ronchial Asthma

Perioperative
Management

Asthma

Asthma is a chronic pulmonary disease characterized

by airway inflammation and hyper-responsiveness

Results in episodic wheezing, coughing,

breathlessness, chest tightness, and reversible airflow
obstruction

Contributing factors include genetics, atopy, and

respiratory syncytial virus infection in infancy

Common environmental triggers are pollen, mold,

animals, dust, tobacco smoke, and anxiety.

Asthma

It is estimated that up to 300 million people are

affected worldwide

Asthma prevalence of 7.7% for adults and 9.5% for

children, with a slightly higher prevalence in women
(9.2%) than in men (7.0%)

The overall number of asthma-related

hospitalizations and deaths has decreased, possibly
due to improved prevention of attacks through
inhaled steroid use and novel pharmaceutical agents
introduced over the past decade

Pathophysiology
Bronchoconstriction results from contraction of bronchial
smooth muscle induced by a myriad possible stimuli
Vagal and sympathetic factors directly modulate airway tone
Inflammatory edema and mucous plugging exacerbate airflow
limitation and progressively impair the response to
bronchodilator therapy.
Airway remodeling, thickening, and abnormal
communications between the injured airway epithelium and
the pulmonary mesenchyme confer resistance to
corticosteroid therapy as well

Pathophysiology
The immunologic-inflammatory pathways involved
in the pathogenesis of asthma are complex and
include lymphocytes immunoglobulin E, eosinophils
neutrophils, mast cells, leucotrienes, and cytokines
These pathways are triggered and modified by
extrinsicand environmental factors
Thus, asthma ultimately represents a dynamic
interaction between host and environmental
factors

Triggering Factors For

Bronchospasm

Cardiopulmonary Effects
Progressive acute bronchoconstriction rapidly
leads to

Increased work of breathing (WOB)

Decreased airflow
Air trapping
Dynamic hyperinflation
Ventilationperfusion (V/Q) mismatch
Increased pulmonary vascular resistance (PVR)
Right ventricular overload

Pulmonary Function Tests

The forced expiratory volume in the first second of expiration
(FEV1) is substantially decreased during active bronchospasm
The forced vital capacity (FVC), expiratory reserve volume (ERV),
inspiratory capacity, and forced expiratory flow FEF25 75% are
also decreased whereas residual volume, functional residual
capacity, and total lung capacity are increased

All these indices can return towards normal between

bronchospastic attacks

The dynamic compliance of the lungs decreases because of air

trapping, and accessory muscles (scalene and
sternocleidomastoid) are recruited to preserve the tidal volume
(Vt) despite increased ERV

Treatment
Bronchodilators
Short acting
2 agonists (albuterol)
Anti-cholinergics (ipratropuim)

Long acting
2 agonists (salmeterol, folmeterol)
Anti-cholinergics (thiotropuim)

Anti-inflammatory drugs
Beclomethasone and fluticasone
Others

Preoperative
Management
A thorough history and physical examination provides
the anesthesiologist with information that allows for
appropriate identification of level of disease, degree of
symptom control, and anesthetic risk stratification
Review of
Baseline exercise tolerance
Hospital visits secondary to asthma (including
whether endotracheal intubation or IV infusions
were required)
Allergies
Previous surgical/anesthetic history
The patients medication regimen should be reviewed
This applies especially to steroid therapy: inhaled vs
systemic use, duration of exposure, and side-effects

Physical Exam
Physical examination should include vital signs and
assessment of breath sounds
Use of accessory muscles, and level of hydration.
The presence of labored breathing, use of accessory
muscles, and prolonged expiration time suggest
poorly-controlled asthma.
Wheezing on auscultation is concerning, particularly
if the wheezing is noticed in phases of the
respiratory cycle other than end-expiration
Arterial blood gas may be useful in determining
baseline oxygenation, carbon dioxide retention, and
acid-base status.
A chest x-ray may be obtained to assess for lung
hyperinflation and air-trapping

Intraoperative
Management
The overriding goal in anesthetizing an asthmatic patient is to
avoid bronchospasm and reduce the response to tracheal
intubation
Severe bronchospasm may cause fatal or near-fatal events such
as irreversible brain damage due to inability to ventilate
It is extremely important that the patient be at a deep level of
anesthesia prior to instrumenting the airway, as tracheal
intubation during light levels of anesthesia can precipitate
bronchospasm
Regional anesthetic techniques should be considered when
appropriate, to avoid airway instrumentation. The risk of
pulmonary complications is lower when the surgical anesthetic
was performed under epidural or spinal anesthesia

Intraoperative
Management
Intravenous lidocaine has been successfully used
to decrease airway irritability
Anti-muscarinics such as glycopyrrolate and
atropine may decrease secretions and provide
additional bronchodilation if given in sufficient
time prior to induction
Propofol is the induction agent of choice in the
hemodynamically stable patient due to its ability
to attenuate the bronchospastic response to
intubation

