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(Chest. 2000;118:384-390.)
© 2000 American College of Chest Physicians

Exercise Capacity of Thoracotomy Patients in the Early Postoperative Period*

Shinichiro Miyoshi, MD; Tatsuya Yoshimasu, MD; Taeko Hirai, MT; Issei Hirai, MD; Shinji Maebeya, MD; Toshiya Bessho, MD and Yasuaki Naito, MD

* From the General Thoracic Surgery (Dr. Miyoshi), Department of Surgery, Osaka University Graduate School of Medicine, Osaka, Japan; and Thoracic Surgery (Drs. Yoshimasu, Hirai, Maebeya, Bessho, Naito, and Ms. Hirai), Wakayama Medical College, Wakayama, Japan.

Correspondence to: Shinichiro Miyoshi, MD, 2–2 Yamadaoka, Suita, Osaka, Japan, 565-0871;


   Abstract
TOP
 Abstract
Introduction
 Materials and Methods
 Results
 Discussion
 References
 
Objective: We investigated the mechanism involved with the initial drop and subsequent recovery of exercise capacity in the early postoperative period of thoracotomy patients.

Methods: Sixteen patients (13 who had undergone lobectomy, 3 who had undergone pneumonectomy) underwent a routine pulmonary function test (PFT) and a cardiopulmonary exercise test preoperatively, within 14 postoperative days (POD; post-1; mean ± SD, 9 ± 2 POD), and after 14 POD (post-2; mean, 26 ± 12 POD).

Results: After surgery on post-1, PFT results of FVC, FEV1, and maximum ventilatory volume (MVV) significantly decreased. Oxygen uptake (O2) at a venous blood lactate level of 2.2 mmol/L (La-2.2), which was adopted as the empirical anaerobic threshold, and maximum O2 (O2max) decreased significantly to 88.2 ± 7.9% and 73.1 ± 15.4% of the preoperative values, respectively. La-2.2 min ventilation (E)/ MVV and maximum E (Emax)/MVV increased significantly from 0.36 ± 0.08 to 0.66 ± 0.20 and from 0.58 ± 0.14 to 0.80 ± 0.09, respectively. On post-2, though La-2.2 O2 did not change, O2max improved significantly to 81.5 ± 19.7% of the preoperative values, in association with significant increases in maximal tidal volume and Emax, which were produced by significant increases in the PFT results. La-2.2 E/MVV also decreased significantly to 0.49 ± 0.13, which indicated a sufficient recovery of respiratory reserve at submaximal exercise.

Conclusions: The initial drop of exercise capacity after lung resection seems to be derived from both circulatory and ventilatory limitations. Further, the subsequent recovery within 1 month seems to be produced by an improvement in ventilatory limitation, which was caused by the surgical injury to the chest wall.

Key Words: cardiopulmonary exercise testing • circulation • postoperative recovery • spirogram • thoracotomy • ventilation


   Introduction
TOP
 Abstract
 Introduction
Materials and Methods
 Results
 Discussion
 References
 
Many studies have been conducted to evaluate the effect of lung resection on postoperative pulmonary function, especially in patients with lung cancer. It has been reported that changes in pulmonary function are greatest in the first and second postoperative weeks1 2 and then improve, and the postoperative pulmonary function becomes constant with a permanent loss in 6 months. In the early postoperative period, within 1 month after surgery, pulmonary function test (PFT) results demonstrate the effects not only of loss of lung volume, but also of injury to the chest wall. During this early postoperative period, an initial drop and subsequent remarkable improvements in spirometry,2 lung3 and chest wall4 compliance, and diaphragm function5 results have all been reported. However, an exercise test has not been applied to evaluate this early postoperative period, although it has been administered during the distant postoperative period, such as within 3 to 6 months postoperatively,6 7 8 9 to study the effects of the permanent loss of pulmonary function on exercise capacity.

By means of cardiopulmonary exercise testing in patients who underwent lung resection by standard posterolateral thoracotomy, this present study focuses on the dramatic changes in exercise capacity seen in the early postoperative period and investigates the mechanisms of the initial drop and subsequent recovery from surgical injury.


