Limited evidence for interventions to reduce post-op pulmonary complications
Background: Despite advances in perioperative care, postoperative pulmonary complications represent a leading cause of morbidity and mortality that are associated with increased risk of admission to critical care and prolonged length of hospital stay. There are multiple interventions that are used, despite there being no consensus guidelines aimed at reducing the risk of PPCs.
Dr. Daniel Weaver
Study design: Systemic review and meta-analysis of randomized controlled trials.
Setting: Literature search from Medline, Embase, CINHAL, and the Cochrane Central Register of Controlled Trials from January 1990 to December 2017, including trials investigating short-term, protocolized medical interventions around noncardiac surgeries with clinical diagnostic criteria for PPC outcomes.
Synopsis: The authors reviewed 117 trials that included 21,940 participants. The meta-analysis comprised 95 randomized controlled trials with 18,062 patients. The authors identified 11 categories of perioperative care interventions that were tested to reduce PPCs. None of the interventions evaluated was supported by high-quality evidence. There were seven interventions that showed a probable reduction in PPCs. Goal-directed fluid therapy was the only one that was supported by both moderate quality evidence and trial sequential analysis. Lung protective intraoperative ventilation was supported by moderate quality evidence, but not trial sequential analysis. Five interventions had low-quality evidence of benefit: enhanced recovery pathways, prophylactic mucolytics, postoperative continuous positive airway pressure ventilation, prophylactic respiratory physiotherapy, and epidural analgesia.
Unfortunately, only a minority of the trials reviewed were large, multi-center studies with a low risk of bias. The studies were also heterogeneous, posing a challenge for meta-analysis.
Bottom line: There is limited evidence supporting the efficacy of any intervention preventing postoperative pulmonary complications, with moderate-quality evidence supporting intraoperative lung protective ventilation and goal-directed hemodynamic strategies reducing PPCs.
Citation: Odor PM et al. Perioperative interventions for prevention of postoperative pulmonary complication: Systemic review and meta-analysis. BMJ. 2020 Mar 11. doi: 10.1136/bmj.m540.
Dr. Weaver is a hospitalist and assistant professor of medicine at UK HealthCare, Lexington, Ky.
