This longitudinal study demonstrated the potential utility of the LCQ-MC, a cough-specific instrument to assess impact on HRQOL, for evaluating postoperative cough in patients who undergo VATS for early-stage NSCLC and for detecting differences in recovery from postoperative cough by type of procedure (VATS lobectomy vs. VATS sublobectomy). To the best of our knowledge, this study is the first to define the recovery from postoperative cough using the LCQ-MC as an outcome measure and compare this recovery between VATS lobectomy and VATS sublobectomy.
The LCQ-MC enables real-time reporting of the impact of postoperative cough on HRQOL in terms of physical, psychological and social domains to the surgeon or health care provider, which may improve the likelihood of effectively evaluating ERAS. Patient satisfaction after surgery is largely dependent on his or her recovery experience. Postoperative cough, one of the most common respiratory symptoms after surgery, can adversely affect HRQOL. In severe postoperative cough, patients experience disrupted sleep and difficulty talking, which increases their psychological burden and worsens their HRQOL[2, 20, 21]. The LCQ-MC is a flexible, easily completed, valid instrument that can be deployed in various ways, including through paper and pencil, smartphones, and other electronic data capture methods. The LCQ-MC can be completed in less than 5 minutes with any of these modes. Accurate and convenient evaluations of the impact of postoperative cough on HRQOL are important for ensuring early and effective treatment. We previously showed that the LCQ-MC reliably assessed postoperative cough in patients with NSCLC who underwent VATS. This instrument can be used to guide effective treatment, accelerate the recovery from postoperative cough, and achieve the objective of ERAS.
As expected, VATS sublobectomy had more favourable effects on postoperative recovery and morbidity than VATS lobectomy[25, 26]. This may be related to a combination of factors associated with VATS lobectomy, such as greater stress on the cardiovascular system, larger change in the bronchial angle and more stimulation to cough receptors[27–29]. Postoperative cough symptoms peaked immediately after surgery and were prevalent on PODs 1-2, representing a combined effect from surgical trauma and perioperative care. The patients who underwent VATS lobectomy reported significantly higher physical, psychological, and total LCQ-MC scores at 1 month after discharge than those who underwent VATS sublobectomy. Nevertheless, the LCQ-MC scores at 3 and 6 months after discharge were not significantly different between the two surgery types. Our finding of the different impacts of postoperative cough on HRQOL between the two groups, as measured by LCQ-MC, mirrors previous studies that have reported that the severity of postoperative cough in early-stage NSCLC patients after VATS sublobectomy was lower or similar to that in patients after VATS lobectomy[17, 30, 31]. This demonstrates that the LCQ-MC is sufficiently sensitive to differentiate postoperative cough by type of procedure.
In patients who underwent VATS sublobectomy, the postoperative cough returned to preoperative levels after approximately 3 months (median time for the physical score: 69 days, psychological score: 67 days, and social score: 50 days). In patients who underwent VATS lobectomy, the postoperative cough had a somewhat different pattern of recovery in this study and recovered more slowly (median time for the physical score: 99 days, psychological score: 99 days, and social score: 98 days) (Figure 2, Table 3). Using LCQ-MC as an indicator of the status of postoperative cough symptoms, we not only defined the impact of postoperative cough on HRQOL in this study but also defined the time course of postoperative cough recovery after VATS for early-stage NSCLC. In the current study, repeated LCQ-MC measurements were acquired at selected critical timepoints, beginning with a preoperative assessment, thus sufficiently and sensitively capturing significant differences in the impact of postoperative cough on HRQOL over time and the time needed to return to preoperative levels between two different surgery types for early-stage NSCLC. The minimal clinically important difference (MCID) is the smallest change in the quality-of-life score considered to be clinically meaningful. The mean (SD) total LCQ MCID was 1.3 (3.2), the MCIDs for each domain were as follows: physical: 0.2 (0.8), social: 0.2 (1.1) and psychological: 0.8 (1.5). In the current study, the differences between the immediately postoperative individual physical, psychological, and social domain scores as well as total LCQ-MC scores and those acquired 1 month after discharge were 0.96 (0.96), 0.53 (1.29), 0.43 (1.12) and 1.92 (2.99), respectively, suggesting a clinically meaningful difference.
This study had several limitations. First, the sample size was limited, and the sample was a homogenous group of patients with early-stage NSCLC. Future studies with a more diverse sample are warranted to identify potential risk factors and define the trajectory of postoperative cough recovery to increase the generalizability of the results. Second, we usually administered the LCQ-MC on the day of discharge and did not collect the LCQ-MC scores on PODs 1-3 or 1 week after discharge. The differences in postoperative cough symptoms between VATS lobectomy and VATS sublobectomy that were observed clinically may have been even more striking if these data had been included in the analysis. Third, in addition to charting the return to preoperative levels, the study lacked another objective measure of cough by which to define recovery to a “good” level of postoperative cough symptoms (both cut-off points and MCID), which could be more practical for further decision-making about ongoing cough-specific treatment, and there would be no need for a baseline LCQ-MC assessment.
In conclusion, this study is among the first to describe the nature of and changes in postoperative cough in patients with early-stage NSCLC after VATS during the first 6 months after discharge. The LCQ-MC is a clinically relevant and user-friendly instrument for assessing the patient’s perspective of the impact of postoperative cough on HRQOL. Routine monitoring of postoperative cough recovery with LCQ-MC scores could be a novel addition to ERAS that has the potential to improve standard practice after the patients are discharged after VATS.