Author, year

Definition criteria PPCs

Barbalho-Moulim, 2011

Pneumonia: temperature >38°C, productive cough with purulent sputum, presence of pulmonary infiltration on chest X- ray, increased leukocyte count)

Atelectasis: based on chest X- rays and associated with respiratory discomfort

Acute respiratory failure: poor gas exchange and requirement for mechanical ventilation

Roukema, 1988

Grade I: Minor atelectasis in 1 lung, no hypoxemia or hypoxemia <3d duration, no fever

Grade II: Minor atelectasis in both lungs or major atelectasis in one lung, hypoxemia <3d duration, no fever

Grade III: Major atelectasis in 1 lung or in both lungs, hypoxemia >3d duration, fever >3d duration

Condie, 1993

-

Fagevik Olsén, 1997

-

Chumillas, 1998

Bronchitis: Chest X-ray negative, temperature of <37.5 degrees Celsius, auscultation rales, sputum abundant and clear

Atelectasis: Chest X-ray collapse, diaphragmatic elevation, temperature of < 38 degrees Celsius, auscultation diminished or abolished vesicular murmur

Pneumonia: Chest X-ray consolidation, pleurisy, temperature of <38 degrees Celsius at least 4 days, auscultation rales, sputum abundant and purulent

Dronkers, 2008

-

Barbalho-Moulim, 2011

Pneumonia: temperature >38°C, productive cough with purulent sputum, presence of pulmonary infiltration on chest X- ray, increased leukocyte count)

Atelectasis: based on chest X- rays and associated with respiratory discomfort

Acute respiratory failure: poor gas exchange and requirement for mechanical ventilation

Valkenet, 2018

Pneumonia: a score of 2 points or more with at least 1 point assigned based on Temperature (≥ 36⋅1 and ≤ 38.4°C: 0; ≤ 36⋅0 and ≥ 38⋅5°C: 1), Leucocyte count (≥ 4⋅0 and ≤ 11⋅0 × 109 /l: 0; < 4⋅0 or > 11⋅0 × 109 /l: 1), chest X-rays (No infiltrate: 0; Diffused (or patchy) infiltrate: 1; Well circumscribed infiltrate: 2)

Guinan, 2019

-

Onerup, 2022

-

Huang, 2022

Respiratory infection: Patient has received antibiotics for a suspected respiratory infection and met one or more of the following criteria: new or changed sputum, new or changed lung opacities, fever, white blood cell count > 12 x 10^9 /L

Respiratory failure: Postoperative PaO2 < 8 kPa (60 mmHg) on room air, a PaO2:FI02 ratio < 90% and requiring oxygen therapy

Pleural effusion: Chest radiograph demonstrating blunting of the costophrenic angle, loss of sharp silhouette of the ipsilateral hemidiaphragm in upright position, evidence of displacement of adjacent anatomical structures or (in supine position) a hazy opacity in one hemithorax with preserved vascular shadows

Atelectasis: Lung opacification with a shift of the mediastinum, hilum or hemidiaphragm toward the affected area, and compensatory over-inflation in the adjacent non-atelectatic lung

Pneumothorax: Air in the pleural space with no vascular bed surrounding the visceral pleura

Bronchospasm: Newly detected expiratory wheezing treated with bronchodilators

Aspiration pneumonitis: Acute lung injury after the inhalation of regurgitated gastric contents

Kulkarni, 2010

Pneumonia: based on positive sputum culture and antibiotic treatment

Dronkers, 2010

Atelectasis, diagnosed on chest-XRays by a “blinded” radiologist

Pneumonia, fever, cough, and development of purulent sputum, in conjunction with

radiologic evidence of a new or progressive pulmonary infiltrate, a suggestive Gram

stain, and positive cultures of sputum, tracheal aspirate, pleural fluid, or blood

Acute respiratory failure, need for mechanical ventilation

Soares, 2013

Pneumonia: based on clinical, laboratory and chest X-rays as well as the need for antibiotic therapy

Atelectasis, based on chest X-rays and need for bronchoscopy

Dunne, 2016

-

Abdelaal, 2017

-

Barberan-Garcia, 2018

Clavien-Dindo classification or Thoracic Morbidity and Mortality classification for all complications (grades I to V) (Dindo D, Demartines N, Clavien PA. Ann Surg 2004; 240 :205-13)

Grade I: complication without need for pharmacologic treatment or other intervention.

Grade II: complication requiring pharmacologic treatment or minor intervention.

Grade III: complication requiring surgical, radiologic, endoscopic intervention, or multitherapy.

Grade IIIa: invasive treatment with no need for general anesthesia

Grade IIIb: invasive treatment under general anesthesia

Grade IV: complication requiring intensive care unit management and life support.

Grade IVa: single organ major dysfunction.

Grade IVb: multiorgan major dysfunction.

Grade V: complication leading to the death of the patient.

Boden, 2018

Diagnosis confirmed when four or more criteria are present in a postoperative day:

∙ New abnormal breath sounds on auscultation different from in the preoperative assessment

∙ Production of yellow or green sputum different from in the preoperative assessment

∙ Pulse oximetry oxygen saturation (SpO2 ) 38°C on more than one consecutive postoperative day

∙ Chest radiography report of collapse or consolidation

∙ An unexplained white cell count greater than 11×109 /L

∙ Presence of infection on sputum culture report

∙ Physician’s diagnosis of pneumonia, lower or upper respiratory tract infection, an undefined chest infection, or prescription of an antibiotic for a respiratory infection

Qin, 2020

Pneumonia: chest radiograph with at least one of the following: infiltrates, consolidation, cavitation; and at least one of the following: fever (>38°C) with no other recognized cause, white cell count >12×109 /l or 70years old with altered mental status with no other recognized cause; and at least two of the following: purulent sputum or increased respiratory secretions, cough or dyspnea or tachypnoea, rales or bronchial breath sounds, worsening gas exchange.

