This case report describes a 25-year-old morbidly obese woman with non-insulin dependent diabetes who experienced bronchospasm during induction for cochlear implant surgery. She had no known history of asthma or allergies. During induction with propofol and sufentanil followed by succinylcholine, she developed absent breath sounds, low end-tidal carbon dioxide, and signs of bronchospasm. She required epinephrine and corticosteroids due to hypotension and desaturation. Further evaluation ruled out anaphylaxis and determined this was a case of non-allergic bronchospasm likely triggered by endotracheal intubation and exacerbated by her undiag
1. A 25-year-old morbidly obese woman with diabetes underwent induction for cochlear implant surgery. She developed immediate bronchospasm after intubation.
2. Initial signs included absent breath sounds, low end-tidal carbon dioxide, and decreased lung compliance. Her oxygen saturation dropped to 55% and she became hypotensive.
3. She was treated with epinephrine, fluids, bronchodilators, and steroids. Testing ruled out allergic reaction to induction agents. Her history of exercise-induced wheezing indicated underlying, uncontrolled asthma as the likely trigger.
Intra-operative bronchospasm is a deadly complication during general anaesthesia especially immediately after intubation. This presentation is a guide to tackle such a situation.
REGURGITATION AND ASPIRATION DURING ANESTHESIA abiysileshi
Regurgitation and aspiration is a rare but potentially devastating complication of general anesthesia. Aspiration occurs when gastric contents are inhaled into the lungs. Factors that influence the risk include conditions affecting the lower esophageal sphincter tone and gastric volume. Aspiration can range from asymptomatic to life-threatening pulmonary complications such as chemical pneumonitis or bacterial pneumonia. Prevention strategies include proper pre-operative fasting, reducing gastric acidity, use of rapid sequence induction and cricoid pressure during intubation. Immediate management depends on the patient's stability and may involve airway protection, monitoring or transfer to the ICU.
This document discusses the definition, diagnosis, treatment and management of asthma. It begins by defining asthma as a chronic inflammatory airway disease characterized by variable and recurring symptoms. It then discusses the diagnosis of asthma based on symptoms and evidence of variable airflow limitation. The document outlines treatment for acute severe asthma which focuses on relieving airflow limitation through bronchodilators and treating inflammation with corticosteroids. Key medications discussed include nebulized beta-agonists, ipratropium, systemic corticosteroids, and magnesium sulfate. Perioperative management and considerations are also reviewed.
This document provides an overview of the management of acute asthma exacerbations. It begins with definitions of asthma and exacerbations. It then covers the epidemiology, pathogenesis, diagnosis, differential diagnosis, assessment, and treatment of acute exacerbations. Treatment involves bronchodilator therapy, anti-inflammatory therapy with corticosteroids, supplemental oxygen, and mechanical ventilation if needed. Goals of mechanical ventilation include maintaining oxygen saturation and minimizing dynamic hyperinflation.
The document provides information on indications for mechanical ventilation, criteria for instituting ventilation based on pulmonary function and blood gas parameters, settings for mechanical ventilation including tidal volume, respiratory rate, PEEP, and oxygen concentration. It also outlines the basics of various ventilator modes including assist-control, pressure support, and SIMV. Guidelines are provided for initiating mechanical ventilation and troubleshooting issues like high pressures, low volumes, and patient-ventilator dysynchrony. The nurse's key roles in monitoring the patient and equipment are also summarized.
This document discusses postoperative fever, including definitions, causes, evaluation, and treatment. Fever occurring within the first 3 days is usually non-infectious and can be due to atelectasis, catheter-associated UTI, or surgical site infection. Between days 3-7, infections like pneumonia, UTI, or deeper surgical site infections become more likely. After a week, DVT is a common cause of fever. Evaluation involves vital signs, labs, imaging, and cultures to identify the source. Common causes are treated with antibiotics, oxygen, bronchodilators, or anticoagulants depending on the identified issue.
1. A 25-year-old morbidly obese woman with diabetes underwent induction for cochlear implant surgery. She developed immediate bronchospasm after intubation.
2. Initial signs included absent breath sounds, low end-tidal carbon dioxide, and decreased lung compliance. Her oxygen saturation dropped to 55% and she became hypotensive.
3. She was treated with epinephrine, fluids, bronchodilators, and steroids. Testing ruled out allergic reaction to induction agents. Her history of exercise-induced wheezing indicated underlying, uncontrolled asthma as the likely trigger.
Intra-operative bronchospasm is a deadly complication during general anaesthesia especially immediately after intubation. This presentation is a guide to tackle such a situation.
