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Original Article

Systematic review and meta-analysis on perioperative intervention

to prevent postoperative atelectasis complications after thoracic
surgery

Yongsheng Zhao1
, Renyan Zheng2 , Wanping Xiang1 , Dong Ning1 , Zhenglong Li1
1 2
Department of Thoracic Surgery, Affiliated Hospital of North Sichuan Medical College, Nanchong, China; Department of Integrated Western and
Chinese Colorectal and Anal Surgery, Affiliated Hospital of North Sichuan Medical College, Nanchong, China
Contributions: (I) Conception and design: Y Zhao, R Zheng; (II) Administrative support: W Xiang; (III) Provision of study materials or patients: Y Zhao,
R Zheng, D Ning, Z Li; (IV) Collection and assembly of data: All authors; (V) Data analysis and interpretation: Y Zhao, W Xiang, D Ning, Z Li; (VI)
Manuscript writing: All authors; (VII) Final approval of manuscript: All authors.
Correspondence to: Yongsheng Zhao. Department of Thoracic Surgery, Affiliated Hospital of North Sichuan Medical College, 1 Maoyuan South Road,
Shunqing District, Nanchong 637000, China. Email: [email protected].

Background: In clinical general thoracic surgery, the prevalence of atelectasis is relatively high.
Perioperative interventions can affect the probability of patients with atelectasis after surgery. Therefore, the
incidence of perioperative intervention to prevent atelectasis after thoracic surgery was discussed using meta-
analysis in this study.
Methods: The articles were searched in the English database PubMed and Chinese databases including
China National Knowledge Infrastructure (CNKI), VIP, and China Journal Full-text Database (CJFD). The
duration for publication time of the articles was from the database inception to March 2021, and the articles
were required to be randomized controlled trials (RCTs) using interventions [such as changing the dose of
general anesthesia, continuous positive end expiratory pressure (PEEP) , non-invasive pressure support
ventilation, and physical therapy] after thoracic surgery (such as pulmonary lobectomy, sternum surgery, and
lung cancer surgery) for the treatment of atelectasis. The software RevMan 5.3 provided by the Cochrane
Collaboration was used for meta-analysis.
Results: A total of 5 articles were obtained, including 375 cases in the control group and 268 cases in the
intervention treatment group. A meta-analysis was performed on the included articles, combined effect model
analysis results showed that compared with the control group, the use of PEEP during mechanical ventilation
can significantly reduce the incidence of atelectasis [odds ratio (OR) =0.46; 95% confidence interval (CI):
0.31–0.67; Z=3.94; P<0.0001].
Discussion: Perioperative intervention was more effective for postoperative atelectasis and other complications.

Keywords: Thoracic surgery; perioperative period; meta-analysis; atelectasis

Submitted Aug 12, 2021. Accepted for publication Oct 13, 2021.
doi:10.21037/apm-21-2441
View this article at: https://dx.doi.org/10.21037/apm-21-2441

Introduction atelectasis and pulmonary infection after thoracic surgery

has great clinical value. Although progress has been
The prevalence of atelectasis accounts for 30.00–75.00%
of ordinary thoracic surgery, of which 20.00–42.00% is made in the perioperative care of patients undergoing
due to pulmonary infections after surgery, and the mortality major surgery, postoperative pulmonary complications
rate is as high as 27.00–50.00% (1,2). The treatment of (PPCs) are the main cause of morbidity and mortality. The grouping o

© Annals of Palliative Medicine. All rights reserved. Ann Palliat Med 2021;10(10):10726-10734 | https://dx.doi.org/10.21037/apm-21-2441
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Annals of Palliative Medicine, Vol 10, No 10 October 2021 10727