Atelectasis: Lung opacification with a shift of the mediastinum, hilum or hemidiaphragm toward the affected area, and compensatory overexpansion in the adjacent non-atelectatic area.

Respiratory failure: Postoperative PaO2 <60 mmHg on room air, Ol < 300 mmHg or arterial oxyhemoglobin saturation measured with pulse oximetry <90% and requiring oxygen therapy

Unplanned intubations: Placement of a breathing tube and ventilator support which was not intended or planned

Chen, 2022

Respiratory failure: PaO2 < 60 mmHg when breathing in room air, FiO2 < 300mmHg or arterial oxygen saturation measured with pulse oximetry < 90% and requiring oxygen therapy

Pleural effusion: Chest X-ray demonstrates blunting of the costophrenic angle, loss of clear contour of ipsilateral hemidiaphragm in upright position, displacement of adjacent anatomical structures to the unimpaired side, or a hazy opacity in one hemithorax with preserved vascular shadows in supine position

Atelectasis: Chest X-ray or computed tomography reveals that mediastinum, hilum, or diaphragm move toward the affected area and compensatory hyper-aeration occurs in the adjacent non-atelectasis area

Pneumonia Chest X-ray or computed tomography shows new or progressive and persistent infiltrates in the lungs with at least one of the following: body temperature ≥38.5°C or 12 × 109 /l or <4 x 10^9 and with at least two of the following purulent sputum, new cough or dyspnea, worsening of previous cough or dyspnea

Pneumothorax: Chest X-ray or computed tomography shows air in the pleural space with no vascular bed around the visceral pleura

Yamana, 2015

Clavien-Dindo classification or Thoracic Morbidity and Mortality classification for all complications (grades I to V)

Grade I: complication without need for pharmacologic treatment or other intervention.

Grade II: complication requiring pharmacologic treatment or minor intervention.

Grade III: complication requiring surgical, radiologic, endoscopic intervention, or multitherapy.

Grade IIIa: invasive treatment with no need for general anesthesia

Grade IIIb: invasive treatment under general anesthesia

Grade IV: complication requiring intensive care unit management and life support.

Grade IVa: single organ major dysfunction.

Grade IVb: multiorgan major dysfunction.

Grade V: complication leading to the death of the patient.

Morran, 1983

-

Mackay, 2005

A postoperative pulmonary complication is deemed to have occurred if three or more of the following respiratory signs occur within the same day, in the first 14 days after surgery: • Auscultation changes (decreased breath sounds, crackles, wheezes, bronchial breathing) that were additional to those found prior to surgery. • Temperature over 38 degrees Celsius. • Chest X-ray changes consistent with collapse, consolidation, or atelectasis. • Increase in amount and/or changed colour of sputum produced, compared to what the patient reports is usual for them.

Silva, 2013

A postoperative pulmonary complication is deemed to have occurred if three or more of the following signs occur within the same day: • Auscultation changes (decreased breath sounds, crackles, wheezes, bronchial breath sounds) in addition to those prior to surgery • Otherwise unexplained temperature >38 ◦C • Chest radiography changes (atelectasis, collapse, consolidation) • Changes to sputum (increase in amount and/or change in colour) compared with what the patient reports is usual for them

Celli, 1984

-

Lunardi, 2015

-

Pantel, 2017

-

Svensson-Raskh, 2021

-

Study reference

(first author, publication year)

Was the allocation sequence adequately generated?

Definitely yes

Probably yes

Probably no

Definitely no

Was the allocation adequately concealed?

Definitely yes

Probably yes

Probably no

Definitely no

Blinding: Was knowledge of the allocated

interventions adequately prevented?

Were patients blinded?

Were healthcare providers blinded?

Were data collectors blinded?

Were outcome assessors blinded?

Were data analysts blinded?

Definitely yes

Probably yes

Probably no

Definitely no

Was loss to follow-up (missing outcome data) infrequent?

Definitely yes

Probably yes

Probably no

Definitely no

Are reports of the study free of selective outcome reporting?

Definitely yes

Probably yes

Probably no

Definitely no

Was the study apparently free of other problems that could put it at a risk of bias?

Definitely yes

Probably yes

Probably no

Definitely no

Overall risk of bias

If applicable/necessary, per outcome measure

LOW

Some concerns

HIGH

From Ball, 2020

Roukema, 1988

Probably yes

Reason: Randomization was done by odd or even year of birth.

No information

Reason: Not reported.

Definitely no

Reason: It was not possible to blind patients and health care providers.

Probably yes

Reason: No loss-to-follow-up or missing outcome data reported.

Definitely yes

Reason: All relevant outcome measures were reported.

Probably yes

Reason: No other problems noted.

Some concerns

Condie, 1993

Definitely yes

Reason: Patients were allocated to groups using a table of random numbers.

No information

Reason: Not reported.

Definitely no

Reason: The independent observer did not know to which group each patient had been allocated.

Definitely yes

Reason: 20 of the 330 patients were lost-to-follow-up, which is less than 10%.

Definitely yes

Reason: All relevant outcome measures were reported.

Definitely no

Reason: Personnel involved in treatment and outcome measurement, possible interrater unreliability, treatment time, number of breathing exercises varied.

Some concerns

Fagevik Olsén, 1997

Probably yes

Reason: To avoid patient interference a cluster randomization was performed to alternate months.

No information

Reason: Not reported.

Definitely no

Reason: It was not possible to blind patients and health care providers. 

Definitely yes

Reason: 4 of 368 did not complete the study, which is less than 10%.

Definitely yes

Reason: All relevant outcome measures were reported.

Probably no

Reason: More determinants for pulmonary complications such as length of anaesthesia and type of operation should be taken into account.

Some concerns

Chumillas, 1998

No information

Reason: Not reported.

No information

Reason: Not reported.

No information

Reason: Not reported.

Probably yes

Reason: No loss-to-follow-up or missing outcome data reported.

Definitely yes

Reason: All relevant outcome measures were reported.

