What are the recommendations for anesthesia in patients with pulmonary fibrosis undergoing surgery?

Anesthesia Management for Patients with Pulmonary Fibrosis

For patients with pulmonary fibrosis undergoing surgery, regional anesthesia should be prioritized over general anesthesia whenever possible to reduce postoperative pulmonary complications and improve outcomes. 1, 2

Preoperative Assessment

• Evaluate pulmonary function with:

  • Diffusing capacity (DLCO) - identify patients with >15% decline in 6-12 months
  • Forced vital capacity (FVC) - <80% predicted indicates higher risk
  • 6-minute walk test - 50-meter reduction indicates higher risk
  • VO2max - <8.3 mL/kg/min indicates high risk
  • Home oxygen requirement - indicates higher risk 1

• Calculate ARISCAT score to quantify postoperative pulmonary complication risk 1

Anesthetic Approach

First Choice: Regional/Neuraxial Anesthesia

• Regional or neuraxial anesthesia significantly reduces:

  • Postoperative pneumonia (2.3% vs 3.3% with general anesthesia)
  • Prolonged ventilator dependence (0.9% vs 2.1%)
  • Unplanned postoperative intubation (1.8% vs 2.6%)
  • Overall composite morbidity (12.6% vs 15.4%) 3

• Options include:

  • Spinal anesthesia
  • Epidural anesthesia
  • Peripheral nerve blocks
  • Paravertebral blocks 2

When General Anesthesia is Necessary

1. Airway Management:

   • Use video laryngoscope for intubation by most experienced provider
   • Avoid mask ventilation during preoxygenation to reduce aerosolization
   • Connect ventilator after inflating endotracheal tube cuff 4

2. Ventilation Strategy:

   • Implement lung-protective ventilation with:
     • Low tidal volumes (≤6 mL/kg predicted body weight)
     • Individualized PEEP (5-8 cmH2O)
     • Recruitment maneuvers using lowest effective plateau pressure (30-40 cmH2O in non-obese; 40-50 cmH2O in obese)
     • Lowest possible FiO2 to maintain adequate oxygenation 4

3. Neuromuscular Blockade:

   • Use shorter-acting agents (atracurium or vecuronium) rather than pancuronium
   • Ensure complete reversal before extubation to prevent residual blockade 4, 5

4. Fluid Management:

   • Implement restrictive fluid strategy (2-6 mL/kg/h)
   • Avoid fluid rates >6 mL/kg/h as this significantly increases pulmonary complication risk
   • Consider esophageal Doppler monitoring for fluid guidance 4, 5

Pain Management

• First-line: Thoracic epidural analgesia or continuous paravertebral block

  • Reduces pneumonia risk from 5% to 3% compared to IV opioids alone 4, 5

• Second-line: Multimodal analgesia

  • Short-course NSAIDs
  • Patient-controlled analgesia (PCA) if regional techniques fail 5

Emergence and Extubation

• Optimize patient positioning (head elevated 30°)
• Avoid zero end-expiratory pressure (ZEEP)
• Avoid routine tracheal suctioning before extubation
• Avoid apnea with ZEEP before extubation
• Consider using lower FiO2 (<0.4) during emergence to reduce atelectasis 4

Postoperative Care

• Early mobilization
• Incentive spirometry and deep breathing exercises
• Adequate pain control to facilitate respiratory effort
• Supplemental oxygen only when SpO2 <94% on room air
• Consider prophylactic CPAP/NIV for patients who routinely use these at home 4, 5

Special Considerations

• Patients with pulmonary fibrosis have restrictive lung disease requiring careful ventilatory management
• Higher risk of bleeding may be present in some forms of pulmonary fibrosis (e.g., Hermansky-Pudlak syndrome) 6
• Postoperative respiratory insufficiency may require prolonged mechanical ventilation 6

Common Pitfalls to Avoid

• Using pancuronium or other long-acting neuromuscular blockers
• Liberal fluid administration (>6 mL/kg/h)
• High FiO2 without clinical necessity
• Inadequate pain control limiting respiratory effort
• Failure to recognize early signs of respiratory deterioration

By following these recommendations, the risk of postoperative pulmonary complications in patients with pulmonary fibrosis can be minimized, improving overall outcomes and reducing mortality.