A systematic review and consensus definitions for standardised end-points in perioperative medicine:Pulmonary complications

T.E.F. Abbott,1,2 A.J. Fowler,1 P. Pelosi,3 M. Gama de Abreu,4 A.M. Moller,5 J. Canet,6 B. Creagh-Brown,7, 8 M. Mythen,2 T. Gin,9 M. Lalu,10 E. Futier,11 M.P. Grocott,12, 13 M.J. Schultz,14, 15 and R.M. Pearse,1 and the StEP-COMPAC Group*

*members listed below

  1. Queen Mary University of London, London EC1M 6BQ, UK
  2. Department of Anaesthesia and Critical Care, University College London Hospital, London, NW1 2BU, UK
  3. Department of Surgical Sciences and Integrated Diagnostics, San Martino Policlinico Hospital, IRCCS for Oncology, University of Genoa, Genoa, Italy
  4. Department of Anesthesiology and Intensive Care Therapy, University Hospital Carl Gustav Carus, Technische Universität Dresden, Germany
  5. Department of Anaesthesia, Herlev University Hospital, DK-2730 Herlev, Denmark
  6. Department of Anaesthesiology, Hospital Universitari Germans Trias i Pujol, Barcelona. Spain
  7. Intensive Care Unit, Royal Surrey County Hospital, Guildford, GU2 7XX, UK
  8. Surrey Perioperative Anaesthesia Critical Care collaborative research group (SPACeR), Faculty of Health and Medical Sciences, University of Surrey, Guildford, GU2 7XH, UK
  9. Department of Anaesthesia and Intensive Care, The Chinese University of Hong Kong, Hong Kong, China.
  10. Health Innovations Coordinating Center, Montreal Heart Institute, Montreal, QC, Canada.
  11. Department of Perioperative Medicine, Anaesthesiology and Critical Care, Estaing Hospital, University Hospital of Clermont-Ferrand, Clermont-Ferrand, France
  12. Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
  13. Critical Care Research Group, Southampton NIHR Biomedical Research Centre, University Hospital Southampton, Southampton, UK
  14. Department of Intensive Care, Academic Medical Center, Amsterdam, The Netherlands
  15. Mahidol Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand

Correspondence to:

Rupert Pearse

Adult Critical Care Unit

Royal London Hospital

London E1 1BB

United Kingdom

e-mail:

Tel: +44 20 3594 0351

Members of the StEP-COMPAC Group (Chairpersons in bold print)

  1. Patient Comfort – Paul Myles, TJ Gan,Andrea Kurz, Phil Peyton, Dan Sessler, Martin Tramèr, Alan Cyna, Gildasio S. De Oliveira Jr, Christopher Wu, Mark Jensen, Henrik Kehlet, Mari Botti, Oliver Boney
  1. Clinical Indicators – Guy Haller, Mike Grocott, Tim Cook, Lee Fleisher, Mark Neuman, David Story, Russell Gruen, Sam Bampoe
  1. Delirium, Postoperative Cognitive Dysfunction, Stroke – Lis Evered, David Scott, Brendan Silbert, Diederik van Dijk, Cor Kalkman, Matthew Chan, Hilary Grocott, Guy Haller, Rod Eckenhoff, Lars Rasmussen, Lars Eriksson
  1. Cardiovascular –Scott Beattie, Duminda Wijeysundera, Lee Fleisher, Giovanni Landoni, Kate Leslie, Bruce Biccard, Simon Howell, Hilary Grocott, Peter Nagele, Toby Richards, Andre Lamy, Manoj Lalu
  1. Pulmonary – Rupert Pearse, Monty Mythen, Jaume Canet, Ann Moller, Tony Gin, Marcus Schultz, Paolo Pelosi, Marcelo Gabreu, Emmanuel Futier, Ben Creagh-Brown, Manoj Lalu, Alexander Fowler, Tom Abbott.
  1. Inflammation, Sepsis – Monty Mythen, Cor Kalkman, Andy Klein, Tomas Corcoran, D. Jamie Cooper, Stefan Dieleman, Elisabeth Diouf
  1. Acute Kidney Injury – David McIlroy, Rinaldo Bellomo, Andrew Shaw, John Prowle, Keyvan Karkouti, Josh Billings
  1. Bleeding Complications, Patient Blood Management – Duminda Wijeysundera, Andy Klein, Toby Richards, David Mazer, Paul Myles, Mohindas Jayarajah, Keyvan Karkouti, Michael Murphy, Andre Lamy, Justyna Bartoszko
  1. Healthcare Resource Utilisation – Rob Sneyd, Scott Beattie, Lee Fleisher, Mike Grocott, Dan Sessler, Steve Morris, Ron George
  1. Patient-Centred Outcomes - Ramani Moonesinghe, Matthew Chan, Tim Cook, Paul Myles, Mark Shulman, Mark Neuman, Cor Kalkman, Meghan Lane-Fall, Ulrica Nilsson, Nathalie Stevenson
  1. Organ Failure and Survival – Mike Grocott, Paul Myles, Rupert Pearse, Andrea Kurz, Ramani Moonesinghe, Jamie (DJ) Cooper, Wilton van Klei, Luca Cabrini, Tim Miller, Nathan Pace, Sandy Jackson
  1. Cancer Surgery – Donal Buggy, Dan Sessler, Kate Leslie, Tim Short, Andrea Kurz, Bernhard Riedel, Vijay Gottumukkala, Nathan Pace, Bilal Alkhaffaf, Mark Johnson

