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Surgery to remove part or all of a lung is the main way early lung cancer is cured. How much is removed varies from a small wedge to an entire lung. Before offering the operation the team has to work out whether breathing and fitness will still be good enough afterwards — which is where exercise testing comes in. This page covers those decisions, the recovery, and the complications to watch for.
The operations
| Resection | What is removed | Typical indication |
|---|---|---|
| Wedge resection | A non-anatomical portion of a lobe | Small peripheral nodule, diagnostic biopsy, limited reserve |
| Segmentectomy | One anatomical segment with its vessels and bronchus | Small peripheral tumours; increasingly preferred over lobectomy for tumours ≤2 cm |
| Lobectomy | An entire lobe | The standard resection for early-stage lung cancer |
| Sleeve resection | A lobe plus a cuff of bronchus, with the airway reconstructed | Central tumours — performed to avoid pneumonectomy |
| Pneumonectomy | An entire lung | Central or extensive disease not amenable to lesser resection |
| Chest wall resection | Lung plus ribs, with or without reconstruction | Tumour invading the chest wall |
The trend is firmly towards parenchyma-sparing surgery: segmentectomy where once a lobectomy was performed, and sleeve resection where once a pneumonectomy was. Pneumonectomy rates have fallen accordingly, which matters because its complication profile is entirely different.
Deciding who can have surgery
The question is not whether the tumour is resectable but whether the patient is operable — whether the lung and cardiovascular reserve remaining after resection will support life and activity. The ERS/ESTS and ACCP frameworks are the standard.1,2
Predicted post-operative function
FEV1 and DLCO are measured, then scaled to what will remain — predicted post-operative (ppo) values, calculated by segment count or by perfusion scanning. Both matter independently; a normal FEV1 with a low DLCO still carries substantial risk, and DLCO is measured in all candidates regardless of spirometry.
Broadly, ppoFEV1 and ppoDLCO both above 60% predicted indicate low risk and no further testing. Values below 30% predicted indicate high risk. The territory between is where exercise testing decides.
Exercise testing
| Test result | Interpretation |
|---|---|
| Peak VO2 >20 mL/kg/min | Suitable for resection up to pneumonectomy |
| Peak VO2 10–20 mL/kg/min | Increased risk; extent of resection tailored |
| Peak VO2 <10 mL/kg/min | High risk of mortality; major resection generally not offered |
| Stair climb >22 m | Reassuring low-technology surrogate |
| Shuttle walk <400 m | Screens as low exercise capacity — proceed to cardiopulmonary exercise testing (CPET) rather than accept as definitive |
See Cardiopulmonary Exercise Testing for how these values are derived and their limitations. Note that field walking tests are useful for ruling in good capacity and poor at grading the middle range.
Prehabilitation
Short-course high-intensity interval training before lung cancer surgery improves aerobic capacity within the two to four weeks typically available, though the effect on post-operative complications is less certain.3 Prehabilitation should not delay cancer surgery, and this is a real tension in practice — the window is short and the priority is the operation. See Pre-Surgical Rehabilitation.
The early post-operative course
Expect a chest drain, an air leak that may persist, pain proportional to the approach, and a patient who is at real risk of a pulmonary complication.
| Complication | Notes for physiotherapy |
|---|---|
| Prolonged air leak | The commonest cause of delayed discharge. Does not contraindicate mobilisation — patients mobilise with drains as standard under Enhanced Recovery After Surgery (ERAS).4 Avoid sustained high-pressure expiratory manoeuvres without surgical agreement. |
| Atrial fibrillation | Common after major resection, particularly pneumonectomy. Rate is an unreliable exercise-prescription variable in atrial fibrillation (AF) — use perceived exertion. |
| Post-operative pulmonary complications | The main preventable morbidity; modifiable risk factors in this specific population are well characterised.5 |
| Surgical emphysema | Usually benign and self-limiting; rapid progression with a swinging drain suggests a blocked or displaced tube — escalate. |
| Empyema and bronchopleural fistula | Uncommon, serious. New fever with a sudden increase in air leak, or expectoration of thin serous fluid, warrants immediate medical review. |
| Chylothorax | Milky drain output after feeding resumes; managed medically or surgically, not by physiotherapy. |
Pneumonectomy is a different operation
Removing an entire lung is not simply a larger resection. There is no lung left to re-expand on the operated side, the bronchial stump is vulnerable to positive pressure, fluid is deliberately restricted, and positioning follows unit protocol rather than general principle. Several routine physiotherapy interventions are altered or contraindicated.
