Effect of Prehabilitation in Lung Cancer Patients Undergoing Lobectomy: A Review

Deaths from lung cancer are mostly caused by smoking. Cough, dyspnea, fatigue, weight loss, and Horner's syndrome are among the symptoms. Non-small cell lung cancer (NSCLC) and small cell lung cancer (SCLC) are the two categories into which lung cancer may be divided. Because of its effectiveness and lower death rates, lobectomy is the primary line of therapy for benign and early-stage lung illnesses. Pulmonary rehabilitation is a routine treatment for thoracic surgery individuals who are at a high risk to improve functional ability, avoid postoperative deterioration, avoid postoperative deterioration, and reduce complications and even hospital stays. Pulmonary rehabilitation is a multifaceted continuum of services intended to help individuals with pulmonary disease and their families reach and sustain their highest possible degree of independence and community functioning, typically provided by an interdisciplinary team of specialists. The objective of this research was to gather preliminary information and assess the effects of pre-rehabilitation on those suffering from lung cancer and having lobectomy. The pre-rehabilitation program's outcomes include increased lung functional capacity, enhanced quality of life, patient independence in daily living activities, and a shorter hospital stay. Gradually increasing walking distance over time can build endurance, requiring consistency, pacing, proper hydration, nutrition, and regular breaks. This review analyzed the effect of pre-rehabilitation in lung cancer patients undergoing lobectomy. Pre-rehabilitation program for individuals with lung cancer improves both preoperative and postoperative health through various exercises. Pulmonary rehabilitation is a multidisciplinary approach that encourages physical activity, learning about disease, treatment options, and coping mechanisms. Instead of curing the illness, its goal is to lessen its symptoms and limitations. Patients with pulmonary diseases or undergoing thoracic surgery prefer pre-rehabilitation programs due to their non-traumatic nature and fewer resources required. Elastic resistance band exercises are beneficial for lung cancer patients' pre-rehabilitation by strengthening and stretching muscle groups, improving exercise capacity, and supporting white blood cell counts. These exercises can be customized to individual needs, making them a safe and effective addition to a patient's exercise routine. They have to be carried out at least three days a week. Pulmonary exercise, including the use of a tri-ball pulmonary exerciser or three-ball spirometer, can improve lung function, respiratory muscle strength, and exercise capacity in lung cancer patients. It involves breathing techniques, cough exercises, and inflating a balloon. Pulmonary rehabilitation has a positive impact on patient health. Improved lung vital capacity, shorter hospital stays, and fewer problems following surgery are all achieved with pulmonary rehabilitation. The pre-rehabilitation plan allows the patient to resume their daily routines.


Introduction And Background
Lung cancer is a highly frequent malignancy globally with notable fatality rates [1].Bronchogenic carcinoma, another name for lung cancer, which originates in the bronchi or lung parenchyma, is an important factor in deaths from cancer in the United States (US).The primary cause of its sharp increase in subsequent decades is the rise in both male and female smoking, which was once uncommon [2].The disease is often diagnosed late because it has no symptoms at first, which frequently results in a bad prognosis [3].Smoking is linked to lung cancer in 90% of cases, with males being more at risk.The risk is increased by 20-30% by using other tobacco products, such as pipes and cigars.The risk is also raised by 20-30% by passive smoking.Around 90% of occurrences of lung cancer are related to smoking, with men being more susceptible.Using pipes and cigars, among other tobacco products, increases the risk by twenty to thirty percent.Passive smoking also raises the risk by twenty to thirty percent with other additional pollutants and metals and causes other lung disorders such as idiopathic pulmonary fibrosis [4].Lung cancer represents 12.4% of all cases worldwide and is the leading cause of cancer-related mortality.It is also the most common disease worldwide.Even with better treatment, women's five-year survival rates were 24%, higher than men's, which were at 17%.The primary treatment modalities include surgery, radiation, and chemotherapy, with treatment selection dependent on the kind, stage, location, and health of the patient's tumour [5].Physiotherapists should be aware of and manage symptoms, including cough, breathing difficulty, chest discomfort, exhaustion, appetite loss, and Horner's syndrome, characterized by a tiny pupil and drooping eyelid [6].Lung cancer is categorized into two groups: non-small cell lung cancer (NSCLC) and small cell lung cancer (SCLC), with NSCLC accounting for 85% and SCLC accounting for 15%, respectively [7].

