The importance of intraoperative fluid balance for the prevention of postoperative acute exacerbation of idiopathic pulmonary fibrosis after pulmonary resection for primary lung cancer

Abstract

To prevent PAE of IPF, intraoperative management that minimizes intravenous fluid administration is essential. Moreover, caution is particularly important in patients with preoperative evidence of inflammation.

Acute exacerbation of idiopathic pulmonary fibrosis: shifting the paradigm

“…For example, idiopathic AE-IPF is more common in the winter months [24,30], and in patients that are immunosuppressed [9], indicating that some cases of idiopathic AE-IPF may be triggered by a preceding infection [40][41][42]. Additional potential triggers that can lead to a similar presentation in patients with IPF include aspiration [43,44], pollution [45], thoracic surgical procedures [20,25,26,37,[46][47][48][49][50], cryobiopsy [51] and, possibly, bronchoalveolar lavage [20,52]. AE-IPF has also been reported following non-pulmonary surgery [47], potentially related to mechanical trauma secondary to mechanical ventilation.…”

Critically Ill Patients with Interstitial Lung Disease

“…[59][60][61][62] Patients with underlying IPF are at risk of developing an acute exacerbation after operation for lung cancer with rates varying from 7% to 27% 59,61,63,64 and mortality of 80% to 100% if an exacerbation occurs. 59,63,64 It is unclear what causes postoperative acute exacerbations, although trauma caused by mechanical ventilation has been suggested by evidence that the nonoperative lung shows more radiographic evidence of injury, likely from overdistention during single lung ventilation. 65 Patients with a composite physiologic index score of greater than 40 (see calculation in Box 3) have a 50% chance of developing ARDS/acute lung injury, which in current literature is best classified as AE-IPF.…”

“…64 Similar to ARDS 27 a restrictive fluid strategy has been associated with decreased risk of perioperative lung injury in patients with IPF undergoing resection for lung cancer, and minimization of perioperative fluid administration is advised. 63 Open lung biopsy for diagnosis of interstitial lung disease Biopsy to determine underlying histopathology is, at times, needed to establish underlying histopathology in the undifferentiated ILD. 66 It is not known what threshold of impairment in PFTs should prohibit diagnostic open lung biopsy, and evaluation should be made on a case-to-case basis.…”

Volume Management and Resuscitation in Thoracic Surgery

“…Fluid in excess of 2 L total volume administered during pneumonectomy is linked with negative effects on postoperative respiratory outcomes [3,13,15,17], and similar results have been demonstrated with high perioperative fluid loads and lesser pulmonary resections [3,10,16]. In patients with pulmonary fibrosis, higher perioperative fluid volumes and balance are linked to an increased risk of postoperative respiratory compromise after lung resection surgery, a devastating complication [19]. Similar findings have also been demonstrated in esophagectomy, however, in these patients larger volumes of fluid (in the order of 5 L) are implicated [6,20].…”