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Bronchospasmduringinduction 130207040615-phpapp01
1. Pascale Dewachter, Claudie Mouton-Faivre, Charles W. Emala,Sadek Beloucif
Anesthesiology 2011; 114:1200 –10
DR. RISHABH MITTAL
MODERATOR – DR. AVNISH BHARADWAJ
2. Case Report
A 25-yr-old woman
Body mass index: 54 kg/m2 ( morbidly obese)
Noninsulin-dependent diabetes
Scheduled for cochlear implant surgery.
h/o 2 previous surgeries without incident during childhood.
NO history of atopy or drug allergy
Normal Chest auscultation before anaesthesia.
3. Case Report – Anaesthetic course
Premedication – Tab. Hydroxyzine (100 mg) the day before
and 1 h before induction
Induction - Inj. sufentanil (20 µg I.V) + Inj. propofol (350 mg
I.V)
Tracheal Intubation (Cormack and Lehane grade I) -
Inj. succinylcholine (130 mg I.V).
Chest auscultation -complete absence of bilateral breath
sounds.
End-tidal carbon dioxide (ETCO2) - Low. initially
4. What had happened??
SUSPECTED -Esophageal intubation ??
Patient immediately extubated
Mask ventilation attempted - difficult to perform
Dramatically decreased lung compliance
ETCO2 - marked prolonged expiratory upstroke of the capnogram
Bronchospasm !!!!!!!!
5. What was DONE??
WITHIN FIVE MINUTES –
SpO2 – 55%, Arterial hypotension ( From 130/75 to 50/20 mmHg),
Moderate tachycardia (100 beats/min)
Titrated epinephrine (two I.V boluses of 100 µg each) ,
Ringer lactate- 1000 ml
Blood pressure, 110/50 mmHg; heart rate, 110 beats/min),
Ventilation became easier to perform
Audible wheezing over both lung fields.
A localized (face and upper thorax) erythema -
Hydrocortisone(200 mg) I.V
Blood sample 40 and 90 min after the clinical reaction- to measure
serum tryptase concentrations
6. And then…..
Surgery was postponed
Patient was transferred to the intensive care unit.
Inhaled β 2-agonist (salbutamol)
I.V corticoids (hydrocortisone, cumulative dose: 800 mg
over24 h)
Respiratory symptoms resolved within 2 h
h/o wheezing induced by cold and exercise was elicited
No additional supportive vasopressor therapy was
required
Patient discharged home the following day
Allergologic assessment - after 6 wk
7.
8. Bronchospasm??
Is defined as constriction of bronchi and bronchioles
Clinical feature of exacerbated underlying airway hyper-
reactivity
symptoms include difficulty in breathing, wheezing,
coughing, and dyspnea.
Chest auscultation –
wheezing
decreased or absent breath sounds - critically low airflow.
9. Peri-operative bronchospasm..
Usually arises during induction of anesthesia
May be detected at any stage of the anaesthetic course.
Bronchoconstriction due to -
Immediate hypersensitivity reaction – EVOKING
ALLERGY
I. IgE-mediated anaphylaxis
II. Anaphylactoid reaction – Non immune Mechanism
Non-allergic mechanism triggered by
I. Mechanical factors ( intubation-induced bronchospasm)
II. Pharmacologic factors (via histamine-releasing drugs such as
atracurium or mivacurium )
10. D/D of Intra-operative Bronchospasm
Esophageal intubation
Inadequate anaesthesia
Mucous plugging of the airway
Kinked or obstructed tube/circuit,
Pulmonary aspiration.
Unilateral wheezing suggests endobronchial intubation or
an obstructed tube by a foreign body (such as a tooth).
If the clinical symptoms fail to resolve despite appropriate
therapy, pulmonary edema or pneumothorax should be
considered.
11. Periop. Immediate Hypersenstivity Reaction
Clinical entity evoking allergy that varies in severity
Occurs within 60 min after the injection/introduction of the
culprit agent
Diagnosis is linked to a triad including -
1. Clinical features ( Graded acc. to Ring and Messmer clinical
severity scale)
2. Blood tests (Tryptase level measurements, serum-specific IgEs)
3. Postoperative skin tests with the suspected drugs or agents
12. Ring and Messmer clinical severity scale
Grade I: Erythema, urticaria with or without angioedema
Grade II: Cutaneous-mucous signs ± hypotension ±
tachycardia ± dyspnea ± gastrointestinal disturbances
Grade III: Cardiovascular collapse ± tachycardia or
bradycardia ± cardiac dysrythmia ± bronchospasm ±
cutaneous-mucous signs ± gastrointestinal disturbances;
Grade IV: Cardiac arrest
13. Etiology in the Current Case
Clinical diagnosis initially suggested drug-induced
anaphylactic reaction (allergic bronchospasm)
Sudden occurrence of bronchospasm after induction
Cardiovascular disturbances
Cutaneous signs
Succinylcholine-induced anaphylaxis was suggested as the
most likely etiology at first sight.