   Materials and Methods
TOP
 Abstract
 Introduction
 Materials and Methods
Results
 Discussion
 References
 
Subjects
With their informed consent, we studied 16 patients who had undergone pulmonary resection. The patient characteristics and preoperative pulmonary functions are shown in Table 1 . The subjects were 12 men and 4 women with a mean (± SD) age of 60 ± 11 years (range, 41 to 80 years). Of the 16 subjects, 14 had bronchogenic carcinoma, and 2 had inflammatory pseudotumors. A standard posterolateral thoracotomy was employed for all patients. The pulmonary resection was performed as a lobectomy in 12 patients, bilobectomy in 1, and pneumonectomy in 3. The PFTs were nearly all normal, except for three patients (patients no. 4, 11, and 14), who had moderate obstructive pulmonary function disorders.


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  		Table 1. Patient Characteristics and Preoperative Pulmonary Function Data*

 
PFT and Exercise Test
A routine PFT and an incremental exercise test were performed on the same day with each patient preoperatively, within 14 postoperative days (POD; post-1; mean ± SD, 9 ± 2 POD) and after 14 POD (post-2; mean, 26 ± 12 POD).

The incremental exercise test was administered using an electronically braked cycle ergometer (232C Ergometer; Minato Medical Science; Osaka, Japan) at a pedaling frequency of between 50 and 60 revolutions/min. After a 5-min rest, the work rate was increased by 15 W every 3 min until the symptom-limited maximum. Capillary oxygen saturation (ScO2) and pulse rate were monitored continuously with a pulse oximeter (Nellcor Pulse Oxymeter N-200; Nellcor Puritan Bennett; Pleasanton, CA). Before exercise and during the last 30 s of each workload, venous blood samples were taken from the subjects by means of a catheter attached to an antecubital vein for lactate determination. Hemoglobin concentration (Hb) was also measured from blood samples taken at rest.

Inspired and expired gases were analyzed by a computerized on-line breath-by-breath system (Aeromonitor AE-280S; Minato Medical Science).10 The oxygen concentration was determined by a zirconia solid electrolyte O2 analyzer,11 and the carbon dioxide concentration was determined using an infrared CO2 analyzer.12 Both analyzers were calibrated with room air and a standard gas (O2, 92%; CO2, 8%). Inspiratory and expiratory flow rates were measured by a hot-wire flowmeter,13 which had been calibrated with a 2-L syringe. Temperature and humidity of the room air were measured before each test, and the output of the flowmeter was compensated.14 Breath-by-breath respiratory rate (RR), tidal volume (VT), minute ventilation (E, body temperature and pressure saturated with water vapor), O2 uptake (O2, standard temperature and pressure, dry), and CO2 output (CO2, standard temperature and pressure, dry) were measured and integrated for 1-min intervals. A time delay (transport and dynamic response delay) of the gas concentration vs flow was compensated.15 The data from the last minute of each workload were taken for analysis.

The highest workload increment completed was defined as the maximum work rate, and the O2 at this level was defined as maximum O2 (O2max). Moreover, O2 at a venous blood lactate level of 2.2 mmol/L (La-2.2) was also determined as the empiric anaerobic threshold.16 The data at La-2.2, such as O2, heart rate, ScO2, RR, VT, and E, were calculated by linear interpolation between two adjacent values. The percentage of maximum heart rate (HRmax) against the predicted HRmax was calculated by (HRmax/predicted HRmax) x 100, where predicted HRmax was obtained by the formula as follows: predicted HRmax = 220 minus age of patient ( in years) studied.17

Statistics
All values are presented as mean ± SD. Comparisons between preoperative and post-1 data, as well as between post-1 and post-2, were analyzed by a paired t test. Maximum exercise data on post-1, between patients with La-2.2 and those without La-2.2, were compared with an unpaired t test. These statistical analyses were calculated with the StatView program (SAS Institute; Heidelberg, Germany), and p < 0.05 was regarded as a statistically significant difference.


