Ann Thorac Surg 2005;79:1162-1166
© 2005 The Society of Thoracic Surgeons
Original articles: General thoracic
Nocturnal Hypoxemia After Lobectomy for Lung Cancer
Hideki Kawai, MD, PhDa,*,
Yoshimasa Tayasu, RPTa,
Ayaka Saitoh, RPTa,
Kyoko Ooyama, RNa,
Yuichi Tanaka, MDa,
Yoshihiro Minamiya, MD, PhDb,
Junichi Ogawa, MD, PhDb
a Department of Thoracic Surgery, Nakadori General Hospital
b Department of Surgery II, School of Medicine, Akita University, Akita, Japan
Accepted for publication September 29, 2004.
* Address reprint requests to Dr Kawai, Dept of Thoracic Surgery, Nakadori General Hospital, 3–15 Minamidori Misonocho, Akita 010–8577, Japan (E-mail: hkawai{at}doc.med.akita-u.ac.jp).
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Abstract
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BACKGROUND: Although nocturnal episodic hypoxemia after major abdominal surgery has been reported, the condition of nocturnal oxygen saturation after lung surgery is largely unknown. We evaluated nocturnal oxygen saturation during the perioperative period after lobectomy for lung cancer. This study also compared the postoperative course of nocturnal oxygen saturation after standard lobectomy with posterolateral thoracotomy and lobectomy with video-assisted thoracic surgery.
METHODS: Twenty-one consecutive patients who had undergone lobectomy for lung cancer by either the posterolateral thoracotomy approach (n = 11) or the video-assisted thoracic surgery approach (n = 10) were studied. Fifteen consecutive patients who had undergone gastrectomy for gastric cancer were also studied. Overnight oxygen saturation was measured on the third and 14th postoperative days.
RESULTS: The frequency of hypoxemia in the lobectomy group was higher than that in the gastrectomy group (p = 0.043). The frequency of hypoxemia on the 14th postoperative day (p = 0.009) and the severity of hypoxemia on the third and 14th postoperative days (p = 0.041, 0.046) for the video-assisted thoracic surgery approach were lower than those for the posterolateral thoracotomy approach. In terms of mean arterial oxygen saturation, heart rate, forced vital capacity, and forced expiratory volume in 1 second, there were no statistically significant differences between the video-assisted thoracic surgery group and the posterolateral thoracotomy group.
CONCLUSIONS: Video-assisted thoracic surgery lobectomy was superior in terms of early postoperative nocturnal oxygen saturation. We conclude that the video-assisted thoracic surgery approach is more beneficial than the posterolateral thoracotomy approach for high-risk patients.
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Introduction
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In the postoperative period, sufficient oxygen saturation is required for recovery from surgical stress. Several studies have observed changes in oxygen saturation after major abdominal surgery, and reports have shown the occurrence of episodic nocturnal hypoxemia in the late postoperative period [1–5]. In the case of the postoperative period after lung surgery, nocturnal hypoxemia might be much more severe than that of abdominal surgery. Several studies have shown that lobectomy by the video-assisted thoracic surgery (VATS) approach is less invasive than lobectomy by the posterolateral thoracotomy (PLT) approach [6–9]. However, there has been no report of changes in nocturnal oxygen saturation after lung resection. In this study, we evaluated nocturnal oxygen saturation after lobectomy for lung cancer using both the PLT approach and the VATS approach.
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Patients and Methods
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Patients
To start this prospective study, we obtained institutional review board approval for the study and informed consent from each patient at Nakadori General Hospital. From May 2003 to March 2004, 21 consecutive patients with lung cancer underwent lobectomy at Nakadori General Hospital. Eleven patients underwent lobectomy by the PLT approach, and 10 patients underwent VATS lobectomy. As a control group, 15 consecutive patients who had undergone gastrectomy for gastric cancer by upper median laparotomy were also studied. The surgical approach was chosen according to the tumor size. Patients whose tumor size was 2 cm or less in maximum diameter with no lymph node swelling on computed tomography were assigned to VATS lobectomy. The VATS lobectomy was performed through two incisions. One incision was 8 cm in length placed at the fourth or fifth intercostal space in the anterior axillary line without dividing the latissimus dorsi muscle. The other incision was for a thoracoscopic port. In the PLT approach, the incision was approximately 20 cm in length, placed at the fifth intercostal space, dividing the latissimus dorsi muscle and the serratus anterior muscle. No ribs were resected in either approach. All patients received epidural administration of 1% mepivacaine for pain control during the operation and early postoperative periods. Diclofenac sodiums were also administered for pain control during the early postoperative period. All patients were able to stop oxygen supplement therapy by the third postoperative morning. The chest drainage tubes were removed by the third postoperative day (POD 3). Measurements of arterial oxygen saturation (SpO2) were then performed that night after the chest tubes were removed. Early postoperative pulmonary rehabilitation for lung surgery was administered from POD 4 to POD 14. The pulmonary rehabilitation consisted of range of motion, upper and lower extremity training, breathing assistance, and ventilatory muscle training. Each session was safely performed while monitoring SpO2. The effect of the pulmonary rehabilitation was evaluated by measurement of SpO2.
