Incidence of mortality and morbidity related to postoperative lung injury in patients who have undergone abdominal or thoracic surgery: a systematic review and meta-analysis

doi:10.1016/S2213-2600(14)70228-0

The Lancet Respiratory Medicine

Volume 2, Issue 12, December 2014, Pages 1007-1015

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https://doi.org/10.1016/S2213-2600(14)70228-0 Get rights and content

Summary

Background

Lung injury is a serious complication of surgery. We did a systematic review and meta-analysis to assess whether incidence, morbidity, and in-hospital mortality associated with postoperative lung injury are affected by type of surgery and whether outcomes are dependent on type of ventilation.

Methods

We searched MEDLINE, CINAHL, Web of Science, and Cochrane Central Register of Controlled Trials for observational studies and randomised controlled trials published up to April, 2014, comparing lung-protective mechanical ventilation with conventional mechanical ventilation during abdominal or thoracic surgery in adults. Individual patients' data were assessed. Attributable mortality was calculated by subtracting the in-hospital mortality of patients without postoperative lung injury from that of patients with postoperative lung injury.

Findings

We identified 12 investigations involving 3365 patients. The total incidence of postoperative lung injury was similar for abdominal and thoracic surgery (3·4% vs 4·3%, p=0·198). Patients who developed postoperative lung injury were older, had higher American Society of Anesthesiology scores and prevalence of sepsis or pneumonia, more frequently had received blood transfusions during surgery, and received ventilation with higher tidal volumes, lower positive end-expiratory pressure levels, or both, than patients who did not. Patients with postoperative lung injury spent longer in intensive care (8·0 [SD 12·4] vs 1·1 [3·7] days, p<0·0001) and hospital (20·9 [18·1] vs 14·7 [14·3] days, p<0·0001) and had higher in-hospital mortality (20·3% vs 1·4% p<0·0001) than those without injury. Overall attributable mortality for postoperative lung injury was 19% (95% CI 18–19), and differed significantly between abdominal and thoracic surgery patients (12·2%, 95% CI 12·0–12·6 vs 26·5%, 26·2–27·0, p=0·0008). The risk of in-hospital mortality was independent of ventilation strategy (adjusted HR 0·71, 95% CI 0·41–1·22).

Interpretation

Postoperative lung injury is associated with increases in in-hospital mortality and durations of stay in intensive care and hospital. Attributable mortality due to postoperative lung injury is higher after thoracic surgery than after abdominal surgery. Lung-protective mechanical ventilation strategies reduce incidence of postoperative lung injury but does not improve mortality.

Funding

None.

Introduction

More than 230 million major surgical procedures are performed worldwide each year.¹ Complications after major surgery increase use of resources and are important causes of death.¹ Postoperative pulmonary complications, including postoperative lung injury, are associated particularly with morbidity and mortality after major surgery.2, 3, 4 Evidence suggests that intraoperative lung-protective mechanical ventilation strategies, which use low tidal volumes with or without high levels of positive end-expiratory pressure (PEEP), prevent postoperative lung injury compared with conventional ventilation (high tidal volume and low PEEP levels).2, 3, 4 A large retrospective study showed that use of low tidal volumes during general anaesthesia for surgery were associated with increased mortality, and excess mortality was suggested to have been caused by the use of too-low PEEP levels.⁵

The exact effects of postoperative lung injury on morbidity and mortality are uncertain, and the outcome of postoperative lung injury could be different in patients who had abdominal surgery from those who underwent thoracic surgery. Additionally, whether different lung-protective ventilation strategies affect the development of postoperative lung injury and outcomes needs to be better defined.2, 3, 4

Improved understanding of the incidence, morbidity, and mortality of postoperative lung injury could help in the design of future trials and might improve the approach to prevention and treatment of this condition. We aimed to test the hypotheses that crude and attributable mortality differ between patients after abdominal and thoracic surgery and that outcome of postoperative lung injury is dependent on intraoperative ventilation settings.

Section snippets

Methods

The full statistical analysis plan for this meta-analysis has been published.⁶ We did an individual-patient-data meta-analysis of studies and trials of intraoperative ventilation during abdominal and thoracic surgery, which allowed us to quantify crude and attributable mortality of postoperative lung injury and assess its relation to different ventilation strategies. We compared incidence of lung injury and outcomes in patients who underwent abdominal surgery with those in patients who

Results

We identified three observational studies and 21 randomised controlled trials comparing different tidal volume, PEEP settings, or both, in intraoperative ventilation during general anaesthesia for major abdominal or thoracic surgery.8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31 We were unable to collect data from five randomised controlled trials because the corresponding author could not provide data of interest or no longer had access to the

Discussion

This meta-analysis of data at the individual patient level shows that postoperative lung injury is associated with high attributable mortality. Additionally, it is associated with important increases in resource use, as reflected by longer stays in intensive care and hospital than for patients without postoperative lung injury. The incidence of postoperative lung injury was similar in patients undergoing abdominal or thoracic surgery, but the attributable mortality was higher in those who

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ArticlesIncidence of mortality and morbidity related to postoperative lung injury in patients who have undergone abdominal or thoracic surgery: a systematic review and meta-analysis

Summary

Background

Methods

Findings

Interpretation

Funding

Introduction

Section snippets

Methods

Results

Discussion

Br J Anaesth

Br J Anaesth

Br J Anaesth

Br J Anaesth

J Cardiothorac Vasc Anesth

J Clin Anesth

Chest

J Thorac Cardiovasc Surg

J Clin Anesth

Prediction of postoperative pulmonary complications in a population-based surgical cohort

Anesthesiology

Intraoperative ventilatory strategies to prevent postoperative pulmonary complications: a meta-analysis

Curr Opin Anaesthesiol

Protective lung ventilation in operating room: systematic review

Minerva Anestesiol

Association between use of lung-protective ventilation with lower tidal volumes and clinical outcomes among patients without acute respiratory distress syndrome: a meta-analysis

JAMA

Protocol for a systematic review and individual patient meta-analysis of benefit of so-called lung-protective ventilation-settings in patients under general anesthesia for surgery

Syst Rev

The American-European Consensus Conference on ARDS. Definitions, mechanisms, relevant outcomes, and clinical trial coordination

Am J Respir Crit Care Med

The effects of different ventilatory settings on pulmonary and systemic inflammatory responses during major surgery

Anesth Analg

Articles
Incidence of mortality and morbidity related to postoperative lung injury in patients who have undergone abdominal or thoracic surgery: a systematic review and meta-analysis