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Introduction and objectives The new BTS lung cancer surgery guidelines mention patient optimisation to reduce risk. Our aim was to develop a multi-stranded pragmatic rehabilitation programme for this group of patients, apply it in a pilot study and look at feasibility, process indicators, outcome measures, local adaptability, compliance and potential cost benefit. Methods An outpatient based complex intervention was developed by doctors, allied health professional and patients to optimise physical status, prepare for inpatient journey and support through recovery after surgery. Tested in an enriched cohort study over 11 months 45 patients received the intervention compared to 198 who received standard care. Results Potential surgical candidates at a regional thoracic unit were identified early at lung cancer multidisciplinary team meetings and enrolled on a COPD-type rehabilitation programme which included exercise classes, smoking cessation, dietary advice and patient education. Patients attended exercise classes twice a week until surgery, (which was not delayed). On average patients waited 7 days (range 0-29) to be seen in a rehabilitation class and attended on 5 sessions (range 1-12) resulting in 39 m improvement in 6-minute walk test. The education classes were delivered by lung cancer nurse and addressed diet, smoking, lifestyle change, inpatient expectations, preparation for discharge, and pain management. Six patients identified as potentially or at risk of being malnourished received nutritional supplementation. 5 out of 10 current smokers agreed to be fast tracked into locally available smoking cessation pathways and were biochemically proven to have given up. In the two referring hospitals one delivered classes in outpatient individualised setting while the other in community based group class. An additional four patients following further investigations did not receive surgery. Both groups were matched for age, lung function comorbidity and type of surgery and outcomes are presented in Abstract S28 table 1. The intervention resulted in cash releasing saving to the PCT of £938 per patient. Conclusion A viable outpatient based complex intervention pathway of enhanced recovery/pulmonary rehabilitation has been developed and tested. Initial results are promising but a multicentre randomised controlled trial is warranted to test efficacy. [ABSTRACT FROM AUTHOR]

Background Reduced activity is a routine observation following major surgery, however no studies have yet measured or explored this. Causative factors include sedative drugs, reduced exercise tolerance and pain, as well as pre-existing pathology. We aimed to measure postoperative activity and observe outcomes of thoracotomy and lung resection patients, as well as identify predictive factors. Methods A prospective observational study was conducted in a regional thoracic surgery centre. Sense Wear Pro 3 armbands were worn by patients from postoperative day (POD) 1 to 4. Post-operative physiotherapy included early mobilisation, which was progressed daily. Results 99 patients were observed, 46 male (46%) and 92 (93%) had lung cancer. Mean (SD) age was 67 (±10) years and percentage predicted FEV1 75% (±19). During PODs 2/3 patients took a median (IQR) of 472 (908) steps with >99% of time spent in sedentary activity (<3 METs). Low activity was defined as <500 steps during PODs 2/3 (n=50), and high activity >500 steps (n=49). Patients with lower activity demonstrated a median of only 220 (282) steps compared to 1128 (960) in more active patients (p<0.001), less time spent in moderate activity >3 METS (p=0.003) and more perceived pain during PODs 2/3 (p=0.013 and 0.004 respectively). Frequency of postoperative pulmonary complication (PPC) was 4% (n=2) vs 20% (n=10) (p=0.34) in patients with lower activity, with a median LOS of 6 (3) days vs 5 (2) days (p=0.013). Logistic regression identified age =75 years, predicted FEV1 <70% and poor preoperative activity to be predictive of reduced postoperative activity, and COPD predictive of PPC (p<0.05). Conclusion Low activity levels following thoracotomy are common despite regular physiotherapy; studies measuring pre and post-operative activity are needed to reveal the exact impact of surgery. It is not known whether reduced activity may cause PPC, or vice versa, and studies randomising patients to lower/ higher activity are needed to confirm this. Predictive factors could potentially be modified by preoperative physiotherapy/rehabilitation, and targeted postoperative exercise and escalation of analgesia may also be beneficial, however, evaluation of these strategies is required. [ABSTRACT FROM AUTHOR]

