Interact CardioVasc Thorac Surg 2009;9:934-938. doi:10.1510/icvts.2009.212332
© 2009 European Association of Cardio-Thoracic Surgery
Work in progress report - Thoracic non-oncologic |
Influence of major pulmonary resection on postoperative daily ambulatory activity of the patients
Nuria Novoa*,
Gonzalo Varela,
Marcelo F. Jiménez and
Jose Luis Aranda
Thoracic Surgery Service, University Hospital of Salamanca, Spain
Received 23 May 2009;
received in revised form 30 July 2009;
accepted 3 August 2009
 Presented at the 17th European Conference on General Thoracic Surgery, Krakow, Poland, May 31–June 3, 2009.
*Corresponding author. Thoracic Surgery Service, Paseo de San Vicente 52-84, 37007 Salamanca, Spain. Tel./fax: +34 923 291 383.
E-mail address: nuria.novoa{at}usal.es (N. Novoa).
 |
Abstract
|
|---|
To describe and compare the daily ambulatory activity of the patients before and one month after major lung resection. Daily activity was measured using a pedometer (OMROM Walking Style PRO®) given preoperatively in a prospective way to a series of 21 consecutive cases scheduled for lobectomy or pneumonectomy. Analyzed variables were age, pulmonary function, mean number of total and aerobic steps per day, walked distance and mean daily time of aerobic activity. Activity variables were analyzed individually and as a new differential variable DELTA. Wilcoxon and Mann–Whitney nonparametric tests were used for comparison between groups. General series data: 19 male. Age: 63±10.9 years. FEV1%: 88.4±22.7. DLCO: 86.2±21.6. Eleven cases had COPD criteria. Type of surgery: 3 pneumonectomy/18 lobectomy. Activity data: all patients showed a global decrease of their activity one month after surgery but, patients in the pneumonectomy group are unable to keep aerobic activity meanwhile patients that undergone lobectomy showed only a 25% reduction in the measured variables. Major pulmonary resection decreases the time and the quality of the daily ambulatory activity of the patients during the first postoperative month. Despite limitations, the chosen pedometer OMRON Walking Style Pro® is an efficient tool to evaluate the perioperative daily ambulatory activity of patients.
Key Words: Pedometer; Major lung resection; Daily ambulatory activity; Quality of life
|
1. Introduction
|
|---|
In the majority of patients, functional respiratory parameters suffer a postoperative impairment after lung resection and remain decreased up to three months after surgery [1]. On the contrary, patients have a more early and complete recovery of their exercise tolerance, measured as peak VO2 [2]. Thus, traditional parameters used to assess the postoperative cardio-respiratory function seem not to correlate with the postoperative exercise capacity.
On the other hand, lung resection determines a transient worsening of quality of life (QOL) at one month following the operation with most of the scales returning to preoperative values at three months, except after pneumonectomy [3–5], and it has been shown that functional assessment of respiratory capacity and exercise tests do not correlate with the QOL reported by the patients [3].
We have hypothesized that daily activity measured by means of a pedometer could be a good correlate of postoperative QOL. To our knowledge, there are no published papers measuring daily exercise capacity of the patients after lung resection. In COPD patients, moderate relationships have been observed between clinical characteristics and physical activity and only GOLD stages III and IV correctly predicted very inactive patients [6].
We have conducted a cross-sectional study to measure daily activity in a series of patients before and after lung resection as a first step to investigate the correlation between postoperative daily exercise capacity and QOL.
|
2. Methods
|
|---|
2.1. Studied population
This is a prospective study performed on 21 consecutive patients referred to our unit for lobectomy (18 cases) or pneumonectomy (3 cases) due to non-small cell lung cancer. Patients that had preoperative chemo- or radiotherapy were excluded. All patients signed their informed consent to participate in the study, which was approved by the local IRB. The selection criteria for operation were the same all over the recruitment period and consisted of: Karnofski index over 50%, a predicted postoperatory forced expiratory volume in percentage (FEV1ppo) of over 30%, absence of hypercarbia and no concomitant bad prognostic systemic disease. Patients scheduled for chest wall or diaphragm resections also were excluded. All cases were operated through a muscle-sparing mini-thoracotomy and a lobe-specific or systematic nodal dissection was also performed. Postoperative data acquisition continued a mean of 30 days and stopped before any adjuvant treatment was started.