REGURGITATION AND ASPIRATION DURING ANESTHESIA abiysileshi
Regurgitation and aspiration is a rare but potentially devastating complication of general anesthesia. Aspiration occurs when gastric contents are inhaled into the lungs. Factors that influence the risk include conditions affecting the lower esophageal sphincter tone and gastric volume. Aspiration can range from asymptomatic to life-threatening pulmonary complications such as chemical pneumonitis or bacterial pneumonia. Prevention strategies include proper pre-operative fasting, reducing gastric acidity, use of rapid sequence induction and cricoid pressure during intubation. Immediate management depends on the patient's stability and may involve airway protection, monitoring or transfer to the ICU.
This document discusses the definition, diagnosis, treatment and management of asthma. It begins by defining asthma as a chronic inflammatory airway disease characterized by variable and recurring symptoms. It then discusses the diagnosis of asthma based on symptoms and evidence of variable airflow limitation. The document outlines treatment for acute severe asthma which focuses on relieving airflow limitation through bronchodilators and treating inflammation with corticosteroids. Key medications discussed include nebulized beta-agonists, ipratropium, systemic corticosteroids, and magnesium sulfate. Perioperative management and considerations are also reviewed.
This document provides an overview of the management of acute asthma exacerbations. It begins with definitions of asthma and exacerbations. It then covers the epidemiology, pathogenesis, diagnosis, differential diagnosis, assessment, and treatment of acute exacerbations. Treatment involves bronchodilator therapy, anti-inflammatory therapy with corticosteroids, supplemental oxygen, and mechanical ventilation if needed. Goals of mechanical ventilation include maintaining oxygen saturation and minimizing dynamic hyperinflation.
The document provides information on indications for mechanical ventilation, criteria for instituting ventilation based on pulmonary function and blood gas parameters, settings for mechanical ventilation including tidal volume, respiratory rate, PEEP, and oxygen concentration. It also outlines the basics of various ventilator modes including assist-control, pressure support, and SIMV. Guidelines are provided for initiating mechanical ventilation and troubleshooting issues like high pressures, low volumes, and patient-ventilator dysynchrony. The nurse's key roles in monitoring the patient and equipment are also summarized.
This document discusses postoperative fever, including definitions, causes, evaluation, and treatment. Fever occurring within the first 3 days is usually non-infectious and can be due to atelectasis, catheter-associated UTI, or surgical site infection. Between days 3-7, infections like pneumonia, UTI, or deeper surgical site infections become more likely. After a week, DVT is a common cause of fever. Evaluation involves vital signs, labs, imaging, and cultures to identify the source. Common causes are treated with antibiotics, oxygen, bronchodilators, or anticoagulants depending on the identified issue.
This document discusses various respiratory complications that can occur during and after anesthesia and surgery. It covers complications related to intubation like damage to teeth or larynx. Other complications discussed include respiratory obstruction, hypoxemia, hypercapnia, hypoventilation, and aspiration pneumonia. Causes, signs, and treatments are provided for each complication. The most common causes of hypoventilation in the post-anesthesia care unit are residual effects of anesthetic drugs and lingering neuromuscular blockade.
Acute severe asthma is a life-threatening condition characterized by airway inflammation and bronchospasm. Clinical assessment is important for determining severity and response to treatment. Initial emergency department management involves high-flow oxygen, nebulized bronchodilators, corticosteroids, and magnesium sulfate for refractory cases. Non-invasive ventilation is becoming more widely used and can prevent intubation in some patients. For those requiring intubation and mechanical ventilation, permissive hypercapnia and low tidal volumes are recommended to minimize risks of barotrauma and hemodynamic collapse. Experience and rapid response are critical given the potential for acute deterioration in these patients.
Aspiration Pneumonia General Medicine Rotation 12 15 09Trennette Gilbert
Aspiration pneumonia occurs when gastric or oropharyngeal contents are inhaled into the lungs. It requires both compromise of lung defenses and a large bacterial inoculum. Risk factors include reduced consciousness, neurological impairment, and GI disorders. Diagnosis is based on new infiltrates on chest x-ray along with signs of infection. Treatment involves oxygen, empiric antibiotics targeting likely pathogens, and treating predisposing conditions. Monitoring includes following vitals, labs, imaging and oxygenation to ensure response to therapy. The patient case involved an elderly man with post-op ileus who developed aspiration pneumonia responding well to broad-spectrum IV antibiotics.
General anesthesia involves inducing a state of unconsciousness and loss of protective reflexes through administration of anesthetic agents. While effective for surgery, general anesthesia can cause various complications. Complications range from minor issues like nausea and vomiting to more serious problems involving the respiratory, cardiovascular and neurological systems. It is important for anesthesiologists to carefully monitor patients during and after surgery to promptly identify and address any complications in order to minimize negative outcomes.
