RU2802133C1 - Method of preoperative preparation of lung cancer patients after covid-19 associated pneumonia - Google Patents

Abstract

FIELD: medicine; oncology; pulmonology.

SUBSTANCE: invention can be used to improve the functional tolerance of radical surgery in patients with lung cancer after suffering from COVID-19 associated pneumonia. In patients in the preoperative period, preoperative preparation is carried out for 7–10 days, including the appointment of a direct anticoagulant fraxiparine 0.3 ml subcutaneously 2 times a day, breathing exercises in the form of exercises with a loading spirometer based on the effect of inhalation resistance, 2 approaches per hour (except at night), and the following drug therapy: dexamethasone 4 mg intramuscularly 2 times a day, meldonium 10 ml with eufillin 2.4% 10.0 intravenously in saline 100 ml intramuscularly 1 time per day, in combination with omeprazole 20 mg orally 2 times a day.

EFFECT: method provides facilitating the tolerance of radical surgical interventions for lung cancer, reducing the frequency and severity of postoperative complications, the duration of the patient's stay in the anesthesiology and intensive care unit, and postoperative bed days.

1 cl, 1 ex

Description

SUBSTANCE: invention relates to medicine, namely to oncology, pulmonology, and can be used in preoperative preparation of patients with lung cancer after moderate and severe COVID-19 associated pneumonia to improve the functional tolerance of radical surgical operations.

For the first time, official information about cases of pneumonia of unknown etiology in the city of Wuhan (PRC) appeared on December 31, 2019. Subsequently, it was found that the causative agent is a new coronavirus called SARS-CoV-2 (Severe Acute Respiratory Syndrome Coronavirus 2), and the disease was given the name COVID -19. Due to the high rate of infection and the severity of the disease, on March 11, 2020, the World Health Organization (WHO) declared a COVID-19 pandemic. In Russia, the first cases of infection were recorded on January 31, 2020 [1]. In most infected patients, the disease proceeds relatively favorably, however, in 14% of patients, a severe course is noted, accompanied by the development of bilateral pneumonia and requiring hospitalization, and in 5% of cases, intensive care in the intensive care unit [3, 4, 5].

With the accumulation of clinical experience, categories of the population were identified that are most likely to become infected and die from severe infection and subsequent complications. A separate high-risk group consisted of patients with tumor pathology. General exhaustion and immunodeficiency states against the background of the oncological process, if adequate anti-epidemic measures are not observed, significantly increase the likelihood of infection and a severe course of viral pneumonia [6, 7]. According to studies, the complicated course of COVID-19 associated pneumonia in patients with cancer is 39%, of which lung cancer accounts for 25%, which causes special attention [8, 9]. For patients with an already established oncological diagnosis, new recommendations for management and specialized treatment in a pandemic were urgently developed and implemented [6, 7, 10]. However, mass hospitalizations and examinations of those infected in respiratory hospitals contributed to diagnostic findings in the form of neoplasms of various localizations, primarily lung cancer. The experience gained during the pandemic in accompanying patients with severe respiratory viral infections has improved the results of treatment for both the elderly and patients with a pronounced comorbid background, including cancer. As a result, after being discharged from the respiratory hospital, oncologists began to see patients characterized by COVID-19 associated pneumonia and newly diagnosed lung cancer. A distinctive feature of such a patient is pronounced physical and emotional exhaustion, the continuing consequences of a viral lesion of the lung parenchyma with a decrease in the functional parameters of external and tissue respiration, as well as disorders of the rheological properties of the blood.

Thus, oncologists are faced with a new model of a patient who requires specialized surgical treatment, but given his general condition, this treatment will be accompanied by an extremely high risk of complications and mortality. One of the possible solutions to the problem of reducing postoperative complications and mortality in patients with lung cancer after suffering COVID-19 associated pneumonia is the development and use of a preoperative preparation complex aimed at restoring functional disorders in a limited period of time.

There is a known method of preoperative preparation of patients with lung cancer after suffering COVID-19 associated pneumonia, which consists in the following: 7 weeks before surgical treatment, a rehabilitation complex is carried out, represented by three modules: nebulizer therapy with inhalation of a mixture of solutions of lazolvan 1 ml and alternation of sulfate mineral water 2 ml and bromine-iodine mineral water 2 ml, which is performed daily, three times a day for 10 minutes. Pulmonary rehabilitation therapy, including a set of breathing exercises, consisting of 4 exercises aimed at training the respiratory muscles. A set of strength exercises, consisting of 2 exercises for the upper and 2 exercises for the lower groups of skeletal muscles. A complex of aerobic training, including, at the patient's choice, walking, exercise bike, swimming. As well as drug therapy, including the appointment for the entire period of preparation of the oral anticoagulant Eliquis at a dosage of 2.5 mg 2 times a day and a mixture of Nutridrink 200 ml per day. EFFECT: method provides performing radical surgical treatment in patients with lung cancer after suffering COVID-19 associated pneumonia and reducing the risk of postoperative complications and mortality due to a complex of correction of consequences and restoration of functional disorders in a limited period of time (see patent RU 2766291 C9) [2].