Neuromuscular blocking agents are the most frequent
agents involved in perioperative anaphylaxis in adults
14. Etiology in the Current Case
How can we differentiate between allergic and non-
allergic bronchospasm clinically??
Clinical variables predicting IgE mediated anaphylaxis
Presence of any cutaneous symptoms ( 7times)
Shock (cardiovascular collapse) – HALLMARK (27 t1mes)
Episodes of desaturation (22 times)
Prolonged duration of clinical features (longer than 60
min)
Cardiovascular collapse -usually the inaugural clinical
event , occur within minutes after the drug challenge
May occur either before or after instrumentation of the
airway
15. Etiology in the Current Case
Non-allergic bronchospasm
Immediately follows nonspecific stimuli (irritation by ETT,
suction catheter)
Usually not associated with cardiovascular symptoms but..
PEEP with severe bronchospasm may lead to a decrease in venous
return & hence cardiac output.
Hypoxia and respiratory failure from inadequate ventilation may
lead to cardiovascular collapse (occurs late after bronchospasm)
Cutaneous signs may be observed
16.
17. Etiology in the Current Case
In the current case
Skin testing remained negative in response to propofol,
sufentanil, succinylcholine, and latex solutions.
Tryptase level were unchanged (N less than 13.5 µg/l.) -
specific for mast cell activation
Serum-specific IgEs against succinylcholine and latex were not
detectable.
Basophil activation test- Succinylcholine induced neither
CD63 nor CD203c up-regulation.
Succinylcholine-induced anaphylaxis was ruled out
18. Etiology in the Current Case
Bronchospasm triggered by endotracheal tube insertion and
followed by cardiovascular collapse (hypoxemia) suggests
non-allergic bronchospasm
Erythema may also be observed during non-allergic
bronchospasm.
Morbid obesity of the patient -precipitating factor of rapid
arterial desaturation
Uncontrolled Asthma -main trigger of this non-allergic
bronchospasm (h/o wheezing induced by cold and exercise
elicited from patient in post-op period)
19. What is ASTHMA??
“Asthma is a chronic disorder of the airway in which many cells and
cellular elements play a role. The chronic inflammation is
associated with airway responsiveness that leads to recurrent
episodes of wheezing, breathlessness, chest tightness and
coughing, particularly at night or in the early morning. These
episodes are usually associated with widespread, but variable
airflow obstruction within the lung, that is often reversible
either spontaneously or with treatment.” (2008)
20.
21.
22. ASTHMA
Two main phenotypes:-
Allergic
Non-allergic
Overlap may occur within these groups
Allergic Rhinitis and Allergic Asthma Belong to the
Same Airway Disease -More than 80% of asthmatic individuals
have rhinitis, and 10–40% of patients with rhinitis have asthma
23. Allergic Asthma
Onset occurs primarily in early childhood
Results from immunologic reactions, mostly initiated by IgE
antibodies
Atopy - (Genetic predisposition for the development of an IgE-
mediated response to common aeroallergens) - strongest
identifiable predisposing factor
Triggers-
Environmental factors - tobacco smoke, air pollutants,
and exposure to allergens
Obesity, diet, and hygiene hypothesis
ATOPY + TRIGGERS ALLERGIC ASTHMA
24. Non-allergic Asthma: Aspirin-induced Asthma
Widely under diagnosed condition
Not seen in childhood
Inhibition of cyclooxygenase enzymes by aspirin-like drugs in
the airway of sensitive patients
Characterized by eosinophilic rhinosinusitis, nasal polyposis,
senstivity to aspirin or NSAID’s and asthma
Rhinorrhea, nasal congestion, and anosmia are the first clinical
features
Asthma and sensitivity to aspirin appear approximately 1–5 yr after
the onset of rhinitis
25. Perioperative Bronchospasm & Asthma
Westhorpe RN, Ludbrook GL, Helps SC: Crisis management during anaesthesia: Bronchospasm. Qual Saf Health Care 2005; 14:e7
In a study conducted by Westhorpe RN et al (103 cases)
PERIOPERATIVE BRONCHOSPASM
Allergic (21%) / Non-allergic mechanism(79%)
Of Non-allergic cases, 44% during induction, 36% during
maintenance phase, and 20% during emergence/recovery stage.
