Anesthesia-related risk factors for postoperative pulmonary complications in patients with COPD: A systematic review and meta-analysis

Abstract

Background: Chronic obstructive pulmonary disease (COPD) is prevalent among surgical patients and is a well-documented risk factor for postoperative pulmonary complications (PPCs). Despite this, there is limited evidence guiding anesthetic management for patients with COPD undergoing surgery. Objective: To synthesize associations of anesthetic factors and PPCs in patients with COPD undergoing inpatient elective surgery. Methods: We searched MEDLINE, EMBASE, and Web of Science from inception until April 2026 for studies including adults with COPD undergoing inpatient elective non-cardiothoracic surgery. We included studies reporting any anesthesia-related exposures, including type of anesthesia (e.g., regional versus general) and specific anesthetic drugs or techniques. Outcomes of interest were PPCs (composite score), pneumonia, prolonged ventilation, and respiratory failure. When possible, quantitative synthesis was performed using random-effects meta-analyses; remaining evidence was narratively summarized using harvest plots. Critical appraisal was conducted with the Newcastle–Ottawa Scale for observational studies and RoB2 for randomized trials. Results: From 3,048 studies screened, we included twelve cohort studies and one randomized trial involving 7,302 patients. Of these, eleven studies compared regional versus general anesthesia techniques and were included for the evidence synthesis. In six studies, regional anesthesia was associated with lower odds of PPCs when compared to general anesthesia. Pooled analysis of five studies reporting pneumonia demonstrated a lower risk with regional anesthesia (pooled OR 0.68, 95% CI 0.49–0.84; I² = 0%). Five small studies reported lower incidence of respiratory failure or prolonged mechanical ventilation with regional rather than general anesthesia, although estimates were imprecise. The risk of bias was moderate in seven studies and low in six studies, and the certainty of evidence was low. Conclusions: In adults with COPD undergoing elective surgery, regional anesthetic techniques may reduce PPCs such as pneumonia compared with general anesthesia alone; however, the evidence is limited by high risk of bias and imprecision. Well-designed prospective studies with standardized outcome definitions are required to define optimal anesthetic approaches.