If the resection was a pneumonectomy, read Pneumonectomy before the first session — the differences are substantial and easy to miss in a handover.
Rehabilitation and recovery
Exercise training after lung resection improves exercise capacity, and there is reasonable evidence for programmes commenced within the first year following surgery for non-small-cell lung cancer.6 Recovery of function is slower than patients expect — breathlessness on exertion typically improves over months, not weeks, and a proportion never return to their pre-operative capacity, particularly after pneumonectomy.
Practical priorities: progressive walking from day one, shoulder and thoracic mobility where the approach was open (see VATS and thoracotomy), and referral into a structured programme at discharge rather than a leaflet.
Role of the physiotherapist
Before surgery: contribute to the fitness assessment, deliver the pre-operative education session, and start prehabilitation where the window allows. After surgery: mobilise early and with drains in place, target respiratory intervention at those who develop a problem, know the pneumonectomy-specific cautions, and make the referral into ongoing rehabilitation rather than assuming it will happen.
Evidence summary
Framing. Surgical resection remains the only reliably curative treatment for early-stage non-small-cell lung cancer, and the population presenting for it is characterised by the coexistence of the disease with the comorbidity that shares its cause — most have some degree of chronic obstructive pulmonary disease (COPD), many have cardiovascular disease, and exercise capacity is frequently the limiting factor in the operability decision rather than spirometry.1,2
Evidence — operabilityThe ERS/ESTS algorithm and the ACCP physiological evaluation guideline are concordant: ppoFEV1 and ppoDLCO are assessed together, both are required regardless of the other, and CPET arbitrates the intermediate zone with peak VO2 thresholds of 20 and 10 mL/kg/min.1,2 Low-technology surrogates — stair climb, shuttle walk — are validated as screens rather than substitutes.
Evidence — physiotherapyPerioperative physiotherapy in lung resection has a weaker evidence base than in upper abdominal surgery, with heterogeneous trials and inconsistent effects on post-operative pulmonary complications (PPC).5 Prehabilitation with short-course high-intensity interval training (HIIT) reliably improves aerobic capacity pre-operatively; translation to reduced complications is not established.3 Post-operative exercise training improves exercise capacity in the first year after resection.6 ERAS/ESTS guidance supports mobilisation within 24 hours and early drain removal.4
Clinical reasoningTwo decisions dominate. First, whether the presenting problem is volume loss, secretion retention or simply pain-limited breathing — they are managed differently and only one responds to a clearance technique. Second, whether the operation was a pneumonectomy, which alters the positioning, pressure and fluid rules entirely. A protocol that does not distinguish the two is unsafe.
Evidence gapsNo adequately powered trial establishes which lung resection patients need post-operative physiotherapy in a contemporary minimally invasive ERAS pathway. The optimal prehabilitation dose within the two-to-four-week oncological window is unknown, as is whether it should ever delay surgery. Physiotherapy practice after pneumonectomy rests almost entirely on physiological reasoning and unit convention rather than trial evidence.
References & evidence base
- Brunelli A, Charloux A, Bolliger CT, et al. ERS/ESTS clinical guidelines on fitness for radical therapy in lung cancer patients (surgery and chemo-radiotherapy). Eur Respir J 2009;34(1):17–41.
- Brunelli A, Kim AW, Berger KI, Addrizzo-Harris DJ. Physiologic evaluation of the patient with lung cancer being considered for resectional surgery: diagnosis and management of lung cancer, 3rd ed. ACCP evidence-based clinical practice guidelines. Chest 2013;143(5 Suppl):e166S–e190S.
- 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(2):323–333.
- Batchelor TJP, Rasburn NJ, Abdelnour-Berchtold E, et al. Guidelines for enhanced recovery after lung surgery: recommendations of the ERAS Society and the European Society of Thoracic Surgeons. Eur J Cardiothorac Surg 2019;55(1):91–115.
- Agostini P, Cieslik H, Rathinam S, et al. Postoperative pulmonary complications following thoracic surgery: are there any modifiable risk factors? Thorax 2010;65(9):815–818.
- Cavalheri V, Burtin C, Formico VR, et al. Exercise training undertaken by people within 12 months of lung resection for non-small cell lung cancer. Cochrane Database Syst Rev 2019;(6):CD009955.
References are numbered in citation order (Vancouver/BMJ style) and were current at the time of writing. Guidelines are living documents — verify against the latest version before clinical use.
Physiotherapy around major chest, cardiac and upper abdominal procedures — from open surgery to bronchoscopic, catheter-based and bedside treatments — aims to reduce chest complications and shorten the return to normal function.
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