Major causes during -
Induction - airway irritation (64%), tube misplacement (17%),
aspiration (11%), and other pulmonary edema or unknown causes (8%).
Maintenance -allergy (34%), endotracheal tube malposition (23%),
airway irritation (11%), aspiration with a laryngeal mask airway(9%)
26. Perioperative Bronchospasm & Asthma
Bronchospasm induced by airway irritability occurred more
frequently in patients who had one or more predisposing
factors such as asthma, heavy smoking, or bronchitis.
Previous history of asthma was present in
50% cases of Non-allergic Bronchospasm
60% patients with allergic bronchospasm
Uncontrolled asthma/chronic obstructive pulmonary disease is
frequently involved with both allergic and non-allergic
bronchospasm, regardless of the stage of anesthesia (induction
or maintenance)
27. Mechanisms of Reflex-induced Bronchoconstriction
Irritation of the upper airway by a foreign body
Afferent sensory pathways
Nucleus of solitary Tract
Airway-related Vagal Pre- ganglionic Neurons
Airways via Vagus nerve
Bronchoconstriction
Stimulatory - Glutamate++
Glutamate++
Inhibitory- γ aminobutyric acid - -
Acetylcholine
release ++
(M3 muscarinic receptor)
28. Reflex-induced Bronchoconstriction
Non-adrenergic non-cholinergic nerves (releasing tachykinins,
vasoactive intestinal peptide, and calcitonin gene-related peptide) may
participate in this reflex arc and/or locally release the pro-
contractile neurotransmitters via activation of inter-neurons in
the airway.
Since Acetylcholine acting on M3 muscarinic receptors on
airway smooth muscle is a key component in mechanism, use of
antimuscarinic - inhaled medications (e.g., ipratropium or
tiotropium) should be advantageous to prevent /treat it.
29. Reflex-induced Bronchoconstriction
Propofol and volatile inhalational anaesthetics (except
desflurane) are clinically effective
Have activity at inhibitory GABA-A chloride channels
Have direct bronchodilatory effects at the level of airway smooth muscle
(via GABA-A channels/ modulating calcium sensitivity of the
contractile proteins)
Propofol preferentially relaxes tachykinin- induced airway constriction
Deepening anesthesia
Prevents /relieves reflex-induced bronchoconstriction
Modulation of GABA input to the airway-related vagal preganglionic
neurons from the nTS/ higher centers
30.
31. BUT….
Despite these protective effects of intravenous
propofol and the adequate induction dose used in the
current case, reflex-induced bronchoconstriction
developed in this patient who had previously
unrecognized and untreated asthma.
32. Obesity and Asthma: Is There Any Relationship?
Obesity- body mass index of at least 30 kg/m2
Both are systemic inflammatory states
Chromosomal regions with loci common to obesity and asthma
phenotypes have been identified
Obesity
FRC & TV
contractile responses of airway smooth muscle
airway reactivity
33. Obesity and Asthma: Is There Any Relationship?
Gastroesophageal reflux resulting from obesity may potentially trigger a
latent asthmatic condition
Hormonal influences-
hormone leptin produced by adipocytes has effects on immune cell
function and inflammation
Recent changes in lifestyle and diet are associated with both
Asthma remains under diagnosed in obese patients - respiratory
symptoms are frequently attributed to being overweight (current case)
Sleep-disordered breathing is more prevalent in asthmatic as well as obese
individuals
34. Prevention of Perioperative Bronchospasm
Acc. To Global Initiative for Asthma guidelines -
Perioperative and postoperative complications rely on
Severity of asthma at the time of surgery
Type of surgery (thoracic /upper abdominal surg risk)
Modalities of anesthesia (GA with intubation risk)
Uncontrolled asthma is considered to be the main risk
factor for bronchoconstriction during surgery.
35. Prevention of Perioperative Bronchospasm
HISTORY
Poorly controlled Asthma may be assessed through
Degree of asthma control (inc. Use of medications, recent
exacerbations of symptoms, hospital visit within the last months)
Potential risks or complication factors (recent respiratory
tract inf., previous bronchospasm / pulmonary complications
during/after previous surg, long-term use of a systemic corticosteroids,
assso. gastroesophageal reflux or smoking).
