What is the clinical evidence from this study?

Study design: Meta-Analysis. Population: Adults undergoing major surgery (n=2070). Intervention: Preoperative exercise training vs. Usual care or sham training. Primary outcome: Postoperative pulmonary complications (PPCs) (RR 0.52, 95% CI 0.41 to 0.66).

October 8, 2020Open Access

Preoperative Exercise Training to Prevent Postoperative Pulmonary Complications in Adults Undergoing Major Surgery. A Systematic Review and Meta-analysis with Trial Sequential Analysis

Key Result

Preoperative exercise training reduced the incidence of postoperative pulmonary complications compared with usual care or sham training (RR 0.52; 95% CI 0.41 to 0.66).

Study Design

Type

Meta-Analysis (n=2,070)

Structured PICO

Does preoperative exercise training reduce the incidence of postoperative pulmonary complications in adults undergoing major surgery?

Population

2,070 adults undergoing elective major surgery (cardiac, lung, esophageal, or abdominal) pooled from 29 RCTs. Median of reported mean ages 64 years, 34% female, median COPD prevalence 30%.

Intervention

Preoperative exercise training (endurance training, respiratory muscle training, or combined) for 1 to 8 weeks before surgery (median cumulated time 460 min).

Comparator

Usual care or sham training.

Outcome

Incidence of postoperative pulmonary complications (PPCs).composite

Preoperative exercise training significantly improves physical fitness and reduces the risk of postoperative pulmonary complications in adults undergoing major surgery.

Main Result

Effect estimate: RR 0.52 (95% CI 0.41 to 0.66)

Abstract

Abstract Rationale Poor preoperative physical fitness and respiratory muscle weakness are associated with postoperative pulmonary complications (PPCs) that result in prolonged hospital length of stay and increased mortality. Objectives To examine the effect of preoperative exercise training on the risk of PPCs across different surgical settings. Methods We searched MEDLINE, Web of Science, Embase, the Physiotherapy Evidence Database, and the Cochrane Central Register, without language restrictions, for studies from inception to July 2020. We included randomized controlled trials that compared patients receiving exercise training with those receiving usual care or sham training before cardiac, lung, esophageal, or abdominal surgery. PPCs were the main outcome; secondary outcomes were preoperative functional changes and postoperative mortality, cardiovascular complications, and hospital length of stay. The study was registered with PROSPERO (International Prospective Register of Systematic Reviews). Results From 29 studies, 2,070 patients were pooled for meta-analysis. Compared with the control condition, preoperative exercise training was associated with a lower incidence of PPCs (23 studies, 1,864 patients; relative risk, 0.52; 95% confidence interval CI, 0.41 to 0.66; grading of evidence, moderate); Trial Sequential Analysis confirmed effectiveness, and there was no evidence of difference of effect across surgeries, type of training (respiratory muscles, endurance or combined), or preoperative duration of training. At the end of the preoperative period, exercise training resulted in increased peak oxygen uptake (weighted mean difference WMD, +2 ml/kg/min; 99% CI, 0.3 to 3.7) and higher maximal inspiratory pressure (WMD, +12.2 cm H2O; 99% CI, 6.3 to 18.2). Hospital length of stay was shortened (WMD, −2.3 d; 99% CI, −3.82 to −0.75) in the intervention group, whereas no difference was found in postoperative mortality. Conclusions Preoperative exercise training improves physical fitness and reduces the risk of developing PPCs while minimizing hospital resources use, regardless of the type of intervention and surgery performed. Systematic review registered with https://www.crd.york.ac.uk/prospero/ (CRD 42018096956).

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