# Clinical effectiveness of perioperative oxygen therapy strategies in children: a systematic review and meta-analysis of randomised controlled trials

## TL;DR

This study reviews the effects of different oxygen therapy strategies in children during surgery but finds insufficient evidence to recommend any specific approach.

## Contribution

A systematic review and meta-analysis of randomized trials on perioperative oxygen strategies in children, revealing very uncertain clinical outcomes.

## Key findings

- High Fio2 vs low Fio2 showed very uncertain effects on surgical site infection and postoperative pulmonary complications.
- Postoperative HFNO use significantly reduced reintubation rates compared to conventional oxygen therapy.
- Evidence remains very uncertain for HFNO vs NIV effects on reintubation and pneumothorax.

## Abstract

Oxygen is routinely used in the perioperative period. However, its impact on clinical outcomes remains unclear. This systematic review aimed to assess the clinical effectiveness of oxygen strategies in paediatric patients undergoing surgical procedures.

We searched MEDLINE, Embase, and Cochrane CENTRAL on May 1, 2025, for randomised controlled trials comparing perioperative oxygen strategies in children. Two reviewers independently identified eligible studies, extracted data, and assessed risk of bias and GRADE certainty in evidence. Meta-analyses were conducted with random effects models.

The review included 16 trials involving 1337 participants from 11 countries. Five trials compared intraoperative high fraction of inspired oxygen (Fio2, 60–80%) with low Fio2 (30–35%). In the postoperative period, four trials compared high-flow nasal oxygen (HFNO) with conventional oxygen therapy (COT), four trials investigated the effectiveness of noninvasive ventilation (NIV) compared with COT, and three trials compared HFNO with NIV. The evidence was very uncertain about the effect of high Fio2vs low Fio2 on surgical site infection (risk ratio [RR], 0.75; 95% confidence interval [CI], 0.33–1.73; risk difference [RD], −3%; 95% CI, −7.9% to +8.6%) and postoperative pulmonary complications (RR, 0.58; 95% CI, 0.24–1.42; RD, −5.4%; 95% CI, −9.8% to +5.4%). Postoperative HFNO use resulted in a large reduction in reintubation rate (RR, 0.34; 95% CI, 0.13–0.88; RD, −10.7%; 95% CI, −14.1% to −1.9%) compared with COT; however, GRADE certainty in evidence was low. The evidence was very uncertain about the effect of HFNO vs NIV use in the postoperative period on the incidence of reintubation (RR, 0.60; 95% CI, 0.26–1.37; RD, −5.2%; 95% CI, −9.7% to +4.8%) and pneumothorax (RR, 0.92; 95% CI, 0.11–7.76; RD, −0.5%, −5.9% to +45.1%)

Current evidence does not support the routine use of any specific paediatric perioperative oxygen strategy. Further high-quality randomised trials are needed in this population.

PROSPERO (CRD42022331515).