Lung Neoplasms, Sleep Wake Disorders
Conditions
Keywords
Repetitive Transcranial Magnetic Stimulation, Postoperative Sleep Disturbance, Thoracoscopic Lung Resection, Perioperative Care, Dorsolateral Prefrontal Cortex
Brief summary
This randomized, double-blind, sham-controlled trial will evaluate whether perioperative low-frequency repetitive transcranial magnetic stimulation (rTMS) can improve early postoperative in-hospital sleep quality in adults undergoing elective thoracoscopic lung resection for primary lung cancer. A total of 220 participants with preoperative sleep impairment will be randomly assigned in a 1:1 ratio to active rTMS or matched sham stimulation. Active rTMS will target the left dorsolateral prefrontal cortex. Five stimulation sessions will be delivered within a 7-day perioperative window: two sessions before surgery, one session after extubation when the participant is clinically stable, and one session on each of postoperative days 1 and 2. The primary outcome is sleep quality measured using the Richards-Campbell Sleep Questionnaire during the first three postoperative inpatient nights. The study will also evaluate wearable-device sleep measures, postoperative pain and analgesic use, recovery, safety, feasibility, and changes in brain activity measured by 64-channel electroencephalography.
Detailed description
This is an investigator-initiated, single-center, prospective, randomized, double-blind, parallel-group, sham-controlled trial in adults undergoing elective thoracoscopic lung resection for primary lung cancer. Eligible participants will have evidence of preoperative sleep impairment, defined as an Insomnia Severity Index (ISI) score of at least 8 or a Richards-Campbell Sleep Questionnaire (RCSQ) score below 70 on the most recent evaluable preoperative inpatient night. Participants will be randomized in a 1:1 ratio to active or sham stimulation. Active treatment will consist of 1-Hz repetitive transcranial magnetic stimulation over the left dorsolateral prefrontal cortex at the F3 position, delivered at 100% of the resting motor threshold with 1,800 pulses per session over approximately 30 minutes. Five sessions will be delivered within a 7-day perioperative window: on preoperative day 2, preoperative day 1, 2-6 hours after extubation when clinically stable, postoperative day 1, and postoperative day 2. No more than one study stimulation session will be delivered on the same calendar day, and study procedures will not delay surgery, necessary clinical care, or discharge. The sham group will undergo matched stimulation using a dedicated sham coil or validated active/sham masking module. Target location, participant positioning, stimulation rhythm, sound, session duration, and study interaction procedures will be matched to active treatment, but the sham procedure will not provide the intended therapeutic cortical stimulation. Participants and outcome assessors will remain blinded to treatment allocation; stimulation operators cannot be blinded because of device-operation requirements but will not participate in recruitment, primary outcome assessment, data entry, or statistical analysis. The primary outcome is the participant-level mean RCSQ total score across postoperative inpatient nights 1, 2, and 3. RCSQ scores range from 0 to 100, with higher scores indicating better sleep. The primary analysis will compare active and sham groups using ANCOVA/linear regression adjusted for the preoperative baseline RCSQ score and prespecified randomization stratification factors. Secondary and exploratory outcomes include total sleep time measured using the Lifesense HR6 wearable device, sleep efficiency and other device-derived sleep measures when reliably available, postoperative pain, opioid consumption, rescue analgesia, quality of recovery, chest-tube duration, length of hospital stay, postoperative complications, longer-term sleep symptoms and chronic postsurgical pain, psychological symptoms, health-related quality of life, safety, and feasibility. Resting-state 64-channel EEG and a prespecified TMS-EEG mechanistic substudy will explore changes in spectral power, alpha peak frequency, functional connectivity, network topology, and TMS-evoked cortical responses.
Interventions
Active rTMS will be delivered over the left dorsolateral prefrontal cortex at the F3 position using a figure-of-eight coil. Stimulation parameters are 1 Hz, 100% of the resting motor threshold, and 1,800 pulses per session over approximately 30 minutes. Five sessions will be delivered within a 7-day perioperative window: preoperative day 2, preoperative day 1, 2-6 hours after extubation when clinically stable, postoperative day 1, and postoperative day 2. No more than one study stimulation session will be administered on the same calendar day.
DEVICESham Repetitive Transcranial Magnetic Stimulation
Sham stimulation will be administered using a dedicated sham coil or validated active/sham masking module compatible with the study device. Target location, participant positioning, stimulation rhythm, sound, session duration, and interaction procedures will match active rTMS, but the sham procedure will not produce the intended therapeutic cortical stimulation. Five sham sessions will be delivered according to the same perioperative schedule as the active treatment.
Sponsors
The First Affiliated Hospital of Guangzhou Medical University
Study design
Allocation
RANDOMIZED
Intervention model
PARALLEL
Primary purpose
TREATMENT
Masking
DOUBLE (Subject, Outcomes Assessor)
Masking description
Participants and outcome assessors will be masked to treatment allocation. The clinical care team, follow-up personnel, and statistical personnel will also remain masked whenever applicable. Because of device-operation requirements, the stimulation operator cannot be masked but will not participate in participant recruitment, primary outcome assessment, data entry, or statistical analysis. Emergency unmasking will be permitted only when knowledge of treatment allocation is necessary for urgent clinical management.
