Perioperative Management of Idiopathic Pulmonary Fibrosis
Patients with idiopathic pulmonary fibrosis (IPF) require specialized perioperative management focused on respiratory optimization, risk assessment, and enhanced recovery protocols to reduce morbidity and mortality.
Preoperative Assessment and Optimization
Risk Stratification
- Assess disease severity through pulmonary function tests (PFTs)
Medication Management
- Continue antifibrotic medications (nintedanib or pirfenidone) throughout the perioperative period 2, 3
- Evaluate for pulmonary hypertension, which significantly increases perioperative risk 1
- Screen for and treat comorbidities:
- Gastroesophageal reflux disease (GERD)
- Obstructive sleep apnea
- Cardiovascular disease 2
Preoperative Optimization
- Implement prehabilitation program for high-risk patients:
- Pulmonary rehabilitation exercises
- Nutritional assessment and correction of deficiencies
- Smoking cessation 1
- Consider chlorhexidine oropharyngeal decontamination to reduce infection risk 1
Intraoperative Management
Ventilation Strategy
- Implement protective one-lung ventilation:
- Low tidal volumes (6 mL/kg ideal body weight)
- Appropriate PEEP (5-10 cmH2O)
- Recruitment maneuvers after periods of one-lung ventilation 1
Fluid Management
- Restrict intraoperative fluids to 2-6 mL/kg/h
- Consider goal-directed fluid therapy using esophageal Doppler monitoring 1
- Avoid fluid overload which can worsen gas exchange and precipitate respiratory failure
Anesthesia Technique
- Either total intravenous anesthesia (TIVA) with propofol or volatile anesthetics are acceptable 1
- Regional anesthesia techniques are preferred for postoperative pain management:
- Paravertebral blocks are preferred over thoracic epidural due to better safety profile 1
- For thoracoscopic procedures, intercostal nerve blocks or erector spinae plane blocks
Postoperative Management
Respiratory Care
- Early mobilization within 24 hours of surgery 1
- Multimodal physiotherapy including:
- Breathing exercises
- Coughing techniques
- Early ambulation 1
- Avoid routine use of non-invasive ventilation (NIV) or high-flow oxygen therapy
- Reserve for patients with postoperative desaturation or acute respiratory distress 1
Thromboprophylaxis
- Extended thromboprophylaxis (up to 8 weeks) for patients with additional risk factors:
- Age >65 years
- Obesity
- Previous VTE history 1
Pain Management
- Multimodal analgesia:
- Regional anesthesia techniques
- Short courses of NSAIDs if not contraindicated
- Opioid-sparing techniques when possible 1
- Avoid respiratory depression which can lead to atelectasis and pneumonia
Monitoring for Complications
- Monitor for acute exacerbation of IPF, which carries high mortality
- Watch for signs of respiratory deterioration:
- Increasing oxygen requirements
- Worsening dyspnea
- New infiltrates on chest imaging 1
- Early detection of postoperative pulmonary complications through regular assessment of vital signs and oxygen saturation
Special Considerations
Surgical Approach
- Prefer minimally invasive approaches (thoracoscopy over thoracotomy) when feasible 1
- For thoracotomy, muscle-sparing techniques are preferred
Chest Tube Management
- Use digital chest drainage systems for better monitoring
- Remove chest tubes as soon as possible when:
- No air leaks present
- Serous pleural drainage <300 mL/day 1
Postoperative Follow-up
- Close monitoring for disease progression after surgery
- Resume antifibrotic therapy as soon as oral intake is established
- Monitor pulmonary function at 3-6 month intervals 1, 2
- Consider palliative care consultation for symptom management in advanced disease 1
Pitfalls to Avoid
- Delaying surgery unnecessarily in patients with mild to moderate disease
- Overlooking comorbidities that increase perioperative risk
- Inadequate pain control leading to respiratory compromise
- Excessive fluid administration causing pulmonary edema
- Failure to recognize early signs of acute exacerbation of IPF
By following this comprehensive approach to perioperative management of IPF patients, clinicians can minimize complications and optimize outcomes in this high-risk population.