Protocol for Guidelines on the Comprehensive Perioperative Management of Elderly Patients with Lung Cancer (2025)

Published in Chinese Journal of Evidence-Based Medicine, 2025; Working Group led by West China Hospital, Sichuan University. Disclaimer: This summary is for academic reference only, not for direct clinical application. All elderly lung cancer patients should be managed by a multidisciplinary team (MDT). Age alone is not an absolute contraindication for thoracic surgery. Core principle: Comprehensive Geriatric Assessment (CGA) as the core tool; screen and intervene geriatric syndromes preoperatively; risk stratification; minimally invasive surgery and ERAS; reduce perioperative complications and preserve quality of life.

1. Scope and Definition

• Elderly patients: ≥70 years old with resectable non-small cell lung cancer (NSCLC).
• MDT composition: Thoracic surgery, geriatrics, anesthesiology, respiratory medicine, cardiology, clinical nutrition, rehabilitation, pharmacy, nursing.
• Seven key geriatric syndromes to screen: frailty, delirium, sarcopenia, cognitive impairment, malnutrition, dysphagia, mood disorders (anxiety/depression).

2. Preoperative Assessment and Prehabilitation

2.1 Comprehensive Geriatric Assessment (CGA, mandatory)

1. Frailty screening (Fried Frailty Phenotype / FRAIL scale). Frail patients have markedly higher postoperative complication risk.
2. Cognitive function (MMSE/MoCA).
3. Nutritional status: BMI, serum albumin, prealbumin, handgrip strength for sarcopenia.
4. Functional status: ADL / IADL.
5. Mood screening and swallowing assessment.

2.2 Cardiopulmonary risk evaluation

• Pulmonary: PFT, 6-minute walk test, peak expiratory flow; predicted postoperative FEV1 and DLCO.
• Cardiac: ECG; echocardiogram and biomarkers for high-risk patients; evaluate arrhythmia, heart failure, coronary artery disease.
• Tumor staging: Chest + abdominal enhanced CT; PET-CT for selected cases.

2.3 Prehabilitation (for high-risk patients)

• Respiratory training, inspiratory muscle training.
• Nutritional support: oral nutritional supplements if malnourished.
• Sarcopenia resistance training; optimize glycemic control, blood pressure management.
• Medication reconciliation: deprescribe inappropriate sedatives, anticholinergics.

3. Intraoperative Management

1. Minimally invasive priority: VATS/RATS preferred over open thoracotomy for elderly patients. Limited resection (wedge / segmentectomy) may be considered for high-risk frail patients instead of lobectomy after MDT discussion.
2. Anesthesia: Short-acting agents; lung-protective ventilation; restrictive fluid strategy; active warming to avoid hypothermia.
3. Multimodal analgesia: Intercostal nerve block + low-dose opioids, reduce high-dose opioid-induced delirium.
4. Antibiotic prophylaxis: Single-dose preoperative antibiotics; avoid prolonged use.
5. Intraoperative monitoring: Hemodynamics, bispectral index, regional cerebral oxygen saturation in high-risk cases.

4. Postoperative Management

4.1 Early rehabilitation & ERAS

• Early mobilization within 24 hours.
• Early oral feeding; swallow screening before free oral intake to prevent aspiration pneumonia.
• Thromboprophylaxis: sequential compression device + low molecular weight heparin.

4.2 Prevention of key complications

1. Delirium: Noise reduction, orientation cues, sleep hygiene; minimize benzodiazepines; treat pain without oversedation.
2. Pulmonary complications: Cough training, chest physiotherapy, oral care.
3. Cardiac events: Continuous monitoring; electrolyte correction.
4. Persistent air leak, arrhythmia, acute kidney injury: standardized fast-track response protocol.

4.3 Discharge planning

Discharge assessment jointly by geriatric nurse and rehabilitation team; caregiver education; home rehabilitation referral.

5. Geriatric Syndrome Targeted Interventions

1. Frailty: Prehabilitation before surgery; less extensive resection.
2. Sarcopenia: Protein supplementation + resistance exercise.
3. Cognitive impairment: Family companion, avoid polypharmacy.
4. Malnutrition: Preoperative nutritional support for at least 7–14 days when feasible.
5. Dysphagia: Formal swallow evaluation; texture-modified diet.
6. Mood disorders: Psychological intervention; cautious psychotropic medication.

6. Post-discharge Follow-up

• Tumor surveillance per lung cancer staging protocol.
• Geriatric follow-up: Reassess frailty, sarcopenia, nutrition and functional status.
• Rehabilitation continuation and polypharmacy review.

7. Recommendations NOT Supported by the Guideline

❌ Use chronological age alone to deny curative-intent thoracic surgery. ❌ Omit CGA in patients ≥70 years before lung resection. ❌ Overuse long-acting benzodiazepines and anticholinergics perioperatively. ❌ Routine open thoracotomy when minimally invasive approach is feasible. ❌ Skip swallow assessment and allow free oral intake in patients with suspected dysphagia. ❌ Ignore caregiver and family support planning.

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