Akademik Veri Yönetim Sistemi
Toraman F. (Yürütücü)
Diğer Ülkelerin Sivil Toplum Kuruluşları Tarafından Desteklenmiş Proje, 2022 - 2024
Preoperative inspiratory muscle training coupled to aerobic exercises to prevent
postoperative pulmonary complications in patients undergoing thoracic surgery
(INSPIRE study):
a multicentre randomized controlled trial
Contents
1.2. Medical problem/Background. 6
Postoperative pulmonary complications: incidence and
risk factors. 6
Pre-operative optimisation, exercise and inspiratory
muscle training. 7
1.4. Methods and Measurements. 9
1.4.2. Inclusion/Exclusion Criteria for Studies. 9
1.6. Risk Benefit Assesment 14
1.8. Ethical and Regulatory Aspects (including support
of departmental chairs) 15
2.4. Total funds requested. 19
2.7. List of facilities, equipment, supplies and
services. 20
Title: Preoperative inspiratory muscle training coupled to
aerobic exercices to prevent postoperative pulmonary complications in patients
undergoing thoracic surgery (INSPIRE study): a multicentre randomized controlled
trial
Date : 14/06/2019
Lead applicant :
Dr. Emre Sertaç Bingül
Other applicants :
Prof Dr Marc Licker
Prof Dr Frédéric Triponez
Prof Dr Bengt Kayser
Prof Dr Fevzi Toraman
Prof Dr Zerrin Sungur
Institution of the lead applicant: Istanbul University,
Istanbul Faculty of Medicine, Department of Anesthesiology, Capa Clinics, PK 34093,
Istanbul - Turkey
Corresponding applicant
Dr. Emre Sertaç Bingül
Tel : + 90 554 424 88 22
Fax : + 90 212 533 20 83
E-mail: dremrebingul@gmail.com
Postoperative pulmonary complications (PPCs) are the most
frequent complications occurring after thoracic surgery and they are associated
with prolonged hospital stay, decreased survival and expanding medical costs.
Preoperative aerobic endurance training (AET) and Inspiratory Muscle Training
(IMT) by enhancing skeletal muscle function and improving tissue oxygen
delivery may result in fewer PPCs. Therefore, we propose a multicentre
randomized, open, blinded end point controlled trial evaluating the effectiveness
of IMT coupled with AET in patients scheduled for thoracic surgery. Patients
awaiting surgery will be randomized on a 1:1 basis into an intervention arm (coached,
home-based AET-IMT group) and a sham- arm (Control group). In the AET-IMT
group, patients will will be asked to use a flow resistive device (five sets of
10 repetitions, twice a day and to increase their daily physical activities
(targeting an equivalent of 5’000 steps) until surgery. Primary study endpoint
will be the incidence of PPCs (e.g., atelectasis, pneumonia, respiratory
failure) according to European Perioperative Clinical Outcome (EPCO)
definitions. Secondary outcomes will include non-respiratory complications
(e.g., myocardial infarct, new/worsening heart failure, wound infection), utilization
of hospital resources (e.g., hospital length of stay, ICU admission, health
cost analysis), recovery outcomes (e.g., patient-reported survey of health outcomes
(SF-36) and Patient-Reported Outcomes Measurement Information System (PROMIS)),
functional data (maximal inspiratory pressure and endurance, diaphragm
thickness and maximal excursion, 6-min walking test, room-air test), and in
vitro studies of diaphragm samples (e.g., morphometry, oxidative stress and
ubiquitin-proteasome pathway). Assuming an incidence of 39% PPCs and expecting 33% reduction of PPCs in
AET-IMT group, 203 patients will be required in each arm (significance level of
0.05 and power of 80%). Taking into account dropouts (5%) and in-hospital
mortality rate (2.0%), a total of 436 thoracic surgery patients will be
enrolled.