2.2. Measuring daily activity
Activity was measured by means of an OMROM Walking Style Pro® pedometer. This model is capable of differentiating between activity producing an increment of the cardiac rate up to 85% of the maximal adjusted by age (called ‘aerobic’) and other type of movement. After 10 min of continuous walking 60 steps per minute, the aerobic mode is activated and it gets deactivated after 1 min break.
Capacity of the pedometer memory assured 41 days of complete activity store.
Data acquisition was performed by downloading pedometer records on a computer using the specific software.
At the initial consultation, patients were instructed on how to use the pedometer and it was adjusted for weight and stride length of each patient. Data were downloaded at admission for surgery and the patients were asked to wear the pedometer again at discharge and to return to outpatient clinic 30 days after discharge.
2.3. Variables and data analysis
The recorded variables were the following:- For typifying the group of selected patients: age, sex, body mass index (BMI), preoperative FEV1%, preoperative carbon monoxide diffusing capacity (DLCO) and presence or absence of chronic obstructive pulmonary disease (COPD) according to the standard Gold criteria.
- From the pedometer: preoperative mean daily total steps (named as PreTotals), preoperative mean daily aerobic steps (PreAerobs), mean preoperative time of aerobic activity measured in minutes (PreAtime) and mean daily walked distance measured in km in the preoperative period (PreDis). The same variables were recorded during the postoperative period named as PosTotals, PostAerobs, PostAtime and PostDis.
- A new variable (DELTA) was created to measure the variation between pre- and postoperative values. The new variable was calculated as follows:
| (1) |
For data analysis and comparison, Wilcoxon and Mann–Whitney non-parametric tests were used.
|
3. Results
|
|---|
Twenty-one patients agreed to participate and were included in the study. Nineteen were males and 18 underwent lobectomy. General characteristics of the patients are as follows expressed as mean±S.D.: age: 63±10.9 (range: 48–85); BMI: 24.6±4.1 (range 17.1–32.5); FEV1(%): 88.45±22.7 (range: 47.2–131.7); FVC(%): 98.5±23.2 (range 56.3–137) and DLCO: 86.2±21.6 (range: 47–118). COPD was present in 11 patients. Cardiac morbidity consisted of five patients that have current treatment for hypertension and three that have ischemic cardiac disease: two in functional class I and the other one in functional class II of the NYHA (New York Heart Association). These three patients underwent a lobectomy. Postoperative mortality was nil and four lobectomy cases had a postoperative complication: two cases of prolonged air-leak treated conservatively, and two cases of atrial fibrillation treated with amiodarone.
In Table 1 individual pre- and postoperative data of daily exercise are shown. Preoperative walked distance ranged from 2.8 up to 15.5 km (3904.8 to 21,819 steps). Three patients were able to walk <5000 steps a day (patients 1, 2 and 20) and eight cases walked <10,000 steps a day (patients 3, 7, 8, 9, 12, 14, 19 and 21). The preoperative aerobic activity ranged from 62.3–15,406 steps which correspond to 1.1–70.1% of the total ambulatory recorded activity. Patients expend between 0.81–121.4 min in daily aerobic activity.
View this table:
[in this window]
[in a new window]
|
Table 1 Preoperative and postoperative individual data arranged by type of surgery and by presence or absence of COPD
|
|
During the first postoperative month after discharge, total ambulatory activity ranged from 1053 to 20,053 steps (0.75 to 14.23 km per day). In this period, eight patients were unable to walk over 5000 steps a day and eight more were unable to reach 10,000 steps. The mean daily aerobic ambulatory activity ranged from 0–14,932.1 steps. Two patients were unable to perform aerobic activity along all the postoperative period. Patients walked in the aerobic mode between 0 up to 115.9 min. COPD was neither related to pre- nor postoperative activity (Mann–Whitney U comparison: PreTotals P=0.944; PreAerobs P=0.481; PreAtime P=0.379; PosTotals P=0.181; PostAerobs P=0.121; PostAtime P=0.181).