Definitely no

Reason: Limitations due to sample size

HIGH

Dronkers, 2008

Definitely yes

Reason: An independent research assistant randomly assigned patients to the intervention or control group.

Definitely yes

Reason: An independent research assistant randomly assigned patients to the intervention or control group by opening a sealed and numbered envelope.

Definitely no

Reason: The main postoperative outcome was diagnosed by a blinded radiologist. Single-blind study. Patients and physiotherapists could not be blinded.

Definitely yes

Reason: All patients completed primary outcome assessment, secondary outcomes assessment was not completed by 6 of 20 patients.  

Definitely yes

Reason: All relevant outcome measures were reported.

Probably no

Reason: Relatively small groups, underpowered.

Some concerns

Barbalho-Moulim, 2011

Definitely yes

Reason: Patients were randomly assigned to the intervention or control group by opening a sealed envelope.

Definitely yes

Reason: Patients were randomly assigned to the intervention or control group by opening a sealed envelope.

Definitely no

Reason: The images were analysed by a radiologist who was blinded to the information regarding to which group each patient belonged.

Definitely yes

Reason: All patients completed postoperative assessment.

Definitely yes

Reason: All relevant outcome measures were reported.

Probably yes

Reason: No other problems noted.

LOW

Valkenet, 2018

Definitely yes

Reason: Participants were assigned randomly in a 1:1 ratio to intervention and control. Randomization was concealed and performed with a web-based system.

No information

Reason: Not reported.

Definitely no

Reason: Assessors of the baseline and follow-up measurements, and assessors of the postoperative outcomes were blinded for allocation. Patients and physiotherapists could not be blinded.

Definitely no

Reason: 29 of 270 patients were lost to follow-up, which is more than 10%.

Definitely yes

Reason: All relevant outcome measures were reported.

Probably yes

Reason: No other problems noted.

Some concerns

Guinan, 2019

Definitely yes

Reason: Randomization was performed on a 1:1 ratio using a flexible web-based randomized system.

No information

Reason: Not reported.

Definitely no

Reason: Baseline assessments were completed by a physiotherapist that was blinded to the participants’ intervention assignment. Patients and physiotherapists could not be blinded.

Definitely no

Reason: 12 of 72 patients were lost to follow-up, which is more than 10%.

Definitely yes

Reason: All relevant outcome measures were reported.

Definitely no

Reason: Results are a subset of a larger trial, statistical power not high enough, randomization stratified by recruiting site, full data not available at all time points, use of ANCOVA, unsupervised intervention

HIGH

Dronkers, 2010

Definitely yes

Reason: Participants were randomly assigned (block randomization)

Definitely yes

Reason: Use of prepared envelopes.

Definitely no

Reason: It was not possible to blind patients and physical therapists.

Definitely yes

Reason: Loss to follow-up was less than 10%.

Definitely yes

Reason: All relevant outcome measures were reported.

Definitely no

Reason: The effect of an intensive therapeutic exercise program was not investigated, patients were less active, study is not powered to detect significant effects on all outcome measures.

Some concerns

Soares, 2013

Definitely yes

Reason: Patients were randomly allocated, by means of sealed envelope randomization.

Definitely yes

Reason: Patients were randomly allocated, by means of sealed envelope randomization.

Definitely no

Reason: Neither patients nor physical therapists were blinded to group assignment, and the investigators responsible for data collection were aware of allocation.

Definitely no

Reason: 9 out of 37 patients were lost to follow-up, which is more than 10%.

Definitely yes

Reason: All relevant outcome measures were reported.

Definitely no

Reason: Low-intensity  exercises, small sample size and number of participants who completed all variables and all assessments, duration of post-operative physical therapy, heterogeneity of the surgical procedures, lack of strict protocol for assessment of postoperative pulmonary complications.

Some concerns

Dunne, 2016

Definitely yes

Reason: Participants were randomized by means of a random number block randomization list.

Definitely yes

Reason: An individual, independent of the study group, held this list and provided e-mail results of randomization following recruitment.

Probably no

Reason: Clinicians providing care were blinded to the intervention and to the results of all but the baseline CPET values.

Definitely yes

Reason: Loss to follow-up was less than 10%.

Definitely yes

Reason: All relevant outcome measures were reported.

Probably no

Reason: Confirmation for the benefits associated with improved fitness is required in a larger trial.

LOW

Abdelaal, 2017

No information

Reason: Not reported.

No information

Reason: Not reported.

No information

Reason: Not reported.

Definitely yes

Reason: Loss to follow-up was less than 10%.

Definitely yes

Reason: All relevant outcome measures were reported.

Probably no

Reason: Low-intensity exercises used in the preoperative physical therapy program.

HIGH

Barberan-Garcia, 2018

Definitely yes

Reason: Assignment to group allocation was carried out by means of a computer-generated random number through a web-based centralized procedure.

No information

Reason: Not reported.

Definitely no

Reason: The collaborating anaesthesiologists and surgeons who attended and followed the patients to register perioperative incidents were blinded to the patients’ group allocation.

Definitely no

Reason: 34 of 144 patients were lost to follow-up, which is more than 10%.

Definitely yes

Reason: All relevant outcome measures were reported.

Probably no

Reason: Design limitation.

HIGH

Boden, 2018

Definitely yes

Reason: The allocation sequence was determined by a web based computer generated blocked random number table.

Definitely yes

Reason: Preoperative physiotherapists randomly assigned consecutive patients using sequentially numbered sealed opaque envelopes containing allocation cards wrapped in aluminium foil.

Definitely yes

Reason: Site investigators and preoperative physiotherapists aware of group allocation had no contact with patients postoperatively. Patients, postoperative physiotherapists, hospital staff, and statisticians were unaware of group allocation.

Definitely yes

Reason: 9 of 441 patients were withdrawn, which is less than 10%.

Definitely yes

Reason: All relevant outcome measures were reported.

Definitely no

Reason: Larger sample size needed for some outcome measures,

LOW

Morran, 1983

No information

Reason: Not reported.