An approach combining AET and IMT represents a simple,
non-expansive intervention that may recondition patient’s physical fitness and
enhance his ability to sustain surgical stress. Since a sizeable number of
cancer patients are declared unfit for surgery due to severe cardiopulmonary
disease or poor functional status, implementation of an AET-IMT protocol may
represent a cost-effective approach to increase the number of surgical
candidates and to facilitate the fast-track pathway of major surgery.
Complications arising following major surgery pose a major
healthcare challenge by prolonging hospital stay and increasing medical costs
while decreasing patient quality of life and survival. 1–4 Presently, postoperative
pulmonary complications (PPC) are the most common serious adverse events with a
reported incidence of 2%–50%.5,6 The variability in PPC
reporting has been addressed in the European Perioperative Clinical Outcome
consensus document which defines PPCs based on the presence of respiratory
failure, pneumonia, atelectasis, pleural effusion, pneumothorax and
bronchospasm.7 Estimates suggest that more
than 1 million PPCs occur annually in the United States, with 46 200 related
deaths and 4.8 million additional hospitalization days.8
Patients undergoing thoracic or abdominal surgery are prone
to develop PPCs that largely contribute to postoperative morbidity and
mortality.5,9–12 Consistent mechanisms involve
reduction in functional residual capacity (CRF) and total lung capacity (TLC)
that results in ventilation– perfusion mismatch, atelectasis and hypoxemia.13 The restrictive pulmonary
syndrome may be a consequence of general anaesthesia, postoperative pain from
thoracic incisions and diaphragmatic dysfunction, as well as decreased lung and
chest wall compliance. 13,14
Advanced age, the severity of pre-existing cardiopulmonary
diseases, the extent and duration of surgical resection, body mass index,
nutritional status as well as low aerobic capacity have all been identified as
risk factors for PPCs.15–17 Lower aerobic fitness, evaluated
by measuring the peak oxygen consumption (VO2peak) during cardiopulmonary
maximal exercise testing, and poor exercise tolerance have been reported in
patients scheduled for lung cancer resection and the group of patients with VO2peak
lower than 15-16 ml.kg-1.min-1 is at greater risk to develop major
postoperative cardiopulmonary complications.18,19
So far, the importance of respiratory muscle dysfunction has
largely been underestimated in the pathogenesis of PPCs. Weakness of the
respiratory muscles is often associated with poor aerobic fitness in the
context of chronic obstructive pulmonary disease (COPD), heart failure (HF) and
muscular deconditioning.(Verissimo et al. 2015; Montemezzo et al. 2014; Jung et
al. 2016) In the early postoperative period, further impairment in the
contractile performance of respiratory muscles results from residual effects of
anaesthetic agents, surgery-induced systemic inflammation, ventilator-associated
respiratory muscle disuse and incisional pain.(Welvaart et al. 2011; Kim et al.
2010) Importantly, weak inspiratory muscles are less “fatigue resistant” when
faced with the increased inspiratory loading conditions that prevail following
anaesthesia emergence as a result of reduced lung volumes and airflow
limitations.(Sieck et al. 2013)
Pre-operative patient’s optimisation entailed general
measures such as correction of anaemia and malnutrition, adjusting treatments
for chronic obstructive pulmonary disease (COPD) and asthma as well as providing
advices to stop (or reduce) smoking and alcohol consumption 20–22.
