Journal article

View all Respiratory Digests

Preoperative Evaluation of Patients With Interstitial Lung Disease

Author(s): Patel NM, Kulkarni T, Dilling D et al

Chest. 2019;156: 826-833

Interstitial lung diseases
General respiratory patient care
Surgery

Digest Author(s): Stylianos Loukides, e-Learning Director / 24 November, 2019

Patients with interstitial lung diseases (ILDs) experience an increased risk of postoperative complications (PPCs) or mortality when undergoing either pulmonary or/and non pulmonary surgery. No published recommendations exist to guide clinicians for a pre-operative assessment. The current manuscript combines existing data with expert opinion and provides an algorithm for the pre-operative evaluation and management.

Many arising questions exist for patients with ILDs undergoing surgery. Do patients with ILD have the same risk of PPCs when undergoing nonthoracic surgery as compared with thoracic surgery? Does the histologic or/and the radiographic pattern impact the PPC risk? How important is the lung function impairment? How we manage the patients receiving either immunosuppressive treatment or/anti-fibrotics drugs? Does lung protective ventilation minimize the risk? Which is the role of chronic respiratory failure?

Two are the main strategies for the pre-operative assessment. The ARISCAT index and the patient- and Procedure-Related Risk Factors for ILD-Related PPCs. The first one consists of many parameters like age, preoperative SpO2 %, respiratory infection the last 4 weeks, pre-operative anemia, surgical incision site, duration of surgery and emergency procedure. All of them are stratified by a risk score. Finally 3 groups are created. The low risk, the intermediate risk and the high risk.

The second strategy consists of various parameters like gender, DLCO<60% pred, home oxygen treatment, presence of acute exacerbation, PAH, OSAs, type of surgery, time of surgery, immunosuppressive status and presence of co-morbidities. Patients with significant PAH, acute exacerbation and CRF are at high risk for PPCs. For the remaining patients a high ARISCAT score is indicative for high risk PPCS. For the intermediate ARISCAT based score there are two options. The first one is associated with >4 parameters patient and Procedure-Related Risk Factors for ILD-Related PPCs and is considered as high risk for PPCs. The second option has less than 4 parameters and is considered as medium risk. Finally a low ARISCAT score is indicative for low risk PPCs.

Comment

The risk of postoperative pulmonary complications in patients undergoing thoracic or non-thoracic surgery in the ILD population is elevated. In this manuscript the authors provide an algorithm approach that stratify patients into low-, intermediate-, and high-risk categories. Interestingly some parameters like the lung function impairment are missing for the above stratification. We need more prospective studies coming from the real life in order to strengthen the above recommendations. Finally we need to address some other issues which are mainly related to the effect of the current antifibrotic drugs on different outcomes before, during and post surgical procedures.