术前短期综合肺康复训练对肺癌合并轻中度慢性阻塞性肺病患者的影响:一项前瞻性随机对照试验

Impact and Effect of Preoperative Short-term Pulmonary Rehabilitation Training on Lung Cancer Patients with Mild to Moderate Chronic Obstructive Pulmonary Disease: A Randomized Trial

背景与目的围术期肺康复训练计划能够加速肺癌手术患者的术后快速康复,但是其应用方案、时间等仍未统一。肺癌合并慢性阻塞性肺病(chronic obstructive pulmonary disease,COPD)的手术患者,由于其相对较差的肺功能及心肺耐力,一直以来,都是肺部相关并发症的高危人群。本研究旨在探讨术前短期综合肺康复训练对肺癌合并轻中度COPD手术患者的影响。方法前瞻性分析2015年3月11日至2015年11月31日四川大学华西医院胸外科行肺叶切除的原发性非小细胞癌合并轻中度COPD患者48例,随机分成实验组和对照组;实验组患者术前完成一周短期综合肺康复方案,包括以雾化吸入普米克令舒、博利康尼和沐舒坦静脉滴注为主的药物康复以及呼吸训练+耐力训练(Nustep)的物理康复;而对照组患者按常规术前准备进行。结果最终24例患者纳入实验组,24例患者纳入对照组:实验组患者的术后住院时间[(6.17±2.91)d vs(8.08±2.21)d;P=0.013]和术后抗生素使用时间[(3.61±2.53)d vs(5.36±3.12)d;P=0.032]低于对照组,总住院费用[(46,455.6±5,080.9)$vs(45,536.0±4,195.8)$,P=0.498]、住院材料费用[(21,155.5±10,512.1)$vs(21,488.8±3,470.6)$,P=0.883]、住院药物费用[(7,760.3±2,366.0)$vs(6,993.0±2,022.5)$,P=0.223]在两组间均无统计学差异;实验组患者对比训练前后,最大峰值流速(peak expiratory flow,PEF)[(268.40±123.94)L/min vs(343.71±123.92)L/min;P<0.001]、6分钟运动距离(6-min walk distance,6-MWD)[(595.42±106.74)m vs(620.90±99.27)m;P=0.004]及能量消耗[(59.93±10.61)kcal vs(61.03±10.47)kcal;P=0.004]提高;术后肺部相关并发症(postoperative pulmonary complications,PPCs)发生率(8.3%,2/24 vs 20.8%,5/24,P=0.416)差异无统计学意义。结论术前短期综合肺康复训练能够提高肺癌合并轻中度慢性阻塞性肺病患者心肺耐力,加速患者术后快速康复,可作为术前快速康复计划的重要部分。

Background and objective Pulmonary rehabilitation（PR） is proposed as an effective strategy to decrease surgical morbidity. However, appropriate rehabilitation plan, initiation time, and optimal duration of PR remain unclear. Lung cancer patients with chronic obstructive pulmonary disease（COPD） are considered high-risk population for postoperative pulmonary complications（PPCs） because of poor lung fitness and cardiopulmonary endurance. This study aims to assess the impact of a one-week, systematic and highly-intensive rehabilitation on surgical lung cancer patients with mild to moderate COPD. Methods A randomized controlled trial with 48 subjects was conducted（24 patients each for the intervention and groups）. The intervention group received seven days of systematic, integrated and highly-intensive PR before surgical treatment, including： pharmacotherapy with atomizing terbutaline, pulmicort and infusion of ambroxol; and physical rehabilitation with respiratory training and endurance training. The control group underwent standard preoperative care. Results For the in-tervention group, the postoperative length of stay was shorter [（6.17±2.91） d vs（8.08±2.21） d; P=0.013]; likewise for the duration of antibiotics use [（3.61±2.53） d vs（5.36±3.12） d; P=0.032]. No significant difference was found between the groups in total in-hospital cost [（46,455.6±5,080.9） ￥ vs（45,536.0±4,195.8） ￥, P=0.498], medicine cost [（7,760.3±2,366.0） vs（6,993.0±2,022.5）, P=0.223], and material cost [（21,155.5±10,512.1） ￥ vs（21,488.8±3,470.6） ￥, P=0.883]. In the intervention group, peak expiratory flow [（268.40±123.94） L/min vs（343.71±123.92） L/min; P〈0.001], 6-min walk distance（6-MWD） [（595.42±106.74） m vs（620.90±99.27） m; P=0.004], and energy consumption [（59.93±10.61） kcal vs（61.03±10.47） kcal; P=0.004] were statistically different after the seven-day exercise, compared with those on the first day. Finally, for the intervention group the incidence of PPCs（8.3%, 2/24 vs 20.8%, 5/24, 20.8%; P=0.416） were lower. Conclusion The systematic and highlyintensive pulmonary rehabilitation combining abdominal respiration training, respiratory exercise with incentive spirometry, and aerobic exercise could improve the cardiorespiratory endurance of lung cancer patients with mild to moderate COPD. The proposed program may be a practicable preoperative strategy.