No information

Reason: Not reported.

No information

Reason: Not reported.

Probably yes

Reason: No loss to follow-up reported.

Definitely yes

Reason: All relevant outcome measures were reported.

Probably yes

Reason: No other limitations reported.

Some concerns

Mackay, 2005

Definitely yes

Reason: Patients were randomized using a random numbers table.

Probably yes

Reason: Concealed allocation prior to the initial contact.

Probably yes

Reason: All outcomes were assessed by a physiotherapist who was blinded to group allocation. Chest X-ray findings were reported by a radiographer who was blinded.

Definitely no

Reason: 6 of 56 patients were lost to follow-up, which is more than 10%.

Definitely yes

Reason: All relevant outcome measures were reported.

Probably  yes

Reason: No other limitations noted.

Some concerns

Silva, 2013

Probably yes

Reason: An independent investigator selected one of 105 sealed opaque envelopes with the group allocation for that week. All patients operated on during that week were allocated to that group.

Definitely yes

Reason: An independent investigator selected one of 105 sealed opaque envelopes with the group allocation for that week. All patients operated on during that week were allocated to that group.

Probably yes

Reason: Patients were blinded, the assessor was blinded, the radiologist was blinded, but the ward physiotherapist was not blinded.

Definitely yes

Reason: There were no dropouts.

Definitely yes

Reason: All relevant outcome measures were reported.

Definitely no

Reason: Patient numbers were small, with cluster randomization it is unclear whether there was contamination, despite being blinded the staff may have encouraged deep breathing exercises, patient adherence was not measured, the assessor was not involved in group allocation or treatment.

Some concerns

Lunardi, 2015

No information

Reason: Not reported.

No information

Reason: Not reported.

Definitely no

Reason: PPC occurrence was monitored by a blinded assessor. Patients and health care providers could not be blinded.

Definitely yes

Reason: 7 of 164 patients were lost to follow-up, which is less than 10%.

Definitely yes

Reason: All relevant outcome measures were reported.

Definitely no

Reason: The control group performed deep breaths, which could have been considered an intervention, ambulation during hospitalization was not quantified.

HIGH

Pantel, 2017

Probably yes

Reason: Use of a simple randomization scheme for group allocation. Computer randomized list was generated.

Probably yes

Reason: Patients were randomized by sequentially accessing this list. Concealment of the next allocation was used.

Definitely no

Reason: Power analysis and statistical analysis were performed by a blinded data assessor. Patients and health care providers could not be blinded.

Definitely yes

Reason: Missing data of 10 out of 224 patients, which is less than 10%.

Definitely yes

Reason: All relevant outcome measures were reported.

Definitely no

Reason: The study was not powered to detect differences in pulmonary complications, patients with COPD were not stratified, observed compliance in the control group was lower than policy.

Some concerns

Individual studies

Chen, 2022

Definitely yes

Reason: Patients were randomly allocated by Statistics Analysis System, which was used to computer-generated random numbers.

Definitely yes

Reason: Participants were assigned in numerical order with sealed opaque envelopes containing the grouping information by an independent researcher.

Definitely no

Reason: single blind study, assessment of the 6 min walk test by blinded doctor. Patient could not be blinded.

Definitely yes

Reason: 5 out of 264 patients were lost to follow-up, which is less than 10%. 

Definitely yes

Reason: All relevant outcome measures were reported.

Definitely no

Reason: Relatively small number of patients, patients’ physical activity after discharge was not accurately supervised, single-centre study.

Some concerns

Huang, 2022

Definitely yes

Reason: The online random generator was used for randomization.

No information

Reason: Not reported.

Definitely no

Reason: Blinding was not achievable both in subjects and researchers due to an individualized respiratory muscle training program.

Definitely yes

Reason: 2 out of 30 patients were lost to follow-up, which is less than 10%.

Definitely yes

Reason: All relevant outcome measures were reported.

Definitely no

Reason: Small sample size, single surgical procedure, lack of long-term follow-up.

Some concerns

Qin, 2020

Definitely yes

Reason: Patients were randomly assigned to either an intervention or control group using a computer-generated randomized block design.

Definitely yes

Reason: The numbers were sealed in sequentially numbered opaque envelopes organized in randomization sequence by an independent researcher.

Definitely no

Reason: Single-blind study.

Definitely yes

Reason: 5 out of 245 patients were lost to follow-up, which is less than 10%.

Definitely yes

Reason: All relevant outcome measures were reported.

Definitely no

Reason: The study is unable to evaluate the effect of breathing training on long-term outcomes, the mobilization of patients during hospitalization was not accurately quantified, single large academic hospital.

Some concerns

Svensson-Raskh, 2021

Definitely yes

Reason: A computer-generated randomization in blocks of 9 was used to allocate patients to the different trial groups.

Definitely yes

Reason: A nurse at the recovery unit, independent of the trial, randomly assigned the patients to the different groups, using opaque sealed envelopes.

Definitely no

Reason: Patients and health care professionals at the recovery unit were not blinded, but surgeons, anaesthesiologists, research nurses, and physical therapists were blinded.

Definitely yes

Reason: 13 out of 214 patients were lost to follow-up, which is less than 10%.

Definitely yes

Reason: All relevant outcome measures were reported.

Definitely no

Reason: Baseline imbalances in patient characteristics, study inclusion limited to daytime only, missing PaO2 data, some patients discharged before third hour assessment.

Some concerns

Onerup, 2022

Definitely yes

Reason: Participants were randomly assigned to 1 of the 2 study groups through a computer system creating the allocation sequence with a block size of 4, unknown to personnel.

Probably yes

Reason: Study numbers were assigned sequentially as patients were recruited and study group could not be changed.

Definitely no

Reason: Due to the nature of the intervention neither participants nor personnel were blinded. Medical staff was not actively informed, and outcome assessors for postoperative complications and length of hospital stay were masked regarding allocation.