Intraoperative
Management
Thiopental or etomidate may also be used as induction
agents but lack the bronchodilating properties of
propofol and in the case of thiopental, may lead to
detrimental histamine release
Ketamine is an ideal induction agent for
hemodynamically unstable asthmatics due to its ability
to produce direct smooth muscle relaxation and
bronchodilation without decreasing arterial pressure or
systemic vascular resistance
However, ketamine-induced bronchodilation is not as
pronounced as with propofol

Intraoperative
Management
Volatile anesthetics are excellent choices for
general anesthesia, as they depress airway
reflexes and produce direct bronchial smooth
muscle relaxation
Sevoflurane has the most pronounced
bronchodilation effect
Desflurane increases airway resistance and
should be avoided in asthmatics, specifically at
lighter levels of general anesthesia.

Intraoperative
Management
Warm, humidified gases should be provided at all
times
The use of a laryngeal mask airway or even mask
ventilation may be preferable to tracheal
intubation in asthmatics
The benefits of an LMA must be balanced against
the risks of an unsecured airway and in patients
with severe GERD, obesity, diabetic gastroparesis,
or recent oral intake, the need for a secured
airway may take precedence

Intraoperative
Management
If endotracheal intubation is deemed necessary,
histamine-releasing neuromuscular blockers should be
avoided
Vecuronium, rocuronium, and cis-atracurium are safe for
use in asthmatics.
Succinylcholine, which releases low levels of histamine,
has been used safely in asthmatics with little morbidity
Reversal of neuromuscular blockade with
acetylcholinesterase inhibitors should be used with
caution in asthmatics due to the risk of muscarinic side
effects including bronchospasm
Sugammadex is an alternative medication for reversal of
neuromuscular blockade

Ventilatory Strategies
limiting peak inspiratory pressures and tidal
volumes
lengthening the I:E ratio
Assist in avoiding air-trapping and auto PEEP
Patients should be kept adequately hydrated as
usual, but fluid overload, pulmonary congestion,
and edema can precipitate bronchospasm
(cardiac asthma)

Intra-Operative
Bronchospasm
Signs of intraoperative bronchospasm may
include wheezing, a change in capnography
(upslope on CO2 waveform, or decreased/absent
CO2 waveform), decreased tidal volumes, or high
peak inspiratory pressures
Investigate alternative diagnoses including
Ventilator malfunction
Endotracheal tube obstruction (e.g. kink,
mucous plug, clot)
Endobronchial intubation
Medical conditions such as tension
pneumothorax or pulmonary embolus

Intra-Operative
Bronchospasm
Switch to 100% O2
Switch to Manual Bag Ventilation (to evaluate
pulmonary and circuit compliance)
Deepening the plane of anesthesia by the
administration of rapid-acting intravenous
bronchodilators such a propofol or ketamine and
by increasing the concentration of volatile
anesthetic
Inhaled -2 agonists should be administered for
further bronchodilation using a MDI

Intra-Operative
Bronchospasm
Other bronchodilating strategies include
administering anticholinergics, intravenous
steroids, and intravenous or subcutaneous agonists such as epinephrine
Theophylline may be added for refractory
bronchospasm
ECMO is reserved for patients with severe
bronchospasm refractory to maximal medical
therapy.
Used successfully with good neurological outcomes to
treat status asthmaticus in children

Emergence
Bronchospasm, poor ventilation, and hypoxaemia
are major hazards of the emergence phase
Suctioning of the airways must be rendered
cautiously, if at all
Aspiration can trigger bronchospasm
Reversal of neuromuscular block has a number of
hazards
Deep extubation (tracheal extubation while still
deeply anaesthetized) has been practiced for
many years, especially in children

Postoperative
Management
Dictated by the intraoperative course
If the surgery was uneventful, and pain, nausea,
and respiratory status are well-controlled,
asthmatics may safely be discharged
In the setting of significant intraoperative
complications such as severe bronchospasm,
special care must be taken
Post op ventilation
Readminister -agonists prior to emergence and
throughout the postoperative recovery period as needed
for recurrent bronchospasm
Maintaining a head of the bed up position

Summary and Guidelines

The keys to an uncomplicated perioperative
course are
Assiduous attention to detail in preoperative
assessment,
Maintenance of the anti-inflammatory and
bronchodilatory regimen through the perioperative
period

Vigilant monitoring is needed for immediate

recognition and calling for assistance

References

Perioperative considerations for the patient with

asthma and bronchospasm B. D. Woods and R. N.
Sladen*Department of Anesthesiology PH 527-B, College of
Physicians and Surgeons of Columbia University, 630 West
168th Street, New York, NY 10032, USA

The Perioperative Management of Asthma Richard

Applegate, Ryan Lauer*, John Lenart, Jason Gatling and
Marisa Vadi Department of Anesthesiology, Loma Linda
University School of Medicine, USA
Millers Basics of Anesthesia 6th Edition