[Anatomical resection for non-small cell lung cancer: cardiopulmonary exercise testing in assessing the risk of respiratory complications]. / Anatomicheskie rezektsii po povodu nemelkokletochnogo raka legkogo: kardiorespiratornoe nagruzochnoe testirovanie v otsenke riska respiratornykh oslozhnenii.

OBJECTIVE: To assess the role of cardiopulmonary exercise testing in examination of patients with high risk of respiratory complications in anatomical resections for non-small cell lung cancer. MATERIAL AND METHODS: A non-randomized retrospective single-center study was devoted to immediate results of surgical treatment of patients with NSCLC between December 2020 and April 2021. Median age of patients was 65 (84; 30) years, male-to-female ratio - 129 (57%)/98 (43%). All patients were examined according to a unified algorithm recommended by the American (ATS) and European (ESTS) societies of thoracic surgeons. At the first stage, we analyzed airflow rate and performed non-invasive exercise tests (6-minute walk and/or stair test). Resections of lungs were performed in 231 patients, anatomic lung resections - in 227 patients (lobectomy - 199, bilobectomy - 4, segmentectomy - 17, pneumonectomy - 7). We excluded 4 patients who underwent non-anatomic lung resections (marginal resections). RESULTS: Among 236 patients referred for anatomical lung resections, 34 (14.4%) ones were selected for cardiopulmonary testing. Selection was based on low exercise tolerance and/or severe decrease in predictive respiratory parameters (FEV<50%). Patients were divided into 4 groups depending on peak oxygen consumption. There were 5 (2%), 10 (29.4%), 11 (32.3%) and 8 (23.5%) patients with extremely high, high, moderate and low risk of respiratory complications, respectively. Surgeries were performed for IA1 (n=6), IA2 (n=50), IA3 (n=37), IB (n=31), IIA (n=19), IIB (n=37), IIIA (n=25) and IIIB (n=4) stages. The overall incidence of postoperative complications was 23% (95% CI: 18-28.8). Complications Clavien-Dindo grade I, IIIA, IIIB, IVA, IVB and V prevailed in both groups. Median postoperative hospital-stay (6 (6; 8) vs. 7 (6; 8) days) and time of pleural drainage (4 (2; 5) vs. 3 (3; 4) days) were similar. Organ-sparing procedures prevailed in the main group (5 (26%) out of 19 (95% CI: 11.81-48.8) vs. 12 (6.7%) out of 180 (95% CI: 3.8-11.3)). Overall mortality (n=231) was 1.7% (95% CI: 0.7-4.4). Mortality throughout the first postoperative year was 24% (95% CI: 12.2-42.1) and 7.4% (95% CI: 4.2-11.3), respectively. CONCLUSION: Cardiopulmonary exercise testing makes it possible to objectively assess exercise tolerance and identify high-risk patients for respiratory complications. These data are valuable when planning the treatment of patients with non-small cell lung cancer.

[Enhanced recovery in thoracic surgery]. / Uskorennaya reabilitatsiya v torakal'noi khirurgii.

OBJECTIVE: To present an experience of adapting the accelerated rehabilitation protocol at the thoracic surgery department of the Moscow City Clinical Oncology Hospital No. 1. MATERIAL AND METHODS: An effectiveness of the accelerated rehabilitation program in the city oncology hospital was retrospectively analyzed for the period from February to December 2019. Lung resections were performed in 252 patients with median age 66 (59; 71) years and an equal ratio of men and women (124/128). Primary non-small cell lung cancer was noted in 194 (77%) patients, secondary malignant neoplasms of lungs - in 58 (23%) cases. ASA grading system of anesthetic risk was applied (American Society of Anesthesiologists): grade II - 56 (22.2%) patients, grade III - 203 (75.2%) patients, grade IV - 7 (2.8%) patients. RESULTS: Lobectomy was performed in 147 patients, segmentectomy - in 32, bilobectomy, pneumonectomy and marginal resection - in 1, 3 and 69 cases, respectively. Endoscopic operations made up 13.6% (n=20), 12.5% (n=4) and 78% (n=54). Postoperative 30-day complications occurred in 19 (7.5%) out of 252 patients (95% CI 4.9-11.5). Postoperative 30-day mortality was 1.98% (5 out of 252 patients, 95% CI 0.9-4.6). Median postoperative hospital-stay was 7 (6; 8) days. CONCLUSION: Implementation of fast track protocol requires time and the first results can be assessed after 6-12 months. Continuous monitoring of implementation of the protocol elements by all members of multidisciplinary team, analysis of complications and long-term results are required to realize all potential benefits of this program.