Measurements
Overnight SpO2 and heart rate were continuously recorded with a pulse oximeter using a finger probe (PULSOX-M24; Teijin, Tokyo, Japan) for 9 hours (from 21:00 to 6:00; Fig 1). Measurements were performed 2 days before the operation and on POD 3 and POD 14. Data were analyzed using the manufacturer's software, producing values for mean and minimum overnight SpO2 and the number of episodes of desaturation per hour of recording (DS-M; Teijin). We evaluated episodes of SpO2 levels less than 90% and the number of these episodes during the measurement period. Because the length of the measurement period differed by patient, we created a desaturation index, which is defined as the number of episodes of desaturation per hour (desaturation index). Desaturation index was described previously [2, 4]. Briefly, it is defined as dips in the SpO2 level of greater than 4% for longer than 10 seconds. Desaturation index reflects a significant respiratory event. Dips in the SpO2 of greater than 4% for longer than 10 seconds were recorded and analyzed. Pulmonary function studies, including forced vital capacity (FVC) and forced expiratory volume in 1 second (FEV1.0), were performed 1 week before the operation and on POD 14. Postoperative FVC and FEV1.0 were evaluated as percentages of predicted postoperative values (FVC/predictive value and FEV1.0/predictive value), according to the formula of Nakahara and colleagues [10].
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Fig 1. Nocturnal oximetry. Continuous measurement of arterial oxygen saturation (SpO2) and heart rate (beats per minute; bpm) were performed for 9 hours (from 21:00 to 6:00) using a finger probe.
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Statistics
Data were analyzed with two-way analyses of variance in combination with least square methods using the statistical software JMP IN 5.1.1 (SAS Institute Inc, Cary, NC). Significances of individual differences were evaluated by contrast tests. Probability values of less than 0.05 were regarded as statistically significant differences. All data are expressed as mean ± standard error of the mean.
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Results
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Patient characteristics are shown in Table 1. There were no statistically significant differences in demographics, pulmonary function, heart rate, or intraoperative bleeding between the lung and stomach groups, although the average operation time was longer in the stomach group. No statistically significant differences were found in the characteristics between the VATS and PLT groups. The resected lobes were as follows: the right upper lobe in 4 patients, the right middle lobe in 1 patient, the right lower lobe in 2 patients, the left upper lobe in 2 patients, and the left lower lobe in 1 patient in the VATS group; and the right lower lobe in 3 patients, the left upper lobe in 6 patients, and the left lower lobe in 2 patients in the PLT group. In the stomach group, 11 patients underwent distal gastrectomy, 3 patients underwent total gastrectomy, and 1 patient underwent proximal gastrectomy. No postoperative complications occurred in any group.
To determine whether the nocturnal episodic hypoxemia occurred after lung resection, we analyzed the desaturation index and the duration rate of SpO2 less than 90%. The duration rate of SpO2 less than 90% in the lung group (2.46 ± 0.67) was statistically significantly higher (p = 0.043) than that in the stomach group (0.87 ± 0.34) on POD 3 (Fig 2). The desaturation index in each group was elevated on POD 3 compared with before surgery (desaturation index on POD 3, lung 4.60 ± 0.94, stomach 4.53 ± 1.65). However, there was no statistically significant difference in the desaturation index between the lung and stomach groups.
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Fig 2. Changes in duration rate of arterial oxygen saturation (SpO2) less than 90% during the perioperative period. There were statistically significant differences (p = 0.043) between the lung group and the stomach group. (POD = postoperative day.)
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We also further analyzed the desaturation index and the duration rate of SpO2 less than 90% in the VATS and PLT groups (Figs 3, 4). The desaturation index in each group was significantly higher on POD 3 than before surgery (desaturation index on POD 3, VATS 2.97 ± 0.66, PLT 5.71 ± 1.49; desaturation index on POD 14, VATS 1.55 ± 0.46, PLT 6.43 ± 1.25). On POD 14, the desaturation index in the PLT group was still elevated. On the other hand, the desaturation index in the VATS group had dropped to the preoperative level. There was a statistically significant difference in the desaturation index between the PLT and VATS groups (p = 0.009) on POD 14 (Fig 3). The duration rate of SpO2 less than 90% in each group increased on POD 3 (VATS 1.68 ± 0.28, PLT 3.17 ± 1.00) and decreased on POD 14 (VATS 0.15 ± 0.08, PLT 1.48 ± 0.56). There were statistically significant differences between the two groups on POD 3 (p = 0.041) and on POD 14 (p = 0.046; Fig 4).