   Results
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
Discussion
 References
 
The preoperative and postoperative PFTs and incremental exercise tests are summarized in Table 2 and Table 3 , respectively.


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  		Table 2. Preoperative and Postoperative Pulmonary Function Data in Thoracotomy Patients*

 

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  		Table 3. Preoperative and Postoperative Exercise Data in Thoracotomy Patients*

 
FVC, FEV1, and maximum ventilatory volume (MVV) were all significantly decreased at post-1, then significantly improved at post-2.

Hb also decreased significantly after surgery, at post-1, because of perioperative bleeding. None of the patients received a transfusion; however, Hb was significantly increased at post-2.

Although all 16 patients went beyond La-2.2 at maximum exercise during the preoperative and post-2 tests, 5 patients did not reach La-2.2 on post-1, even at maximum exercise. Therefore, the empirical anaerobic threshold expressed by La-2.2 O2 and other parameters at La-2.2 could not be obtained for post-1 in these 5 patients.

Levels of La-2.2 O2 and La-2.2 O2 pulse decreased significantly post-1 but did not increase at post-2, unlike the PFTs. La-2.2 heart rate significantly increased from preoperative to post-1, then decreased significantly at post-2. La-2.2 ScO2 did not change at all after surgery for either post-1 or post-2. La-2.2 RR increased and La-2.2 VT decreased significantly at post-1. As a result, La-2.2 E did not change. La-2.2 VT/FVC and La-2.2 E/MVV significantly increased at post-1, which demonstrated that breathing reserve significantly decreased. Although La-2.2 RR and La-2.2 VT did not change significantly at post-2, La-2.2 E decreased slightly, but significantly. Although La-2.2 VT/FVC decreased slightly at post-2, it did not reach statistically significant levels (p = 0.16). However, La-2.2-E/MVV dramatically decreased, reflecting the significant increase in MVV (Table 2) and decrease in La-2.2 E.

O2max and HRmax significantly decreased post-1, then increased significantly at post-2, unlike La-2.2 O2. The percentage of HRmax against the predicted maximum heart rate, expressed by HRmax/predicted HRmax, changed after surgery, as did HRmax. Maximum O2 pulse significantly decreased at post-l but did not improve at post-2. Maximum ScO2 did not change after surgery at either post-1 or post-2. Maximum RR significantly increased at post-l and did not improve at post-2. While VTmax and Emax decreased significantly at post-1, VTmax/FVC and Emax/MVV increased significantly to their maximum values of 54.8% and 0.77, respectively, at post-1. These results suggested that the breathing reserves were extremely small at maximum exercise on post-1. Vtmax and Emax significantly increased after 14 POD (post-2), which shows a significant improvement in ventilatory capacity. The results, showing that VTmax/FVC and Emax/MVV did not improve at post-2, indicated that patient breathing reserve at maximum exercise was still small on post-2.


   Discussion
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
References
 
A posterolateral thoracotomy and pulmonary resection procedure causes damage, which can be seen in the early postoperative period, to both the chest wall and the lung mechanics of patients. The reduction in chest wall compliance is thought to be due to fixation of portions of the chest by local muscle spasms associated with pain.4 Lung compliance is also diminished because of reduced lung volume, accumulated bronchial secretion, microatelectasis, increased lung water, or reduced surfactant activity.3 4 18 Further, diaphragm dysfunction is also induced during this period,5 causing severely impaired spirograph results. However, as the chest wall and lung injuries improve, their mechanics return to close or equal to their preoperative status. This improvement is generally observed by the seventh postoperative day and continues for at least 1 month.3 During this early postoperative period, thoracotomy patients recover dramatically, originally lying in bed, then walking, and finally returning to almost normal activity. The present study was conducted to investigate the mechanisms of the initial drop and subsequent recovery from surgical injury in the early postoperative period by means of cardiopulmonary exercise testing.

