All participants in the present study were selected from Banan Hospital Affiliated to Chongqing Medical University (Chongqing, China) where they underwent surgical treatment for lung cancer. The patients who needed surgical treatment between January 2022 and January 2023 were included. These individuals were diagnosed with NSCLC in accordance with Oncology Society of Chinese Medical Association guidelines for the clinical diagnosis and treatment of lung cancer (2021 edition) (9), and subsequently underwent thoracoscopic lobectomy. The patients were diagnosed through careful evaluation of clinical manifestations, comprehensive analysis of imaging studies and employment of histological or cytological examination techniques. Inclusion criteria were as follows: i) Patients with primary NSCLC confirmed by pathological diagnosis before operation; ii) those suspected of having lung cancer underwent a pathological analysis of a biopsy during the operation, and the results confirmed the diagnosis of NSCLC.; iii) patients in whom thoracoscopic lobectomy or partial wedge lobectomy was indicated; and iv) patients who agreed to participate in the study and provided written informed consent. The exclusion criteria were as follows: i) The results of intraoperative rapid freezing or postoperative paraffin pathological examination did not conform to the diagnosis of primary NSCLC; ii) patients who were not suitable for thoracoscopic surgery; iii) patients who underwent a pulmonary bilobectomy and total pneumonectomy; iv) patients with massive bleeding during the operation; v) patients who required an unplanned reoperation; vi) those who did not cooperate with lung rehabilitation training or refused to implement a nutrition plan; vii) patients with severe hepatic and renal insufficiency, intestinal obstruction and gastrointestinal bleeding; viii) patients who were participating in other clinical research projects; and ix) patients who refused to provide informed consent.

The research has been duly registered in the Chinese Clinical Trial Register platform (registration no. ChiCTR2300078681; registered, Dec 15, 2023), marking it as a randomized controlled study. Random numbers were generated according to a random number table, and a number plate was prepared and sealed in envelopes. Patients randomly selected envelopes after admission. If the number plate in the envelope was odd, they were included in the test group, while patients with even numbers were included in the control group.

Rehabilitation physicians were invited to provide comprehensive explanations on the intricacies of pulmonary rehabilitation training in the form of instructional videos. Subsequently, upon patient enrollment, the attending physicians deftly integrated these videos into their guidance on pulmonary rehabilitation training. In the test group, lung rehabilitation training commenced 2 weeks prior to the operation, accompanied by individually tailored nutrition intervention prescribed by dietitians. Conversely, the control group did not receive lung rehabilitation training or special nutrition intervention. Following routine preoperative preparation, both groups underwent the planned operation and received customary postoperative treatment. Once their condition stabilized, they were discharged. In the test group, lung rehabilitation training commenced 2 weeks after the operation, accompanied by personalized nutrition intervention prescribed by a nutritionist throughout the entire process. Both groups of patients were followed up at the 4th, 8th and 12th weeks after the operation. Generally, the medical staff maintained follow-up communication with patients 2–3 times per week. Patients were provided with detailed instructions on the rehabilitation program, including exercises, frequency, duration and any specific guidelines. Regular communication with the patients was maintained through phone or text messages to provide support, answer any questions and address concerns they may have had. Automated reminders and motivational messages sent via phone or text message were utilized to remind patients about their scheduled exercises and encourage them to stay committed to the program. The objective of this monitoring process was to ensure that patients adhered to the treatment plan and medical directives, while also providing essential support and guidance. Additionally, the medical staff diligently recorded the patient's feedback and monitored any changes in their condition, making necessary adjustments or recommendations accordingly. Fig. 1 presents the project flow chart.

At 3 days before the operation, expectorant (ambroxol hydrochloride syrup, oral, twice a day, 10 ml each time), antiasthmatic (salbutamol, high-frequency atomization inhalation, twice a day, 2.5 mg each time) and anti-inflammatory (budesonide, high-frequency atomization inhalation, twice a day, 1 mg each time) drugs were administered. Anti-infection treatment was administered to patients with a definite infection before the operation. The treatment plan was formulated according to the microbial drug sensitivity test, clinical pharmacy or respiratory consultation. When the two groups of patients entered the research, all smoking patients were advised to give up smoking in order to facilitate their postoperative recovery.

