Antiemetic doses of dexamethasone do not affect pulmonary complications after noncardiac surgery: a matter of pathophysiology?

Postoperative pulmonary complications (PPCs) remain common and are exacerbated by perioperative systemic inflammation. Dexamethasone, administered to millions of patients each year for prophylaxis against postoperative nausea and vomiting, effectively attenuates systemic inflammatory responses, rendering it a plausible adjunct for PPC prevention. In a recent issue of the British Journal of Anaesthesia, Zorrilla-Vaca and colleagues present a well-designed secondary analysis of the individualised, perioperative open-lung ventilation strategy trials showing that antiemetic doses of dexamethasone (4-8 mg i.v.) did not reduce patients' risk of PPCs. In the underlying iPROVE (Individualised, Perioperative Open-Lung Ventilation Strategy) studies, other landmark trials, and clinical routine practice across general patient populations, the key driver and major contributor to PPCs is perioperative atelectasis, which is predominantly determined by surgery, induction of general anaesthesia, and ventilatory management rather than systemic inflammation. The findings by Zorrilla-Vaca and colleagues emphasise the importance of differentiating the pathophysiological pathway of composite clinical outcomes including PPCs when designing preventive strategies, while reaffirming the established safety of dexamethasone at standard doses.