Impairment in aerobic capacity and respiratory muscle
weakness should be considered modifiable risk factors in patients awaiting
major surgery. Both global aerobic physical training and inspiratory muscle
training have been shown effective in inducing morphological and functional
changes in the diaphragm while improving the clinical conditions of patients
with COPD or HF.23,24 Preliminary data also suggest
that preoperative physical training contribute to lower pulmonary morbidity and
to accelerate recovery after lung resection.25–27
The safety and efficacy of a short-term high intensity
interval physical training has been evaluated in a RCT including patients
awaiting lung cancer resection at the University Hospital in Geneva and at the
Valais Hospital in Sion. During the waiting period before surgery, the physical
performances (walking distance at the six-minute walk test and VO2peak)
were significantly improved in the exercise training group whereas further
reductions were reported in the control group.( Licker M et al. 2017) Although mortality and the
composite morbidity endpoint did not differ between the two groups,
preoperative physical training was associated with improved aerobic fitness and
a 40% reduction in PPCs. Yet, these functional benefits were not sustained at
1-year follow-up. 29
The major reasons for failure to achieve positive effects in
some patients are related to the short time period (2-3 weeks), poor adhesion
to treatment and the inability to perform the prescribed exercises (e.g.,
cycling, rowing, running). On the other hand, treatment effects could be also
overestimated due to lack of adequate blinding, small-study effects, and
publication bias. Therefore, underlying mechanisms leading to PPCs deserve new
exploratory translational approaches and innovative treatments need to be
tested. Ïmportantly, most if not all previous trials evaluating the efficacy of
AET or/and IMT have been conducted in hospitals or specialized centers where
patients were trained with various programs; therefore, compliance and adhesion
to the prescribed interventions was sometimes limited or poorly reported.
References are given
at the end of item 1.
The plasticity of the skeletal muscles, particularly respiratory
striated fibers, allows adaptive morphological and functional changes in
response to specific training loads 30. The high intensity modality
for IMT has been shown effective in COPD patients and those with HF 9,31. Such type of physical
training provides a time-efficient alternative to high volume and global
endurance training in increasing respiratory muscle function before major
surgery.
Our main research question will be to question whether an
individualized respiratory training program coupled with global aerobic
exercises would protect the thoracic surgical patients against PPCs. In
contrast with previous trials, the training program will be home-based and
individualized according to the patient’s abilities.
Secondary aims are to find whether preoperative AET-IMT
·
induces phenotypic changes within the diaphragm
and minimizes the early postoperative reduction in maximal inspiratory pressure
and lung volumes
·
is associated with shorter hospital length of
stay, fewer admission in ICU and it represents a cost-effective perioperative
intervention
·
is associated with lower in-hospital morbidity
and improved medium-term quality of life.
The INSPIRE Study is a multicenter randomized, open, blinded
end point controlled trial. The trial will be conducted in Switzerland and
Turkey in the following hospitals:
·
Acıbadem University Hospital in Istanbul,
·
Istanbul University Istanbul Faculty of Medicine
Hospital in Istanbul,
·
the
Hôpitaux Universitaires de Genève (HUG),
·
the
Centre Hospitalier Universitaire Vaudois (CHUV) in Lausanne,
·
the
Hôpital du Valais in Sion
Adult thoracic surgery patients with proven or suspected non-small
cell lung cancer, stage IIIA or less (TNM classification) will be recruited if
the following inclusion criteria will be met:
·
Planned lung resection,
·
ARISCAT 11 score >30
·
Patients unable to understand and perform the AET-IMT,
·
Patients with chest pain (osteoarticular
problem) or at risk of pneumothorax
·
Patients<18 years of age will be excluded.
·
Any postoperative complications occurring during
the hospital stay and within 30 days after surgery will be reported according
to Clavien-Dindo classification schema with a modified version of the thoracic
mortality and morbidity (TMM) classification system for thoracic surgery 32 and European Perioperative
Clinical Outcome (EPCO) definitions for single organ and composite outcomes for
abdominal surgery 7.
·
Information regarding patient characteristics
and treatment such as comorbidities, treatment and prior chemotherapy, lung
functional testing, cardiopulmonary exercise test, tumor staging, operation
details (incision, duration of surgery and anesthesia, extent of resection,
fluids), ICU admission; hospital length stay; discharge location (home,
rehabilitation center, nursing home, other hospital).
·
Maximal voluntary respiratory pressures will be
registered at the mouth: from total lung capacity for maximal expiratory pressure
(MEP) or from residual volume for maximal inspiratory pressure (MIP). To
measure inspiratory muscle endurance, patients will be asked to breathe against
a submaximal inspiratory load provided by the flow resistive loading device
(POWER breathe KH1or KH5), until task failure. 33 Number of breaths, average
duty cycle (inspiratory time as a fraction of the total respiratory cycle
duration), average mean load, average mean power and total external inspiratory
work will be recorded.