Abstinence from smoking before surgery reduces
perioperative pulmonary complications
36. Prevention of Perioperative Bronchospasm
Preoperative Clinical and Physical Examination
Acc. To Smetana et al perioperative pulmonary
complications occur if preoperative examination reveals
-
Decreased breath sounds
Dullness to percussion
Wheezing
Rhonchi
Prolonged expiratory phase
In the presence of active bronchospasm, elective surgery
should be postponed
Smetana GW: Preoperative pulmonary evaluation. N Engl J Med 1999; 340:937– 44
37. Prevention of Perioperative Bronchospasm
Measurement of lung function (PFT)
FEV1 /PEFR -better indicators of the severity of asthma
exacerbation than clinical symptoms.
FEV1/ FVC (normal > 75%) - sensitive measure of severity
and control
Reversibility with the use of a bronchodilator –defined as
increase in FEV1 of at least 12% or 200 ml.
Before surgery
PEF or FEV1 >> 80% of the predicted or personal best is
recommended.
If PEF or FEV1 is << 80%, a brief course of oral
corticosteroids should be considered
38. Prevention of Perioperative Bronchospasm
REVIEW OF MEDICATION
Rapid-acting inhaledβ 2-agonists are used for quick relief of
acute asthma exacerbations
Inhaled glucocorticosteroids are currently the most effective
anti-inflammatory drug for the treatment of persistent
asthma.( reduce asthma symptoms, improve lung function, decrease airway hyper-
reactivity, modulate airway inflammation, and reduce asthma exacerbations & asthma
mortality)
Inhaled long-acting β 2-agonists (formoterol, salmeterol)
should never be used as single therapy.
efficient when combined with glucocorticosteroids (synergistic)
39. Prevention of Perioperative BronchospasmStepwise Approach for Asthma Treatment / optimization of Treatment
Level of Asthma Control Step Levels Treatment
Global Initiative for Asthma Five
At each step, short-acting β2-agonist is
recommended as needed
Intermittent treatment 1 —
Daily medication 2 Low-dose inhaled corticosteroid
— 3
Low-dose inhaled corticosteroid + inhaled long-
acting β 2-agonist
— 4
Medium- or high-dose inhaled Steroid + inhaled
long-acting β 2-agonist
— 5 Addition of oral steroid to other controllers
Expert Panel Report six
At each step, short-acting β 2-agonist is
recommended as needed
Intermittent treatment 1 —
Daily medication 2 Low-dose inhaled corticosteroid
— 3 Medium-dose inhaled corticosteroid
— 4
Medium-dose inhaled corticosteroid + inhaled
long-acting β 2-agonist
— 5
High-dose inhaled corticosteroid + inhaled long-
acting β2-agonist
— 6 Step 5 + oral corticosteroids
40. Follow Up of Current Case
Initial Spirometric evaluation
FEV1 - 67%
PEFR - 70%
FEV1/forced vitality capacity - 83% of predicted.
Treatment started –
High doses of inhaled therapy with fluticasone and salmeterol
(1,000 μg BD)
Educative measures
Second Spirometric evaluation (after 3 months)
Reversibility of nearly - 15%,
FEV1 -80%
PEFR - 82%,
FEV1/forced vitality capacity - 97% of predicted values
Reduction of clinical signs noted by the patient
Wheezing disappeared
41. Follow Up of Current Case
Surgery was performed 6 months after the initial
perioperative event.
Anesthesia was conducted with propofol, sufentanil, and
sevoflurane
Anesthesia and surgery as well as the postoperative course
remained uneventful
42. Perioperative Bronchospasm - Treatment
AIM- to relieve airflow obstruction and subsequent
hypoxemia as quickly as possible.
FiO2 – 100%
Switch to Manual Bag Ventilation - Bains circuit (to evaluate
pulmonary and circuit complaince)
conc. of volatile anaesthetic (except desflurane)
Deepening anaesthesia with an intravenous anaesthetic
(if bronchospasm related to inadequate depth)
43. Perioperative Bronchospasm - Treatment
Inhaled Short-acting β2-Selective Agents - immediately
Terbutaline and Salbutamol
onset of action - 5 min
peak effect - 60 min
duration of action - 4–6 h.
VIA
Nebulizer (8–10 puffs repeated at 15- to 30-min intervals)
Metered-dose inhaler (5–10 mg/h) connected to the
inspiratory limb of the ventilator circuit.