Our patients did not experience any postoperative complication that affected their postoperative pulmonary function or exercise capacity. It has been reported that changes in pulmonary function are greatest in the first and second postoperative weeks,1 2 then improve to the point where postoperative pulmonary function becomes constant with a permanent loss in 6 months.9

The post-1 (mean, 9 ± 2 POD) and post-2 (mean, 26 ± 12 POD) PFTs of our patients were about 60% and 70%, respectively, of the preoperative values, as shown in Table 2 , which are similar to findings reported by others.1 2 4 Postoperative PFTs should reach about 90% of the preoperative values within 6 months.8 9

We originally had planned to administer the exercise test three times postoperatively. However, since it was difficult to achieve this goal for all of the patients, two series of data were adopted for analysis, one of which was obtained within 14 POD and the other at 14 POD.

The O2-blood lactate curves of patient 1, who underwent the exercise test three times postoperatively, are shown in Figure 1 . The preoperative curve is shifted to the left on POD 6, and therefore, both La-2.2 O2 and O2max results are reduced. Only O2max was found to improve on POD13, then further improve on POD 20. This phenomenon was observed in many of the patients, as shown in Table 3 and Figure 2 .



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  		Figure 1. O2-blood lactate curves of patient 1 obtained preoperatively (pre), and on postoperative days 6, 13, and 20 (POD). The curve shifts to the left after surgery, and only O2max improves on POD 13 and 20 compared with that on POD 6.

 


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  		Figure 2. La-2.2 O2 and O2max after surgery expressed as percentages of the preoperative values. La-2.2 O2 did not change between post 1 (88.2 ± 7.9%) and post-2 (82.1 ± 12.9%), but O2max increased significantly from post-1 (73.1 ± 15.4%) to post-2 (81.5± 19.7%).

 
Five of 16 patients stopped exercising before their blood lactate levels reached La-2.2 on post-1, but all of them went beyond La-2.2 on post-2. Since the shift of the O2-blood lactate curve to the left can be explained mainly by the reduction of oxygen delivery, which consists of circulatory factors,19 circulatory capacity is considered to be reduced after a lung resection. However, the improvement in O2max, from post-1 to post-2, seems to be due to other factors.

Maximum exercise data on post-1 were compared between patients who reached La-2.2 and those who did not, and the results are shown in Table 4 . Circulatory and ventilatory parameters were larger in patients with La-2.2 than in those without La-2.2. Further, both heart rate and respiratory reserves were smaller in patients with La-2.2 than in those without La-2.2. These results might indicate that the limiting factor for the patients without La-2.2 was due to their poor effort. However, the high RR of patients without La-2.2 shows their maximum respiratory effort. Although subjective factors concerning the patients were not obtained, pain from the surgical wound in the chest could be the most important limiting factor for patients without La-2.2 in the very early postoperative period. However, Tmax/FVC and Emax/MVV results for patients with La-2.2 were as high as 57.8% and 0.807, respectively (Table 4) . These data are compatible with the results of interstitial lung disease reported by Gallagher and Younes.20 Post-l heart rate reserve was slightly larger than preoperative heart rate reserve, while post-1 breathing reserve was quite a lot smaller than preoperative breathing reserve (Table 3) . These findings suggest that the maximal factor limiting exercise in thoracotomy patients who overcame wound pain in the chest was ventilation, rather than circulation, in the first 2 weeks postoperatively.


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  		Table 4. Comparison of Maximam Exercise Data on Post-1 Between Thoracotomy Patients with La-2.2 and Those Without La-2.2*

 
From post-1 to post-2, O2max improved significantly, but La-2.2 O2 did not, as shown in Figure 2 . During this period, HRmax significantly increased, while maximum O2 pulse did not. It is notable that these findings do not indicate that the improvement of O2max was derived from the improvement of circulatory capacity. In contrast, VTmax and Emax were extremely improved (Table 3) . The associated improvement of FVC and MVV from post-1 to post-2 caused an increase in VTmax and Emax, and, consequently, O2max as well.