·
In a subset of patients (N=50), the diaphragm
thickness (mm) will be assessed by B-mode ultrasonography at FRC and at TLC
using a linear 7.5-MHz linear probe.34 The largest excursion of the
diaphragm will be recorded from the end of normal expiration to end of maximal
inspiration.
·
The six-minute walk test will be performed by
the researcher; the severity of dyspnoea will be rated using the modified Borg
scale (from 0 to 10), as well as the level of physical activity over 3
consecutive days (pre/post-IMT) with a multiaxis accelerometer (ActiSmile SA,
Baar, CH).
·
The Short Form 36 (SF-36) Health-related Quality
of Life Questionnaire
·
Self-report measures for adults for functions,
symptoms, behaviors, and feelings by computer adaptive testing (Patient-Reported
Outcomes Measurement Information System (PROMIS)) will be used.
·
Direct health care costs (i.e., preoperative
ambulatory treatment; in-hospital treatment costs, covering costs for staff and
materials) will be reported using time units (e.g., time for nursing and
anaesthesia services), units of other resources (e.g., drugs or medical
materials), and current prices via the hospital cost accounting system.
At the end of the surgical procedure, biopsies will be taken
from the anterior costal diaphragm (lateral to the insertion of the phrenic
nerve) and stored frozen (N=12 per group) only for thoracic surgical patients.
·
Histology: the fiber cross sectional area and
the relative proportions of myosin heavy chain (MHC) I (type I), MHC IIa (type
IIa), and MHC IIx/IIb (type IIx/IIb) will be determined.
·
Studies of the Ubiquitin-Proteasome pathway and
caspase-3, mitochondrial e- transport
o
Isolation of 20S proteasomes and measurement of
the proteolytic Activity (fluorogenic substrates
succinyl-Leu-Leu-Val-Tyr-7-amido-4-methylcoumarin (LLVY) and
N-carbenzoxy-Leu-Leu-Glu-7-amido-4-methylcoumarin)
o
The mRNA expressions of E3 ligases involved in
skeletal muscle protein ubiquitination will be measured by real-time PCR
(FBOX32 (Atrogin-1), TRIM36 (MuRF1), TRIM32 and FBOX30 (MUSA1)).
o
Quantification of Enzymatic Activities: NAD(P)H
oxidase, aconitase, fumarase, glutathione peroxidase, catalase, superoxide
dismutase and manganese superoxide dismutase (Mn-SOD) as well as creatine
kinase.
In each participating centre, one researcher will screen for
eligibility in the preoperative clinic and will perform the informed consent
procedure and the baseline and follow-up measurements. This local researcher,
the surgeons, and other medical staff will be blinded for group allocation.
Consenting patients will be randomized on-line via research electronic data
capture software randomization module (REDCAP) on a 1:1 basis into an
intervention arm (AET-IMT group) and a sham arm (Control group) by the physical therapist who will not be
blinded.
All patients will be adviced to remain physically active, to
avoid alcohol beverage and to stop smoking. Instructions will be given about
postoperative physical therapy to facilitate early mobilization and independent
functioning in daily living activities.
·
In the AET-IMT group, patients will receive
detailed instructions and be trained how to use the IMT device and which type of
exercise they should perform. Several exercise modalities (walking, stair
climbing) will be proposed according to patient’s abilities and choice with the
aim to achieve approximately 5’000 steps/day. Respiratory training will be
tailored individually using a variable flow resistive loading device
(POWERbreathe KH1-series). The application of a tapered load allows patients to
get close to maximal inspiration, even at high-training intensities. Based on
our preliminary results, the inspiratory training session will start at 40% of
baseline maximal inspiratory pressure (MIP) and the patient will be asked to
perform five sets of 10 repetitions followed by 1–2 min of unloaded recovery
breathing off the device, twice a day, 7 days a week. Patients will be instructed
during a face-to-face instruction session using the IMT device and educational
video. To facilitate compliance to the training protocol, patients will receive
an instruction movie (with step-by-step description of AET-IMT), they will also
be asked to record their activities (diary) and to contact the research
assistant whenever necessary.