In the pneumonectomy group, preoperative mean daily total ambulatory recorded activity was 4809.2±828.9 and ranged from 3904.7–5532.5 steps (2.8–3.92 km). The number of aerobic steps ranged from 732.6–2209.6 (daily mean: 1642.8±796.15 steps, 33% of the total recorded exercise). Patients in this group kept the aerobic exercise to a mean of 17.3±7.4 min a day (range 8.75–21.8 min). Along the postoperative period, mean daily total ambulatory activity ranged from 1681.5–3439 steps (mean 2491.7±886.7 steps) and the walked distance range was 1.2–2.43 km/day (mean 1.7±0.61 km). In this group, the aerobic activity ranged from 0–229.8 steps (mean 144.5±125.8 steps) and the daily mean time of aerobic activity was 1.62±1.4 min. During the postoperative period, the aerobic activity was 5.1% of the total activity registered. We found a reduction of the mean number of total steps and of the walked distance during the postoperative period of the 49% compared to the preoperative values and a reduction of the 92% when considering the aerobic steps along with a reduction of the 91% in the time of aerobic activity (Table 2).
In the lobectomy group, preoperative mean daily total ambulatory activity was 10,703.3±3807.6 (range: 4365.8–21,819 steps). Patients walked a mean of 7.5±2.92 km/day (range: 2.85–15.5). The range of aerobic steps was 62.3–15,406 (mean: 4391.8±4062.6 steps/day). The aerobic exercise was 37% of the total recorded exercise. In the preoperative period, patients in this group kept the aerobic exercise to a mean of 40.7±33.9 (range: 0.81–121.4) min/day. Along the postoperative period, daily total ambulatory activity ranged from 1053–20,052.9 steps (mean 7978.7±4486.9) and the walked distance varied from 0.75 to 14.23 km/day (mean 5.54±3.27 km). In this group, the daily mean time of aerobic activity was 30.37±29.1 min/day (35.4% of the total activity), and the mean postoperative aerobic activity was 3236.2±3625.1 steps (range 0–14,932.1). We found a reduction of the postoperative mean number of total steps and of the postoperative aerobic time of the 25% compared to the preoperative values, a reduction of the 27% in the mean number of aerobic steps and a reduction of the 28% of the walked distance during the postoperative period (Table 2).
Comparing the changes of activity after lobectomy or pneumonectomy (Figs. 1 and 2) only the DELTA of the mean daily aerobic activity and the DELTA of the mean time of aerobic activity were significantly different (P=0.035 and P=0.017).
View larger version (18K):
[in this window]
[in a new window]
|
Fig. 1. Comparison of changes in the daily mean aerobic activity depending on the type of surgery (P=0.035).
|
|
View larger version (18K):
[in this window]
[in a new window]
|
Fig. 2. Comparison of changes in mean time of daily aerobic activity depending on the type of surgery (P=0.017).
|
|
|
4. Discussion
|
|---|
Lung resection is followed by a decrease in exercise capacity (measured as VO2 max) at one month [1, 6]. In patients without further adverse events, exercise capacity increases thereafter [1] and reaches 95% of its preoperative value one year after the operation [7]. According to several authors [3–5], lung resection determines a transient impairment of QOL parameters, which is not related to the postoperative decrease of pulmonary volumes or exercise capacity. In most published papers evaluating QOL after lung resection, mental scales remained unchanged after lung resection while physical ones showed a significant impairment at one month and were fully recovered at three months after surgery. Nevertheless, no published objective measurements of daily exercise activity after lobectomy or pneumonectomy are available. We have supposed that measuring daily activity of the operated patients could offer an objective assessment of both physical and mental status after lung resection and serve as a useful tool to evaluate surgical outcomes besides operative mortality and/or morbidity.
