REVIEW ARTICLE (META-ANALYSIS)| Volume 102, ISSUE 12, P2416-2427.e4, December 2021

Effects of Preoperative Breathing Exercise on Postoperative Outcomes for Patients With Lung Cancer Undergoing Curative Intent Lung Resection: A Meta-analysis

Published:April 26, 2021DOI:



      To determine the benefits of preoperative breathing exercises on hospital length of stay (LOS), pneumonia, postoperative pulmonary complications (PPC), 6-minute walk distance (6MWD), forced expiratory volume in 1 second (FEV1), and health-related quality of life (HRQOL) in patients undergoing surgical lung cancer resection.

      Data Sources

      PubMed, EMBASE, Web of Science Core Collection, and Cochrane Central Register of Controlled Trials were comprehensively searched from inception to March 2021.

      Study Selection

      Only studies including preoperative inspiratory muscle training (IMT) and/or breathing exercises compared with a nontraining control group were included. The meta-analysis was done using Cochrane software for multiple variables including LOS, pneumonia, PPC, 6MWD, FEV1, mortality, and HRQOL.

      Data Extraction

      Two authors extracted the data of the selected studies. The primary outcomes were LOS and PPC.

      Data Synthesis

      A total of 10 studies were included in this meta-analysis, 8 of which had both IMT and aerobic exercise. Pooled data for patients who performed preoperative breathing exercises, compared with controls, demonstrated a decrease in LOS with a pooled mean difference of –3.44 days (95% confidence interval [CI], –4.14 to –2.75; P<.01). Subgroup analysis also demonstrated that LOS was further reduced when breathing exercises were combined with aerobic exercise (χ2, 4.85; P=.03). Preoperative breathing exercises reduce pneumonia and PPCs with an odds ratio of 0.37 (95% CI, 0.18-0.75; P<.01) and 0.37 (95% CI, 0.21-0.65; P<.01), respectively. An increase in 6MWD of 20.2 meters was noted in those performing breathing exercises (95% CI, 9.12-31.21; P<.01). No significant differences were noted in FEV1, mortality, or HRQOL.


      Preoperative breathing exercises reduced LOS, PPC, and pneumonia and potentially improved 6MWD in patients undergoing surgical lung cancer resection. Breathing exercises in combination with aerobic exercise yielded greater reductions in LOS. Randomized controlled trials are needed to test the feasibility of introducing a preoperative breathing exercise program in this patient population.


      List of abbreviations:

      CI (confidence interval), COPD (chronic obstructive lung disease), DLCO (diffusing capacity for carbon monoxide), FEV1 (forced expiratory volume in 1 second), FVC (forced vital capacity), HRQOL (health-related quality of life), IMT (inspiratory muscle training), LOS (length of stay), MCID (minimal clinically important difference), OR (odds ratio), PMD (pooled mean difference), PPC (postoperative pulmonary complication), RCT (randomized controlled trial), 6MWD (6-minute walk distance)
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