Perioperative Management of Patients with Idiopathic Pulmonary Fibrosis Undergoing Noncardiac Surgery: A Narrative Review

Figures & data

Figure 1 A graphical overview of interstitial lung disease. Heterogeneity of subtypes is evident, all leading to common presenting symptoms of cough, weight loss and shortness of breath. Histologically, common features of fibrotic changes are shared amongst the subtypes with subtle differences. The idiopathic interstitial pneumonias comprise the majority of identified cases. a: denotes more common subtypes.

Table 1 Preoperative Risk Factors Associated with Increased Postoperative Complications in Patients with IPF

Modifiable Risk Factors	Non-Thoracic Surgery	Thoracic Surgery	References
Low DLCO	•	•	4
FVC <80%	∞	•	23, 24, 60
Decreased VC	∞	•	60, 62, 25
High BMI	∞	•	60
Increasing comorbidities	∞	•	27
Pulmonary hypertension	∞	•	33, 60, 31, 32, 80
Heart failure	•	•	29, 30
GERD (conflicting findings)	∞	•	36, 71
Home oxygen use	•	•	22
Use of immunosuppressants	•	•	60, 62, 63, 25
Absence of pirfenidone treatment	•	•	17, 18, 64, 65, 66
Elevated serum CRP	•	∞	37, 63
Elevated serum LDH	•	•	38, 63
Elevated serum KL-6	∞	•	38, 62
Hypoalbuminemia	•	•	39, 63
Low BMI	•	•	75
No pulmonary rehabilitation	∞	•	87
Non-modifiable Risk Factors
Male gender	∞	•	62, 25
Prior history of AE-ILD	∞	•	62, 25
Interstitial pneumonitis on CT	∞	•	26, 25
Increasing age	•	•	21

Notes: •: Yes, ∞: Unknown.

Abbreviations: DLCO, diffusing capacity of lung for carbon monoxide; FVC, forced vital capacity; VC, vital capacity; BMI, body mass index; GERD, gastroesophageal reflux disease; CRP, C-reactive protein; LDH, lactate dehydrogenase; KL-6, sialylated carbohydrate antigen; AE-ILD, acute exacerbation of interstitial lung disease.

Figure 2 A methodical approach to diagnosis of postoperative hypoxemia in IPF patients is necessary to ensure that potentially treatable causes have been excluded. In addition, early pulmonary consultation may assist in rapidly diagnosing and treating AE-ILD in postoperative patients.

Abbreviations: ILD, interstitial lung disease; AE-ILD, acute exacerbation of interstitial lung disease.

Figure 3 Optimal perioperative strategies with IPF patients focuses on identifying high-risk patients, ensuring that early risk mitigation and detection of common postoperative complications is performed in a timely fashion.

Abbreviations: IPF, idiopathic pulmonary fibrosis; UIP, usual interstitial pneumonia; HRCT, high-resolution computed tomography; DLCO, diffusing capacity for carbon monoxide; V_o2Max, maximal oxygen consumption; 6MWT, six-minute walk test; BNP, NT-proB-type natriuretic peptide; PEEP, positive end-expiratory pressure; ARISCAT, Assess Respiratory Risk in Catalonia; GERD, gastroesophageal reflux disease.