Present Indications and Future Perspectives—State of the Art

“…As an echo to the ERAS concept, respiratory prehabilitation has recently shown its positive impact in the management of respiratory fragile patients by reducing short-term complications and adverse events [13,14] as well as improving the surgical experience. Nevertheless, these programs must be short or started very early at the time of diagnosis, in order not to delay therapeutic management to prevent cancer progression.…”

Is ventilatory efficiency the next new thing in prehabilitation?

“…Gravier and colleagues 7 found no change in the slope, but the VO 2peak increased, and there was a moderate correlation between the change in VE/VCO 2 slope and change in the VO 2peak . They conclude that the slope did not change with the exercise program, even though other measures, such as VO 2peak and maximum power reached (W peak ), changed in the expected direction.…”

“…An elevated slope (>35) is an independent prognostic factor in lung resection, 4 heart failure, 5 and chronic obstructive pulmonary disease. 6 In their article in this issue of the Journal, Gravier and colleagues 7 determine whether VE/VCO 2 can be improved with an exercise program.…”

“…Second, Gravier and colleagues 7 concluded that there is no relationship between slope and exercise after comparing the medians of the slope. They did, however, find a significant correlation between changes in VE/VCO 2 slope and VO 2peak .…”

Commentary: Work in progress—Defining optimal surgical prehabilitation before lung resection

“…Paleiron and colleagues 1 are among a cohort of investigators seeking to develop protocols for the purpose of respiratory prehabilitation in advance of lung cancer surgery, with unfortunately modest results thus far. [4][5][6] Whereas earlier efforts in this area aimed to explore nutritional optimization and smoking cessation programs as targets, more contemporary approaches have attempted to improve ventilatory function and efficiency to reduce postoperative pulmonary complications. As our focus shifts toward proactive, rather than reactive, compensatory measures to improve lung function, novel concepts and methods are required to overcome the expected difficulties with patient motivation and compliance, as has been repeatedly demonstrated with smoking cessation efforts, perhaps one of the earliest cornerstones of surgical prehabilitation.…”