Post-Operative Outcomes of Pre-Thoracic Surgery Respiratory Muscle Training vs Aerobic Exercise Training: A Systematic Review and Network Meta-analysis

Published:December 17, 2022DOI:



      To compare the postoperative outcomes of preoperative respiratory muscle training (RMT) with a device to preoperative aerobic exercise training (AET) in patients undergoing thoracic surgeries (cardiac and lung).

      Data Sources

      PubMed, EMBASE, Cochrane, and Web of Science were comprehensively searched upon inception to 9/2020.

      Study Selection

      All randomized control studies, including preoperative RMT and preoperative AET compared with a non-training control group, were included.

      Data Extraction

      The meta-analysis was performed for outcomes including postoperative pulmonary complications (PPC), pneumonia, postoperative respiratory failure (PRF), hospital length of stay (HLOS), and mortality. We performed a network meta-analysis based on Bayesian random-effects regression models.

      Data Synthesis

      A total of 25 studies, 2070 patients were included in this meta-analysis. Pooled data for the patients who performed RMT with a device showed a reduction in PPCs, pneumonia, PRF with odds ratio (OR) of 0.35 (P value .006), 0.38 (P value .002), and 0.22 (P value .008), respectively. Pooled data for the patients who performed AET showed reduction in PPC, pneumonia with a OR of 0.33 (P value <.00001) and OR of 0.54 (P value .01), respectively. HLOS was decreased by 1.69 days (P value <.00001) by performing RMT and 1.79 days (P value .0008) by performing AET compared with the usual group. No significant difference in all-cause mortality compared with usual care in both RMT and AET intervention groups. No significant difference in the incidence of PRF compared with usual group in RMT + AET and AET alone intervention groups (OR 0.32; P=.21; OR 0.94; P=.87). Based on rank probability plots analysis, on network meta-analysis, RMT and AET ranked similarly on the primary outcome of PPC and secondary outcomes of pneumonia, PRF and HLOS.


      In thoracic surgeries, preoperative RMT is comparable with preoperative AET to prevent PPC, pneumonia, and PRF and reduce HLOS. It can be considered in patients in resource-limited settings.


      List of abbreviations:

      AET (aerobic exercise training), CI (confidence interval), HLOS (hospital length of stay), I2 (Heterogeneity), MD (mean difference), NMA (network meta-analysis), OR (odds ratio), PPC (postoperative pulmonary complications), PRF (postoperative respiratory failure), RMT (respiratory muscle training), SUCRA (surface under the cumulative ranking curve)
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Archives of Physical Medicine and Rehabilitation
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Dindo D
        • Demartines N
        • Clavien P-A.
        Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey.
        Ann Surg. 2004; 240: 205-213
        • Reeve JC
        • Nicol K
        • Stiller K
        • McPherson KM
        • Denehy L.
        Does physiotherapy reduce the incidence of postoperative complications in patients following pulmonary resection via thoracotomy? A protocol for a randomised controlled trial.
        J Cardiothorac Surg. 2008; 3: 48
        • Kroenke K
        • Lawrence VA
        • Theroux JF
        • Tuley MR.
        Operative risk in patients with severe obstructive pulmonary disease.
        Arch Intern Med. 1992; 152: 967-971
        • Brooks-Brunn JA.
        Postoperative atelectasis and pneumonia: risk factors.
        Am J Crit Care. 1995; 4 (quiz 350-41): 340-349
        • Lugg S
        • Agostini P
        • Tikka T
        • et al.
        Long-term impact of developing a postoperative pulmonary complications after lung surgery.
        Eur Res J. 2015; 46: OA1740
        • Fleischmann KE
        • Goldman L
        • Young B
        • Lee TH.
        Association between cardiac and noncardiac complications in patients undergoing noncardiac surgery: outcomes and effects on length of stay.
        Am J Med. 2003; 115: 515-520
        • Shander A
        • Fleisher LA
        • Barie PS
        • Bigatello LM
        • Sladen RN
        • Watson CB.
        Clinical and economic burden of postoperative pulmonary complications: patient safety summit on definition, risk-reducing interventions, and preventive strategies.
        Crit Care Med. 2011; 39: 2163-2172
        • Smetana GW.
        Postoperative pulmonary complications: an update on risk assessment and reduction.
        Cleve Clin J Med. 2009; 76: S60-S65
        • Agostini P
        • Cieslik H
        • Rathinam S
        • et al.
        Postoperative pulmonary complications following thoracic surgery: are there any modifiable risk factors?.
        Thorax. 2010; 65: 815-818
        • Hulzebos EH
        • Helders PJ
        • Favié NJ
        • De Bie RA
        • de la Riviere AB
        • Van Meeteren NL.
        Preoperative intensive inspiratory muscle training to prevent postoperative pulmonary complications in high-risk patients undergoing CABG surgery: a randomized clinical trial.
        JAMA. 2006; 296: 1851-1857
        • Licker M
        • Karenovics W
        • Diaper J
        • et al.
        Short-term preoperative high-intensity interval training in patients awaiting lung cancer surgery: a randomized controlled trial.
        J Thorac Oncol. 2017; 12: 323-333
        • Assouline B
        • Cools E
        • Schorer R
        • Kayser B
        • Elia N
        • Licker M.
        Preoperative exercise training to prevent postoperative pulmonary complications in adults undergoing major surgery. A systematic review and meta-analysis with trial sequential analysis.
        Ann Am Thorac Soc. 2021; 18: 678-688
        • Pu CY
        • Batarseh H
        • Zafron ML
        • Mador MJ
        • Yendamuri S
        • Ray AD.
        Effects of preoperative breathing exercise on postoperative outcomes for patients with lung cancer undergoing curative intent lung resection: a meta-analysis.
        Arch Phys Med Rehabil. 2021; 102 (e2414): 2416-2427
        • Cavalheri V
        • Granger C.
        Preoperative exercise training for patients with non-small cell lung cancer.
        Cochrane Database Syst Rev. 2017; 6Cd012020
        • Katsura M
        • Kuriyama A
        • Takeshima T
        • Fukuhara S
        • Furukawa TA.
        Preoperative inspiratory muscle training for postoperative pulmonary complications in adults undergoing cardiac and major abdominal surgery.
        Cochrane Database Syst Rev. 2015; 2015CD010356
        • Kendall F
        • Oliveira J
        • Peleteiro B
        • Pinho P
        • Bastos PT.
        Inspiratory muscle training is effective to reduce postoperative pulmonary complications and length of hospital stay: a systematic review and meta-analysis.
        Disabil Rehabil. 2018; 40: 864-882
        • Carvalho T
        • Bonorino K
        • Panigas T.
        Preoperative respiratory muscle training reduces complications in coronary artery bypass surgery.
        Eur Heart J. 2011; 32: 382
        • Chen X
        • Hou L
        • Zhang Y
        • et al.
        The effects of five days of intensive preoperative inspiratory muscle training on postoperative complications and outcome in patients having cardiac surgery: a randomized controlled trial.
        Clin Rehabil. 2019; 33: 913-922
        • Ferreira PEG
        • Rodrigues AJ
        • Évora PRB.
        Effects of an inspiratory muscle rehabilitation program in the postoperative period of cardiac surgery.
        Arquivos brasileiros de cardiologia. 2009; 92: 275-282
        • Hulzebos EH
        • van Meeteren NL
        • van den Buijs BJ
        • de Bie RA
        • De La Riviere AB
        • Helders PJ.
        Feasibility of preoperative inspiratory muscle training in patients undergoing coronary artery bypass surgery with a high risk of postoperative pulmonary complications: a randomized controlled pilot study.
        Clin Rehabil. 2006; 20: 949-959
        • Sobrinho MT
        • Guirado GN
        • Silva MAdM
        Preoperative therapy restores ventilatory parameters and reduces length of stay in patients undergoing myocardial revascularization.
        Braz J Cardiovasc Surg. 2014; 29: 221-228
        • Weiner P
        • Zeidan F
        • Zamir D
        • et al.