OPTIMUM LEVEL OF POSITIVE END-EXPIRATORY PRESSURE IN ACUTE RESPIRATORY DISTRESS SYNDROME CAUSED BY INFLUENZA A(H1NI)PDM09: BALANCE BETWEEN MAXIMAL END-EXPIRATORY VOLUME AND MINIMAL ALVEOLAR OVERDISTENSION.

THE AIM: to determine optimum level ofpositive end-expiratory pressure (PEEP) according to balance between maxi- mal end-expiratory lung volume (EEL V)(more than predicted) and minimal decrease in exhaled carbon dioxide volume (VCO) and then to develop the algorithm of gas exchange correction based on prognostic values of EEL K; alveolar recruitability, PA/FiO2, static compliance (C,,,) and VCO2. MATERIALS AND METHODS: 27 mechanically ventilatedpatients with acute respiratory distress syndrome (ARDS) caused by influenza A (HINJ)pdm09 in Moscow Municipal Clinics ICU's from January to March 2016 were included in the trial. At the beginning of the study patients had the following characteristic: duration offlu symptoms 5 (3-10) days, p.0/FiO2 120 (70-50) mmHg. SOFA 7 (5-9), body mass index 30.1 (26.4-33.8) kg/m², static compliance of respiratory system 35 (30-40) ml/mbar: Under sedation and paralysis we measured EELV, C VCO and end-tidal carbon dioxide concentration (EtCO) (for CO2 measurements we fixed short-term values after 2 min after PEEP level change) at PEEP 8, 11,13,15,18, 20 mbar consequently, and incase of good recruitability, at 22 and 24 mbar. After analyses of obtained data we determined PEEP value in which increase in EELV was maximal (more than predicted) and depression of VCO2 was less than 20%, change in mean blood pressure and heart rate were both less than 20% (measured at PEEP 8 mbar). After that we set thus determined level of PEEP and didn't change it for 5 days. RESULTS: Comparision of predicted and measured EELV revealed two typical points of alveloar recruiment: the first at PEEP 11-15 mbar, the second at PEEP 20-22 mbar. EELV measured at PEEP 18 mbar appeared to be higher than predicted at PEEP 8 mbar by 400 ml (approx.), which was the sign of alveolar recruitment-1536 (1020-1845) ml vs 1955 (1360-2320) ml, p=0,001, Friedman test). we didn't found significant changes of VCO2 when increased PEEP in the range from 8 to 15 mbar (p>0.05, Friedman test). PEEP increase from 15 to 18 mbar and more lead to decrease in VCO2 (from 212 (171-256) ml/min to 200 (153-227) ml/min, p<0,0001, Friedman test, which was the sign of overdistension. Next decrease of VCO2 was observed at PEEP increase from 22 to 24 mbar (from 203 (174-251 ml/min) to 185 (182-257) ml/min, p=0.0025, Friedman test). Adjusted PEEP value according to balance between recruitment and overdistension was higher than the one initially set (16(15-18) mbar vs 12(7-15) mbar, p <0.0001). We observed increase of SpO2 from 93 (87-96) to 97(95-100)% (p<0.0001 followed by decrease in inspiratory oxygen fraction from 60(40-80) to 50(40-60)%(p<0.0001). Low EELV VCO2 and VCO2/EtCO2 at PEEP 8 mbar has low predictive value for death (AUROC 0,547, 0706 and 0.596, respectively).Absolute EELV value at PEEP 18 and 20 mbar were poor predictors of mortality (AUROC 0.61 and 0.65 respectively) Alveolar recruit ability was measured by subtraction of EELV at PEEP 20 and at PEEP II mbar - value below 575 ml was a good predictor of death (sensitivity 75%, specificity 88%, AUROC 0.81). Lowering of VCO2 at PEEP 20 mbar to less than 207 ml/min was a marker of alveolar overdistension and associated with poor prognosis (sensitivity 83%, specificity 88%, AUROC 0,89). C has poor predictive value at PEEP 8 and 20 mbar (AUROC 0,58 and 0,74 respectively. Conclusion: PEEP adjustment in ARDS due to influenza A (H1N1) pdm09 in accordance with balance between recruitment and overdistension (based on EELV and VCO measurements) can improve gas exchange, probably, not leading to right ventricular failure. This value of "balanced" PEEP is in the range between 15 and 18 mbar: Low lung recruitabiilty is associated with poor prognosis. Measurements of EELV and VCO2 at PEEP 8 and 20 mbar can be used to make a decision on whether to keep "high" PEEP level or switch to extracorporeal membrane oxygenation in patient with ARDS due to influenza A (N1H1).