Definitely no

Reason: 93 out of 761 patients were lost to follow-up, which is more than 10%.

Definitely no

Reason: The outcome measure quality of life is not reported.

Definitely no

Reason: Pragmatic design, the primary outcome measure had not been evaluated regarding measurement properties or minimally important difference, Sample size was not calculated for postoperative complications, rate of missing data regarding adherence.

Some concerns

Kulkarni, 2010

Definitely yes

Reason: Patients were allocated to four groups by computer-generated, random numbers placed in sequentially numbered sealed envelopes.

Definitely yes

Reason: Patients were allocated to four groups by computer-generated, random numbers placed in sequentially numbered sealed envelopes.

Definitely no

Reason: Group allocation was non-blinded.

Definitely no

Reason: 14 of the 80 patients were lost-to-follow-up, which is more than 10%.

Definitely no

Reason: Multiple secondary outcome measures were not reported.

Probably no

Reason: Some patients may be fitter and at lower risk than others, there may be a case for selecting only high-risk patients, a large number of patients awaiting intra-abdominal cancer surgery were not included.

HIGH

Yamana, 2015

No information

Reason: Not reported.

Definitely yes

Reason: The patients were randomly assigned by opening a sealed envelope.

No information

Reason: Not reported.

Definitely yes

Reason: 3 of the 63 patients were lost-to-follow-up, which is less than 10%.

Definitely yes

Reason: All relevant outcome measures were reported.

Definitely no

Reason: Only the value of the PEF was evaluated as an indicator of the respiratory muscle strength, the impact of PR appears to influence only minor lung infiltrates, because there was no mortality and a few major complications.

Some concerns

Reference

Reason for exclusion

An KR, Seijas V, Xu MS, Grüßer L, Humar S, Moreno AA, Turk M, Kasanagottu K, Alzghari T, Dimagli A, Ko MA, Villena-Vargas J, Papatheodorou S, Gaudino MFL. Does prehabilitation before esophagectomy improve postoperative outcomes? A systematic review and meta-analysis. Dis Esophagus. 2024 Feb 29;37(3):doad066. doi: 10.1093/dote/doad066. PMID: 38018252.

More relevant systematic review available

Assouline B, Cools E, Schorer R, Kayser B, Elia N, Licker M. Preoperative Exercise Training to Prevent Postoperative Pulmonary Complications in Adults Undergoing Major Surgery. A Systematic Review and Meta-analysis with Trial Sequential Analysis. Ann Am Thorac Soc. 2021 Apr;18(4):678-688. doi: 10.1513/AnnalsATS.202002-183OC. PMID: 33030962.

More relevant systematic review available

Auclair A, Harvey J, Leclerc J, Piché ME, O'Connor K, Nadreau É, Pettigrew M, Haykowsky MJ, Marceau S, Biertho L, Hould FS, Lebel S, Biron S, Julien F, Bouvet L, Lescelleur O, Poirier P. Determinants of Cardiorespiratory Fitness After Bariatric Surgery: Insights From a Randomised Controlled Trial of a Supervised Training Program. Can J Cardiol. 2021 Feb;37(2):251-259. doi: 10.1016/j.cjca.2020.03.032. Epub 2020 Mar 30. PMID: 32738206.

Wrong outcome (No PPCs)

Bilyy A, El-Nakhal T, Kadlec J, Bartosik W, Tornout FV, Kouritas V. Preoperative training education with incentive spirometry may reduce postoperative pulmonary complications. Asian Cardiovasc Thorac Ann. 2020 Nov;28(9):592-597. doi: 10.1177/0218492320957158. Epub 2020 Sep 11. PMID: 32915659.

Wrong study design (cohort)

Boden I, Denehy L. Respiratory prehabilitation for the prevention of postoperative pulmonary complications after major surgery. Curr Anesthesiol Rep. 2022;1-15.

More relevant systematic review available

Boden I, Reeve J, Jernås A, Denehy L, Fagevik Olsén M. Preoperative physiotherapy prevents postoperative pulmonary complications after major abdominal surgery: a meta-analysis of individual patient data. J Physiother. 2024 Jul;70(3):216-223. doi: 10.1016/j.jphys.2024.02.012. Epub 2024 Mar 11. PMID: 38472053.

Wrong study design/more relevant systematic review available

Boden I, Reeve J, Robertson IK, Browning L, Skinner EH, Anderson L, Hill C, Story D, Denehy L. Effects of preoperative physiotherapy on signs and symptoms of pulmonary collapse and infection after major abdominal surgery: secondary analysis of the LIPPSMAck-POP multicentre randomised controlled trial. Perioper Med (Lond). 2021 Oct 25;10(1):36. doi: 10.1186/s13741-021-00206-3. PMID: 34689825; PMCID: PMC8543902.

Secondary analysis of other article, no relevant outcomes

Boden I, Robertson IK, Neil A, Reeve J, Palmer AJ, Skinner EH, Browning L, Anderson L, Hill C, Story D, Denehy L. Preoperative physiotherapy is cost-effective for preventing pulmonary complications after major abdominal surgery: a health economic analysis of a multicentre randomised trial. J Physiother. 2020 Jul;66(3):180-187. doi: 10.1016/j.jphys.2020.06.005. Epub 2020 Jul 14. PMID: 32680742.

Wrong outcome (cost-effectiveness instead of PPCs)

Boden I, Sullivan K, Hackett C, Winzer B, Hwang R, Story D, Denehy L. Intensive physical therapy after emergency laparotomy: Pilot phase of the Incidence of Complications following Emergency Abdominal surgery Get Exercising randomized controlled trial. J Trauma Acute Care Surg. 2022 Jun 1;92(6):1020-1030. doi: 10.1097/TA.0000000000003542. Epub 2022 Jan 18. PMID: 35609291.

