Educational Series about Anesthesia & Pulmonary Fibrosis: Part 2

Thank you to our guest blog contributor, Dr. Wu, for volunteering his time and expertise to review this educational series and provide feedback prior to its launch. Learn more about him below, and then keep reading for information and considerations about anesthesia for patients with pulmonary fibrosis. 

 

A southern California native, Patrick Wu graduated from UC Irvine undergraduate as a neurobiology major, and then went to medical school at the University of Virginia in Charlottesville, VA.  He then returned to UCI for anesthesiology training and completed a fellowship in Critical Care.  He decided to work at the Long Beach VA after graduating residency to provide his training and services to the veterans in need of medical care.  He currently performs anesthesia, regional anesthesia, critical care, and stellate ganglion blocks for PTSD to the veterans under his care, which he finds extremely rewarding.  He has been married to his wife for going on 10 years and has two school age children at home.

 

Part 2 of this educational series about anesthesia explains the details of common procedures for patients with PF. To review part 1, which explains different types of anesthesia, click here. 

Bronchoscopy: How anesthesia is used

Bronchoscopy is very common in PF—used for diagnosis, sampling, and sometimes treatment.

1. Flexible bronchoscopy (with or without simple biopsy)

What it is: A thin, flexible camera is passed through your nose or mouth into the airways. It may be used for:

• Looking inside the airways
• Washing an area with fluid (bronchoalveolar lavage)
• Taking small biopsies with forceps

Typical anesthesia plan:

1. Topical (local) anesthesia
   • Lidocaine spray, gel, or nebulized solution is used to numb the nose, throat, and airways to reduce coughing and discomfort. 
2. Moderate sedation 
   • Short-acting medicines through your IV to help you relax or sleep lightly.
   • You keep breathing on your own, usually with oxygen by nasal cannula or mask.

In some high-risk PF patients with very fragile lungs and high oxygen needs, doctors may choose lighter sedation or even local anesthesia alone to keep breathing as stable as possible. 

PF-specific considerations:

• Your team will watch your oxygen levels very closely and may use higher-flow oxygen or noninvasive ventilation if needed. 
• Extra coughing can strain the lungs, so good topical anesthesia and gentle technique help protect you.

1. Transbronchial lung cryobiopsy (TBLC)

Cryobiopsy is sometimes used instead of surgical lung biopsy to sample lung tissue in ILD/PF. A very cold probe freezes a small area of lung, creating a larger tissue sample than standard forceps.

Typical anesthesia plan:

• Many centers perform TBLC under general anesthesia with a breathing tube or rigid bronchoscope, to fully control the airway and limit coughing. 
• Others use deep sedation with a protected airway device (like a laryngeal mask airway) and spontaneous breathing. 

Why the stronger anesthesia?

• Cryobiopsy carries higher risks of bleeding and pneumothorax (collapsed lung) than simple bronchoscopy. 
• Suppressing big coughs and keeping you very still helps reduce these risks and allows the team to react quickly if there’s a complication. 

PF-specific considerations:

• Your pulmonologist and anesthesiologist will weigh:
  • How badly tissue is needed for diagnosis
  • Your oxygen needs and lung function
  • Whether the potential benefits outweigh the added risks of deeper anesthesia

Surgical lung biopsy (VATS or open biopsy)

Sometimes, when bronchoscopy isn’t enough to make a diagnosis, a surgical lung biopsy is considered. Today this is often done with video-assisted thoracoscopic surgery (VATS), “keyhole” surgery through small chest incisions.

Typical anesthesia plan:

• General anesthesia with a breathing tube is standard.
• Often a double-lumen endotracheal tube is used so the anesthesia team can ventilate one lung while the other is collapsed for the surgeon to see and operate—this is called one-lung ventilation (OLV). 
• Pain control after surgery may include nerve blocks or epidurals plus non-opioid medicines to help you breathe deeply and cough effectively.