The lung rehabilitation training included breathing training combined with walking training.

A breathing trainer (Leventon S.A.U.) was used. The respirator was connected correctly, and deep and even inhalations were drawn through the mouthpiece, ensuring that the yellow buoy ball was kept raised to the preset mark for as long as possible. Next, the patient removed the breathing trainer and exhaled slowly. These steps were repeated. The training time was between 10 and 15 min, following which a normal breath rest was taken. During waking hours, breathing training was performed every 2 h. It was ensured that patients were able to tolerate subjective feelings and that the training did not cause fatigue (10).

Patients performed stretching exercises for the muscles in their legs, waist, shoulders, chest and arms, before walking. The total duration of the stretching exercises was 5 min. Next, the patient walked at a slower speed (1.98 km/h as the initial speed) on a treadmill. Gradually, the patients increased their running speed within 5 min, and then walked at a suitable speed. Each walking training session lasted between 20 and 40 min. Alternatively, walking training was performed on a flat road and involved walking slowly for an initial 5 min, followed by gradually increasing the walking speed and maintaining a faster walking speed for 20–40 min.

The nutritionist provided one-to-one nutrition consultation and dietary guidance for each patient, and calculated the daily total energy and nutrient intake of the patient according to the dietary survey, based on the nutritional support requirements of patients with malignant tumors (11). The daily intake of patients reached 70% of the target value, the total energy requirement was 25–30 kcal/kg/day and the protein requirement was 1.5-2.0 g/kg/day [body weight was calculated according to ideal body weight; ideal body weight (kg)=height (cm)-105]. Oral nutrition support (ONS) was given to patients with an insufficient independent diet. If the implementation of ONS was poor, and the dietary survey showed that the dietary intake did not reach 60% of the energy intake standard for 7 consecutive days, the clinician and dietitian discussed the nutrition support plan and decided whether to provide tube feeding enteral nutrition or parenteral nutrition support based on patients' choice.

Intraoperative general anesthesia was administered intravenously. Both groups of patients underwent thoracoscopic lobectomy + systematic lymph node dissection (the left side was cleared of the 4L, 5, 6, 7, 8, 9 and 10 groups of lymph nodes, and the right side was cleared of the 2R, 3, 4R, 7, 8, 9 and 10 groups of lymph nodes) (12).

Expectorant, antiasthmatic and anti-inflammatory treatments were administered 3–7 days after the operation. If a pulmonary infection was present, antibiotics were administered according to microbial drug sensitivity tests, and clinical pharmacy or respiratory consultations. Postoperative epidural analgesia was administered. A patient-controlled analgesia (PCA) pump is a fluid infusion device that can automatically administer medication. Sufentanil, an analgesic drug, was continuously and slowly injected into the epidural space through a PCA pump, and the drug infusion concentration was maintained at 2 µg/ml/h to relieve the pain of the patients. The PCA pump was used for 2 consecutive days. After the pump was removed, oral ibuprofen sustained release capsules were provided for pain relief if the patient still felt significant pain. According to the results of the chest X-ray, the thoracic drainage tube was removed as soon as possible at the appropriate time. Patients were encouraged to perform early passive activities, gradual bedside sitting and standing, and slow walking after surgery.

Five observation indicators were used. i) Quality of life: The fourth version of the Functional Assessment of Cancer Therapy-Lung (FACT-L) in Chinese was used for assessing the quality of life (13). The scale was categorized into five areas, namely, physiological status, social/family status, emotional status, functional status and additional lung cancer concerns. The higher the score, the better the quality of life (14). ii) Lung function: The forced expiratory volume in 1 sec (FEV1), the forced vital capacity (FVC) and the FEV1/predicted value ratio (FEV1% pred) were evaluated. iii) Nutritional status: Body mass index (BMI), and total protein (TP), albumin (Alb) and hemoglobin (Hb) levels were measured. iv) Exercise endurance: A 6-min walk distance (6MWD) test was used to assess endurance (15). v) Postoperative pulmonary complications: Pulmonary infection, pneumothorax (air entering the pleural cavity, with a lung compression area of ≥30%), pleural effusion, subcutaneous emphysema and respiratory failure were recorded.