PPC includes a series of diseases that affect the respiratory the burden of related economic and health outcomes (11,12).
system, usually alveolar expansion or respiratory failure in However, compared with postoperative cardiovascular
the first week after surgery. The physical condition of the complications, consensus guidelines for perioperative
patient is also related to the success of the operation. management to reduce the risk of PPCs are still rare.
Atelectasis, pneumonia, tracheobronchitis, bronchospasm, Due to the extensive and diverse evidence base of many
acute exacerbation of chronic obstructive pulmonary disease, interventions and the lack of consensus, there are great
hypoxemia, dyspnea, acute respiratory failure, and difficulty differences in clinical practice (13,14).
in weaning can all be diagnosed as pulmonary complications The objective of this systematic review was to summarize
after thoracic surgery. The main causes are postoperative the evidence of randomized controlled trials (RCTs), with the
respiratory muscle dysfunction, ventilatory blood flow ratio aim of reducing PPC after thoracic surgery in adults.
imbalance, central and peripheral nervous system depression, This study aimed to compare the quality, quantity, and
reduced cough efficiency, respiratory secretions retention, deviation risk of PPC management treatment effect. The
increased respiratory frequency, decreased tidal volume, inherent focus of this approach was to focus on whether the
functional residual capacity, and vital capacity. Postoperative benefits are related to each treatment, rather than comparing
pain is related to analgesia. their side effects. This was because although the benefits of
For example, performing ankle surgery on healthy young treatment should be similar, the harms are very different due
people may have a less than 1% risk, while performing to them working very differently. In this study, 8 articles
surgery on frail elderly patients bears a higher risk. When related to the treatment of postoperative pulmonary infections
thoracic surgery is performed, the surgical incision is close and the treatment effect of atelectasis after thoracic surgery
to the thoracic cavity, which increases the risk of infection. were included for multiple screening and meta-analysis on
Complications can cause pain, which will stimulate the results of domestic and international comparative studies of
muscle recovery after surgery. Age is one of the predictive cases. It aimed to provide a scientific and theoretical basis
indicators of PPC, evidenced by the fact that healthy elderly for postoperative pulmonary infection and prevention of
patients are at higher risk of PPC (3). The PPCs are also atelectasis after thoracic surgery. We present the following
predictors of short- and long-term recovery after surgery, and article in accordance with the PRISMA reporting checklist
the increased risk of patients receiving critical care is also (available at https://dx.doi.
related to prolonged hospital stay (4,5). About 14–30% of org/10.21037/apm-21-2441).
PPC patients may die within 30 days after surgery, while the
mortality rate of patients without PPC is 0.2–3%. The causes
of PPCs are multi-factorial and are Methods

related to the patient's suboptimal health status and the acute Strategy for article retrieval
side effects of surgery accompanied by anesthesia (6,7). The
surgery itself can inhibit lung function, especially when the The databases of Medline, Embase, Cumulative Index of
operation is severe enough to impair breathing. Nursing and Allied Health Literature (CINHAL), and Cochrane
Anesthesia has an adverse effect on lung function during the Central Register of Controlled Trials were searched by taking
operation, which may continue to a lesser extent until the the related keywords and medical subject heading terms of
recovery time after the operation. Chronic risk factors for PPCs. The researched articles were limited to RCTs
PPC include poor cardiorespiratory health, increasing age, published from 1 January 1990 to 8 December 2020 and
lifestyle, and living habits (8,9). RCTs related to contemporary surgical and anesthesia
Fortunately, there are multiple opportunities for intervention, practices, including laparoscopic surgical techniques.
which may hinder the development of PPC. According to the European Perioperative Clinical Outcome
Interventions are diverse, including preemptive strategies (EPCO) definition and combined with the descriptive terms
(before surgery) to optimize respiratory physiology, and (such as intraoperative complications, perioperative
intraoperative and postoperative interventions to minimize complications, preoperative care, intraoperative care,
the adverse effects of surgery and anesthesia (10). postoperative care, and anesthesia-associated with
The treatment of PPCs requires the multidisciplinary postoperative respiratory complications, the Chinese search
participation of anesthesia, surgery, respiratory medicine, keywords included atelectasis , postoperative complications,
physical therapy, and intensive care professionals, and bears postoperative atelectasis,

© Annals of Palliative Medicine. All rights reserved. Ann Palliat Med 2021;10(10):10726-10734 | https://dx.doi.org/10.21037/apm-21-2441
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10728 Zhao et al. Meta-analysis on atelectasis-preventing intervention