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Fig 3. Changes in desaturation index during the postoperative period. There were statistically significant differences (p = 0.009) between the video-assisted thoracic surgery (VATS) group and the posterolateral thoracotomy (PLT) group on postoperative day (POD) 14.
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Fig 4. Changes in duration rate of arterial oxygen saturation (SpO2) less than 90% during the postoperative period. There were statistically significant differences between the video-assisted thoracic surgery (VATS) group and the posterolateral thoracotomy (PLT) group on postoperative day (POD) 3 (p = 0.041) and on postoperative day 14 (p = 0.046).
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Preoperative and postoperative pulmonary function data in thoracotomy patients are shown in Table 2. Pulmonary function was evaluated 1 week preoperatively and on POD 14. Comparing preoperative values, there was no significant difference between the two groups (FVC/predictive value on POD 14, VATS 94.9% ± 7.72% and PLT 103.2 ± 7.22%). The FEV1.0 values were also not significantly different between the two groups (FEV/predictive value on POD 14, VATS 92.3% ± 6.7% and PLT 99.6 ± 5.7%). Changes in mean SpO2 and heart rate were also analyzed. However, there were no differences in these values between the groups.
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Comment
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In general, patients who undergo major surgery under general anesthesia need supplemental oxygen therapy for a few days after the operation. Most patients who undergo lung resection discontinue supplemental oxygen therapy based on the results of blood gas analysis, and the chest drainage tube is removed by the third morning. However, we occasionally encounter severe complications such as a cardiovascular disturbance a few days after an operation. Rosenberg and colleagues [1] reported that severe nocturnal episodic desaturation occurred in the postoperative period (days 1 to 3 after operation) after major abdominal surgery. It is still unknown whether nocturnal episodic hypoxemia contributes to development of severe postoperative cardiac or pulmonary disturbances, but several reports have mentioned the possibility that nocturnal episodic hypoxemia takes part in cardiac or pulmonary disturbances occurring in the postoperative period [11–14]. Although several studies suggested that rapid eye movement sleep might contribute to respiratory disturbance and episodic desaturation in the postoperative period [15–17], the pathogenesis of nocturnal episodic hypoxemia in the postoperative period is also unknown.
In this study, we observed severe nocturnal episodic hypoxemia in the postoperative period after lung resection. As we expected, the duration period of the desaturation in the lung resection group was longer than that in the abdominal surgery group. However, the desaturation index, a reflection of the severity of desaturation, was not significantly different in either group. This discrepancy might result from the difference in mean SpO2 level between the two groups. In 4 patients in the PLT group on POD 3 or POD 14, desaturation indexes were more than 10 (11.59 and 15.90 on POD 3; 11.28 and 13.59 on POD 14). These values satisfied the criterion for obstructive sleep apnea. Briefly, obstructive sleep apnea was diagnosed if the number of apneas or hypopneas per hour of sleep was greater than 10 [17]. In 3 patients in the gastrectomy group, desaturation indexes were also more than 10 (desaturation index on POD 3, 10.99, 17.59, and 18.08). However, in the VATS group, there was no patient whose desaturation index was greater than 10. From these data, desaturation index in the postoperative period might depend on the degree of surgical stress, because the VATS approach was thought to be less invasive than any other approaches. On the other hand, during the postoperative period, decreases in FVC and FEV1.0 are caused by restrictive damage of the thoracic wall and reduced muscular activity of the diaphragm. Although some studies have shown that lobectomy by the VATS approach better preserves pulmonary function in the early postoperative period [18–20], our data showed no significant difference between the VATS approach and the PLT approach. This phenomenon might be produced by the effect of early postoperative pulmonary rehabilitation. In future, the effect of early postoperative pulmonary rehabilitation should be evaluated. In this study, we suggested that the desaturation index depended not on FVC or FEV1.0 but on the degree of the surgical stress in the postoperative phase. Therefore, we concluded that VATS lobectomy is superior to lobectomy by the PLT approach in terms of avoiding postoperative cardiac or pulmonary complications.
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Acknowledgments
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We are indebted to Mitsuru Kobayashi from Teijin for providing a PULSOX-M24 pulse oximeter, and to Hisako Sagawa, RN, Takako Ono, RN, Tomoko Sato, RN, Hiromi Suzuki, RN, Tomoko Tanaka, RN, Yuko Takahashi, RN, and Chiharu Togashi, RN, for indispensable assistance with collecting the data.