        Prophylactic inspiratory muscle training in patients undergoing coronary artery bypass graft.
        World J Surg. 1998; 22: 427-431
        • Laurent H
        • Aubreton S
        • Galvaing G
        • et al.
        Preoperative respiratory muscle endurance training improves ventilatory capacity and prevents pulmonary postoperative complications after lung surgery.
        Eur J Phys Rehabil Med. 2019; 56: 73-81
        • Arthur HM
        • Daniels C
        • McKelvie R
        • Hirsh J
        • Rush B.
        Effect of a preoperative intervention on preoperative and postoperative outcomes in low-risk patients awaiting elective coronary artery bypass graft surgery: a randomized, controlled trial.
        Ann Intern Med. 2000; 133: 253-262
        • Fang Y
        • Zhao Q
        • Huang D
        • Guan S
        • Lv J
        Effects of exercise training on surgery tolerability in lung cancer patients with impaired pulmonary function.
        Life Sci J. 2013; 10: 1943-1948
        • Huang J
        • Lai Y
        • Zhou X
        • et al.
        Short-term high-intensity rehabilitation in radically treated lung cancer: a three-armed randomized controlled trial.
        J Thorac Dis. 2017; 9: 1919-1929
        • Lai Y
        • Huang J
        • Yang M
        • Su J
        • Liu J
        • Che G
        Seven-day intensive preoperative rehabilitation for elderly patients with lung cancer: a randomized controlled trial.
        J Surg Res. 2017; 209: 30-36
        • Lai Y
        • Su J
        • Qiu P
        • et al.
        Systematic short-term pulmonary rehabilitation before lung cancer lobectomy: a randomized trial.
        Interact Cardiovasc Thorac Surg. 2017; 25: 476-483
        • Lai Y
        • Su J
        • Yang M
        • Zhou K
        • Che G
        [Impact and effect of preoperative short-term pulmonary rehabilitation training on lung cancer patients with mild to moderate chronic obstructive pulmonary disease: a randomized trial].
        Zhongguo Fei Ai Za Zhi. 2016; 19: 746-753
        • Lai Y
        • Wang X
        • Zhou K
        • Su J
        • Che G
        Impact of one-week preoperative physical training on clinical outcomes of surgical lung cancer patients with limited lung function: a randomized trial.
        Ann Transl Med. 2019; 7: 544
        • Liu Z
        • Qiu T
        • Pei L
        • et al.
        Two-week multimodal prehabilitation program improves perioperative functional capability in patients undergoing thoracoscopic lobectomy for lung cancer: a randomized controlled trial.
        Anesth Analg. 2020; 131: 840-849
        • Rosenfeldt F
        • Braun L
        • Spitzer O
        • et al.
        Physical conditioning and mental stress reduction–a randomised trial in patients undergoing cardiac surgery.
        BMC Complement Altern Med. 2011; 11: 1-7
        • Sawatzky JA
        • Kehler DS
        • Ready AE
        • et al.
        Prehabilitation program for elective coronary artery bypass graft surgery patients: a pilot randomized controlled study.
        Clin Rehabil. 2014; 28: 648-657
        • Sebio García R
        • Yáñez-Brage MI
        • Giménez Moolhuyzen E
        • Salorio Riobo M
        • Lista Paz A
        • Borro Mate JM
        Preoperative exercise training prevents functional decline after lung resection surgery: a randomized, single-blind controlled trial.
        Clin Rehabil. 2017; 31: 1057-1067
        • Stefanelli F
        • Meoli I
        • Cobuccio R
        • et al.
        High-intensity training and cardiopulmonary exercise testing in patients with chronic obstructive pulmonary disease and non-small-cell lung cancer undergoing lobectomy.
        Eur J Cardiothorac Surg. 2013; 44: e260-e265
        • Steinmetz C
        • Bjarnason-Wehrens B
        • Baumgarten H
        • Walther T
        • Mengden T
        • Walther C.
        Prehabilitation in patients awaiting elective coronary artery bypass graft surgery—effects on functional capacity and quality of life: a randomized controlled trial.
        Clin Rehabil. 2020; 34: 1256-1267
        • Argunova Y.
        Effects of prehabilitation program on quality of life and adherence to therapy in patients undergoing coronary artery bypass grafting.
        Eur J Prevent Cardiol. 2019; 26: S35
        • Benzo R
        • Wigle D
        • Novotny P
        • et al.
        Preoperative pulmonary rehabilitation before lung cancer resection: results from two randomized studies.
        Lung Cancer. 2011; 74: 441-445
        • Morano MT
        • Araújo AS
        • Nascimento FB
        • et al.
        Preoperative pulmonary rehabilitation versus chest physical therapy in patients undergoing lung cancer resection: a pilot randomized controlled trial.
        Arch Phys Med Rehabil. 2013; 94: 53-58
        • Sterne JA
        • Savović J
        • Page MJ
        • et al.
        RoB 2: a revised tool for assessing risk of bias in randomised trials.
        BMJ. 2019; 366: l4898
      1. Shi J, Luo D, Wan X, et al. Detecting the skewness of data from the sample size and the five-number summary. arXiv e-prints, arXiv:2010.05749.2020. Available at: Accessed January 11, 2023.

        • Luo D
        • Wan X
        • Liu J
        • Tong T.
        Optimally estimating the sample mean from the sample size, median, mid-range, and/or mid-quartile range.
        Statist Meth Med Res. 2018; 27: 1785-1805
        • Wan X
        • Wang W
        • Liu J
        • Tong T.
        Estimating the sample mean and standard deviation from the sample size, median, range and/or interquartile range.
        BMC Med Res Methodol. 2014; 14: 1-13
        • van Valkenhoef G
        • Lu G
        • de Brock B
        • Hillege H
        • Ades AE
        • Welton NJ.
        Automating network meta-analysis.
        Res Synth Methods. 2012; 3: 285-299
        • Salanti G
        • Ades AE
        • Ioannidis JPA.
        Graphical methods and numerical summaries for presenting results from multiple-treatment meta-analysis: an overview and tutorial.
        J Clin Epidemiol. 2011; 64: 163-171