Wrong population/type of surgery (only emergency surgery)

Chang PC, Chen PH, Chang TH, Chen KH, Jhou HJ, Chou SH, Chang TW. Incentive spirometry is an effective strategy to improve the quality of postoperative care in patients. Asian J Surg. 2023 Sep;46(9):3397-3404. doi: 10.1016/j.asjsur.2022.11.030. Epub 2022 Nov 24. PMID: 36437210.

Wrong type of surgery (thoracic)

DeSai AR, Hathila VP. Effectiveness of respiratory and abdominal strength exercises in postoperative patients with abdominal surgeries: a narrative review. J Clin Diagn Res. 2022;16(4).

Wrong study design (narrative review, no systematic search and analysis)

Dhillon G, Buddhavarapu VS, Grewal H, Munjal R, Verma RK, Surani S, Kashyap R. Evidence-based Practice Interventions for Reducing Postoperative Pulmonary Complications: A Narrative Review. Open Respir Med J. 2023 Dec 4;17:e18743064271499. doi: 10.2174/012210299X247199231128100613. PMID: 38655075; PMCID: PMC11037507.

Wrong study design (narrative review, no systematic search and analysis)

do Nascimento Junior P, Módolo NS, Andrade S, Guimarães MM, Braz LG, El Dib R. Incentive spirometry for prevention of postoperative pulmonary complications in upper abdominal surgery. Cochrane Database Syst Rev. 2014 Feb 8;2014(2):CD006058. doi: 10.1002/14651858.CD006058.pub3. PMID: 24510642; PMCID: PMC6769174.

More recent systematic review available

Freitas ER, Soares BG, Cardoso JR, Atallah ÁN. Incentive spirometry for preventing pulmonary complications after coronary artery bypass graft. Cochrane Database Syst Rev. 2012 Sep 12;2012(9):CD004466. doi: 10.1002/14651858.CD004466.pub3. PMID: 22972072; PMCID: PMC8094624.

Wrong type of surery (CABG)

Fuchita M, Ridgeway KJ, Kimzey C, Melanson EL, Fernandez-Bustamante A. Accelerometer-Measured Inpatient Physical Activity and Associated Outcomes After Major Abdominal Surgery: Systematic Review. Interact J Med Res. 2023 May 15;12:e46629. doi: 10.2196/46629. PMID: 37184924; PMCID: PMC10227699.

Wrong type of intervention

Janssen THJB, Fransen LFC, Heesakkers FFBM, Dolmans-Zwartjes ACP, Moorthy K, Nieuwenhuijzen GAP, Luyer MDP. Effect of a multimodal prehabilitation program on postoperative recovery and morbidity in patients undergoing a totally minimally invasive esophagectomy. Dis Esophagus. 2022 Jul 12;35(7):doab082. doi: 10.1093/dote/doab082. PMID: 34875680.

Wrong study design (retrospective cohort)

Kızmaz E, Gürsoy S, Atalay OT, Sungurtekin U. Expiratory muscle training versus incentive spirometry after colorectal surgery. Ann Clin Anal Med. 2023.

Wrong comparison (2 interventions no control group/usual care)

Kotta PA, Ali JM. Incentive Spirometry for Prevention of Postoperative Pulmonary Complications After Thoracic Surgery. Respir Care. 2021 Feb;66(2):327-333. doi: 10.4187/respcare.07972. Epub 2020 Aug 25. PMID: 32843511.

Wrong study design (narrative review, no systematic search and analysis)

Kumar S, Gupta S, Upreti L, Parik RM. A prospective study to evaluate the effect of deep breathing exercises and incentive spirometry on pulmonary functions in patients before and after laparoscopic cholecystectomy. Int J Pharm Clin Res. 2022;14(7):409-413.

Wrong outcome (no PPCs)

Kumar S, Parshad S, Bijyal S, Mittal G, Sikka G. A Comparison of Two Methods of Pre-operative Inspiratory Muscle Training on Post-operative Outcome Following Esophagectomy. Indian J Surg Oncol. 2023 Dec;14(4):956-962. doi: 10.1007/s13193-023-01812-x. Epub 2023 Sep 25. PMID: 38187852; PMCID: PMC10766938.

Wrong comparison (2 intervention groups, no control/usual care)

Kunadharaju R, Saradna A, Ray A, Yu H, Ji W, Zafron M, Mador MJ. Post-Operative Outcomes of Pre-Thoracic Surgery Respiratory Muscle Training vs Aerobic Exercise Training: A Systematic Review and Network Meta-analysis. Arch Phys Med Rehabil. 2023 May;104(5):790-798. doi: 10.1016/j.apmr.2022.10.015. Epub 2022 Dec 17. PMID: 36539175.

More relevant systematic review available

Labuschagne R, Roos R. Pre-operative physiotherapy for elderly patients undergoing abdominal surgery. S Afr J Physiother. 2022 Sep 27;78(1):1782. doi: 10.4102/sajp.v78i1.1782. Erratum in: S Afr J Physiother. 2023 Jun 23;79(1):1870. doi: 10.4102/sajp.v79i1.1870. PMID: 36262215; PMCID: PMC9575366.

Less than 10 patients per arm

López-Rodríguez-Arias F, Sánchez-Guillén L, Aranaz-Ostáriz V, Triguero-Cánovas D, Lario-Pérez S, Barber-Valles X, Lacueva FJ, Ramirez JM, Arroyo A. Effect of home-based prehabilitation in an enhanced recovery after surgery program for patients undergoing colorectal cancer surgery during the COVID-19 pandemic. Support Care Cancer. 2021 Dec;29(12):7785-7791. doi: 10.1007/s00520-021-06343-1. Epub 2021 Jun 24. PMID: 34169328; PMCID: PMC8225311.

Wrong intervention (multimodal programme)

Maity B, Choudhury A, Banerjee C. The efficacy of incentive spirometry in restoring baseline lung capacity after upper abdominal and midline laparotomy: a randomised case control study. Int J Acad Med Pharm. 2023;5(3):1961-1966.

