Anesthesia for Patients with End-Stage Lung Disease

Abstract

Preoperative optimization with pulmonary rehabilitation, smoking cessation, and education can improve surgical outcomes in patients with end-stage lung disease (ESLD). ESLD is associated with a high incidence of pulmonary hypertension and right ventricular dysfunction. The anesthetic goals for these patients include optimizing preload, maintaining a low normal heart rate, maintaining contractility, decreasing pulmonary vascular resistance, and ensuring systemic pressures that are greater than pulmonary pressures. Compared with general anesthesia, regional anesthesia and analgesia may reduce the risk of pulmonary complications and perioperative morbidity. Even mild pulmonary insults will be poorly tolerated by patients with ESLD. Ventilation strategies that utilize low tidal volumes and low airway pressures may reduce the risk of volutrauma, barotrauma, and acute lung injury. Intraoperative management can facilitate early recovery and early tracheal extubation after general anesthesia. Short-acting anesthetic agents are recommended. As elimination of inhalational agents is impaired by ESLD, total intravenous anesthesia (TIVA) may be preferred. Maintenance of normothermia will avoid increases in ventilatory demand associated with postoperative shivering. Effective postoperative analgesia is essential in patients with ESLD. Regional analgesia is preferred over parenteral opioid analgesics. Adjuvant pain medications which have an opioid-sparing effect should be used. Chronic obstructive pulmonary disease is a common cause of ESLD. Severe airflow obstruction results in a high risk of air trapping, pneumothorax, and dynamic hyperinflation. In addition to aggressive bronchodilation, ventilation with low inspiratory/expiratory ratios (1:3 to 1:4.5) and low respiratory rates (6-10/min) will optimize expiratory airflow. Cystic fibrosis is a multisystemic disease that results in abnormally viscous secretions. Inability to clear pulmonary secretions results in airflow obstruction and chronic infection. Management focuses on improving sputum clearance and minimizing airway obstruction. The interstitial lung diseases cause lung restriction and are characterized by chronic inflammation and fibrosis. Ventilation strategies that minimize tidal volume and airway pressures should be used.