Cigarette smoking is the leading cause of preventable death worldwide. It causes chronic lung disease and predisposes individuals to acute lung injury and pulmonary infection. Alveolar macrophages are sentinel cells strategically positioned in the interface between the airway lumen and the alveolar spaces. These are the most abundant immune cells and are the first line of defence against inhaled particulates and pathogens. Recently, there has been a better understanding about the ontogeny, phenotype and function of alveolar macrophages and their role, not only in phagocytosis, but also in initiating and resolving immune response. Many of the functions of the alveolar macrophage have been shown to be dysregulated following exposure to cigarette smoke. While the mechanisms for these changes remain poorly understood, they are important in the understanding of cigarette smoking-induced lung disease. We review the mechanisms by which smoking influences alveolar macrophage: (1) recruitment, (2) phenotype, (3) immune function (bacterial killing, phagocytosis, proteinase/anti-proteinase release and reactive oxygen species production) and (4) homeostasis (surfactant/lipid processing, iron homeostasis and efferocytosis). Further understanding of the mechanisms of cigarette smoking on alveolar macrophages and other lung monocyte/macrophage populations may allow novel ways of restoring cellular function in those patients who have stopped smoking in order to reduce the risk of subsequent infection or further lung injury., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: Vaping may increase the cytotoxic effects of e-cigarette liquid (ECL). We compared the effect of unvaped ECL to e-cigarette vapour condensate (ECVC) on alveolar macrophage (AM) function., Methods: AMs were treated with ECVC and nicotine-free ECVC (nfECVC). AM viability, apoptosis, necrosis, cytokine, chemokine and protease release, reactive oxygen species (ROS) release and bacterial phagocytosis were assessed., Results: Macrophage culture with ECL or ECVC resulted in a dose-dependent reduction in cell viability. ECVC was cytotoxic at lower concentrations than ECL and resulted in increased apoptosis and necrosis. nfECVC resulted in less cytotoxicity and apoptosis. Exposure of AMs to a sub-lethal 0.5% ECVC/nfECVC increased ROS production approximately 50-fold and significantly inhibited phagocytosis. Pan and class one isoform phosphoinositide 3 kinase inhibitors partially inhibited the effects of ECVC/nfECVC on macrophage viability and apoptosis. Secretion of interleukin 6, tumour necrosis factor α, CXCL-8, monocyte chemoattractant protein 1 and matrix metalloproteinase 9 was significantly increased following ECVC challenge. Treatment with the anti-oxidant N-acetyl-cysteine (NAC) ameliorated the cytotoxic effects of ECVC/nfECVC to levels not significantly different from baseline and restored phagocytic function., Conclusions: ECVC is significantly more toxic to AMs than non-vaped ECL. Excessive production of ROS, inflammatory cytokines and chemokines induced by e-cigarette vapour may induce an inflammatory state in AMs within the lung that is partly dependent on nicotine. Inhibition of phagocytosis also suggests users may suffer from impaired bacterial clearance. While further research is needed to fully understand the effects of e-cigarette exposure in humans in vivo, we caution against the widely held opinion that e-cigarettes are safe., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2018. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: Postoperative pulmonary complications (PPC) such as atelectasis and pneumonia are common following lung resection. PPCs have a significant clinical impact on postoperative morbidity and mortality. We studied the long-term effects of PPCs and sought to identify independent risk factors., Methods: A prospective observational study involved all patients following lung resection in a regional thoracic centre over 4 years. PPCs were assessed daily in hospital using the Melbourne group scale based on chest X-ray, white cell count, fever, purulent sputum, microbiology, oxygen saturations, physician diagnosis and intensive therapy unit (ITU)/high-dependency unit readmission. Follow-up included hospital length of stay (LOS), 30-day readmissions, and mortality., Results: 86 of 670 patients (13%) who had undergone a lung resection developed a PPC. Those patients had a significantly longer hospital LOS in days (13, 95% CI 10.5-14.9 vs 