The advantages of this technique include simplicity and sufficient localization over the time interval. The disadvantages include, in our opinion, an insufficiently comprehensive approach to such a serious problem.

The technical result is the development of a method for preoperative preparation of patients with lung cancer after suffering from COVID-19 associated pneumonia, which improves the functional tolerance of radical surgical operations.

The technical result is achieved by the fact that in patients in the preoperative period for 7-10 days preoperative preparation is carried out, including the appointment of a direct anticoagulant fraxiparin 0.3 ml subcutaneously 2 times a day, breathing exercises in the form of exercises with a loading spirometer in 2 approaches per hour, except at night, drug therapy: dexamethasone 4 mg intramuscularly 2 times a day, meldonium 10 ml + eufillin 2.4% 10.0 IV in saline 100 ml IV bolus 1 time per day, in combination with omeprazole 20 mg orally 2 times a day.

The method is performed as follows.

A patient with lung cancer, after undergoing COVID-19 associated pneumonia 7-10 days before surgical treatment, is prescribed the direct anticoagulant fraxiparin (calcium nadroparin) 0.3 ml subcutaneously 2 times a day, breathing exercises in the form of exercises with a loading spirometer, based on the effect resistance to inhalation, 2 approaches per hour (except at night), drug therapy: dexamethasone 4 mg intramuscularly 2 times a day, meldonium 10 ml + eufillin 2.4% 10.0 i.v. in saline 100 ml i.v. bolus 1 time per day, in combination with omeprazole 20 mg orally 2 times a day. This type of exercise spirometer is designed to help patients take long, deep breaths that resemble a yawn. The respiratory simulator ensures the achievement of a number of targeted therapeutic and prophylactic effects: the load on the respiratory muscles increases; the airways remain open in the expiratory phase, preventing bronchial collapse; deepening inhalation and exhalation; the removal of mucus and sputum from the respiratory tract improves, thereby increasing pulmonary ventilation; parts of the bronchopulmonary system with insufficient aeration are involved in the respiratory act; air flow increases at the end of the expiratory phase and the vital capacity of the lungs increases; cough is suppressed [11, 12, 13].

We use the Portex Coach 2 exercise spirometer in our practice, which simplifies incentive spirometry for both patients and physicians. The one-way valve allows the patient to inhale rather than exhale into the machine. Highly visible pistons and versatile graphics (indicating the correct inspiratory rate) help patients perform and control their postoperative breathing exercises without direct observation. Our proposed approach to the use of loading spirometers is 2 approaches within an hour. Each time, try for at least 5 seconds in the preoperative period and 3 seconds in the postoperative period, in our opinion, on the one hand, it is quite effective, and, on the other hand, does not tire the patient, does not cause aggravation of hypoxia, not only in the preoperative, but also in the postoperative period.

We give a clinical example of the application of the method.

Patient U., 70 years old, was admitted to the Department of Thoracic Oncology of the Federal State Budgetary Institution National Medical Research Center of Oncology of the Ministry of Health of the Russian Federation on August 26, 2022, with a diagnosis of peripheral cancer in/lobe of the right lung cT2aN1M0 st IIb, class gr 2. History of confirmed coronavirus infection with the development of 2-sided polysegmental pneumonia with 50% lung involvement. After admission to the hospital for 7 days, the patient underwent preoperative preparation according to the method proposed by us. On 09/01/2022, an operation was performed - an extended upper lobectomy on the right. Histological analysis: in the lung tissue - squamous nonkeratinized carcinoma with foci of necrosis, perineural and perivascular invasion, invasion of the large bronchus wall. Signs of germination of the visceral pleura were not found. In the lung tissue, outside the tumor - uneven focal fibrosis of the interalveolar septa in the form of layers and fields, dystelectasis, peribronchial and perivascular fibrosis, a sharp plethora of blood vessels. Focal infiltration of the parenchyma with xanthoma cells, small lymphocytes, histiocytes. No tumor growth was found in the resection line of the bronchus and vessels. In 1 of 8 peribronchial lymph nodes - carcinoma metastasis. In 8 lymph nodes of the root of the lung, 2 roots of the lung, 6 paratracheal, 5 bifurcations - sinus histiocytosis, deposition of dust pigment. On the 1st day of the postoperative period, the patient was transferred from the intensive care unit to the department of thoracic oncology; on the 14th day of the postoperative period, the patient was discharged at the place of residence in a satisfactory condition.

This method was treated 12 patients.

The technical and economic efficiency of the method lies in the fact that patients after COVID-19 associated pneumonia tolerate radical surgical interventions for lung cancer more easily, the frequency and severity of postoperative complications decrease, the length of the patient's stay in the anesthesiology and intensive care unit decreases, and the postoperative bed-day decreases. .

List of sources

1. Kaprin A.D., Khoronko V.E. Experience in the treatment of cancer patients during the COVID-19 pandemic. Anesthesiology and resuscitation (Media Sphere). 2021. No. 2. S. 117-123.