Pedometers are simple, non-expensive devices used for recording body movement. They have been used in the assessment of physical activity behaviors and are considered useful for a valid assessment of physical activity both in the general population [8] and in people having health problems such COPD [9]. The use of a pedometer has been associated to an increase in physical activity and reduction of BMI and blood pressure [10]. The one used in our investigation has been previously tested in clinical settings and its reliability has been demonstrated [11]. Nevertheless, the selected device for this study gave no information on the heart rate and the assumption that after 10 min of continuous walking heart rate reached 85% of its maximal value for age remains unproved. The type of movement could not be evaluated in this study. Using other more sophisticated devices [12], information on the occurrence of stair climbing or other high energy-consuming movements can be retrieved. Nevertheless, we selected a simple pedometer to make the study easier for patients and decrease costs.
We have to acknowledge other limitations in our study. First, the number of cases is not enough to draw definitive conclusions. In this paper, we have communicated preliminary data based on a pilot sample of patients. Then, no evidences can be offered on several issues such as the correlation of pre- and postoperative daily activity to complex exercise tests, the influence of COPD, and a possible post-lobectomy lung volume effect [13, 14], on the daily activity of the patients and other relevant and interesting topics.
We cannot be sure that the recorded activity corresponds to really by the patients. All patients were instructed on the pedometer use but non-adverted bad functioning or bad usage could have existed without the patient or surgeon being conscious of it.
Our patients were not encouraged to increase their walking activity before admission for surgery. It has been demonstrated that using pedometers increases physical activity in adults [10] and it could be hypothesized that differences between pre- and postoperative values could have been biased due to a potential encouraging effect of the pedometer on patient's activity. We do not think this possible bias had relevant influence on our patients since, according to previously published information [15], the expected encouraging effect of a pedometer in adults over 65 years of age is low.
As a conclusion of this study, we have objectively demonstrated an impairment of the postoperative daily activity in patients after lung resection. This effect is more pronounced after pneumonectomy. Our data are valid to further design of studies with larger series of cases. It is important that, despite limitations, the chosen pedometer OMRON Walking Style Pro® is an efficient tool to evaluate the perioperative daily ambulatory activity of patients.
|
Conference discussion
|
|---|
Dr. A. Brunelli (Ancona, Italy): My question is, did you try to correlate some objective measure like oxygen consumption before and after operation with these differences in mobility, and did you try to verify whether there is a difference or a correlation with quality of life. In other words, if changes in ambulatory activity correlate with quality of life in these patients?
Dr. Novoa: Really, we are working now on correlation between the pedometry data and the VO2 max, but at this point I have no data I can comment on. I didn't think about it previously, but I think it is a good idea to correlate this data with the quality of life of the patients.
Dr. B. Balduyck (Antwerp, Belgium): Because this is a preliminary study, are you planning to do in your bigger study some sleeve resections, too, because it is known that the quality of life is much better compared to pneumonectomy patients.
Dr. Novoa: Well, really, we were not planning that. We were planning just to see what happened depending on the amount of lung that is resected. So, of course, you can see the difference between the pneumonectomy group and the lobectomy group; the difference is huge. I do not know how but we can think about to make this distinction.
Dr. D. Wood (Seattle, WA): I have one question. I was a little unclear on the postoperative studies. Are those studies that are averaged over the whole month of postoperative activity or is it a snapshot of activity 30 days after recovery? It would make a difference, obviously, and I just wasn't clear.
Dr. Novoa: The pedometer has a capability of 41 days to gather the information. So what we did is to collect all the data and analyze all the data. What I can say, that is not here, is that really patients showed the complete activity they are going to have at the end of the month from the very, very beginning. I mean, it can be day 2, day 3 after discharge, and patients are walking almost the same amount of steps that they are going to do at the end of the month. And we didn't want to prolong the study, because most of the patients will go into adjuvant treatment lines. So maybe that will interfere with the quality and the amount of steps they can take.
Dr. E. Stoelben (Cologne, Germany): I saw in the abstract that the preoperative results in the pneumonectomy group and the lobectomy group were different. The pneumonectomy group was worse than the lobectomy group. Can you explain this? Is it explained by the tumor?
Dr. Novoa: That is not completely right.
Dr. Stoelben: It was the same results preoperatively in both groups?
