From the Guidelines
Pneumonitis poses a significant perioperative risk, with an incidence of pulmonary aspiration as low as 1 in 7000, and morbidity and deaths even lower, at 1 in 1700 and 1 in 100,000, respectively, as reported by 1. The risk of pneumonitis is a critical consideration in the perioperative period, particularly in patients undergoing elective general anesthesia.
- The incidence of pulmonary aspiration is relatively low, but the consequences can be severe, with pneumonitis being a potential complication.
- The severity of pneumonitis is influenced by factors such as gastric pH and volume of contents, with acid secretion continuing during fasting, as noted in the study by 1.
- Preoperative optimization is crucial in patients with pneumonitis, and may include strategies such as individualized fluid therapy and stroke volume optimization, as discussed in the context of modern perioperative care by 1.
- The use of corticosteroids and antibiotics may be considered in certain cases, although the specific details of such therapy are not addressed in the provided evidence.
- Intraoperative management should focus on lung-protective ventilation strategies, with careful attention to tidal volumes, PEEP, and FiO2, although specific recommendations are not provided in the study by 1.
- Postoperative care should prioritize early mobilization, incentive spirometry, adequate pain control, and continued monitoring for respiratory complications, as part of a comprehensive approach to minimizing the risks associated with pneumonitis in the perioperative period.
From the Research
Perioperative Risk of Pneumonitis
The perioperative risk of pneumonitis is a significant concern in patients undergoing surgery, particularly those with preexisting lung conditions or those who have received radiotherapy or immunotherapy.
- The risk of pneumonitis is increased in patients with preoperative pneumonia, with a higher odds ratio of postoperative mortality and composite morbidity 2.
- Radiotherapy-induced lung injury (RILI) is a well-documented complication of radiotherapy, which can lead to pneumonitis and fibrosis 3, 4.
- The use of corticosteroids and azathioprine does not prevent radiation-induced lung injury, including pneumonitis 4.
- Perioperative aspiration pneumonitis can be prevented by reducing the volume and acidity of gastric content, and the use of gastrointestinal stimulants, histamine-2 receptor antagonists, proton pump inhibitors, antacids, antiemetics, and anticholinergics can be effective in reducing the risk of pulmonary aspiration 5.
- Immunotherapy, particularly the use of programmed cell death-1 (PD-1) or ligand-1 (PD-L1) inhibitors, is associated with a higher risk of pneumonitis, particularly in patients with squamous cell carcinoma and poorer performance status 6.
Risk Factors for Pneumonitis
Several risk factors have been identified for the development of pneumonitis, including:
- Preoperative pneumonia 2
- Radiotherapy-induced lung injury 3, 4
- Immunotherapy, particularly the use of PD-1 or PD-L1 inhibitors 6
- Squamous cell carcinoma 6
- Poorer performance status 6
Prevention and Management of Pneumonitis
Prevention and management of pneumonitis are crucial to reduce the risk of postoperative mortality and morbidity.
- Delaying elective surgery until preoperative pneumonia resolves can reduce the risk of postoperative complications 2.
- The use of corticosteroids can be effective in treating pneumonitis, but its use must be standardized and considered in the prophylaxis setting 3.
- Reducing the volume and acidity of gastric content can prevent perioperative aspiration pneumonitis 5.