Lobectomy
Dr. Hugh Morriston Davies conducted a lobectomy in 1913, surgically excising the whole lung lobe.Incisions of less than 8 cm are commonly used to treat both benign and malignant conditions such as lung abscess, emphysema, fungal infection, and lung cancer [8].Video-assisted thoracoscopic surgery (VATS) and roboticassisted thoracoscopic surgery are effective methods for treating both benign and malignant lung diseases.However, a significant pulmonary reserve is necessary for a successful resection [9].Risks associated with surgical procedures involving the pleural space and lungs include bleeding, accumulation of pus or fluid, lung collapse, bronchopleural fistula, empyema, infections, pneumothorax, haemorrhage, and other potential complications [10].Due to growing evidence that VATS lobectomy reduces mortality and morbidity rates and is effective, it is presently advised as the initial treatment option in some cases of early-stage lung cancer and benign lung illnesses [11].

Prehabilitation
Thoracic surgery frequently uses pre-rehabilitation to enhance functional capacity and avoid postoperative deterioration, particularly for high-risk patients receiving lung transplants and volume reduction surgery [12].Pulmonary rehabilitation is done in order to enhance the emotional and physical health of those suffering from long-term pulmonary conditions; this programme promotes sustained dedication to activities that improve health [13].Over the last 10 years, research has demonstrated the many advantages of pulmonary rehabilitation for exercise training for people with chronic obstructive pulmonary disease (COPD).A crucial element in improving the effectiveness of rehabilitation for patients who have undergone lung transplants is comprehensive care tailored to their individual needs [14].Pulmonary rehabilitation is a comprehensive surgery that seeks to reduce symptoms such as tiredness and dyspnea while improving quality of life, exercise tolerance, and functional status [15].
A multifaceted progression of services provided to individuals with pulmonary disease and their families, typically by an interdisciplinary team of specialists, with the goal of achieving and maintaining the individual's maximum level of independence and community functioning, is known as pulmonary rehabilitation [16].Before surgery, pulmonary rehabilitation is an essential part of individualised, familyfocused, multidisciplinary care.This entails medical professionals, nurses, respiratory therapists, physical therapists, occupational therapists, dietitians, and psychologists [17].Pulmonary rehabilitation, involving interventional techniques and exercise, has been shown to reduce hospital stays and postoperative issues in patients undergoing lobectomies or lung resections [18].For two to four weeks, patients in the pulmonary rehabilitation group had training in peripheral muscle training, respiratory exercise, and appropriate breathing methods under the supervision of physiotherapists.Exercises for peripheral circulation, aerosol treatment, mobilising the shoulder girdle, and expanding the chest were all part of the pulmonary rehabilitation that was started [19].It is possible to decrease atelectasis, avoid hospital-acquired infections, and speed up recovery from major thoracic surgery by combining preoperative oxygen use with a six-minute walk distance [20].