thoracic surgery, pulmonary lobectomy, sternotomy, lung methods, research plan design, intervention measures for
cancer intervention, general anesthesia, and physical experimental group and control group, outcome evaluation
intervention. The full text of the target articles could be indicators, and outcome data.
obtained in accordance with the pre-established inclusion
and exclusion criteria. In addition, the perioperative fluid and
Quality assessment
hemodynamic management strategies, intraoperative
neuromuscular block and monitoring, airway devices, and To assess the quality of the articles, quality evaluation was
lung aspiration techniques were studied. carried out according to the “bias risk assessment”
recommended by Cochrane system review manual (version
5.3; https://training.cochrane.org/handbook). The evaluation
Inclusion and exclusion criteria of the articles
contents included the following 7 items: which random method
The inclusion criteria were defined as follows: articles was used; whether allocation concealment was used;
which were RCTs; articles which compared the incidence of implementation of blinding between patients and researchers;
pulmonary infection and atelectasis after thoracic surgery no assessment on the effect of shielding; whether the results
matter with hidden or blind method; articles whose research were complete; whether the survey results were credible; and
results contained the relevant goals involved in this study; other biases. Regarding the RCTs in item 7 above, “satisfied”
articles which investigated the vital signs of patients with meant that the bias was relatively small and “unsatisfied”
thoracic surgery; and articles which introduced the treatment meant a high degree of bias. If the study had not been fully
methods and processes of pulmonary infections and atelectasis. reported in detail, the risk was deemed unknown. The
The exclusion criteria were defined as follows: articles modified Jadad scale review was used to assess the quality
involving participants under 18 years old; articles with of the attached research and literature.
repeated data; articles with inconsistent data that could not The evaluation included random sequence generation,
be explained by reporting bias (data error); and articles allocation concealment, blinding, and tracking/exit with a
including participants with a history of adverse reactions. score of 1 to 3, which was considered low quality, and 4 to 7
points were considered high quality.

Screening of articles
The articles were screened and data was extracted Lung ultrasound (LUS) score for diagnosis of atelectasis

independently, and cross-checking was performed. In the Diagnosis of atelectasis: divide the chest into 12 areas, both
case of different opinions, expert opinions were sought to the left and right chests have 6 areas, each side is divided
determine the data selection. into anterior area, lateral area, posterior area by the
parasternal line, anterior axillary line, posterior axillary line,
Data extraction and the nipple . The upper 1 cm is the boundary, which is
divided into upper and lower areas. Ventilation loss is
The data extraction of this study was carried out independently evaluated by calculating the LUS score. According to the
by two researchers. During data extraction, two researchers scoring system, each of the 12 districts is rated as 0 to 3
firstly extracted the data independently, and created an Excel points, and then the 12 quadrant scores are added together
table based on the basic information of the to calculate the total LUS score (0 to 36 points), and the
articles, participant characteristics, intervention measures, higher score indicates that the ventilation loss is more serious.
outcome indicators, and bias evaluation. After the extraction LUS scoring criteria for each area is as follows: 0 points for
was completed, cross-check was performed. If there were normal ventilation (0 to 2 lines B), 1 point for mild ventilation
differences of opinion during the data extraction process, the loss (greater than or equal to 3 lines B), 2 points for moderate
researchers sought resolution through discussion or requested ventilation loss (poly B line ), and 3 points for severe
the opinion of a third researcher. The data to be extracted in ventilation loss (consolidation).
this study included basic information of the article (title, first
author, publication year, author information, source, and so
Statistical analysis
on), basic participant characteristics (gender, age, research
sample size, baseline comparability, and so on). on), research The RevMan 5.3 software (Copenhagen: The Nordic

© Annals of Palliative Medicine. All rights reserved. Ann Palliat Med 2021;10(10):10726-10734 | https://dx.doi.org/10.21037/apm-21-2441
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Annals of Palliative Medicine, Vol 10, No 10 October 2021 10729

Identification of studies via databases and registers

noitacifitnedI
Records identified from: Records removed before screening:
Databases (n=367) Duplicate records removed (n=204)
Registers (n=237) Records marked as ineligible by automation tools
(n=97)
Records removed for other reasons (n=102)

Records screened Records excluded

(n=201) (n=59)
gnineercS

Reports sought for retrieval Reports not retrieved

(n=142) (n=92)

Reports assessed for eligibility Reports excluded:

(n=50) 1. The efficacy was observed as a non-
perioperative period (n=25)
2. Pulmonary complications after surgery (n=9)
3. Interinterventions were not similar enough to
dedulcnI

merge with the other RCT (n=11)

Studies included in review
(n=5)

Figure 1 The flow chart for the article retrieval process. RCT, randomized controlled trial.

