Table 1. Research questions and recommendations within each domain.
| Pain control |
| Research questions |
| Does PVB have an equal effect in decreasing pneumonia following major abdominal and thoracic surgery? |
| Are centers across the country considering other forms of anesthesia to minimize epidural-associated complications? |
| What are the barriers to adoption of different, perhaps more effective, anesthetic techniques by anesthesia providers? |
| How many patients are being seen by dedicated anesthesia pain services during their inpatient stay? |
| What adjuncts are being used in pain control to pre-empt postoperative pain (i.e., non-opioid analgesics)? |
| What is the most cost-effective option for perioperative anesthesia? |
| What is the utilization of PVB versus thoracic epidural in lung resection? |
| Recommendations |
| Patients should be treated with regional anesthesia techniques at the discretion of institutional capability to minimize pain following thoracotomy and VATS (IA) |
| Paravertebral and intercostal blockade should be considered to be favorable over thoracic epidural anesthesia if providers skilled in these techniques are available (IA) |
| Prevention of chronic pain should be focused on prevention of acute pain and nerve sensitization during the perioperative period (III) |
| The approach to perioperative pain control should be multimodal (IA) |
| Exercise |
| Research questions |
| What is the national current practice for provision of pre- and post-operative exercise programs for thoracic surgery? |
| Do thoracic and general surgeons feel that preoperative exercise programs represent an effective intervention for reducing PPCs? |
| What percentage of patients would be willing to adhere to these programs if made widely available before lung cancer surgery? |
| Are intensive preoperative exercise programs cost-effective and scalable? |
| Recommendations |
| Patients should undergo preoperative pulmonary and exercise assessment prior to proceeding to surgical resection (IA) |
| Preoperative exercise programs of at least one week in duration should be offered to all patients undergoing lung surgery (IB) |
| Exercise programs should incorporate aerobic, resistance, and breathing exercises to appropriately prepare a patient for surgery (IA) |
| Recommendation for frailty assessment and pre-operative planning for those patients deemed at risk for discharge planning to a setting other than home (or pre-op assessment of home health needs/support system) (III) |
| Nutrition |
| Research questions |
| What is the current state of practice of preoperative nutritional optimization nationally? |
| Are thoracic surgery patients being appropriately evaluated for nutritional risk prior to going to the operating room? |
| What interventions are being pursued in patients with swallowing difficulty following surgery, and how long does it take to establish an enteral route? |
| What is the role of immunonutrition in well-nourished and under-nourished thoracic surgery patients? |
| What is the current state of nutritional support immediately following surgery? |
| Recommendations |
| All elective thoracic surgery patients should be assessed for nutritional risk prior to scheduling for surgery (IA) |
| Elective thoracic surgery patients at high nutritional risk should receive at least 7–14 days of preoperative nutritional therapy to optimize preparation for surgery (IB) |
| Elective thoracic surgery patients at no elevated risk should receive nutritional counseling and should be considered for nutritional therapy to optimize preparation for surgery (III) |
| Preoperative fasting should be limited to 6 hours prior to surgery for solids and 2 hours prior to surgery for clear liquids (IA) |
| Immunonutrition supplementation should be considered in patients with high nutritional risk (III) |
| Smoking cessation |
| Research questions |
| What is the current state of smoking cessation programs in the thoracic surgical outpatient setting? |
| What percentage thoracic surgeons prescribe nicotine replacement therapy? |
| What opportunities are available in national databases which have smoking cessation data? |
| How often do NSQIP captured data describe smoking cessation in thoracic surgery patients? |
| How do smoking cessation programs alter the cardiovascular risk profile in thoracic surgical patients? |
| Recommendations |
| All elective thoracic surgery patients should be offered smoking cessation interventions prior to their surgical procedure (IIB) |
| Benefits of smoking cessation increase with greater length until procedure, however cessation interventions should be initiated at any time before proceeding to surgical resection (III) |
| Nicotine Replacement and Pharmacologic Therapies can be safely and effectively used to aid in patients quitting smoking prior to surgery (IB) |
| What is the current state of nutritional support immediately following surgery? |
PVB, paravertebral block; VATS, video-assisted thoracoscopic surgery.