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

Background 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. Methods 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. Results The review included 16 trials involving 1337 participants from 11 countries. Five trials compared intraoperative high fraction of inspired oxygen (Fio 2 , 60–80%) with low Fio 2 (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 Fio 2 vs low Fio 2 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%) Conclusions 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. Systematic review protocol PROSPERO (CRD42022331515).