Wrong comparison (2 intervention groups, no comparison with control group/usual care)

Mikami Y, Kouda K, Kawasaki S, Okada KI, Kawai M, Kitahata Y, Miyazawa M, Hirono S, Unno M, Tajima F, Yamaue H. Preoperative In-Hospital Rehabilitation Improves Physical Function in Patients with Pancreatic Cancer Scheduled for Surgery. Tohoku J Exp Med. 2020 Aug;251(4):279-285. doi: 10.1620/tjem.251.279. PMID: 32759553.

Wrong study design (single arm)

Mohamed B, Wang MC, Bisson EF, Dimar J, Harrop JS, Hoh DJ, Mummaneni PV, Dhall S. Congress of Neurological Surgeons Systematic Review and Evidence-Based Guidelines for Perioperative Spine: Preoperative Pulmonary Evaluation and Optimization. Neurosurgery. 2021 Oct 13;89(Suppl 1):S33-S41. doi: 10.1093/neuros/nyab319. PMID: 34490879.

Wrong study aim/outcome (identification of risk facors)

Molenaar CJL, Minnella EM, Coca-Martinez M, Ten Cate DWG, Regis M, Awasthi R, Martínez-Palli G, López-Baamonde M, Sebio-Garcia R, Feo CV, van Rooijen SJ, Schreinemakers JMJ, Bojesen RD, Gögenur I, van den Heuvel ER, Carli F, Slooter GD; PREHAB Study Group. Effect of Multimodal Prehabilitation on Reducing Postoperative Complications and Enhancing Functional Capacity Following Colorectal Cancer Surgery: The PREHAB Randomized Clinical Trial. JAMA Surg. 2023 Jun 1;158(6):572-581. doi: 10.1001/jamasurg.2023.0198. Erratum in: JAMA Surg. 2023 Jun 1;158(6):675. doi: 10.1001/jamasurg.2023.1553. PMID: 36988937; PMCID: PMC10061316.

Wrong intervention (multimodal programme)

Nirali M, Srivastava S. Added effect of deep breathing and diaphragmatic breathing exercise in upper abdominal surgery patients: a randomised clinical trial. Indian J Public Health Res Dev. 2020;11(2).

Wrong comparison (2 intervention groups, no comparison with control group/usual care), wrong outcome (no PPCs)

Overbeek MC, Reijneveld EA, Valkenet K, van Adrichem EJ, Dronkers JJ, Ruurda JP, Veenhof C. The Association Between Preoperative Inspiratory Muscle Training Variables and Postoperative Pulmonary Complications in Subjects With Esophageal Cancer. Respir Care. 2024 Feb 28;69(3):290-297. doi: 10.4187/respcare.11199. PMID: 37935528; PMCID: PMC10984600.

Wrong study design (cohort)

Pazzianotto-Forti EM, da Costa Munno CM, Merino DFB, Simões da Rocha MR, de Mori TA, Júnior IR. Effects of Inspiratory Exercise With Linear and Nonlinear Load on Respiratory Variables Post-Bariatric Surgery. Respir Care. 2019 Dec;64(12):1516-1522. doi: 10.4187/respcare.05841. Epub 2019 Aug 6. PMID: 31387894.

Wrong study design (cohort)

Perry R, Herbert G, Atkinson C, England C, Northstone K, Baos S, Brush T, Chong A, Ness A, Harris J, Haase A, Shah S, Pufulete M. Pre-admission interventions (prehabilitation) to improve outcome after major elective surgery: a systematic review and meta-analysis. BMJ Open. 2021 Sep 30;11(9):e050806. doi: 10.1136/bmjopen-2021-050806. PMID: 34593498; PMCID: PMC8487197.

More relevant systematic review available

Piraux E, Reychler G, de Noordhout LM, Forget P, Deswysen Y, Caty G. What are the impact and the optimal design of a physical prehabilitation program in patients with esophagogastric cancer awaiting surgery? A systematic review. BMC Sports Sci Med Rehabil. 2021 Mar 25;13(1):33. doi: 10.1186/s13102-021-00260-w. PMID: 33766107; PMCID: PMC7993458.

More relevant systematic review available

Ramkumar PP, Kalaiyarasan K, Sridhar R, Sendhil R. Postoperative pulmonary complications in chronic obstructive pulmonary disease patients undergoing abdominal surgery in a tertiary care institute. Int J Acad Med Pharm. 2023;5(4):633-639.

Wrong study design (cohort)

Sadiq H, Rampam S, Patel J, Crawford S, Walz M, Kapoor A. Preoperative walking intervention did not appear to improve patient-reported postoperative recovery in older adults with frailty traits: Randomized trial. Medicine (Baltimore). 2022 Sep 23;101(38):e30689. doi: 10.1097/MD.0000000000030689. PMID: 36197179; PMCID: PMC9509049.

Wrong outcome (no PPCs)

Singh V, Agumbe Pai S, Hosmath V. Clinical outcome of patients undergoing preoperative chest physiotherapy in elective upper abdominal surgeries. J Perioper Pract. 2023 Jun;33(6):182-189. doi: 10.1177/17504589211045225. Epub 2022 May 5. PMID: 35510720.

Wrong population (patients with respiratory system disorder excluded)

Smith NA, Martin G, Marginson B. Preoperative assessment and prehabilitation in patients with obesity undergoing non-bariatric surgery: A systematic review. J Clin Anesth. 2022 Jun;78:110676. doi: 10.1016/j.jclinane.2022.110676. Epub 2022 Feb 10. PMID: 35152081.

More relevant systematic review available

Swaminathan N, Kundra P, Ravi R, Kate V. ERAS protocol with respiratory prehabilitation versus conventional perioperative protocol in elective gastrectomy- a randomized controlled trial. Int J Surg. 2020 Sep;81:149-157. doi: 10.1016/j.ijsu.2020.07.027. Epub 2020 Jul 30. PMID: 32739548.