Cochrane Center, The Cochrane Collaboration, 2014) was eliminated 59 literatures that did not meet the inclusion
used for meta-analysis. The calculation method took odds criteria. After carefully reading the titles and abstracts of
ratio (OR) as the effect size, and 95% confidence interval the documents, 92 literatures that did not meet the
(CI) to express the result. A heterogeneity test was requirements were further eliminated. After downloading
performed on the included articles, and ÿ=0.1 was taken the literature, read the specific content of the literature,
as the test level. If there was no heterogeneity among the and delete 25 literatures on “pulmonary complications
articles (P>0.1; I2 <50%), the fixed effects model (FEM) after surgery”, 9 literatures on “pulmonary complications
was selected for meta-analysis; Otherwise, subgroup after surgery”, 11 literatures on “interventions were not
analysis was performed on the included data. AP value similar enough to merge with the other RCT ”.
<0.05 indicated that the difference was statistically significant. Finally, a total of 5 documents meeting the requirements
were included for meta-analysis (14-18). The literature
Results retrieval process was shown in Figure 1. Funnel chart
analysis showed that there was no obvious evidence of
Results of articles retrieval
publication bias, or that the results of the smaller trial were
Initially, a total of 604 articles were retrieved. After reading systematically different from the larger trial.
the title of the article, 403 literatures that did not fit the According to Cochrane criteria, the risk of bias in most
research theme were initially excluded. Then, we briefly articles could be judged. The basic characteristics of the
browsed the abstracts of the literature, and document were shown in Table 1.

© Annals of Palliative Medicine. All rights reserved. Ann Palliat Med 2021;10(10):10726-10734 | https://dx.doi.org/10.21037/apm-21-2441
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10730 Zhao et al. Meta-analysis on atelectasis-preventing intervention

Table 1 The basic characteristics of the included articles

Author Publication year Intervention method Age (years old) Number of cases Study method

Marret (14) 2018 Low tide ventilation unclear 343 RCT

Futier (15) 2013 Continuous PEEP unclear 400 RCT

Talab (16) 2009 Non-invasive pressure support ventilation unclear 66 RCT

park (17) 2016 physical therapy ÿ18 40 RCT

Sooh (18) 2018 Reduced lung protection ventilation 18–80 78 RCT

PEEP, positive end expiratory pressure; RCT, randomized controlled trial.

Random sequence generation (selection bias)

Allocation concealment (selection bias)

Blinding of participants and personnel (performance bias)

Blinding of outcome assessment (detection bias)

Incomplete outcome data (attrition bias)

Selective reporting (reporting bias)

Other bias

0% 25% fifty% 75% 100%

Low risk of bias Unclear risk of bias High risk of bias

Figure 2 Assessment of risk bias of the included articles.

Risk bias assessment of the included articles they were at low risk; 1 article did not mention whether the outcome
assessor was blinded, suggesting that the risk was unclear; and
Cochrane Handbook 5.3 version of the systematic review writing
the last article did not clearly describe it, so it was high risk; (V)
manual was adopted to evaluate the risk of bias in the 5 articles
data completeness: the research data of 2 articles were complete,
included in this study and output the risk of bias chart, as shown in
indicating low risk; (VI) selective reporting: 3 articles had no
Figures 2,3 . The risk of bias included the following items: (I)
selective report, suggesting low risk; 1 article was unclear, because
whether it was a random sequence: 2 of the 5 included articles
it was unclear risk; 1 article had selective report, which was high
reported the random grouping, suggesting that these 2 articles
risk.; (VII) whether there were other biases: 1 article of high quality,
were all in low risk. Two articles did not report whether it was
random grouping, suggesting that these were unclear risk; and 1 so it was low risk; 1 article was impossible to determine whether

article clearly mentioned the grouping method as “non-random”, there were other biases, which suggested that the risk was unclear;

suggesting that it was high risk; (II) mention of allocation other articles were high risk.
concealment: 4 articles mentioned allocation concealment,
indicating that these 4 articles were in low risk, and 1 article did
not mention whether allocation concealment was used, suggesting
Incidence of atelectasis
that it was high risk; (III) whether to blind participants: 1 article
mentioned the patient's informed consent, indicating high risk, and Five articles reported the incidence of atelectasis after surgery.
other articles were low risk; (IV) whether to blind the outcome The results of heterogeneity analysis showed that =44% and
2
evaluators: 3 articles mentioned blinding the outcome evaluators, Yo
P=0.13, indicating that there was no obvious heterogeneity in
suggesting that the included articles, so the FEM was used for meta-analysis. The
combined effect model analysis

