Lawrence Valerie A, Cornell John E, Smetana Gerald W
South Texas Veterans Health Care System and Medicine/General Medicine, The University of Texas Health Science Center at San Antonio, San Antonio, Texas 78229-3900, USA.
Ann Intern Med. 2006 Apr 18;144(8):596-608. doi: 10.7326/0003-4819-144-8-200604180-00011.
Postoperative pulmonary complications are as frequent and clinically important as cardiac complications in terms of morbidity, mortality, and length of stay. However, there has been much less research and no previous systematic reviews of the evidence of interventions to prevent pulmonary complications.
To systematically review the literature on interventions to prevent postoperative pulmonary complications after noncardiothoracic surgery.
MEDLINE English-language literature search, 1 January 1980 through 30 June 2005, plus bibliographies of retrieved publications.
Randomized, controlled trials (RCTs); systematic reviews; or meta-analyses that met predefined inclusion criteria.
Using standardized forms, the authors abstracted data on study methods, quality, intervention and control groups, patient characteristics, surgery, postoperative pulmonary complications, and adverse events.
The authors qualitatively synthesized, without meta-analysis, evidence from eligible studies. Good evidence (2 systematic reviews, 5 additional RCTs) indicates that lung expansion interventions (for example, incentive spirometry, deep breathing exercises, and continuous positive airway pressure) reduce pulmonary risk. Fair evidence suggests that selective, rather than routine, use of nasogastric tubes after abdominal surgery (2 meta-analyses) and short-acting rather than long-acting intraoperative neuromuscular blocking agents (1 RCT) reduce risk. The evidence is conflicting or insufficient for preoperative smoking cessation (1 RCT), epidural anesthesia (2 meta-analyses), epidural analgesia (6 RCTs, 1 meta-analysis), and laparoscopic (vs. open) operations (1 systematic review, 1 meta-analysis, 2 additional RCTs), although laparoscopic operations reduce pain and pulmonary compromise as measured by spirometry. While malnutrition is associated with increased pulmonary risk, routine total enteral or parenteral nutrition does not reduce risk (1 meta-analysis, 3 additional RCTs). Enteral formulations designed to improve immune status (immunonutrition) may prevent postoperative pneumonia (1 meta-analysis, 1 additional RCT).
The overall quality of the literature was fair: Ten of 20 RCTs and 6 of 11 systematic reviews were good quality.
Few interventions have been shown to clearly or possibly reduce postoperative pulmonary complications.
术后肺部并发症在发病率、死亡率和住院时间方面与心脏并发症一样常见且具有临床重要性。然而，关于预防肺部并发症干预措施的研究要少得多，且此前没有对相关证据进行系统评价。
系统评价非心胸外科手术后预防术后肺部并发症干预措施的文献。
检索1980年1月1日至2005年6月30日的MEDLINE英文文献，并查阅检索到的出版物的参考文献。
符合预定义纳入标准的随机对照试验（RCT）、系统评价或荟萃分析。
作者使用标准化表格提取关于研究方法、质量、干预组和对照组、患者特征、手术、术后肺部并发症及不良事件的数据。
作者对符合条件的研究证据进行定性综合分析，未进行荟萃分析。有力证据（2项系统评价、5项其他RCT）表明，肺扩张干预措施（如激励肺活量测定、深呼吸练习和持续气道正压通气）可降低肺部风险。中等证据表明，腹部手术后选择性而非常规使用鼻胃管（2项荟萃分析）以及使用短效而非长效术中神经肌肉阻滞剂（1项RCT）可降低风险。术前戒烟（1项RCT）、硬膜外麻醉（2项荟萃分析）、硬膜外镇痛（6项RCT、1项荟萃分析）以及腹腔镜（与开放手术相比）手术（1项系统评价、1项荟萃分析、2项其他RCT）的证据相互矛盾或不充分，尽管腹腔镜手术可减轻疼痛并改善肺活量测定所衡量的肺部功能。虽然营养不良与肺部风险增加相关，但常规全肠内或肠外营养并不能降低风险（1项荟萃分析、3项其他RCT）。旨在改善免疫状态的肠内制剂（免疫营养）可能预防术后肺炎（1项荟萃分析、1项其他RCT）。
文献的总体质量中等：20项RCT中的10项以及11项系统评价中的6项质量良好。
很少有干预措施被证明能明确或可能降低术后肺部并发症的发生率。
