Melisa Miller

Feasibility and Effectiveness of Pre-operative Inspiratory Muscle Training in Patients

Undergoing Oesophagectomy: A Pilot Study
An Oesophagectomy is considered a minimally invasive surgery used to remove part or
all of an oesophagus (swallowing pipe) and usually the top part of your stomach. Most patients
who have this surgery have cancer of the oesophagus or cancer located at the very top part of
their stomach (Royal Devon and Exeter). In this pilot study, the researchers just focused on those
patients undergoing this surgery who had carcinomas that needed to be removed. These patients
tend to have a high risk of post-operative complications such as, pulmonary problems and
pneumonia. The researchers were looking to reduce post-operative pulmonary complications by
having the patients get into physiotherapy before their surgeries to learn deep breathing
manoeuvers, improved coughing techniques and early mobilization. The goal is also to help
shorten overall hospital stay by improving pulmonary function and to assess the feasibility and
effectiveness of the pre-operative respiratory muscle training in regards to pneumonia and the
length of patients hospital stays.
This study took place at the Academic Medical Center in Amsterdam, The Netherlands,
and was a non-randomized cohort study. Eligible patients were divided into two groups
depending on their travel distance to the hospital, patients had to visit the hospital once a week
for the inspiratory muscle training (IMT). The patients living within 40 km of the hospital and
planned for surgery with an interval of at least two weeks were considered eligible for IMT.
Those patients living further than 40 km from the hospital became the conventional care group
(CC). The exclusion criteria consisted of language barriers and co-morbidity interfering with
IMT; such as, mental retardation, and neuromuscular disorder.

All the patients were required to have a lung function test before surgery to see where
their lungs were at before the training and before surgery. They were tested at baseline and once
a week during their training period before surgery. The participants in the IMT group trained
every day for two weeks before surgery. The surgery was then performed by either a transhiatal
or a transthoracic approach. The primary outcomes of the pre-operative IMT were feasibility and
initial effectiveness.
The patient characteristics and the type of surgery were comparable for both the IMT
group and the CC group. There were no significant differences between pre-operative lung
function values between smokers and non-smokers. The initial effectiveness in the IMT group
was an increase in their median inspiratory muscle strength, rising from 73.5cmH2O at base line
to 90.5 cmH2O the day before surgery. The endurance values on days 1, 3, 5, 7, and 10 postoperatively were a lot higher in the IMT group than in the CC group. The incidence of postoperative pneumonia was 25% in the intervention group and 23% in the CC group. The overall
hospital stay was 13.5 and 12 day. Overall, in-hospital mortality was 4.8%; one patient in the
intervention group and three patients in the CC group died.
The researchers were able to demonstrate that pre-operative IMT was feasible, safe, and
well tolerated in patients having oesophagectomy surgery. They also demonstrated that IMT two
weeks before surgery increased inspiratory muscle strength. It was found, however, that preoperative IMT did not reduce post-operative pneumonia. The post-operative MIP and endurance
measurements on the first days after surgery were hindered by tiredness, oxygen suppletion,
nasogastric tubes and post-operative complications. The downside about this pilot study was that
the expected reduction of post-operative pneumonia could not be demonstrated. But, they were
able to find significant improvement in respiratory function in those patients who received IMT.

This pilot study did find a beneficial effect in respiratory function, staying in line with
other recent studies. The researchers agreed that further research of pre-operative risk factors is
needed to determine the patients who are at a higher risk to develop post-operative pneumonia.
They suggest that those patients with a high-risk profile should be included in a randomized
controlled trial to detect significant effect of IMT on post-operative outcomes. This article was
very interesting to read because of my interest in physical therapy. It showed that patients in all
sorts of situations could be helped by going to physical therapy not only after surgery, but also
before.
Source
Oesophagectomy Minimally Invasive Procedure. (2011). Retrieved November 1, 2015, from
http://www.rdehospital.nhs.uk/docs/prof/thoracic_uppergi/SG 07 023 003 word.pdf