This document provides information about asthma, including:
1) Asthma is a chronic inflammatory pulmonary disease characterized by recurrent episodes of wheezing, coughing, and dyspnea in response to triggers like allergens or stress.
2) It affects millions of people in the US and rates have been increasing, especially in children.
3) Symptoms include breathlessness, chest tightness, wheezing, and coughing. Tests like spirometry are used for diagnosis and classification as mild, moderate, or severe.
4) Treatment involves avoiding triggers, using inhaled corticosteroids and bronchodilators, and managing exacerbations with quick-relief medications. Proper dental care and management
Status asthmaticus is a life-threatening episode of severe asthma where symptoms are resistant to initial bronchodilator therapy. It is characterized by chest tightness, shortness of breath, cough, and wheezing. Treatment involves aggressive bronchodilator therapy with beta-2 agonists, supplemental oxygen, systemic corticosteroids, and potentially aminophylline for patients not responding to initial treatments. The severity is staged based on blood gas levels, with stages 3-4 requiring intensive care admission and mechanical ventilation.
Most about status asthmaticus, you will find from etiology to treatment and ventilator management. This presentation is made with thanks to medscape and other resources.
Anaphylactic shock is a severe, potentially life-threatening allergic reaction that can occur within minutes of exposure to an allergen. Symptoms involve multiple body systems and can progress rapidly to circulatory collapse and death. Common causes include medications like penicillin, insect bites, foods, and other allergens. Treatment involves stopping exposure to the allergen, administering epinephrine, and managing airway obstruction and circulatory shock through intubation or other interventions. Proper management and treatment are crucial as anaphylactic reactions can be fatal if not addressed promptly.
This document provides information on bronchial asthma, including:
- Asthma is a chronic inflammatory airway disease characterized by wheezing, breathlessness, and coughing.
- It affects over 350 million people globally and causes nearly 400,000 deaths per year, most in developing countries.
- Long-term treatment involves inhaled corticosteroids to reduce inflammation. Other treatments include oral corticosteroids, leukotriene modifiers, and long-acting beta-2 agonists.
- Triggers include infections, allergens, exercise, air pollution, weather changes, drugs, stress, and smoking. Proper management is needed to prevent complications and control symptoms.
(1) Postoperative nausea and vomiting (PONV) is a common complication following anesthesia and surgery, with incidence rates of 22-38% for nausea and 12-26% for vomiting. (2) The vomiting center located in the brainstem plays a key role in coordinating the vomiting reflex in response to various emetogenic stimuli. (3) Identifying patient, anesthesia, and surgery risk factors can help determine those at higher risk of PONV and guide prophylaxis.
This document provides guidelines for managing acute asthma exacerbations. It outlines that severe asthma exacerbations are medical emergencies requiring close supervision. The initial treatment involves administering supplemental oxygen and repetitive doses of a short-acting beta-2 agonist such as albuterol via a nebulizer every 15-30 minutes or continuously for one hour. Patients should be monitored for signs of deterioration and those with severe or life-threatening features require immediate hospital admission.
This document summarizes information about two asthma case studies. It includes details about the patients' symptoms, examination findings, lab and imaging results, diagnoses, and treatment plans. The first case involves a 66-year-old man who had an asthma exacerbation after stopping his medications. The second case involves a 16-year-old girl with a history of asthma who presented with shortness of breath. The document also provides background information on asthma including definitions, pathophysiology, clinical assessment findings, diagnostic tests and their results, differential diagnosis, disease classification guidelines, and treatment approaches.
This document provides an overview of asthma including its definition, epidemiology, risk factors, pathogenesis, clinical features, diagnosis, status asthmaticus, and treatment. Asthma is a heterogeneous disease characterized by airway inflammation and affects approximately 300 million people worldwide. Key risk factors include atopy, genetic predisposition, infections, obesity, and air pollution. Clinical features include symptoms of wheezing, coughing, and shortness of breath. Diagnosis involves assessing symptoms and lung function tests. Treatment involves inhaled corticosteroids and bronchodilators, with status asthmaticus defined as an acute exacerbation not responding to standard treatment and requiring more intensive interventions.
Acute respiratory distress syndrome (ARDS) is an acute hypoxemic respiratory failure characterized by diffuse alveolar damage. It was first described in 1967 and definitions have since been refined. ARDS occurs in approximately 1 in 10 non-cardiothoracic ICU patients and has a mortality rate of 38-41% that increases with age over 70, multi-organ dysfunction, sepsis, and chronic liver disease. Risk factors include diffuse alveolar damage, pulmonary edema, and inflammatory infiltrate. Treatment involves identifying and treating the underlying cause, supportive care including mechanical ventilation with low tidal volumes, moderate PEEP levels, and prone positioning in moderate to severe cases.
