Inspiratory Muscle Training to Improve Total Joint Arthroplasty Outcomes

摘要 全关节置换术(TJA)是美国最常见的选择性手术之一，预计 增加频率增加频率最近的TJA临床实践有效地减少了术后住院时间 然而，尽管TJA护理的效率有所改善，TJA外科手术对肺功能的影响 和呼吸肌功能没有得到广泛的重视。即使在像TJA这样短的手术中， 麻醉、神经肌肉活动不活跃和机械通气使肺急剧恶化。 起作用并触发主要吸气肌--横隔肌的快速、显著的蛋白质分解。然而， 传统的TJA术前护理不能解决这些问题。老年人、吸烟者和 有严重肺部疾病、多种内科合并症或社会经济劣势的人 面临着术后肺和呼吸神经肌肉功能下降的最大风险。多数 使用我们的城市安全网学术医疗中心的患者至少有一个风险因素，即 会干扰急性康复，增加术后肺部并发症的风险，并扩大 住院时间。因此，我们提出了一项术前吸气肌训练的临床研究。 术后肺部并发症风险增加的个体。术前IMT已被证明是 消除术后吸气乏力减少术后肺部并发症 延长的心脏手术，但其潜在的好处还没有在较短的手术中进行调查，如 TJA，预计术后短暂住院。 这个项目的中心假设是，术前IMT是可行的，并将改善呼吸 增强体力，促进术后早期呼吸恢复，优化术后功能活动 出院。计划接受TJA的成年人既有呼吸肌或肺损伤，将 随机完成以下任一项：手术前每日IMT(DIMT)，立即进行单一急性IMT治疗 手术前(AIMT)或通常的手术护理标准(SOC)。手术当天和手术当天的随访检查 术后急性住院期间将明确IMT的可行性(目标1)，区分IMT的效果 吸气和咳嗽强度(目标2)，并评估患者出院准备情况(目标3)。这种高风险， 原则证明提案将提供关于监管中的干扰的第一个受控证据 TJA术后的呼吸功能。我们的计划是，这项研究产生的数据将成为未来研究的基础 IMT的机制研究，以恢复呼吸力量，并进一步优化TJA后的早期康复。

ABSTRACT Total joint arthroplasty (TJA) surgeries are among the most common elective surgeries in the US and projected to increase in frequency. Recent TJA clinical practices have effectively reduced post-operative hospital length of stay, yet despite improvements in the efficiency of TJA care, the effects of TJA surgical procedures on pulmonary and respiratory muscle function are less widely appreciated. Even during surgeries as short as TJA, the administration of anesthesia, neuromuscular inactivity, and mechanical ventilation acutely deteriorate pulmonary function and trigger rapid, significant proteolysis of the primary inspiratory muscle, the diaphragm. However, conventional TJA preoperative care does not conventionally address these issues. Older adults, smokers, and those with significant pre-existing lung disease, multiple medical comorbidities, or socioeconomic disadvantage face the greatest risk for declines in post-operative pulmonary and respiratory neuromuscular function. Most patients who utilize our urban safety-net academic medical center have at least one of these risk factors, which can interfere with acute rehabilitation, increase the risk for post-operative pulmonary complications, and extend hospital length of stay. Thus, we propose a clinical study of preoperative inspiratory muscle training (IMT) among individuals with increased risk for pulmonary post-operative complications. Preoperative IMT has been shown to counteract post-operative inspiratory weakness and reduce postoperative pulmonary complications following prolonged cardiac surgeries, but its potential benefits have not been investigated in shorter surgeries such as TJA, with expected brief post-operative hospitalizations. The central hypothesis of this project is that preoperative IMT is feasible and will improve respiratory strength, hasten the early postoperative respiratory recovery, and optimize functional mobility for hospital discharge. Adults scheduled for TJA with pre-existing respiratory muscle or lung impairment will be randomized to complete either: daily IMT in advance of surgery (dIMT), a single acute IMT session immediately before surgery (aIMT), or usual surgical standard of care (SOC). Follow-up testing on the day of surgery and during the acute post-operative hospitalization will identify the feasibility of IMT (Aim 1), distinguish IMT effects on inspiratory and cough strength, (Aim 2), and evaluate patient readiness for discharge (Aim 3). This high risk, proof-of-principle proposal will provide the first controlled evidence concerning disturbances in the regulatory functions of breathing following TJA. Our plan is that data generated from this study will form the basis for future mechanistic studies of IMT to restore breathing strength and further optimize early rehabilitation following TJA.