OBJECTIVE To identify, appraise, and synthesise the best available evidence on the efficacy of perioperative interventions to reduce postoperative pulmonary complications (PPCs) in adult patients undergoing non-cardiac surgery. DESIGN Systematic review and meta-analysis of randomised controlled trials. DATA SOURCES Medline, Embase, CINHAL, and CENTRAL from January 1990 to December 2017. ELIGIBILITY CRITERIA Randomised controlled trials investigating short term, protocolised medical interventions conducted before, during, or after non-cardiac surgery were included. Trials with clinical diagnostic criteria for PPC outcomes were included. Studies of surgical technique or physiological or biochemical outcomes were excluded. DATA EXTRACTION AND SYNTHESIS Reviewers independently identified studies, extracted data, and assessed the quality of evidence. Meta-analyses were conducted to calculate risk ratios with 95% confidence intervals. Quality of evidence was summarised in accordance with GRADE methods. The primary outcome was the incidence of PPCs. Secondary outcomes were respiratory infection, atelectasis, length of hospital stay, and mortality. Trial sequential analysis was used to investigate the reliability and conclusiveness of available evidence. Adverse effects of interventions were not measured or compared. RESULTS 117 trials enrolled 21 940 participants, investigating 11 categories of intervention. 95 randomised controlled trials enrolling 18 062 participants were included in meta-analysis; 22 trials were excluded from meta-analysis because the interventions were not sufficiently similar to be pooled. No high quality evidence was found for interventions to reduce the primary outcome (incidence of PPCs). Seven interventions had low or moderate quality evidence with confidence intervals indicating a probable reduction in PPCs: enhanced recovery pathways (risk ratio 0.35, 95% confidence interval 0.21 to 0.58), prophylactic mucolytics (0.40, 0.23 to 0.67), postoperative continuous positive airway pressure ventilation (0.49, 0.24 to 0.99), lung protective intraoperative ventilation (0.52, 0.30 to 0.88), prophylactic respiratory physiotherapy (0.55, 0.32 to 0.93), epidural analgesia (0.77, 0.65 to 0.92), and goal directed haemodynamic therapy (0.87, 0.77 to 0.98). Moderate quality evidence showed no benefit for incentive spirometry in preventing PPCs. Trial sequential analysis adjustment confidently supported a relative risk reduction of 25% in PPCs for prophylactic respiratory physiotherapy, epidural analgesia, enhanced recovery pathways, and goal directed haemodynamic therapies. Insufficient data were available to support or refute equivalent relative risk reductions for other interventions. CONCLUSIONS Predominantly low quality evidence favours multiple perioperative PPC reduction strategies. 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. STUDY REGISTRATION Prospero CRD42016035662.

中文翻译：

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预防术后肺部并发症的围手术期干预措施：系统评价和荟萃分析。

目的 确定、评估和综合现有最佳证据，证明围手术期干预措施可减少接受非心脏手术的成年患者术后肺部并发症 (PPC) 的有效性。设计 随机对照试验的系统评价和荟萃分析。数据来源 Medline、Embase、CINHAL 和 CENTRAL，时间为 1990 年 1 月至 2017 年 12 月。 资格标准 纳入了调查在非心脏手术之前、期间或之后进行的短期、程序化医疗干预的随机对照试验。纳入了具有 PPC 结果临床诊断标准的试验。手术技术或生理或生化结果的研究被排除在外。数据提取和综合 审稿人独立确定研究、提取数据、并评估证据的质量。进行荟萃分析以计算具有 95% 置信区间的风险比。根据 GRADE 方法总结证据质量。主要结果是 PPC 的发生率。次要结局是呼吸道感染、肺不张、住院时间和死亡率。试验序贯分析用于调查现有证据的可靠性和结论性。没有测量或比较干预措施的不利影响。结果 117 项试验招募了 21 940 名参与者，调查了 11 类干预措施。95 项随机对照试验纳入了 18 062 名参与者，被纳入荟萃分析；22 项试验被排除在荟萃分析之外，因为干预措施不够相似而无法合并。没有发现降低主要结果（PPC 发生率）的干预措施的高质量证据。七种干预措施具有低或中等质量证据，置信区间表明 PPC 可能降低：增强恢复途径（风险比 0.35，95% 置信区间 0.21 至 0.58），预防性粘液溶解剂（0.40，0.23 至 0.67），术后持续气道正压通气通气（0.49，0.24 至 0.99），肺保护术中通气（0.52，0.30 至 0.88），预防性呼吸物理治疗（0.55，0.32 至 0.93），硬膜外镇痛（0.77，0.65 至 0.92）和目标导向的血流动力学治疗（0.87， 0.77 至 0.98）。中等质量的证据表明，激励性肺活量测定法在预防 PPC 方面没有益处。试验序贯分析调整有信心支持 PPC 在预防性呼吸物理治疗、硬膜外镇痛、增强恢复途径和目标导向血流动力学治疗中的相对风险降低 25%。没有足够的数据来支持或反驳其他干预措施的等效相对风险降低。结论 低质量证据主要支持多种围手术期 PPC 降低策略。临床医生可能会选择重新评估他们的围手术期护理途径，但结果表明，需要进行具有低偏倚风险的新试验才能获得其中许多干预措施有效性的确凿证据。学习注册 Prospero CRD42016035662。没有足够的数据来支持或反驳其他干预措施的等效相对风险降低。结论 低质量证据主要支持多种围手术期 PPC 降低策略。临床医生可能会选择重新评估他们的围手术期护理途径，但结果表明，需要进行具有低偏倚风险的新试验才能获得其中许多干预措施有效性的确凿证据。学习注册 Prospero CRD42016035662。没有足够的数据来支持或反驳其他干预措施的等效相对风险降低。结论 低质量证据主要支持多种围手术期 PPC 降低策略。临床医生可能会选择重新评估他们的围手术期护理途径，但结果表明，需要进行低偏倚风险的新试验才能获得许多这些干预措施有效性的确凿证据。学习注册 Prospero CRD42016035662。但结果表明，需要进行低偏倚风险的新试验才能获得许多这些干预措施的有效性的确凿证据。学习注册 Prospero CRD42016035662。但结果表明，需要进行低偏倚风险的新试验才能获得许多这些干预措施的有效性的确凿证据。学习注册 Prospero CRD42016035662。