Since the patients were living their postoperative lives almost always at below or around the anaerobic threshold during their hospital stay, the data obtained at La-2.2 are thought to be more suitable for analyzing the mechanisms causing their shortness of breath, rather than those obtained at maximal exercise. The marked increase in La-2.2 E/MVV on post-1, which demonstrates only a small breathing reserve even at submaximal exercise, may have been the main cause of patient dyspnea. On post-2, the significant increase in MVV and decrease in La-2.2 E resulted in a dramatic decrease in La-2.2 E/MVV. This restoration of sufficient breathing reserve at submaximal exercise seemed to make it possible for the patients to be discharged and to return to their normal active lives.

To reduce injury to the chest wall, a muscle-sparing thoracotomy,2 21 vertical axillary thoracotomy,22 and median sternotomy23 were each performed in place of the standard posterolateral thoracotomy. More recently, a video-assisted thoracoscopic approach has been attempted for lobectomy in patients with early-stage lung cancer.24 25 However, the benefits of these alternate approaches, are very small compared with a standard posterolateral thoracotomy, especially in terms of pulmonary function.2 25 Cardiopulmonary exercise testing, which is a loading test for both the cardiovascular and respiratory systems, could be more sensitive in evaluating the differences between these thoracotomy approaches.

In the long time period following surgery, the chest wall regains its preoperative mechanical properties. On the other hand, resection of a functioning lung results in permanent decreases in ventilatory alveolar space and pulmonary capillary vasculature. Nezu et al9 studied hemodynamic responses during peak effort before and 3 months after surgery in lobectomy patients. They found that peak cardiac output was significantly decreased, and mean pulmonary artery pressure and pulmonary vascular resistence were significantly increased in association with an significant decrease in maximal O2. The breathing reserve of their lobectomy patients was 34%, which was not significantly different from preoperative breathing reserve. Thus, the chest wall injury became almost negligible within 3 months following surgery, and the limiting factor for exercise was a reduction of circulatory capacity, which was probably suppressed by the reduction of pulmonary vasculature, even in lobectomy patients. In pneumonectomy patients, maximal O2 is also thought to be limited by reduced cardiac output.26 Our previous study,6 demonstrating that vital capacity was closely correlated to empirical anaerobic thresholds in lung cancer patients in the late postoperative period, also supported the notion that the limiting factor of exercise capacity in thoracotomy patients in the late postoperative period was circulation.

In the present study, the reduction of circulatory capacity is evaluated as a shift of the O2-blood lactate curve to the left. According to results of Bolliger et al8 and Nezu et al,9 the O2-blood lactate curve should shift to the right within 6 months of surgery. However, such a small improvement of pulmonary function, from postoperative 3 months to postoperative 6 months, does not explain the improvement in exercise capacity. The improvement of and increase in the patient’s daily activity must itself function as a rehabilitation for lobectomy patients, thereby improving their exercise capacity.

In summary, a posterolateral thoracotomy and pulmonary resection produces a marked reduction in spirograph results and exercise capacity, as expressed by La-2.2 O2 and O2max in the early postoperative period. Within 1 month postoperatively, only O2max significantly improves, as indicated by spirogram results. These findings derive from an improvement in ventilatory limitation, which had originally been caused by the surgical injury to the chest wall.


   Footnotes
 
Abbreviations: Hb = hemoglobin concentration; HRmax = maximum heart rate; La-2.2 = venous blood lactate level of 2.2 mmol/L; MVV = maximum ventilatory volume; PFT = pulmonary function test; POD = postoperative day; post-1 = within 14 POD; post-2 = after 14 POD; RR = respiratory rate; ScO2 = capillary oxygen saturation; E = minute ventilation; O2 = oxygen uptake; O2max = maximum O2; VT = tidal volume; VTmax = maximum VT

Received for publication October 28, 1999. Accepted for publication February 24, 2000.


   References
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
 References
 

  1. Gorlin, R, Knowles, JH, Storey, CF (1957) Effects of thoracotomy on pulmonary function. J Thorac Surg 34,242-249
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