6.3, 95% CI 5.9 to 6.7; p<0.001) and higher rates of ITU admissions (28% vs 1.9%; p<0.001) and 30-day hospital readmissions (20.7% vs 11.9%; p<0.05). Significant independent risk factors for development of PPCs were COPD and smoking (p<0.05), not age. Excluding early postoperative deaths, developing a PPC resulted in a significantly reduced overall survival in months (40, 95% CI 34 to 44 vs 46, 95% CI 44 to 47; p=0.006). Those who developed a PPC had a higher rate of non-cancer-related deaths (11% vs 5%; p=0.020). PPC is a significant independent risk factor for late deaths in non-small cell lung cancer patients (HR 2.0, 95% CI 1.9 to 3.2; p=0.006)., Conclusions: Developing a PPC after thoracic surgery is common and is associated with a poorer long-term outcome., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/)

Positron emission tomography-CT (PET-CT) is one of the initial mediastinal staging modality for non-small cell lung cancer; however, the clinical utility in carcinoid tumours is uncertain. We sought to determine the test performance of PET-CT for mediastinal lymph node staging of pulmonary carcinoid tumours. We collated data from seven institutions, performing a retrospective search on pathological databases for a consecutive series of patients who underwent thoracic surgery (with lymph nodal dissection) for carcinoid tumours with preoperative PET-CT staging. PET-CT results were compared with the reference standard of pathologic results obtained from lymph node dissection and test performance reported using sensitivity and specificity. From November 1999 to January 2013, 247 patients from seven institutions underwent surgery for carcinoid tumours with a corresponding preoperative PET-CT scan. The mean age of the patients was 61 (SD 15, range 73) and 84 were male patients (34%). The pathologic subtype was typical carcinoid in 217 patients (88%) and atypical carcinoid in 30 patients (12%). Results from lymph node dissection were obtained in 207 patients. The calculated sensitivity and specificity of PET-CT to identify mediastinal lymph node disease was 33% (95% CI 4% to 78%) and 94% (95% CI 89% to 97%), respectively. Our results indicate that PET-CT has a poor sensitivity but good specificity to detect the presence of mediastinal lymph node metastases in pulmonary carcinoid tumours. Mediastinal lymph node metastases cannot be ruled out with negative PET-CT uptake, and if the absence of mediastinal lymph node disease is a prerequisite for directing management, tissue sampling should be undertaken., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Background: Following thoracotomy, patients frequently receive routine respiratory physiotherapy which may include incentive spirometry, a breathing technique characterised by deep breathing performed through a device offering visual feedback. This type of physiotherapy is recommended and considered important in the care of thoracic surgery patients, but high quality evidence for specific interventions such as incentive spirometry remains lacking., Methods: 180 patients undergoing thoracotomy and lung resection participated in a prospective single-blind randomised controlled trial. All patients received postoperative breathing exercises, airway clearance and early mobilisation; the control group performed thoracic expansion exercises and the intervention group performed incentive spirometry., Results: No difference was observed between the intervention and control groups in the mean drop in forced expiratory volume in 1 s on postoperative day 4 (40% vs 41%, 95% CI -5.3% to 4.2%, p=0.817), the frequency of postoperative pulmonary complications (PPC) (12.5% vs 15%, 95% CI -7.9% to 12.9%, p=0.803) or in any other secondary outcome measure. A high-risk subgroup (defined by ≥2 independent risk factors; age ≥75 years, American Society of Anaesthesiologists score ≥3, chronic obstructive pulmonary disease (COPD), smoking status, body mass index ≥30) also demonstrated no difference in outcomes, although a larger difference in the frequency of PPC was observed (14% vs 23%) with 95% CIs indicating possible benefit of intervention (-7.4% to 2.6%)., Conclusions: Incentive spirometry did not improve overall recovery of lung function, frequency of PPC or length of stay. For patients at higher risk for the development of PPC, in particular those with COPD or current/recent ex-smokers, there were larger observed actual differences in the frequency of PPC in favour of the intervention, indicating that investigations regarding the physiotherapy management of these patients need to be developed further.