Training results (load, power, volume, t-index)
will be recorded (on-line diary after each training session). The MIP values
and the rates of perceived inspiratory effort on a modified Borg Scale will be
used to support decisions on training load increments for the next sessions
(10% increase, Borg scale, > 6/10).35 After the first face-to-face
instruction session, the researcher will contact the patient by phone or e-mail
within 2 days. When problems detected in adherence to protocol (training and/or
recording is not performed as instructed), researcher will make a follow-up
appointment with the patient to repeat the instruction. Once a week, the AET-IMT
will be supervised by a researcher. Subsequently, training progress will be evaluated
during a weekly consultation by the researcher. At the end of the training
period, the AET-IMT will be evaluated with a questionnaire. All involved
researchers guiding patients during the IMT period will receive same standard education
and training during a meeting on the theory and practice of IMT organized by
the research group.
·
Control group: Patients will receive advices to
remain physically active and to start breathing with the IMT device at an
initial workload of 10 cmH2O and increasing by 2.5 cmH2O every week. Sessions
will be performed twice daily (10 min) until the day of surgery.
For all patients, thoracic surgery will be performed either
through video-assisted thoracic surgery (VATS) or antero-lateral thoracotomy
under general anesthesia and appropriate monitoring. Muscular relaxation will
be achieved and a double-lung tube will be inserted for one lung ventilation.
Protective ventilatory settings and hemodynamic goal-directed with limited fluids
infusion to maintain normovolemia will be applied as reported previously.36 Patients will be extubated in
the operating room and then transferred in the intermediate care unit (or intensive
care unit [ICU]). In the both groups, similar perioperative care will be
conducted including namely prophylactic antibiotics, chest physical therapy and
mobilization scheme until hospital discharge.
Assuming an incidence > 39% PPCs and expecting 33%
reduction of PPCs in thoracic surgery patients, 203 patients will be required
in each arm (significance level of 0.05 and power of 80%) 11. Taking into account dropouts
(5%) and in-hospital mortality rate (2.0%), a total of 436 thoracic surgery
patients will be enrolled. Among functional studies, determination of MIP is a
key element. For an expected 25% increase in MIP (from 85 to 101 cm of water,
baseline standard deviation of 24)37 and with an alpha level of
0.05 and a power of 80%, 21 patients will be required in each arm (total of
84).
Data will be summarized by numbers and proportions, means
(SD) and medians (quartiles) for normal and non-normal distributions. The
impact of AET-IMT on the incidence of PPCs will be evaluated by chi-square
statistics and Kaplan-Meyer analysis. Analysis of variance, t-tests and
Mann-Whitney U statistics will be used to compare continuous outcomes between
groups. Multivariable regression models will be fitted to main outcomes with
treatment and baseline characteristics of participants as predictors to
identify and adjust for potential confounders. Other outcomes (for example,
lung function, respiratory muscle function, quality of life) will be compared
between groups using linear regression for parametric data or the Mann–Whitney
U Test for non-parametric data and the repeated measurements method to
determine differences between time points.
The intervention of inspiratory muscle training is safely
adviced in critical care patients 38–40, congestive heart failure41 and patients in chronic
obstructive pulmonary diseases42. Similarly, a more vigorous
preoperative exercise training has been demonstrated to be feasible and safe in
surgery for adenocarcinoma of the gastro-oesophageal junction43. Therefore, such intervention is not experimental
and may even represent a standard of care in some hospitals. As the level of
physical activity is increased according to patients self-reported rating and
under the supervision of a well-trained physiotherapist, the risk of any
adverse effect (e.g., angina pectoris, hypotension) is well-controlled.