Continuous administration - greater improvement in PEFR
Nebulised epinephrine has no beneficial effect
44. Perioperative Bronchospasm - Treatment
Systemic Glucocorticosteroids
Methylprednisone (1 mg/kg) - preferred over cortisone
Benefit - not immediate
Combined Nebulized ipratropium bromide with a β2-
agonist
0.5 mg 4–6 times/hour
greater bronchodilatation when used in combination
to treat life-threatening bronchospasm
those with a poor initial response
45. Perioperative Bronchospasm - Treatment
Magnesium
Causes bronchial smooth muscle relaxation
Intravenous(single dose: 2 g over 20 min) or
Inhaled (110 mg to 1,100 mg)
In patients with severe bronchospasm that fails to be
relieved with β2-agonists
Salbutamol administered in isotonic magnesium sulfate
provides greater benefit (compared with that diluted with saline)
Bateman ED, Hurd SS, Barnes PJ, Bousquet J, Drazen JM,FitzGerald M, Gibson P, Ohta K, O’Byrne P, Pedersen SE,Pizzichini E,
Sullivan SD, Wenzel SE, Zar HJ: Global strategy for asthma management and prevention: GINA executive summary. Eur
Respir J 2008; 31:143–78
46. Perioperative Bronchospasm - Treatment
AMINOPHYLLINE
Intravenous aminophylline has no role
Not result in additional bronchodilatation
Adverse effects - arrhythmia and vomiting have been
reported
Bateman ED, Hurd SS, Barnes PJ, Bousquet J, Drazen JM,FitzGerald M, Gibson P, Ohta K, O’Byrne P,
Pedersen SE,Pizzichini E, Sullivan SD, Wenzel SE, Zar HJ: Global strategy for asthma management
and prevention: GINA executive summary. Eur Respir J 2008; 31:143–78
47. Perioperative Bronchospasm - Treatment
Epinephrine
In cases of associated cardiovascular collapse suggestive
of IgE-mediated anaphylaxis
In case of Isolated bronchospasm - its inhaled/systemic use
is not recommended
Currently recommended as a rescue therapy in patients with
severe asthma complicated by hypotension that is not
secondary to dynamic hyperinflation.
Elective Surgery should be postponed - bronchospasm
persists at baseline despite maximal medical optimization
of the patient
48.
49. THE CURRENT CASE
Extubation was performed because of suspected
Oesophageal intubation - Resulting in arterial
desaturation and subsequent hemodynamic
disturbances.
Instead- Verification of correct endotracheal tube
position would have been the appropriate procedure
before extubation.
52. KNOWLEDGE GAP
Whether perioperative bronchospasm is a clinical entity of
its own occurring in predisposed patients and triggered
either by mechanical, pharmacologic, or inflammatory (i.e.,
anaphylaxis) factors??
Basic assumptions regarding the management of general
anesthesia in patients at risk for bronchoconstriction have
not been rigorously studied..
53. KNOWLEDGE GAP
Interaction between anesthetics, airway irritation, and the
role of tachykinins and other C fiber neurotransmitters in
the control of airway tone......
Mechanisms by which intravenous and inhaled anesthetics
affect airway nerves and directly modulate airway smooth
muscle tone likely involve modulation of plasma membrane
ion channels, membrane potential, and intracellular calcium
sensitivity but remain poorly understood.....
54. Example of Targeting Questions to Identify Patients at
Risk with Undiagnosed Airway Hyperreactivity..
Do you smoke?
Do you have gastroesophageal reflux disease?
Have you ever felt chest tightness or difficulty catching your breath? If
so, at rest or with physical effort?
Have you ever been told that you have wheezing or asthma?
Have you ever used an inhaled medication for your breathing?
Have you ever visited an emergency department for breathing
problems?
Have you ever had frequent bronchitis?
Have you ever had rhinitis?
Do you frequently cough?
Do you have allergies to latex or tropical fruits (kiwi,
banana, papaya, avocado)?
Editor's Notes
The upper airway is well innervated by afferent sensory pathways synapsing in the nucleus of the solitary tract (nTS), which projects excitatory glutaminergic and inhibitory -aminobutyric acid-A (GABA)-ergic neurons to the airway-related vagal preganglionic neurons
(AVPN). Parasympathetic preganglionic efferents travel in the vagus nerve to release acetylcholine onto M3 muscarinic receptors on airway smooth muscle inducing bronchoconstriction.
Corticosteroids increase the bronchodilatory effect of β2-agonists and increase the number of β2-adrenergic receptors
and their response to β2-agonists
Stepwise approach to treatment of perioperative bronchospasm according to the clinical scenario. * May be used in
life-threatening bronchospasm or those with a poor initial response to 2-agonist; † may be used in cases of severe
bronchospasm that fails to relieve with 2-agonist; ‡ for further details, see Reference 1.