Risk assessment and prevention of postoperative and postprocedural respiratory failure: recommendations from an international expert panel

Respiratory failure after surgery and other major invasive procedures, defined as the unanticipated need for invasive or noninvasive ventilation, is a life-threatening complication affecting ~10 million patients annually. At present, there are no guidelines for risk assessment and prevention of postprocedural respiratory failure. We developed expert-informed practice recommendations for the prediction and prevention of postoperative and postprocedural respiratory failure. These recommendations focused on modifiable pre- and post-procedural risk factors and implementation feasibility, using a structured multidisciplinary expert panel process. An international expert panel reviewed current literature, supplemented evidence gaps with expert opinion, and drafted preliminary action statements. Iterative voting rounds were used to refine expert panel statements, which were classified as recommendations with broad applicability and low likelihood of delaying care, or suggestions that can be applied selectively. The study panel included 25 experts from four continents and multiple medical disciplines. An initial set of 54 preliminary statements was refined into 13 recommendations and 15 suggestions. Recommendations included using screening tools systematically, promoting tobacco cessation, reconsidering procedure timing in patients with symptomatic respiratory tract infections, mobilising patients early and maximising upright positioning, maintaining good oral hygiene, using noninvasive respiratory support to minimise need for invasive ventilation, and minimising deep sedation while promoting early tracheal extubation. These recommendations reflect expert interpretation of a broad and heterogeneous body of evidence and provide practical strategies to predict and prevent postprocedural respiratory failure, offering a framework for future study of a risk-targeted care bundle.