Pulmonology · Medical Literature
Perioperative Butorphanol for the Prevention of Postoperative Pulmonary Complications After Thoracoscopic Lung Resection: A Randomized, Double-Blind, Placebo-Controlled Trial.
Abstract
Postoperative pulmonary complications (PPCs) remain common after thoracoscopic lung resection. Butorphanol, a κ-opioid receptor agonist with analgesic and potential opioid-sparing properties, may influence postoperative respiratory recovery. This trial evaluated whether perioperative butorphanol reduces PPCs after elective thoracoscopic lung resection. In this randomized, double-blind, placebo-controlled trial conducted at a tertiary teaching hospital in China from January to July 2025, adults aged 18-65 years with American Society of Anesthesiologists physical status I-III scheduled for elective thoracoscopic lung resection were assigned to receive butorphanol or placebo. The butorphanol group received an intravenous bolus of 10 μg/kg before anesthesia induction followed by 5 μg/kg/h until the end of surgery. The control group received volume-matched saline. The primary outcome was PPCs within 7 postoperative days. Of 520 randomized patients, 506 were included in the modified intention-to-treat analysis. PPCs occurred in 54 of 254 patients (21.3%) in the butorphanol group and 83 of 252 patients (32.9%) in the control group (relative risk, 0.65; 95% CI, 0.48-0.87; P = 0.004), corresponding to an absolute risk reduction of 11.7% and a number needed to treat of 9. The difference was mainly driven by lower rates of atelectasis and pleural effusion. Butorphanol was also associated with higher QoR-40 scores at 24 h, lower opioid consumption, and a modestly shorter hospital stay. Safety outcomes were similar between groups. Perioperative butorphanol reduced composite PPCs within 7 days after elective thoracoscopic lung resection, mainly through reductions in atelectasis and pleural effusion, without increasing early safety events.
Clinical relevance
Postoperative pulmonary complications (PPCs) represent a significant source of morbidity following thoracoscopic lung resection, yet evidence-based pharmacological strategies to reduce their incidence remain limited. This RCT addresses the gap by evaluating perioperative butorphanol—a κ-opioid receptor agonist with analgesic and opioid-sparing properties—as a preventive intervention in a population of adults undergoing elective video-assisted thoracoscopic surgery (VATS). Given the rising volume of thoracoscopic lung resections globally and the clinical burden of PPCs on hospital resources and patient recovery, these findings are immediately relevant to thoracic anesthesiologists and pulmonologists.
Key findings
1. PPCs within 7 postoperative days occurred in 21.3% (54/254) of butorphanol-treated patients versus 32.9% (83/252) in the placebo group (RR 0.65; 95% CI 0.48–0.87; P = 0.004). 2. The absolute risk reduction (ARR) for composite PPCs was 11.7%, yielding a number needed to treat (NNT) of 9. 3. The primary driver of PPC reduction was lower rates of atelectasis and pleural effusion in the butorphanol group, though individual complication rates were not separately quantified in the abstract. 4. Butorphanol was associated with higher Quality of Recovery-40 (QoR-40) scores at 24 hours postoperatively, indicating superior early recovery quality. 5. Opioid consumption was lower in the butorphanol group, consistent with its opioid-sparing properties as a κ-receptor agonist. 6. Hospital length of stay was modestly shorter in the butorphanol group, and safety outcomes (early adverse events) were similar between groups, suggesting an acceptable perioperative risk profile.
Practice implications
For adults aged 18–65 with ASA physical status I–III undergoing elective thoracoscopic lung resection, clinicians should consider perioperative butorphanol administered as an IV bolus of 10 µg/kg prior to anesthesia induction, followed by a continuous infusion of 5 µg/kg/h through the end of surgery, as this regimen significantly reduced composite PPCs with an NNT of 9. The opioid-sparing effect and improved QoR-40 scores at 24 hours suggest that butorphanol may serve a dual role in optimizing both respiratory outcomes and early postoperative recovery quality, making it a candidate for integration into enhanced recovery after surgery (ERAS) protocols for thoracic procedures. Generalizability should be interpreted cautiously, as this trial was conducted at a single tertiary center in China with a 7-day follow-up window, and further multi-center studies are warranted to confirm efficacy across broader populations and longer endpoints.