Supplementary figure 1. Selection of papers for consideration in the consensus discussion.

Supplementary table 1. Full texts that were excluded after review with reason for exclusion provided.

Lead Author Name / Year / Title / Reason for exclusion
Adbelsattar / 2015 / The Impact of Untreated Obstructive Sleep Apnea on Cardiopulmonary Complications in General and Vascular Surgery: A Cohort Study / RETROSPECTIVE PATIENT RECRUITMENT
Akutsu / 2008 / Impact of preoperative dental plaque culture for predicting postoperative pneumonia in esophageal cancer patients / NO ENGLISH FULL TEXT AVAILABLE
Aldenkortt / 2012 / Ventilation strategies in obese patients undergoing surgery: a quantitative systematic review and meta-analysis / NO OUTCOMES OF INTEREST
Amar / 2010 / A Clinical Prediction Rule for Pulmonary Complications After Thoracic Surgery for Primary Lung Cancer / RETROSPECTIVE PATIENT RECRUITMENT
Beloborodo / 2006 / Diagnostic and therapeutic aspects of pneumonias after cardiosurgical operations associated with artificial ventilation / NO ENGLISH FULL TEXT AVAILABLE
Bergan / 2014 / Impact of improvement in preoperative oral health on nosocomial pneumonia in a group of cardiac surgery patients: a single arm prospective intervention study / PRIMARY OUTCOME NOT DEFINED
Castellani / 2009 / Pleural and pericardial morbidity after minimal access repair of pectus excavatum / RETROSPECTIVE PATIENT RECRUITMENT
Diez-sebastian / 2012 / Prevention of early-onset pneumonia in surgical patients by chemoprophylaxis / PRIMARY OUTCOME NOT DEFINED
Fan / 2011 / Effect of neoadjuvant chemotherapy on the postoperative pulmonary infection of patients with advanced gastric cancer / NO ENGLISH FULL TEXT AVAILABLE
Fernandez-Perez / 2006 / Intraoperative tidal volume as a risk factor for respiratory failure after pneumonectomy / RETROSPECTIVE PATIENT RECRUITMENT
Gonzalez / 2006 / Risk factors for acute respiratory failure after liver transplantation / NO ENGLISH FULL TEXT AVAILABLE
Grigorakos / 2008 / Preoperative pulmonary evaluation (PPE) as a prognostic factor in patients undergoing upper abdominal surgery / NO ENGLISH FULL TEXT AVAILABLE
Gu / 2015 / Effect of lung-protective ventilation with lower tidal volumes on clinical outcomes among patients undergoing surgery: a meta-analysis of randomized controlled trials / NO OUTCOMES OF INTEREST
Gupta / 2013 / Development and Validation of a Risk Calculator for Predicting Postoperative Pneumonia / RETROSPECTIVE PATIENT RECRUITMENT
Hemmes / 2013 / Intraoperative ventilatory strategies to prevent postoperative pulmonary complications: a meta-analysis / PRIMARY OUTCOME NOT DEFINED
Hulzebos / 2007 / Fewer lung complications following inspiratory muscle training in patients undergoing coronary bypass surgery: a randomized trial / NO ENGLISH FULL TEXT AVAILABLE
Ito / 2011 / Prospective study of respiratory complications during urological retroperitoneal laparoscopic surgery / NO ENGLISH FULL TEXT AVAILABLE
Juliani Reminscito / 2011 / Impact of Alveolar Recruitment Maneuver in the Postoperative Period of Videolaparoscopic Bariatric Surgery / PRIMARY OUTCOME NOT DEFINED
Kawahara / 2010 / Prospective randomized controlled study on the effects of perioperative administration of a neutrophil elastase inhibitor to patients undergoing video-assisted thoracoscopic surgery for thoracic esophageal cancer / PRIMARY OUTCOME NOT DEFINED
Kazaure / 2014 / Long-term Results of a Postoperative Pneumonia Prevention Program for the Inpatient Surgical Ward / RETROSPECTIVE PATIENT RECRUITMENT