PF-specific considerations:

• One-lung ventilation and general anesthesia are stressful for fibrotic lungs, and are linked with increased risk of postoperative respiratory problems and acute ILD exacerbation. 
• Because of this, in many PF patients:
  • Less invasive options (like cryobiopsy) are considered first when appropriate.
  • If surgical biopsy is chosen, it’s usually done in specialized centers with thoracic anesthesia expertise.
  • The team uses lung-protective strategies, careful fluids, and close postoperative monitoring. 

Lung transplant: The biggest anesthesia journey

For some people with advanced PF, lung transplantation becomes an option. This is among the most complex procedures in medicine, and anesthesia is a huge part of it.

What the anesthesia looks like:

• Always done under general anesthesia: you’re fully unconscious and pain-free. 
• You’ll have:
  • A breathing tube and mechanical ventilation.
  • Multiple IV lines and an arterial line for continuous blood pressure and blood gas monitoring.
  • Often a catheter to monitor heart pressures.
• For some patients, cardiopulmonary bypass or ECMO (a heart-lung machine) is used to support circulation and oxygenation during the transplant. 

After the surgery:

• You usually wake up in the ICU while still on the ventilator.
• The team gradually adjusts sedation and ventilation as your new lungs start to function, with a goal of eventual extubation (removal of breathing tube) when safe.
• Good pain control (epidurals, nerve blocks, and multimodal medications) is important for breathing, coughing, and early movement. 

The hopeful side:

While transplant anesthesia is intense, it’s done in highly specialized centers where the teams do this regularly, using refined protocols and constant monitoring to support patients with very advanced lung disease.

Non-lung procedures when you have PF

PF patients may also need surgeries or procedures unrelated to their lungs—like gallbladder surgery, joint replacement, cataract surgery, or bariatric surgery.

For many of these, the anesthesia team will try to:

• Use local or regional anesthesia (e.g., spinal, epidural, nerve block) instead of general anesthesia when it’s safe for the type of surgery. 
• If general anesthesia is necessary, they’ll:
  • Use lung-protective ventilation and gentle oxygen strategies.
  • Avoid overly deep sedation afterward.
  • Encourage early mobilization and breathing exercises to reduce complications.

Your prior history (including if you’ve had a lung transplant) also affects anesthesia choices later on; in general, local, regional, and general anesthesia can all be used safely in post-transplant patients with appropriate precautions.

Good questions to ask your anesthesia and lung teams:

Before a procedure, it’s absolutely okay to ask:

1. “What type of anesthesia are you planning to use, and why?”
   Ask how they weighed your PF in that choice.
2. “How will you support my breathing during and after the procedure?”
   • Will I be on oxygen, high-flow nasal cannula, or a ventilator?
   • What’s the plan if my oxygen levels drop?
3. “What are the specific risks for someone with pulmonary fibrosis?”
   • Ask about risk of needing ICU care or prolonged ventilation.
   • Ask how common complications are in people like you.
4. “Is there a less invasive option or a way to use lighter anesthesia safely?”
   Especially relevant for biopsies and non-thoracic surgeries.
5. “What will pain control look like?”
   Good pain management helps you breathe, cough, and move—all crucial for PF patients.
6. “How will the anesthesia team and my pulmonologist coordinate?”
   Ideally, they review your most recent PFTs, imaging, oxygen use, and medications together.

Take-home message: The American Society of Anesthesiologists (ASA) framework (as described in Part 1) is what your anesthesia team uses behind the scenes to decide how deeply to sedate you, how to protect your breathing, and what backup plans to have ready. For someone with pulmonary fibrosis, the goal is almost always to use the lightest level of anesthesia that still keeps you safe and comfortable for the planned procedure:

• Anesthesia isn’t one-size-fits-all, especially in pulmonary fibrosis.
• For smaller procedures like flexible bronchoscopy, anesthesia often combines topical numbing and light-to-moderate sedation while you keep breathing on your own.
• For more invasive procedures such as cryobiopsy, surgical biopsy, and lung transplantation, general anesthesia is standard, but it’s delivered with special care for your lungs.
• Whenever possible, especially for non-lung surgeries, regional or local anesthesia may help reduce risks.
• The most important part is communication: ask questions, share your concerns, and make sure your anesthesia team knows your PF history in detail.

You deserve to feel informed and included in decisions about your care. 

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