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References
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- Rosenberg J, Dirkes WE, Kehlet H. Episodic arterial oxygen desaturation and heart rate variations following major abdominal surgery Br J Anaesth 1989;63:651-654.[Abstract/Free Full Text]
- Thompson JP, Boyle JR, Thompson MM, Bell PRF, Smith G. Nocturnal hypoxaemia and respiratory function after endovascular and conventional abdominal aortic aneurysm repair Br J Anaesth 1999;82:129-131.[Abstract/Free Full Text]
- Reeder MK, Goldman MD, Loh L, et al. Postoperative hypoxaemia after major abdominal vascular surgery Br J Anaesth 1992;68:23-26.[Abstract/Free Full Text]
- Reeder MK, Goldman MD, Loh L, Muir AD, Casey KR, Lehane JR. Late postoperative nocturnal dips in oxygen saturation in patients undergoing major abdominal vascular surgeryPredictive value of pre-operative overnight pulse oximetry. Anaesthesia 1992;47:110-115.[Medline]
- Rosenberg J, Ullstad T, Rasmussen J, Hjorne FP, Poulsen NJ, Goldman MD. Time course of postoperative hypoxaemia Eur J Surg 1994;160:137-143.[Medline]
- Tschernko EM, Hofer S, Bieglmayer C, Wisser W, Haider W. Early postoperative stress: video-assisted wedge resection/lobectomy vs conventional axillary thoracotomy Chest 1996;109:1636-1642.[Abstract/Free Full Text]
- Landreneau RJ, Hazelrigg SR, Mack MJ, et al. Postoperative pain-related morbidity: video-assisted thoracic surgery versus thoracotomy Ann Thorac Surg 1993;56:1285-1289.[Abstract]
- Nagahiro I, Andou A, Aoe M, Sano Y, Date H, Shimizu N. Pulmonary function, postoperative pain, and serum cytokine level after lobectomy: a comparison of VATS and conventional procedure Ann Thorac Surg 2001;72:362-365.[Abstract/Free Full Text]
- Yim APC, Wan S, Lee TW, Arifi AA. VATS lobectomy reduces cytokine responses compared with conventional surgery Ann Thorac Surg 2000;70:243-247.[Abstract/Free Full Text]
- Nakahara K, Monden Y, Ohno K, Miyoshi S, Maeda H, Kawashima Y. A method for predicting postoperative lung function and its relation to postoperative complications in patients with lung cancer Ann Thorac Surg 1985;39:260-265.[Abstract]
- Keats AS. Anesthesia mortality—a new mechanism Anesthesiology 1988;68:2-4.[Medline]
- Ayres SM, Grace WJ. Inappropriate ventilation and hypoxemia as causes of cardiac arrhythmias Am J Med 1969;46:495-505.[Medline]
- Jones JG, Jordan C, Scudder C, Rocke DA, Barrowcliffe M. Episodic postoperative oxygen desaturation: the value of added oxygen J R Soc Med 1985;78:1019-1022.[Abstract]
- Reeder MK, Muir AD, Foex P, Goldman MD, Loh L, Smart D. Postoperative myocardial ischaemia: temporal association with nocturnal hypoxaemia Br J Anaesth 1991;67:626-631.[Abstract/Free Full Text]
- Salmi T, Brander PE. Computer assisted detection of REM and non-REM sleep for analysis of nocturnal hypoxaemia in patients with ventilatory impairment Int J Clin Monit Comput 1994;11:63-70.[Medline]
- Rosenberg J, Wildschiodts MH, Pedersen F, von Jessen F, Kehlet H. Late postoperative nocturnal episodic hypoxaemia and associated sleep pattern Br J Anaesth 1994;72:145-150.[Abstract/Free Full Text]
- Loadsman JA, Wilcox I. Is obstructive sleep apnoea a rapid eye movement-predominant phenomenon? Br J Anaesth 2000;85:354-358.[Abstract/Free Full Text]
- Nakata M, Saeki H, Yokoyama N, Kurita A, Takiyama W, Takashima S. Pulmonary function after lobectomy: video-assisted thoracic surgery versus thoracotomy Ann Thorac Surg 2000;70:938-941.[Abstract/Free Full Text]
- Nagahiro I, Andou A, Aoe M, Sano Y, Date H, Shimizu N. Pulmonary function, postoperative pain, and serum cytokine level after lobectomy: a comparison of VATS and conventional procedure Ann Thorac Surg 2001;72:362-365.
- Kaseda S, Aoki T, Hangai N, Shimizu K. Better pulmonary function and prognosis with video-assisted thoracic surgery than with thoracotomy Ann Thorac Surg 2000;70:1644-1646.[Abstract/Free Full Text]
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Abstract
Introduction