Kim / 2011 / Effect of N-acetylcystein on pulmonary function in patients undergoing off-pump coronary artery bypass surgery / NO OUTCOMES OF INTEREST
Kim / 2009 / New classification and clinical characteristics of reexpansion pulmonary edema after treatment of spontaneous pneumothorax / NON-SURGICAL POPULATION
Kozlov / 2005 / Surfactant-BL and inhaled nitric oxide in acute respiratory distress syndrome in cardiac surgical patients / NO ENGLISH FULL TEXT AVAILABLE
Lawrence / 2006 / Strategies to reduce postoperative pulmonary complications after noncardiothoracic surgery: Systematic review for the American College of Physicians / NO OUTCOMES OF INTEREST
Makino / 2011 / Perioperative use of a neutrophil elastase inhibitor in video-assisted thoracoscopic oesophagectomy for cancer / NO OUTCOMES OF INTEREST
Mans / 2015 / Postoperative outcomes following preoperative inspiratory muscle training in patients undergoing cardiothoracic or upper abdominal surgery: a systematic review and meta analysis / PRIMARY OUTCOME MEASURE NOT DEFINED
Memtsoudis / 2012 / Mortality of patients with respiratory insufficiency and adult respiratory distress syndrome after surgery: the obesity paradox / RETROSPECTIVE PATIENT RECRUITMENT
Memtsoudis / 2011 / Perioperative Pulmonary Outcomes in Patients with Sleep Apnea After Noncardiac Surgery / RETROSPECTIVE PATIENT RECRUITMENT
Morino / 2015 / Complications after video-assisted thoracic surgery in patients with pulmonary nontuberculous mycobacterial lung disease who underwent preoperative pulmonary rehabilitation / RETROSPECTIVE PATIENT RECRUITMENT
Nishiyama / 2005 / Does common cold increase perioperative respiratory complications in adults? / NO ENGLISH FULL TEXT AVAILABLE
Pasquina / 2006 / Respiratory physiotherapy to prevent pulmonary complications after abdominal surgery - A systematic review / PRIMARY OUTCOME NOT DEFINED
Pellegrino / 2009 / Incidence and clinical outcomes of ventilator-associated pneumonia in liver transplant and non-liver transplant surgical patients / RETROSPECTIVE PATIENT RECRUITMENT
Poepping / 2008 / Protective Effects of Epidural Analgesia on Pulmonary Complications After Abdominal and Thoracic Surgery A Meta-Analysis / PRIMARY OUTCOME NOT DEFINED
Santos / 2011 / External validation of models for predicting pneumonia after cardiac surgery / PRIMARY OUTCOME NOT DEFINED
Sato / 2007 / Extravascular lung water measured using single transpulmonary thermodilution reflects perioperative pulmonary edema induced by esophagectomy / NO OUTCOMES OF INTEREST
Spies / 2006 / Intervention at the level of the neuroendocrine-immune axis and postoperative pneumonia rate in long-term alcoholics / NO OUTCOMES OF INTEREST
Van der Sluis / 2014 / A New Clinical Scoring System to Define Pneumonia following Esophagectomy for Cancer / NO OUTCOMES OF INTEREST
Supplementary table 2. Studies included in the Delphi process
Name of lead author / Year / Type of study / Sample size (n) / Primary outcome measure
Agostini et al24 / 2010 / Prospective observational study / 234 / Post-operative pulmonary complications
Akutsu et al25 / 2010 / Prospective observational study / 86 / Post-operative pneumonia
Bagyi et al26 / 2009 / Case-control study / 23 / Pneumonia
Barrera et al27 / 2005 / Prospective observational study / 300 / Post-operative pulmonary complications
Bellinetti et al28 / 2006 / Prospective observational study / 70 / Post-operative respiratory complications
Bouza et al29 / 2008 / Randomised controlled trial / 714 / Ventilator associated pneumonia
Camp et al30 / 2009 / Prospective observational study / 2211 / Early extubation
Canadian Orthopedic trauma31 / 2006 / Randomised controlled trial / 315 / Acute respiratory distress syndrome