Furthermore, the patient may profit from this training and the close monitoring
during the postoperative visits, which may enhance patient's safety.
All the data regarding the study will be kept in written and
electronic CRFs. Individual subject medical information obtained as a result of
this study will be considered confidential and confidentiality will be further
ensured by utilising subject identification code numbers. The investigators
will affirm and uphold the principle of the participant's right to privacy and
will also comply with local applicable privacy laws.
This study has already been approved by the Ethics Committee of Acıbadem University in
Istanbul (ATADEK- 2018/2; Chair: Prof Dr İsmail Hakkı Ulus). The thoracic teams of the University Hospital of Geneva and
other centres have also submitted the study protocol to their local Ethics
Committee. The clinical study will only begin once approval from all
required authorities has been received. Any additional requirements imposed by
the authorities shall be implemented.
The proposed project will be led by a steering committee (Emre
Sertaç Bingül, Marc Licker, Frédéric Triponez, Bengt Kayser, Fevzi Toraman,
Zerrin Sungur) that will meet twice a year to examine safety issues, to review
patient’s enrollment and to decide on scientific and administrative aspects.
All investigators will share responsibility for the project as a whole and will
have access to scientific data with monthly communication of patient’s
enrolment and study processes by e-mail and teleconferences.
This study will be registered with www.clinicaltrials.gov.
This study is supported by the following Departmental
Chairs:
·
Prof Dr Mehmet Tuğrul (Istanbul University,
Istanbul Faculty of Medicine)
·
Prof Dr Fevzi Toraman (Acıbadem University)
·
Prof Dr Martin Tramer (Geneva centers)
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F. et al. Safety and feasibility of preoperative exercise training
during neoadjuvant treatment before surgery for adenocarcinoma of the
gastro-oesophageal junction. BJS Open 3, 74–84 (2019).
·
Physiotherapists – Each centre will employ their
own hospital budget for this item
·
Research data collection- coordination: A part
time research assistant will be employed during 2 years in Turkey- 3000 €
·
Research data collection-researchers in Turkish centers
(Istanbul University- Istanbul Faculty of Medicine Hospital and Acıbadem
University Hospital) will use their elective research time dedicated by their
department and guarenteed by their academic status to contribute to this
project. Researchers in Geneva, Lausanne
and Sion (Switzerland) will be supported by their institutional research grants.
·
IMT Device-KH5- 10 devices (8000€)
·
·
IMT Mouth Piece -400 patients (500 €)
·
Educational website and on-line diary setup and
maintenance – 500€
12000 €
As our co-workers developed a trial on preoperative
rehabilitation, a close and fruitful partnership has emerged between thoracic
surgeons, pneumologists, anesthesiologists and physiotherapists working within
two main hospitals, the HUG in Geneva and the Hôpital du Valais in Sion (HVS).
A similar cooperation also exists in centers in Turkey. Although the modality
of global physical training was well standardized by physiotherapists, some
patients were reluctant to participate in a hospital-based training program
while some others were unable to perform the prescribed training. These
limitations will be overcome in the proposed trial since the AET-IMT program is
focused on respiration and will be home-based with on call assistance and
weekly assessment. New centres added to the study have dedicated respiratory
physiotherapy teams.
Preliminary clinical tests with the respiratory training
device (POWERbreath) at the HUG have been positive in terms of the feasibility
to implement the training program and to perform the physiological measurements
(MIP, inspiratory muscle endurance). This flow resistive inspiratory loading
device has been widely adopted by several leading clinical and research groups
in the field of rehabilitation. If the grant is obtained, it will mainly cover
the expenses related to buy these respiratory training devices in all centres
in order to start and recruit more than one patient at a time in each centre.
We will apply for an additional grant to cover expenses related to in vitro lab
materials.
The ultrasound device and probes (Philips CX 50, 7.5-MHz
linear probe) are currently used by cardiothoracic anesthesiologists and will
be available for the diaphragmatic measurements (thickness and motion) in all
centres.