2. Shefer N.A., Topolnitsky E.B., Dambaev G.Ts. A method for preoperative preparation of patients with lung cancer after suffering COVID-19 associated pneumonia. Patent for invention 2766291 C9, 03/28/2022. Application No. 2021119824 dated 07/07/2021.

3. Chan JF, Yuan S, Kok KH, Kai-Wang ToK et al. A familial cluster of pneumonia associated with the 2019 novel coronavirus indicating personto-person transmission: a study of a family cluster. Lancet. 2020; 395(10223): 514-523. https://doi.org/10.1016/S0140-6736(20)30154-9

4. Srinivasan S, Cui H, Gao Z, Liu M, Lu S, Mkandawire W, Narykov O, Sun M, Korkin D. Structural Genomics of SARS-CoV-2 Indicates Evolutionary Conserved Functional Regions of Viral Proteins. Viruses. 2020; 12(4): 360. https://doi.org/10.3390/v12040360. Page: 11 EN 2766291 C9 (W1 C1).

5. Glowacka I, Bertram S, Muller MA et al. Evidence that TMPRSS2 Activates the Severe Acute Respiratory Syndrome Coronavirus Spike Protein for Membrane Fusion and Reduces Viral Control by the Humoral Immune Response. Journal of virology. 2011; 85(9): 4122-4134. https://doi.org/10.1128/JVI.02232-10

6. Kaprin A.D., Gameeva E.V., Polyakov A.A., Kornietskaya A.L., Rubtsova N.A., Fedenko A.A. The impact of the COVID-19 pandemic on oncology practice. Siberian journal of oncology. 2020; 19(3): 5-22 [Kaprin AD, Gameeva EV, Polyakov AA, Kornieckaya AL, Rubtsova NA, Fedenko AA. Impact of the COVID-19 pandemic on cancer practice. Sibirskiy onkologicheskiy journal 2020; 19(3): 5-22. (in Russ.)]. https://doi.org/10.21294/ 1814-4861-2020-19-3-5-22

7. Kaprin A.D., Fedenko A.A., Polyakov A.A., Polyakov A.P. Surgical treatment strategy for cancer patients during the COVID-19 pandemic. Surgery. Journal them. N.I. Pirogov. 2020; (12): 5-15 [Kaprin AD, Fedenko AA, Polyakov AA, Polyakov AP. Surgical treatment strategy for cancer patients in the context of the COVID19 pandemic. Khirurgiya. Journal im. N.I. Pirogova 2020; (12): 5-15. (in Russ.)]. https://doi.org/10.17116/hirurgia20201215

8. Choinzonov E.L., Zhuikova L.D., Ananina O.A. and others. Lung cancer in the Tomsk region (epidemiological aspects). Modern Oncology. 2019;21(2):6-9 [Choinzonov EL, Zhuikova LD, Ananina OA. et al. Lung cancer in the Tomsk region (epidemiological aspects). Sovremennaya Onkologiya. 2019; 21(2): 6-9. (in Russ.)]. https://doi.org/10.26442/ 18151434.2019.2.190413

9. Liang W., Guan W., Chen R., Wang W., Li J., Xu K. Cancer patients in SARS-CoV-2 infection: a nationwide analysis in China. Lancet Oncol. 2020; 21(3): 335-337.

10. Allahverdyan A.S. Surgical treatment of non-small cell lung cancer in a pandemic of a new coronavirus infection (COVID-19). Surgery. Journal them. N.I. Pirogov. 2020; 7: 82-85 [Allakhverdyan AS. Surgical treatment of non-small cell lung cancer in the context of the novel coronavirus infection (COVID-19) pandemic. Khirurgiya. Journal im. N.I. Pirogova 2020; 7:82-85. (in Russ.)]. https://doi.org/10.17116/hirurgia202007182

11. Ezhov V.V., Tsarev A.Yu. Respiratory simulator "new breath" in the program of kinesiotherapy of patients with chronic cerebral ischemia. Bulletin of physiotherapy and balneology. 2017. V. 23. No. 3. pp. 106-106a.

12. Dudchenko L.Sh., Mizin V.I. Influence of physical training with breathing simulators on the dynamics of clinical and functional parameters of patients with bronchial asthma at the sanatorium-resort stage of rehabilitation. Bulletin of physiotherapy and balneology. 2018. V. 24. No. 3. S. 16-21.

13. Rudenko S.I., Tarina E.D. The role of the respiratory simulator in the rehabilitation program of patients with severe chronic obstructive pulmonary disease. Scientific Bulletin of Public Health of the Kuban. 2019. No. 4 (64). pp. 35-41.

Claims (1)

A method for preoperative preparation of patients with lung cancer after suffering COVID-19 associated pneumonia, which consists in preoperative preparation in patients in the preoperative period for 7-10 days, including the administration of direct anticoagulant fraxiparine 0.3 ml subcutaneously 2 times a day. day, breathing exercises in the form of exercises with a loading spirometer, 2 approaches per hour, except at night, drug therapy: dexamethasone 4 mg intramuscularly 2 times a day, meldonium 10 ml with aminophylline 2.4% 10.0 i.v. saline 100 ml IV bolus once a day, in combination with omeprazole 20 mg orally 2 times a day.