Dr. Novoa: It was not explained. Preoperatively, they are a little different. Patients with very good high capacity were in the lobectomy group. In the pneumonectomy group, one patient was within the sedentary group and the others were in the low level of activity previously. They act as they were a medium-low activity patients as seven patients of the lobectomy group.
|
References
|
|---|
- Brunelli A, Xiumé F, Refai M, Salati M, Marasco R, Sciarra V, Sabbatini A. Evaluation of expiratory volume, diffusion capacity and exercise tolerance following major lung resection: a prospective follow-up analysis. Chest 2007;131:141–147.[Abstract/Free Full Text]
- Larsen KR, Svendsen UG, Milman N, Breøe J, Petersen BN. Cardiopulmonary function at rest and during exercise after resection for bronchial carcinoma. Ann Thorac Surg 1997;64:960–964.[Abstract/Free Full Text]
- Brunelli A, Socci L, Refai M, Salati M, Xiumé F, Sabbatini A. Quality of life before and after major lung resection: a prospective follow-up analysis. Ann Thorac Surg 2007;84:410–416.[Abstract/Free Full Text]
- Cannon J, Win T. Long-term quality of life after lung resection. Thorac Surg Clin 2008;18:81–91.[CrossRef][Medline]
- Ilonen IK, Räsänen JV, Sihvo EI, Knuuttila A, Sovijärvi AR, Sintonen H, Salo JA. Pneumonectomy: postoperative quality of life and lung function. Lung Cancer 2007;58:397–402.[CrossRef][Medline]
- Watz H, Waschki B, Meyer T, Magnussen H. Physical activity in patients with COPD. Eur Respir J 2009;33:262–272.[Abstract/Free Full Text]
- Nagamatsu Y, Maeshiro K, Kimura NY, Nishi T, Shima I, Yamana H, Shirouzu K. Long-term recovery of exercise capacity and pulmonary function after lobectomy. J Thorac Cardiovasc Surg 2007;134:1273–1278.[Abstract/Free Full Text]
- Tudor-Locke C, Williams JE, Reis JP, Pluto D. Utility of pedometers for assessing physical activity: convergent validity. Sports Med 2002;32:795–808.[CrossRef][Medline]
- Schönhofer B, Ardes P, Geibel M, Köhler D, Jones PW. Evaluation of a movement detector to measure daily activity in patients with chronic lung disease. Eur Respir J 1997;10:2814–2819.[Abstract]
- Bravata DM, Smith-Spangler C, Sundaram V, Gienger AL, Lin N, Lewis R, Stave CD, Olkin I, Sirard JR. Using pedometers to increase physical activity and improve health: a systematic review. J Am Med Assoc 2007;298:2296–2304.[Abstract/Free Full Text]
- Holbrook EA, Barreira TV, Kang M. Validity and reliability of Omron pedometers for prescribed and self-paced walking. Med Sci Sports Exerc 2009;41:670–674.[CrossRef][Medline]
- Steele BG, Holt L, Belza B, Ferris S, Lakshminaryan S, Buchner DM. Quantitating physical activity in COPD using a triaxial accelerometer. Chest 2000;117:1359–1367.[Abstract/Free Full Text]
- Sekine Y, Iwata T, Chiyo M, Yasufuku K, Motohashi S, Yoshida S, Suzuki M, Iizasa T, Saitoh Y, Fujisawa T. Minimal alteration of pulmonary function after lobectomy in lung cancer patients with chronic obstructive pulmonary disease. Ann Thorac Surg 2003;76:356–361.[Abstract/Free Full Text]
- Baldi S, Ruffini E, Harari S, Roviaro GC, Nosotti M, Bellaviti N, Venuta F, Diso D, Rea F, Schiraldi C, Durigato A, Pavanello M, Carretta A, Zannini P. Does lobectomy for lung cancer in patients with chronic obstructive pulmonary disease affect lung function? A multicenter national study. J Thorac Cardiovasc Surg 2005;130:1616–1622.[Abstract/Free Full Text]
- Bohanon RW. Number of pedometer-assessed steps taken per day by adults: a descriptive meta-analysis. Phys Ther 2007;87:1642–1650.[Abstract/Free Full Text]
|
|
Top
Abstract
1. Introduction