Wrong intervention (ERAS protocol)

Sweity EM, Alkaissi AA, Othman W, Salahat A. Preoperative incentive spirometry for preventing postoperative pulmonary complications in patients undergoing coronary artery bypass graft surgery: a prospective, randomized controlled trial. J Cardiothorac Surg. 2021 Aug 24;16(1):241. doi: 10.1186/s13019-021-01628-2. PMID: 34429138; PMCID: PMC8383237.

Wrong type of surgery (CABG)

Taha MM, Draz RS, Gamal MM, Ibrahim ZM. Adding autogenic drainage to chest physiotherapy after upper abdominal surgery: effect on blood gases and pulmonary complications prevention. Randomized controlled trial. Sao Paulo Med J. 2021 Nov 15;139(6):556-563. doi: 10.1590/1516-3180.2021.0048.0904221. PMID: 34787294; PMCID: PMC9634842.

Wrong intervention/comparison: autogenic drainage

Tegegne BA, Lema GF, Fentie DY, Bizuneh YB. Perioperative risk stratification and strategies for reducing postoperative pulmonary complications following major surgery in resource-limited areas: a systematic review. Int J Surg Open. 2021;30:100322.

More relevant systematic review available

Triguero-Cánovas D, López-Rodríguez-Arias F, Gómez-Martínez M, Sánchez-Guillén L, Peris-Castelló F, Alcaide-Quirós MJ, Morillas-Blasco P, Arroyo A, Ramírez JM. Home-based prehabilitation improves physical conditions measured by ergospirometry and 6MWT in colorectal cancer patients: a randomized controlled pilot study. Support Care Cancer. 2023 Nov 6;31(12):673. doi: 10.1007/s00520-023-08140-4. PMID: 37930478.

Wrong outcome (no PPCs)

Tukanova KH, Chidambaram S, Guidozzi N, Hanna GB, McGregor AH, Markar SR. Physiotherapy Regimens in Esophagectomy and Gastrectomy: a Systematic Review and Meta-Analysis. Ann Surg Oncol. 2022 May;29(5):3148-3167. doi: 10.1245/s10434-021-11122-7. Epub 2021 Dec 27. PMID: 34961901; PMCID: PMC8990957.

More relevant systematic review available

van Gestel T, Groen LCB, Puik JR, van Rooijen SJ, van der Zaag-Loonen HJ, Schoonmade LJ, Danjoux G, Daams F, Schreurs WH, Bruns ERJ. Fit4Surgery for cancer patients during covid-19 lockdown - A systematic review and meta-analysis. Eur J Surg Oncol. 2022 Jun;48(6):1189-1197. doi: 10.1016/j.ejso.2022.02.010. Epub 2022 Feb 9. PMID: 35183411; PMCID: PMC8828288.

More relevant systematic review available

Vetrugno L, Deana C, Colaianni-Alfonso N, Tritapepe F, Fierro C, Maggiore SM. Noninvasive respiratory support in the perioperative setting: a narrative review. Front Med (Lausanne). 2024 Apr 17;11:1364475. doi: 10.3389/fmed.2024.1364475. PMID: 38695030; PMCID: PMC11061466.

Wrong study design (narrative review, no systematic search and analysis)

Waterland JL, McCourt O, Edbrooke L, Granger CL, Ismail H, Riedel B, Denehy L. Efficacy of Prehabilitation Including Exercise on Postoperative Outcomes Following Abdominal Cancer Surgery: A Systematic Review and Meta-Analysis. Front Surg. 2021 Mar 19;8:628848. doi: 10.3389/fsurg.2021.628848. PMID: 33816546; PMCID: PMC8017317.

More relevant systematic review available

Willner A, Teske C, Hackert T, Welsch T. Effects of early postoperative mobilization following gastrointestinal surgery: systematic review and meta-analysis. BJS Open. 2023 Sep 5;7(5):zrad102. doi: 10.1093/bjsopen/zrad102. PMID: 37846641; PMCID: PMC10580147.

Wrong intervention (mobilization)

Worraphan S, Thammata A, Chittawatanarat K, Saokaew S, Kengkla K, Prasannarong M. Effects of Inspiratory Muscle Training and Early Mobilization on Weaning of Mechanical Ventilation: A Systematic Review and Network Meta-analysis. Arch Phys Med Rehabil. 2020 Nov;101(11):2002-2014. doi: 10.1016/j.apmr.2020.07.004. Epub 2020 Aug 1. PMID: 32750371.

Wrong population (ICU patients who are weaning of mechanical ventilation instead of surgical patients)

Zhao CH, Sun YH, Mao XM. Volume Incentive Spirometry Reduces Pulmonary Complications in Patients After Open Abdominal Surgery: A Randomized Clinical Trial. Int J Gen Med. 2023 Mar 1;16:793-801. doi: 10.2147/IJGM.S400030. PMID: 36883125; PMCID: PMC9985979.

Wrong outcome (no PPCs)

Zhao B, Zhang T, Chen Y, Zhang C. Effects of unimodal or multimodal prehabilitation on patients undergoing surgery for esophagogastric cancer: a systematic review and meta-analysis. Support Care Cancer. 2023 Dec 7;32(1):15. doi: 10.1007/s00520-023-08229-w. PMID: 38060053.

More relevant systematic review available

Zhong J, Zhang S, Li C, Hu Y, Wei W, Liu L, Wang M, Hong Z, Long H, Rong T, Yang H, Su X. Active cycle of breathing technique may reduce pulmonary complications after esophagectomy: A randomized clinical trial. Thorac Cancer. 2022 Jan;13(1):76-83. doi: 10.1111/1759-7714.14227. Epub 2021 Nov 12. PMID: 34773384; PMCID: PMC8720618.

Wrong comparison (control group also receives an intervention)

Zhou W, Woo S, Larson JL. Effects of perioperative exercise interventions on lung cancer patients: An overview of systematic reviews. J Clin Nurs. 2020 Dec;29(23-24):4482-4504. doi: 10.1111/jocn.15511. Epub 2020 Oct 19. PMID: 32979874.

Wrong population (lung cancer patients)