Effectiveness of incentive spirometry in patients following thoracotomy and lung resection including those at high risk for developing pulmonary complications.

BACKGROUND: Following thoracotomy, patients frequently receive routine respiratory physiotherapy which may include incentive spirometry, a breathing technique characterised by deep breathing performed through a device offering visual feedback. This type of physiotherapy is recommended and considered important in the care of thoracic surgery patients, but high quality evidence for specific interventions such as incentive spirometry remains lacking. METHODS: 180 patients undergoing thoracotomy and lung resection participated in a prospective single-blind randomised controlled trial. All patients received postoperative breathing exercises, airway clearance and early mobilisation; the control group performed thoracic expansion exercises and the intervention group performed incentive spirometry. RESULTS: No difference was observed between the intervention and control groups in the mean drop in forced expiratory volume in 1 s on postoperative day 4 (40% vs 41%, 95% CI -5.3% to 4.2%, p=0.817), the frequency of postoperative pulmonary complications (PPC) (12.5% vs 15%, 95% CI -7.9% to 12.9%, p=0.803) or in any other secondary outcome measure. A high-risk subgroup (defined by ≥2 independent risk factors; age ≥75 years, American Society of Anaesthesiologists score ≥3, chronic obstructive pulmonary disease (COPD), smoking status, body mass index ≥30) also demonstrated no difference in outcomes, although a larger difference in the frequency of PPC was observed (14% vs 23%) with 95% CIs indicating possible benefit of intervention (-7.4% to 2.6%). CONCLUSIONS: Incentive spirometry did not improve overall recovery of lung function, frequency of PPC or length of stay. For patients at higher risk for the development of PPC, in particular those with COPD or current/recent ex-smokers, there were larger observed actual differences in the frequency of PPC in favour of the intervention, indicating that investigations regarding the physiotherapy management of these patients need to be developed further.

Postoperative oncological referral patterns for adjuvant treatment of patients undergoing curative resections for non-small-cell lung cancer at a regional thoracic centre.

OBJECTIVE: The Heartlands hospital provides services for 13 hospitals in the Pan Birmingham, Three Counties and Arden Lung Cancer Networks. After surgery for lung cancer, patients may be referred for adjuvant chemotherapy. The referral patterns and follow-up of patients differ between the various trusts. This study examines the current referral patterns following surgery with a view to identify areas for improvement. METHODS: We performed a retrospective review of 115 patients who underwent curative anatomical resection between April 2006 and March 2007. We reviewed the patient's progress following discharge from the surgeons at various defined points, including discussion at a multidisciplinary team (MDT) meeting following surgery, referral to oncologist, oncology treatment acceptance and adjuvant treatment completion. RESULTS: Of the 115 patients, four patients died after surgery. The demographics of the surviving 111 patients mirrored the national trends with the average age being 69+9.6 years. The predominant tumours were adenocarcinomas (44.1%) and squamous cell cancers (44.1%). A total of 82 patients were discussed in an MDT meeting and a further 16 patients were directly referred to the oncologists for consideration for chemotherapy. As many as 67 patients were referred for chemotherapy. Forty-eight patients were offered chemotherapy, 38 patients accepted and 25 of them completed the chemotherapy. Thirteen patients could not complete due to drug toxicity. Data collection for the study highlighted organisational problems with data collection and non-uniformity in the role of the lung cancer co-ordinators. The postoperative management of stage I lung cancer patients varied between the units. CONCLUSIONS: This study highlights areas of improvement in the current patient pathway for postoperative patients following lung cancer surgery and stresses the importance of achieving a consensus with regard to the management of resectable lung cancer. A method of data collection that is accurate, easily accessible and complete is recommended to help in future auditing of patient outcomes and help in improvement of services.