In vitro studies (36 patients) will be performed at the HUG
and research laboratories at the University of Geneva. The HUG, CHUV, HVS and
Istanbul centres will be involved in the clinical part of the study. Given the
annual case load at six participating institutions,[1] the clinical study will be
fully completed over a 2-year period. The grant from the EACTA will mainly be
used to buy the inspiratory training devices which are used in interventional group of the study.
Complementary grant(s) will be sought for completion of the study to finance in
vitro studies.
The trial will be conducted in Switzerland and in Turkey in
the following hospitals:
- the Hôpitaux Universitaires de Genève
(HUG),
- the Centre
Hospitalier Universitaire Vaudois (CHUV) in Lausanne,
- the Hôpital
du Valais in Sion,
- Istanbul
University Istanbul Faculty of Medicine Hospital in Istanbul
- Acıbadem
University Hospital in Istanbul
All centres have adequate preoperative clinics with
dedicated physiotherapy teams and have the facilities to perform diaphragm
ultrasound.
Emre Sertaç Bingul, who was born in 1988, has
graduated from Istanbul University Istanbul Medical Faculty in 2012. He
completed his anaesthesiology residency at the same school after a five-year
training in 2017. He has passed the both written and oral European Diploma of
Anesthesiology and Intensive Care (EDAIC) examinations which is held by
European Society of Anaesthesiology and become a Diplomate. After working as an
attending anaesthesiologist in Istanbul Medical Faculty for several months, he
has been appointed for the obligatory service of Turkish Ministry of Health for
the next two years which takes place in Rize Recep Tayyip Erdogan Training and
Research Hospital recently. During this period, he took part as an “examiner”
in oral Turkish Society of Anesthesiology and Reanimation Competency Board
Examination and his two articles (Effects of Heart Rate Control on Oxygenation
and Vasopressor Need in Sepsis and Septic Shock: A Pilot Randomized Controlled
Study and Large Intraatrial Mass as a Cause of Acute Respiratory Failure: An
Anaesthesiologic approach to preserve cardiorespiratory cycle and literature
review) are accepted to be published in national journals. He is interested in
respiratory physiology, thoracic anesthesia, cardiovascular anaesthesia and
peripheral blocks. Lately, he was accepted to the exchange programme in
Barcelona (Hospital de Clinic) which is held by European Association of
Cardiothoracic Anaesthesiology (EACTA).
Marc Licker studied at the Catholic University of
Louvain (Belgium) where he obtained a doctor's degree and, in 1982, a
doctorate. He then specializes in anesthesiology and resuscitation. After a
Fellowship at the Royal Victoria Hospital in Montreal from 1988 to 1990, then
at the Hospital Center of Liège, he joined the University Hospital in Geneva at
the Department of Anesthesia and Critical Care in 1990, where he was appointed
assistant physician in 1996. He is currently Associate Assistant Physician , in
charge of the anesthesia unit of the central blocks. His clinical expertise is
in anesthesia and resuscitation of cardiac, vascular and thoracic surgery
patients. An appreciated teacher both at the pre-graduate and postgraduate
level, Marc Licker is also a researcher whose work is in the field of
cardiopulmonary physiology and perioperative risk management. Appointed
assistant professor of the Faculty of Medicine of UNIGE in 1999, then associate
professor in the Department of Anesthesiology, Pharmacology and Intensive Care
in 2007, he was promoted to the position of full professor in 2015 and he is
currently lecturer in integrative physiology and respiratory physiology. He has
authored about 200 papers in the field of critical care medicine as well as cardiovascular
and thoracic anesthesia. From 2007 to 2014, he has been member of the
Respiration subcommittee at the European Society of Anesthesiology and from
2009, he is member of the Thoracic subcommittee at the European Association of
Cardio-Thoracic Anesthesia.
Bengt Kayser is director and full professor at the
Institute of Sports Sciences of the University of Lausanne in Switzerland.
