Early ambulation after lung surgery: How early?

Dr. Khandhar of Inova Fairfax Hospital in Falls Church, Virginia and early ambulation after lung surgery

One of the critical benchmarks of recovery from thoracic surgery is early ambulation (walking) after surgery – but “How early?” is a frequently encountered question.

Now, Dr. Sandeep Khandhar, thoracic surgeon of Inova Fairfax Hospital in Falls Church, Virginia aims to answer this question.

The answer, Dr. Khandhar reports is : Within 1 hour of extubation.

In a recent article by Zosia Chustecka for Medscape, she summarizes Dr. Khandhar’s recent study on post-operative ambulation in thoracic patients.  Dr. Khandhar presented these findings at the 2013 World Conference on Lung Cancer this month.

In this study, involving 750 patients who were given a goal of walking 250 feet within an hour after extubation.  In this 3 year project, only 10% of patients were unable to  walk within one hour after extubation.  60% of patients were able to walk the full distance of 250 feet within an hour of extubation.

In these patients, early mobilization was associated with a significant reduction in length of stay: from 3 to 5 days down to just 1.6 days, as well as a decreased need for intravenous narcotics post-operatively.

We have contacted Dr. Khandhar for additional information about this study.

Chustecka, Z. (2013). Lung Cancer Patients Up and Walking Within Hour of Surgery.  Medscape, 28 October 2013.    [Medscape requires a free subscription to review articles and news].

Pre-operative Incentive Spirometry for Pneumonia Prevention

Another study confirming the importance of pre-operative respiratory exercises for surgical patients – this one looking at cardiac surgery patients and the incidence of post-operative pneumonia.

Shared content from sister site.

Another study confirms the utility of using an incentive spirometer (IS) and performing ‘pulmonary toileting’ prior to surgery.  The study, re-posted below looks at the rate of post-operative pneumonia in cardiac surgery patients.

Patients were stratified into two groups; one group received pre-operative IS teaching several weeks before surgery and the other didn’t.  Results: a dramatic reduction in post-operative respiratory complications – confirming what we know (and taught our patients about).

If you don’t have your incentive spirometer – take the deepest breath you can (inhale slowly.. over 2-3 seconds), hold for ten seconds, slowly exhale.  Repeat ten times, then rest..  Do this several times a day – along with coughing exercises..(and get your incentive spirometer)

Article Re-post:

Preop Deep-Breathing Exercises Cut Pneumonia Risk After Cardiac Surgery

By Anne Harding

NEW YORK (Reuters Health) Jun 03 – Using an incentive inspirometer for a few weeks before cardiac surgery can help high-risk patients avoid pneumonia, new research confirms.

“The idea of the inspiratory muscle training before surgery is that if you increase your inspiratory muscle function before surgery, you can do your deep breathing exercises after surgery better and therefore the pulmonary complications can decrease after surgery,” researcher Karin Valkenet of the University Medical Centre Utrecht in the Netherlands told Reuters Health.

On Wednesday at the American College of Sports Medicine’s annual meeting in Denver, she reported that cardiac surgery patients in her study who did not receive at least two weeks of preop inspiratory muscle training (IMT) were three times as likely to develop pneumonia.

Valkenet’s study follows a 2006 paper in the Journal of the American Medical Association by another team from her center, which reported on 279 high-risk patients undergoing coronary artery bypass grafting (CABG) In that study, 6.5% of the IMT group developed pneumonia, compared to 16.1% of controls. Overall, 18% of the IMT group had postoperative pulmonary complications, compared to 35% of controls.

In the new study, Valkenet and her colleagues enrolled patients with diabetes, productive coughing in the previous five days, or impaired pulmonary function. Ninety-four such high-risk patients were given incentive inspirometers, trained to use them, and told to practice for 20 minutes a day at home. Their starting load was 30% of maximal inspiratory pressure, which they increased based on their perceived exertion.

Another 252 high-risk patients served as controls.

One patient in the IMT group developed pneumonia, compared to eight patients in the control group. While the difference was not statistically significant given the low number of events, Valkenet and her colleagues were able to show a relative risk of 2.9 for the patients who didn’t undergo the training, based on a propensity score analysis.

“The data confirms the randomized, controlled data that was published earlier so that’s very good news for us,” Valkenet said”.  [end of re-post]

Remember – this advice goes for all surgical patients – especially lung surgery patients, in addition to heart (cardiac surgery) patients.

Who is performing your thoracic surgery?

The majority of general thoracic surgical operations in the United States are performed by surgeons not specializing in thoracic surgery. [despite the fact that] Both general thoracic surgeons and cardiac surgeons achieve better outcomes than general surgeons.” Schipper et. al (2009).

Research has shown that speciality specific training contributes greatly to surgical outcomes, yet large numbers of surgeons persist in operating outside their area of expertise.
In fact, in the United States, the majority of thoracic surgery procedures are not performed by board-certified thoracic surgeons. Unfortunately, the majority of patients are uninformed about the different training and subspecialties among surgeons, and it appears that general surgeons are not hastening to inform them. While most patients are sophisticated enough to realize and understand that a general surgeon is not the best candidate to remove a large brain tumor, this does not apply to a lung tumor.

It is up to us, as patient advocates, and specialty practitioners to inform and protect the public. (Lest you consider this statement suspect due to self-interest – read the linked article, which reviews the body of literature comparing surgical outcomes in thoracic surgery among thoracic and nonthoracic surgeons.)

Why does this happen? As Wood & Farjah (2009) explain: (italics are mine)
“Thoracic surgeons are well aware of the apparent moral hazard that occurs in a community when a patient is referred to the local general surgeon for lung cancer resection but to the general thoracic surgeon if the patient is higher risk, is a “VIP” (health professional or relative, community or business leader), or if the patient demands specialist care. If high-risk or “important” patients benefit from operations done by thoracic surgeons, it seems likely that other patients will as well. This tacit understanding of the benefits of specialty care is obvious and is supported by research from Schipper and others, yet appears to be undermined by local factors that have yet to be confronted by hospitals, payers, patient advocacy groups, or policy makers.

Physicians referring patients requiring thoracic operations may prefer to direct a patient to a nonspecialist due to local politics and economics, potentially benefiting directly or indirectly if the patient is cared for within the same hospital or same medical group. Although many hospital credentials committees require specialty board certification to provide specialty care, this is often overlooked because of local traditions, reluctance to restrict or offend current medical staff, and concern about potential financial implications if lack of hospital “specialists” results in redirection of certain patients to a competing hospital.”

“National specialty societies representing surgeons are generally silent on the issue in an effort to avoid disenfranchising one or more of their constituencies. These well-intended but incongruous local incentives could be overcome by policy decisions by health care systems, payers, agencies evaluating quality, and government policy makers.”

Does local politics, local traditions and financial incentives to the referring physician seem like a good reason to refer a patient to an unqualified surgeon – when conclusive, and comprehensive data shows otherwise?

The Influence of Surgical Specialty on Outcomes

“STS: Lung Cancer Survival Best When Thoracic Surgeon Wields Scalpel” Dr. Farjah, “Using those figures, he estimated that “500 to 1,000 lives could be saved if all lung cancer surgeries were performed by board certified thoracic surgeons.””

Full-text article at Thoracic Surgery news – Dr. Michele Ellis on lung resection mortality by surgeon specialty.

8/24/2011 :  after a telephone interview with Ilene Little, this story was highlighted at Traveling4Health, a medical site for consumers.