SPSS 23.0 (IBM Corp.) was used for the statistical analysis. The measurement data conformed to the normal distribution and are expressed as the mean ± standard deviation. The inter-group comparisons were conducted using the independent sample t-test. Count data are expressed as n (%) and were analyzed using the χ² test when the expected frequency was ≥5. When the total sample size was <40 or the expected frequency was <5, Fisher's exact test was used. P<0.05 was considered to indicate a statistically significant difference.

During the preliminary phase, an estimation of the requisite sample size was conducted. Considering postoperative quality of life as the pivotal evaluative criterion for patients with lung cancer, the study placed particular emphasis on the FACT-L as the primary outcome measure. Based on an ANOVA F-Test, considering a significance level of 0.05 for two-sided tests, an 80% power and an anticipated standard deviation of 20 points, it was determined that a minimum of 64 cases per group was required. Accounting for an expected dropout rate of 20%, a total enrollment of 155 cases was targeted, thus yielding an initial sample size estimate of 160 cases. Ultimately, this study successfully enrolled a robust cohort of 169 patients, ensuring an ample sample size. A total of 169 patients (86 in the test group and 83 in the control group) were included in the study. Throughout the study duration, there were no instances of mortality related to lung cancer among the patients. The experimental group consisted of a total of 86 patients, with a mean age of 58.26±10.15 years. This group included 32 males with a mean age of 59.28±7.49 years and 54 females with a mean age of 57.65±11.46 years. The control group consisted of a total of 83 patients, with a mean age of 57.23±8.64 years. Among them, there were 35 males with a mean age of 56.14±9.64 years and 48 females with a mean age of 58.02±7.84 years. Table I shows that there no statistically significant disparity (P>0.05) existed between the two groups in terms of variables such as sex, age, smoking status, presence of chronic obstructive pulmonary disease (COPD), operation type and pathological type. Stages I and II represent the early stage of NSCLCs, encompassing the T1a-2aN0M0 and T2b-T3N0-1M0 classifications. By contrast, stage III represents locally advanced NSCLCs, which include the T3N1M0 and T4N0-1M0 classifications (16). Given the lack of statistically significant differences in Tumor-Node-Metastasis classification between the two patient groups, it can be concluded that this particular factor would not affect the research results.

There was no significant difference in FACT-L quality of life scores between the two groups before treatment (P>0.05). At 12 weeks after the operation, the scores of patients in the test group in terms of physical status, social/family status, emotional status, functional status and additional concerns about lung cancer were all significantly higher than those in the control group (P<0.05), as shown in Table II.

There was no significant difference in lung function and 6MWD between the test group and the control group before treatment (P>0.05). After the operation, at 4, 8 and 12/weeks, the indexes related to lung function (FEV1, FVC and FEV1% pred) in the test group were significantly higher than those in the control group (P<0.05). The 6MWD of the experimental group was also significantly longer than that of the control group (P<0.05) (Table III).

There was no statistically significant difference in the nutritional status of the two groups before treatment (P>0.05). At 4, 8 and 12 weeks after the operation, the BMI, and TP, Alb and Hb levels of the test group were significantly improved compared with those of the control group (P<0.05) (Table IV).

In contrast to the control group, patients in the experimental group experienced significantly reduced hospitalization times and incurred fewer expenses (P<0.05). Furthermore, when comparing postoperative complications between the two groups, the test group exhibited significantly lower rates of pulmonary infection, pleural effusion, subcutaneous pneumatosis and respiratory failure (P<0.05) (Table V).