© Annals of Palliative Medicine. All rights reserved. Ann Palliat Med 2021;10(10):10726-10734 | https://dx.doi.org/10.21037/apm-21-2441
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Annals of Palliative Medicine, Vol 10, No 10 October 2021 10731

results showed that compared with the control group, the Analysis of publication bias
use of positive end expiratory pressure (PEEP) during
Funnel chart analysis was performed on the 5 included
mechanical ventilation can significantly reduce the
articles, and the results showed that the funnel charts were
incidence of atelectasis (OR =0.46; 95% CI: 0.31–0.67;
asymmetric (Figures 5), indicating that there may have
Z=3.94, P<0.0001) . It is suggested that preoperative
been publication bias. This may be related to factors such
intervention can reduce the incidence of postoperative
as the small sample size included in the study. However,
atelectasis in patients (as shown in Figure 4).
it was within the 95% CI as a whole, indicating that the
article had high credibility. The postoperative pulmonary
infection funnel chart was a bit scattered outside the
credible interval, suggesting that the literature had publication bias.

Discussion

In this meta-analysis, there were a total of 5 articles (14-18)

included. The limitations of interventional measures in this
study indicated that participants and patients may have
had measurement biases. In order to improve the reliability
and reference of the research, it is expected that the
research method and design could be further improved in
the future. The use of preoperative interventions such as
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changing the dose of general anesthesia, continuous

PEEP, non-invasive pressure support ventilation, and
implementing physical therapy can reduce the incidence
of PPC in thoracic surgery patients and improve the lung
function of patients. Such results were consistent with the
Futier 2013 findings of Jakobsen et al. (19), which showed that
preoperative general anesthesia and hypoventilation can
Marret 2018
reduce the resistance of patients during surgery. In 5
park 2016 articles (14-18), there were slight differences in preoperative
interventional methods, but all treatments had the effect of
soh 2018
shortening the patient's blood loss, pleural expansion, and
Talab 2009 hospital stay. In addition, in the same study, the surgical
method in the control group and the restorative drugs in
Figure 3 Multiple studies in the articles correspond to the multiple the treatment group were the same.
risk bias evaluation results. Therefore, the intervention of patients undergoing thoracic

Figure 4 Forest map for incidence of atelectasis. CI, confidence interval.

© Annals of Palliative Medicine. All rights reserved. Ann Palliat Med 2021;10(10):10726-10734 | https://dx.doi.org/10.21037/apm-21-2441
Machine Translated by Google

10732 Zhao et al. Meta-analysis on atelectasis-preventing intervention

0 and gastrointestinal tract to prevent the occurrence of

endogenous infections; (II) strengthen the nursing of
0.5 endotracheal intubation or tracheotomy, and correctly master
the sputum suction operation. Foreign countries use special
1 endotracheal cannula devices to prevent the inhalation of
)]RO[gEoS
l(

oropharyngeal bacteria and reduce ventilator-associated

1.5
pneumonia by 50%. For high-risk and susceptible patients,
OR selective digestive tract decontamination (SDD) is used to
2
0.01 0.1 1 10 100 kill pathogenic bacteria in the gastrointestinal tract by
Figure 5 The funnel chart for bias of publication of the included applying antibacterial drugs that are not absorbed by the
articles in terms of atelectasis index for patients with thoracic gastrointestinal tract to avoid their migration or translocation.
surgery. SE, standard error; OR, odds ratio. Commonly used antibacterial drugs are tobramycin,
polymyxin E, and amphotericin B.
In this study, the patient's breathing, preoperative
surgery improved lung function and reduced the incidence evaluation, or the effect of preoperative inhalation of a
of postoperative lung complications (20,21). For patients certain drug were studied. Since there was no comparison
undergoing general anesthesia, mechanical ventilation is between the perioperative control group and the treatment
used during the operation. Regardless of whether there is group, the relevant Chinese articles were not included. In
lung disease before anesthesia, about 75% of patients are addition, the treatment times of the 8 articles included in this
in a state of local alveoli in the process of general anesthesia study were contradictory, which may have a certain impact
and mechanical ventilation. This situation can directly lead on the results of this study. There was no report on the
to the lungs. Increased shunt induces hypoxemia in severe randomization method or allocation concealment.
cases. Preoperative intervention can reduce the incidence Therefore, it is recommended to further improve the
of postoperative atelectasis. The reason may be the clinically experimental plan, standardize the specific time, methods,
commonly used volume control ventilation mode that can't and drugs of periodic intervention, and implement high-
fully open the alveoli and excessive tidal volume. Not only quality, large-scale samples. Additionally, multi-center
the effect of improving the oxygenation status is poor, but randomized controlled tests need to be performed to obtain
there is a risk of pneumothorax. The low level of PEEP more reliable evidence.
makes the alveoli and small bronchi in an open state, thereby
increasing the number of effective ventilation alveoli, avoiding Conclusions
unnecessary exudation of the alveoli, improving the oxygen-
carrying function of lung hemoglobin, and increasing PaO2, The results of this study analyzed the interventions (such as
and fundamentally acting hypoxemia (22). changing the dose of general anesthesia, continuous PEEP,
non-invasive pressure support ventilation, and implementation
It is necessary to study whether preoperative and of physical therapy) in perioperative circumstances that
postoperative intervention can reduce PPC in patients included comparative thoracic surgery (such as pulmonary
undergoing thoracic surgery, and further investigate the lobectomy, thoracic surgery , and lung cancer surgery) in
specific time of preoperative intervention. In addition, it is the treatment of pulmonary infection and atelectasis. In
imperative to avoid wasting medical resources and reduce addition, the intervention method was convenient and easy
PPC. The safety of intervention measures such as ventilation to operate. Therefore, more high-quality, large-sample,
in thoracic surgery has also been widely recognized. The multi-center randomized controlled studies should be carried
British Thoracic Association pointed out that the use of out clinically, and after more reliable evidence was obtained,
ventilation intervention is safe and effective they should be promoted and applied clinically.
in the diagnosis and treatment of patients in the intensive
care unit, the elderly, and heart disease. Pulmonary infection
and atelectasis prevention plan and control measures are
Acknowledgments
as follows: (I) reduce or eliminate the colonization and
inhalation of pathogenic bacteria in the oropharynx Funding: None.