After his medical studies at the University of Amsterdam in the Netherlands he
engaged in an academic career in the field of exercise physiology with a
special interest in hypoxia. After obtaining his PhD at the Free University of
Amsterdam, Netherlands, he worked at McGill University in Montreal, Canada,
before joining the University of Geneva in Switzerland. After preparing the
merger of the Lausanne and Geneva institutes of sports and movement sciences he
now is at the University of Lausanne since 2013. His research interests concern
the factors limiting endurance exercise performance, altitude medicine and
physiology, respiratory mechanics during exercise, doping and anti-doping, and
the relationship between physical activity, energy balance and (public) health
and its determinants in different settings. He has authored more than 200
papers in the field of exercise physiology.
Frédéric Triponez studied medicine and basic training
in surgery in Geneva. He completed his training in endocrine surgery (thyroid,
parathyroid and adrenal) in Lille and San Francisco. Back in Geneva in 2005, he
developed this endocrine surgery activity and continued his training in
thoracic surgery and spent 2 years in one of the largest French and European
centers of thoracic surgery in Paris. Since 2013, he is the Chief Medical
Officer of the Department of Thoracic and Endocrine Surgery of the HUG as well
as an ordinary professor at the Faculty of Medicine. He is appointed Chief of
the Department of Surgery on October 1, 2018. Since 2011, the HUG surgical team
has introduced and developed minimally invasive (thoracoscopic) and robotic (Da
Vinci) surgical techniques, including lung resections for cancer. Current
research and developments focus on limited resections for thoracoscopic cancer,
to minimize the extent of lung resection, particularly for small lung cancers
(typically <2 cm). This approach allows healing as good as with more
extensive resection, with minimal impact on quality of life. Innovative
techniques using fluorescent markers are applied for the precise identification
of the areas to be resected. He has authored more than 100 papers in the field
of endocrine and thoracic surgery.
Zerrin Sungur graduated from Istanbul Faculty of Medicine in 1995 and was licensed as
anesthesiologist from Dept. of Anesthesiology and Reanimation of Istanbul
Faculty of Medicine in 2001. She earned degree of Associated Professorship in
2011 and became full professor in 2018. Her publications are focused on cardiac
and thoracic anesthesia (27 in SCIE journals) with an H index of 8, and also
contributed in Postoperative Care in Thoracic Surgery book. She has already
participated in PERISCOPE and LAS VEGAS trials and is the national coordinator
of POSE trial with ESA. She has worked as Secretary General in Board of Turkish
Society of Cardiovascular and Thoracic Anesthesiologists between 2012 and 2014. She is a member of PBM team in Turkish
Cardiovascular and Thoracic Anesthesiologists &Surgeons Collaboration and
member of Executive Board in Turkish Society of Anesthesiology &
Reanimation between 2018-2020. She also performed as member of scientific Pediatric
Subcommittee in European Association of Cardiothoracic Anesthesiologists
between 2017-19.
Fevzi Toraman graduated from Karadeniz Technical University Medical Faculty
in 1986 and was licensed as anesthesiologist from Siyami Ersek Thoracic and
Cardiovascular Surgery Center Istanbul, Turkey in 1994. He earned degree of
Associated Professorship in 1999 and became full professor in 2008. Her
publications are focused on cardiac and thoracic anesthesia (63 articles). He
is a member of Turkish Society of Anesthesiology, Turkish Society of Intensive
Care, Turkish Society of Thoracic and cardiovascular Anesthesia and intensive
care, Turkish Society of Cardiovascular Surgery (TSCVS) and European
Association for Cardiothoracic Anesthesia (EACTA). He is also the chair of Department
of Anesthesiology and Reanimation in Acıbadem University.
[1]
The public hospitals of Geneva, Lausanne and Sion are covering a region with
1.4 million inhabitants and the annual caseload of thoracic surgery is
approximately 800 procedures. Likewise, centers in Istanbul are covering a region with
16 million inhabitants with a high number of medical facilities. The centers
each have roughly 200 cases per year.