Canet et al32 / 2010 / Prospective observational study / 2464 / Post-operative pulmonary complications
Casado et al33 / 2010 / Prospective observational study / 45 / Respiratory complications
Cassidy et al34 / 2013 / Before/After improvement study / 1819 / Post-operative pneumonia
Dronkers et al35 / 2008 / Pilot randomised controlled trial / 20 / Post-operative pulmonary complications
Fernandez-Perez et al21 / 2009 / Case-control study / 4420 / Respiratory failure
Futier et al36 / 2013 / Randomised controlled trial / 400 / Major pulmonary complications
Galvao Serejo et al37 / 2007 / Prospective observational study / 266 / Post-operative pulmonary complications
Grant et al38 / 2015 / Meta-analysis / 16 studies (1054 patients) / Post-operative pulmonary complications
Guimaraes et al39 / 2009 / Meta-analysis / 11 studies (1160 patients) / Pulmonary complications
Haines et al40 / 2013 / Prospective observational study / 72 / Post-operative pulmonary complications
Hemmes et al41 / 2014 / Randomised controlled trial / 900 / Post-operative pulmonary complications
Hodari et al42 / 2013 / Prospective observational study / 971455 / Post-operative respiratory outcomes
Hortal et al43 / 2009 / Prospective observational study / 1844 / Ventilator associated pneumonia
Hulzebos et al44 / 2006 / Randomised controlled trial / 279 / Post-operative pulmonary complications
Ireland et al11 / 2014 / Meta-analysis / 10 studies (709 patients) / Major respiratory complications
Jammer et al20 / 2015 / Systematic review / - / Various pulmonary outcomes
Jiao et al45 / 2015 / Prospective observational study / 92 / Ventilator associated pneumonia
Ladha et al46 / 2015 / Prospective observational study / 69265 / Post-operative respiratory complications
Li et al47 / 2012 / Prospective observational study / 61 / Post-operative pulmonary complications
Lunardi et al48 / 2014 / Randomised controlled trial / 137 / Post-operative pulmonary complications
Mackay et al49 / 2005 / Randomised controlled trial / 56 / Post-operative pulmonary complications
Markar et al50 / 2009 / Prospective observational study / 202 / Post-operative pneumonia
McAlister et al51 / 2005 / Prospective observational study / 1055 / Post-operative pulmonary complications
Muehling et al52 / 2008 / Pilot randomised controlled trial / 58 / Post-operative pulmonary complications
Nascimento Junior et al53 / 2014 / Meta-analysis / 11 studies (1160 patients) / Pulmonary complications
Nicholos et al54 / 2014 / Quasi-experimental study / 300 / Ventilator associated pneumonia
Paisani et al55 / 2012 / Prospective observational study / 137 / Post-operative pulmonary complications
Perkins et al56 / 2014 / Randomised controlled trial / 179 / Acute lung injury
Scholes et al57 / 2009 / Prospective observational study / 273 / Pulmonary complications
Schussler et al58 / 2006 / Prospective observational study / 168 / Post-operative pneumonia
Schussler et al59 / 2008 / Prospective observational study / 478 / Post-operative pneumonia
Severgnini et al22 / 2013 / Randomised controlled trial / 56 / Clinical pulmonary infection score
Squadrone et al60 / 2005 / Randomised controlled trial / 209 / Endotracheal intubation
Vidotto et al61 / 2011 / Prospective observational study / 317 / Post-operative pulmonary complications
Yang et al62 / 2011 / Prospective observational study / 122 / Post-operative pulmonary complications
Zarbock et al63 / 2009 / Randomised controlled trial / 500 / Post-operative pulmonary Complications
ARDS Definition Task Force65 / 2012 / Patient-level meta-analysis / 4188 / Respiratory failure