title: Non-invasive positive pressure ventilation for prevention of complications after pulmonary resection in lung cancer patients.
abstract: BACKGROUND
  Pulmonary complications are often observed during the postoperative period of lung resection for patients with lung cancer. Some conditions such as intubation, a long stay in the intensive care unit, the high cost of antibiotics and mortality may be avoided with the prevention of postoperative pulmonary complications. Non-invasive positive pressure ventilation (NIPPV) is widely accepted and often used in hospitals, and may reduce the number of pulmonary complications and mortality after this type of surgery. Therefore, a systematic review is required to map and critically assess the benefits and harms of NIPPV for patients undergoing lung resection.
  
  
  OBJECTIVE
  To assess the efficacy and safety of NIPPV for preventing complications in patients who underwent pulmonary resection for lung cancer.
  
  
  METHODS
  We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, LILACS and PEDro, to identify potentially eligible trials. We did not use any date or language restrictions in the electronic searches. The databases were last searched on 17 March 2015. We searched the reference lists of relevant papers and contacted experts in the field for information about additional published and unpublished studies. We also searched the Register of Controlled Trials (www.controlled-trials.com) and ClinicalTrials.gov (clinicaltrials.gov) to identify ongoing studies.
  
  
  METHODS
  We considered randomised or quasi-randomised clinical trials that compared NIPPV in the immediate postoperative period after pulmonary resection with no intervention or conventional respiratory therapy.
  
  
  METHODS
  Two authors collected data and assessed trial risk of bias. Where possible, we pooled data from the individual studies using a fixed-effect model (quantitative synthesis), but where this was not possible we tabulated or presented the data in the main text (qualitative synthesis). Where substantial heterogeneity existed, we applied a random-effects model.
  
  
  RESULTS
  Of the 155 references retrieved from searches, 6 randomised clinical trials (RCTs) and 1 quasi-randomised trial fulfilled the eligibility criteria for this review, including a total of 436 patients. Five studies described quantitative measures of pulmonary complications, with pooled data showing no difference between NIPPV compared with no intervention (RR 1.03; 95% CI 0.72 to 1.47). Three studies reported intubation rates and there was no significant difference between the intervention and control groups (RR 0.55; 95% CI 0.25 to 1.20). Five studies reported measures of mortality on completion of the intervention period. There was no statistical difference between the groups for this outcome (RR 0.60; 95% CI 0.24 to 1.53). Similar results were observed in the subgroup analysis considering ventilatory mode (bi-level versus continuous positive airway pressure (CPAP). No study evaluated the postoperative consumption of antibiotics. Two studies reported the length of intensive care unit stay and there was no significant difference between the intervention and control groups (MD -0.75; 95% CI -3.93 to 2.43). Four studies reported the length of hospital stay and there was no significant difference between the intervention and control groups (MD -0.12; 95% CI -6.15 to 5.90). None of the studies described any complications related to NIPPV. Of the seven included studies, four studies were considered as 'low risk of bias' in all domains, two studies were considered 'high risk of bias' for the allocation concealment domain, and one of these was also considered 'high risk of bias' for random sequence generation. One other study was considered 'high risk of bias' for including participants with more severe disease.
  
  
  CONCLUSIONS
  This review demonstrated that there was no additional benefit of using NIPPV in postoperative pulmonary resection for all outcomes analysed (pulmonary complications, rate of intubation, mortality, rate of non-pulmonary complications, postoperative consumption of antibiotics, length of intensive care unit stay, length of hospital stay and adverse effects related to NIPPV). However, the quality of evidence is 'very low', 'low' and 'moderate' since there were few studies, with small sample size and low frequency of outcomes. New well-designed and well-conducted randomised trials are needed to answer the questions of this review with greater certainty.
authors.affiliation: Brazilian Cochrane Centre, Centro de Estudos de Saúde Baseada em Evidências e Avaliação Tecnológica em Saúde, Rua Borges Lagoa, 564 cj 63, São Paulo, SP, Brazil, 04038-000.
authors.forename: Maria F S
authors.initials: MF
authors.lastname: Torres
authors.forename: Gustavo J M
authors.initials: GJ
authors.lastname: Porfirio
authors.forename: Alan P V
authors.initials: AP
authors.lastname: Carvalho
authors.forename: Rachel
authors.initials: R
authors.lastname: Riera
mesh_terms: D000900:Anti-Bacterial Agents / Q000008:administration & dosage; D006801:Humans; D007440:Intubation / Q000706:statistics & numerical data; D008175:Lung Neoplasms / Q000601:surgery*; D063087:Noninvasive Ventilation / Q000379:methods*; D011013:Pneumonectomy / Q000401:mortality; D011175:Positive-Pressure Respiration / Q000379:methods*; D011183:Postoperative Complications / Q000401:mortality / Q000517:prevention & control*; D016032:Randomized Controlled Trials as Topic
chemical_list: D000900:Anti-Bacterial Agents