© Annals of Palliative Medicine. All rights reserved. Ann Palliat Med 2021;10(10):10726-10734 | https://dx.doi.org/10.21037/apm-21-2441
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Annals of Palliative Medicine, Vol 10, No 10 October 2021 10733

footnote complications. Br J Anaesth 2017;118:317-34.

7. Shander A, Fleisher LA, Barie PS, et al. Clinical
Reporting Checklist: The authors have completed the PRISMA
and economic burden of postoperative pulmonary
reporting checklist. Available at https://dx.doi.
complications: patient safety summit on definition, risk-
org/10.21037/apm-21-2441
reducing interventions, and preventive strategies. Crit Care
Med 2011;39:2163-72.
Conflicts of Interest: All authors have completed the ICMJE
8. Lawrence VA, Cornell JE, Smetana GW, et al. Strategies to
uniform disclosure form (available at https://dx.doi.
reduce postoperative pulmonary complications after
org/10.21037/apm-21-2441). The authors have no conflicts of
noncardiothoracic surgery: systematic review for the
interest to declare.
American College of Physicians. Ann Intern Med
2006;144:596-608.
Ethical Statement: The authors are accountable for all aspects
9. Fleisher LA, Fleischmann KE, Auerbach AD, et al. 2014 ACC/
of the work in ensuring that questions related to the accuracy AHA guideline on perioperative cardiovascular evaluation
or integrity of any part of the work are appropriately investigated and management of patients undergoing noncardiac
and resolved. surgery: executive summary: a report of the American
College of Cardiology/American Heart Association Task
Open Access Statement: This is an Open Access article Force on Practice Guidelines. Circulation
distributed in accordance with the Creative Commons
2014;130:2215-45.
Attribution-NonCommercial-NoDerivs 4.0 International License
10. Moher D, Liberati A, Tetzlaff J, et al. Preferred reporting items
(CC BY-NC-ND 4.0), which permits the non-commercial for systematic reviews and meta-analyses: the PRISMA
replication and distribution of the article with the strict provision statement. PLoS Med 2009;6:e1000097.
that no changes or edits are made and the original work is 11. Östberg E, Thorisson A, Enlund M, et al. Positive end-
properly cited (including links to both the formal publication expiratory pressure and postoperative atelectasis: a randomized
through the relevant DOI and the license). controlled trial. Anesthesiology 2019;131:809-17.
See: https://creativecommons.org/licenses/by-nc-nd/4.0/. 12. Pereira SM, Tucci MR, Morais CCA, et al. Individual positive end-
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Cite this article as: Zhao Y, Zheng R, Xiang W, Ning D, Li

Z. Systematic review and meta-analysis on perioperative
intervention to prevent postoperative atelectasis complications
after thoracic surgery. Ann Palliat Med 2021;10(10):10726-10734.
doi:10.21037/apm-21-2441

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