Multimodal prehabilitation before lung resection surgery: a multicentre randomised controlled trial

Respiratory muscle training may improve ventilatory efficiency (VE/VCO2 slope), a strong predictor of postoperative pulmonary complications. We hypothesised that multimodal prehabilitation, incorporating high-intensity respiratory muscle training, before lung resection would reduce postoperative complications and length of hospital stay. We conducted a prospective multicentre, randomised controlled trial (NCT04826575) to examine the effect of prehabilitation in individuals undergoing lung resection. Participants were defined as high-risk for postoperative pulmonary complications if they achieved VE/VCO2 slope ≥33, as determined by cardiopulmonary exercise testing. Participants were then randomised to either usual care or multimodal prehabilitation, which consisted of a 14-day programme of high-intensity respiratory muscle training, smoking cessation, nutritional support, and psychological support. The primary outcome were postoperative pulmonary and cardiovascular complications (pneumonia, atelectasis, respiratory failure necessitating mechanical ventilation, adult respiratory distress syndrome, prolonged air leak). A total of 122 patients (46% female; age range: 64-75 yr) completed the study. Postoperative pulmonary complications occurred in 20/58 (34%) of patients randomised to multimodal prehabilitation, compared with 35/64 (55%) patients receiving usual care (odds ratio 2.29 [95% confidence interval 1.10-4.77]; P=0.029). Hospital length of stay was shorter after multimodal rehabilitation (9 days [7-11]), compared with patients randomised to receive usual care (7 days [6-9]; P=0.038). After prehabilitation, mean (sd) VE/VCO2 slope decreased from 39 (8) to 36 (9); P=0.01. Prehabilitation also improved patient-reported quality of life measures. In high-risk patients undergoing elective lung resection surgery, multimodal prehabilitation, including high-intensity respiratory muscle training to target VE/VCO2, reduced postoperative pulmonary complications and hospital length of stay.