Some Interventions May Reduce Postop Lung Complications

By Reuters Staff

March 25, 2020

NEW YORK (Reuters Health) - Lung protective ventilation and perioperative goal-directed hemodynamic therapy may help reduce postoperative complications (PPCs), but evidence supporting their benefits is of moderate quality at best, according to a new systematic review and meta-analysis.

"We have shown that the best quality evidence is in favor of lung protective ventilation and perioperative goal directed hemodynamic therapy in reducing PPC. Some interventions that are commonly used, sometimes within care bundles, lack supportive evidence," Dr. Peter M. Odor of University College Hospital London in the UK and colleagues write in The BMJ.

"Clinicians may choose to reassess their perioperative care pathways, but the results indicate that new trials with a low risk of bias are needed to obtain conclusive evidence of efficacy for many of these interventions," they add.

PPC prevalence may be as high as 23%, with frail, older patients at highest risk, Dr. Odor and his colleagues write. Age and proximity of surgical incision to the thorax are both "strong predictors" of PPCs, they add.

The lack of up-to-date guidelines on perioperative interventions to help prevent PPCs after surgery means clinical practice is highly variable, the authors note.

To analyze the existing evidence, they reviewed 95 randomized controlled trials (RCTs) including 18,062 patients testing 11 types of perioperative care.

Seven interventions probably reduced PPCs, based on confidence intervals from conventional meta-analysis: enhanced recovery after surgery pathways, prophylactic mucolytics, postoperative continuous positive airway pressure non-invasive ventilation, lung-protective intraoperative ventilation, prophylactic respiratory physiotherapy, epidural anesthesia and goal-directed hemodynamic therapy.

Using trial sequential analysis, four of the seven showed firm evidence of benefit: prophylactic respiratory physiotherapy, epidural analgesia, enhanced recovery after surgery and goal-directed hemodynamic therapies. All of the trials were of low to moderate quality.

"Our main finding is that despite a huge literature and the clinical prevalence and importance of the outcome, the existing evidence is of generally poor quality and does not give definitive answers," Dr. Odor and colleagues write.

"Several large trials that are in progress, or soon to start, will add to our understanding of the role of perioperative goal directed hemodynamic therapy, continuous positive airway pressure, and inspiratory muscle training," they add. "Although it is challenging, trialists should attempt to use standardized endpoints (for both efficacy and adverse effects) and consider aspects relating to the cost and acceptability of interventions. These data are needed to enable the best synthesis of the evidence for making recommendations and informing clinical practice."

SOURCE: The BMJ, online March 11, 2020.