Reduction of postoperative pulmonary complications after lung surgery using a fast track clinical pathway

Abstract

Background: Fast track programs, multimodal therapy strategies, have been introduced in many surgical fields to minimize postoperative morbidity and mortality. In terms of lung resections no randomized controlled trials exist to evaluate such patient care programs. Methods: In a prospective, randomized controlled pilot study a conservative and fast track treatment regimen in patients undergoing lung resections was compared. Main differences between the two groups consisted in preoperative fasting (6 h vs 2 h) and analgesia (patient controlled analgesia vs patient controlled epidural analgesia). Study endpoints were pulmonary complications (pneumonia, atelectasis, prolonged air leak), overall morbidity and mortality. Analysis was performed in an intention to treat. Results: Both study groups were similar in terms of age, sex, preoperative forced expiratory volume in one second (FEV1), American Society of Anesthesiologists score and operations performed. The rate of postoperative pulmonary complications was 35% in the conservative and 6.6% in the fast track group (p = 0.009). A subgroup of patients with reduced preoperative FEV1 (<75% of predicted value) experienced less pulmonary complications in the fast track group (55% vs 7%, p = 0.023). Overall morbidity was not significantly different (46% vs 26%, p = 0.172), mortality was comparable in both groups (4% vs 3%). Conclusion: We evaluated an optimized patient care program for patients undergoing lung resections in a prospective randomized pilot study. Using this fast track clinical pathway the rate of pulmonary complications could be significantly decreased as compared to a conservative treatment regimen; our results support the implementation of an optimized perioperative treatment in lung surgery in order to reduce pulmonary complications after major lung surgery. © 2008 European Association for Cardio-Thoracic Surgery.