Eligibility
Sex/Gender
ALL
Age
18 Years to 80 Years
Healthy volunteers
No
Inclusion criteria
Age 18-80 years and able to understand the study and provide written informed consent. Primary lung cancer diagnosed or suspected based on pathology and/or thoracic surgical multidisciplinary assessment, with planned elective thoracoscopic lung resection. ASA physical status I-III, with expected awake extubation after surgery and ability to complete postoperative sleep and pain assessments. Preoperative sleep impairment, defined as an Insomnia Severity Index (ISI) score ≥8 or a Richards-Campbell Sleep Questionnaire (RCSQ) score \<70 on the most recent evaluable preoperative inpatient night. Able to complete TMS safety screening, resting motor threshold assessment, RCSQ/ISI assessments, at least one baseline night of Lifesense HR6 monitoring, and 64-channel EEG. The preoperative hospitalization schedule permits completion of two preoperative stimulation sessions, and postoperative hospitalization is expected to last at least three nights, allowing completion of the remaining three stimulation sessions without delaying surgery, necessary clinical care, or discharge.
Exclusion criteria
Unable to provide valid informed consent, unwilling to participate, or unable to reliably complete the primary RCSQ assessment. History of epilepsy or unexplained seizures, active intracranial hemorrhage, significant cerebral edema, elevated intracranial pressure, recent stroke, or severe traumatic brain injury. Intracranial ferromagnetic metal, cochlear implant, deep brain stimulator, cardiac pacemaker/implantable cardioverter-defibrillator, or other TMS-incompatible implant. Severe scalp infection, open wound, or inability to safely position the TMS coil or EEG cap. Pregnancy or any condition considered by the investigator to pose unacceptable risk. Emergency surgery, planned open thoracotomy, or planned prolonged postoperative mechanical ventilation or deep sedation. Chronic pain requiring regular preoperative opioid treatment, or pre-existing pain with an NRS score ≥3 in the target thoracic region. Persistent delirium, respiratory distress, hemodynamic instability, active bleeding, or need for urgent reoperation after extubation.
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Mean Richards-Campbell Sleep Questionnaire Total Score Across Postoperative Inpatient Nights 1-3 | Mornings after postoperative inpatient nights 1, 2, and 3 | The Richards-Campbell Sleep Questionnaire (RCSQ) total score is calculated as the mean of five visual analog items and ranges from 0 to 100, with higher scores indicating better sleep. The primary outcome is the participant-level mean RCSQ total score obtained on the mornings after postoperative inpatient nights 1, 2, and 3. At least two valid RCSQ nights are required to calculate the mean. The primary analysis will adjust for the preoperative baseline RCSQ score. |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Mean Total Sleep Time Measured by Lifesense HR6 Across Postoperative Inpatient Nights 1-3 | Postoperative inpatient nights 1, 2, and 3 | Total sleep time (TST), measured in minutes by the Lifesense HR6 wearable device, will be averaged across valid device nights corresponding to postoperative inpatient nights 1, 2, and 3. At least two valid device nights are required to calculate the participant-level mean TST. |
| Generalized Anxiety Disorder-7 Score | Preoperative baseline; within 24-72 hours after the final stimulation session | Anxiety symptoms will be assessed using the Generalized Anxiety Disorder-7 (GAD-7) scale, with total scores ranging from 0 to 21 and higher scores indicating greater symptom severity. |
| Patient Health Questionnaire-9 Score | Preoperative baseline; within 24-72 hours after the final stimulation session; | Depressive symptoms will be assessed using the Patient Health Questionnaire-9 (PHQ-9), with total scores ranging from 0 to 27 and higher scores indicating greater symptom severity. |
| EORTC QLQ-C30 Global Health Status/Quality of Life Score | Preoperative baseline; within 24-72 hours after the final stimulation session; | Health-related quality of life will be assessed using the authorized Chinese Mandarin (China) version of the EORTC QLQ-C30. The prespecified outcome is the Global Health Status/Quality of Life score, ranging from 0 to 100, with higher scores indicating better overall health-related quality of life. |
| Proportion of Participants Completing at Least 4 of 5 Stimulation Sessions | During the 7-day perioperative treatment window | Treatment-course completion will be defined as completion of at least 4 of the 5 planned active or sham stimulation sessions. |
| Incidence of Adverse Events and Serious Adverse Events | From the first study-specific procedure through the final prespecified safety follow-up at postoperative Month 12 | Adverse events and serious adverse events will be recorded, including headache, scalp discomfort, dizziness, auditory discomfort, syncope, seizure, altered consciousness, new focal neurological deficits, vital-sign abnormalities, and interruptions related to study procedures. |
Outcome results
None listed