Review Methodology
Articles were searched on databases like Google Scholar and PubMed with the keywords lung cancer, lobectomy, prehabilitation, pulmonary rehabilitation, peak oxygen uptake (Vo2 peak), six-minute walk test, health-related quality of life, SCLC, NSCLC stages (I-IV), lung surgery, and physical manipulation pulmonary rehabilitation.Relevant publications were evaluated and included in this review, as shown in Table 1.Academic publications, original research, case-control studies, randomised trials, and crosssectional studies were all taken into consideration.The review study analyses the effect of prehabilitation in lung cancer patients undergoing lobectomy by rating and classifying inclusion criteria by subjects who were willing to participate in studies, both male and female, including smokers, participants diagnosed with lung cancer, lobectomy, and acute condition, and exclusion criteria by participants with nerve involvement, rib fracture, recent implantation, and recent coronary artery bypass graft.After manually searching and eliminating unwanted and duplicate articles, 15 articles were selected for this review article (Figure 1

Discussion
Lung cancer, a major cause of cancer-related mortality in the United States, is primarily caused by increased smoking rates among both men and women [2].The disease is frequently diagnosed in its early asymptomatic stage; however, it commonly progresses without symptoms until later stages, leading to a poor prognosis [3].Smoking is responsible for 90% of lung cancer cases with men at higher risk.Passive smoking increases risk by 20-30%.Factors like toxins, metals, and lung conditions also increase risk [4].Physiotherapists must possess proficiency in addressing a range of symptoms associated with the illness, including chest discomfort, fatigue, coughing, dyspnea, appetite loss, and Horner's syndrome [6].NSCLC patients generally have higher survival rates compared to SCLC patients [7].A lobectomy, which treats both benign and malignant lung illnesses, involves surgically removing the whole lung lobe [9].Pleural space lung surgical procedures have many potential dangers; these include infection, pneumothorax, haemorrhage, bronchopleural fistula, empyema, and pleural effusion.In addition to bleeding, bronchopleural fistula, pus in the chest cavity, and fluid in the lungs and chest wall, these dangers also include lung collapse [10].Due to its efficiency in lowering mortality and morbidity rates, VATS lobectomy is advised as the main therapy for early-stage lung cancer and several benign lung illnesses [11].
A comprehensive approach called pulmonary rehabilitation aims to improve the physical and emotional well-being of people with chronic lung disorders and promote long-term health-enhancing practices.[13].
By promoting physical exercise and educating patients about their condition, available treatments, and coping techniques, rehabilitation strives to return patients to their highest degree of independent function [35].Studies show pulmonary rehabilitation positively impacts lung cancer patients before lobectomy and post-resection, reducing dyspnea psychological symptoms, improving exercise ability, and improving the standard of living [21].Following minimally invasive pulmonary lobectomy surgery, prehabilitation considerably lowers the incidence and severity of post-operative problems [25].The workout group showed higher increases in the peak oxygen consumption rate [26].The 6MWD test showed an 8% improvement after two months of exercise training and 43% and 32% improvements after a rehabilitation program [29].
Pulmonary rehabilitation shows the impact on patient health.It improves lung vital capacity [30].Pulmonary rehabilitation reduces the duration of hospital stay and reduces problems following surgery [33].

Conclusions
This review analyzed the impact of prehabilitation on patients with lung cancer who are undergoing lobectomy.The lung cancer patients' prehabilitation program improves preoperative and post-operative health through various exercises.Pulmonary rehabilitation is a multidisciplinary approach that encourages physical activity, learning about disease, treatment options, and coping mechanisms.It aims to reduce symptoms and disability from the disease rather than reversing it.Patients with pulmonary diseases or undergoing thoracic surgery prefer prehabilitation programs due to their non-traumatic nature and fewer resources required.Resistance exercises, including stretching and strengthening routines utilizing an elastic resistance band, need to be carried out thrice a week at a minimum.Pulmonary exercise (using a tri-ball pulmonary exerciser, breathing techniques, cough exercises, and inflating a tiny balloon).Pulmonary rehabilitation has a positive impact on patient health.It improves lung vital capacity, reduces hospital stay, and decreases post-operative complications.With the help of a rehabilitation program, patients easily get back to the activities of daily living.

FIGURE 1 :
FIGURE 1: Preferred Reporting Items for Systematic Reviews and Meta-Analyses flowchart.
), which is shown in the PRISMA flow diagram.