This document discusses aspiration, its classification, risk factors, signs, and prevention. It defines aspiration as the inhalation of oropharyngeal or gastric contents into the larynx and lower respiratory tract. Aspiration can cause aspiration pneumonitis from gastric contents or aspiration pneumonia from oropharyngeal material. Risk factors for aspiration under anesthesia include obesity, impaired consciousness, and recent eating. Signs usually occur within 2 hours and include bronchospasm, hypoxia, and infiltrates on chest x-ray. Prevention methods discussed are using medications to reduce gastric volume or increase pH, as well as applying cricoid pressure during intubation.
1. Acute exacerbations (AEx) in idiopathic pulmonary fibrosis (IPF) patients occur in 5-10% of patients annually and are associated with high mortality.
2. The pathophysiology of AEx-IPF involves diffuse alveolar damage superimposed on the underlying usual interstitial pneumonia pattern. Several hypotheses exist for the triggers but occult infection is not commonly supported.
3. Risk factors for AEx-IPF include lower lung function and more severe fibrosis on imaging. Invasive procedures can precipitate events. Treatment of gastroesophageal reflux may reduce risk.
Status Asthmaticus in Children is a life-threatening form of asthma that is unresponsive to usual therapy. It involves a chronic inflammatory disorder of the small airways that causes recurrent wheezing, coughing, chest tightness and shortness of breath. Key treatments include delivering high flow oxygen, nebulized beta-agonists, systemic steroids, and ipratropium if beta-agonists are not effective. Clinical assessment is important to monitor for signs of impending respiratory failure like altered mental status or absent breath sounds.
This document discusses the case presentation, treatment, and management of acute severe asthma in children. It begins by describing a 2-year-old boy presenting with tight chest and wheezing who was cyanotic and in respiratory distress. He was treated with nebulized bronchodilators and steroids, but desaturated and required intubation. The document then discusses factors that define severe acute asthma attacks, common treatments including inhaled bronchodilators, systemic steroids, magnesium, and intubation in critical cases. It also reviews risks for fatal asthma and cardiopulmonary interactions in acute severe asthma.
The document discusses asthma triggers and diagnosing asthma. It provides information on the most common indoor asthma triggers like dust mites, pet dander, cockroaches, mold, and tobacco smoke. It notes that diagnosing asthma requires identifying recurrent symptoms like coughing, wheezing, and shortness of breath that are at least partially reversible with treatment. The diagnosis can be challenging for young children as lung function tests are difficult.
This resume is for K. Anand, who has over 7 years of work experience in sales and marketing roles. He has a diploma in electronics and communication engineering from Jay Polytechnic College and a B.Tech in information technology from Sakthi Engineering College. Additionally, he has an MBA in marketing management from Madras University. Anand is currently a senior sales executive at Honeywell Electricals, where he is responsible for sales, account management, handling government projects and tenders, and improving secondary sales. His objective is to build a career in a leading corporate environment where he can fully utilize his problem solving, communication, and people skills.
This marketing communication plan aims to increase awareness of the College of Business and Public Policy (CBPP) among non-CBPP students at the University of Alaska Anchorage (UAA). Currently, CBPP lacks awareness and has not previously reached out to these students. The plan recommends using social media marketing to build CBPP's Facebook and Instagram presence. Strategies include posting about events 2-3 times per week, acknowledging successful CBPP students, and offering free food for liking the CBPP page. The goal is to attract more students to enroll in CBPP's programs and courses.
This document discusses various respiratory complications that can occur during and after anesthesia and surgery. It covers complications related to intubation like damage to teeth or larynx. Other complications discussed include respiratory obstruction, hypoxemia, hypercapnia, hypoventilation, and aspiration pneumonia. Causes, signs, and treatments are provided for each complication. The most common causes of hypoventilation in the post-anesthesia care unit are residual effects of anesthetic drugs and lingering neuromuscular blockade.
Acute severe asthma is a life-threatening condition characterized by airway inflammation and bronchospasm. Clinical assessment is important for determining severity and response to treatment. Initial emergency department management involves high-flow oxygen, nebulized bronchodilators, corticosteroids, and magnesium sulfate for refractory cases. Non-invasive ventilation is becoming more widely used and can prevent intubation in some patients. For those requiring intubation and mechanical ventilation, permissive hypercapnia and low tidal volumes are recommended to minimize risks of barotrauma and hemodynamic collapse. Experience and rapid response are critical given the potential for acute deterioration in these patients.
Aspiration Pneumonia General Medicine Rotation 12 15 09Trennette Gilbert
Aspiration pneumonia occurs when gastric or oropharyngeal contents are inhaled into the lungs. It requires both compromise of lung defenses and a large bacterial inoculum. Risk factors include reduced consciousness, neurological impairment, and GI disorders. Diagnosis is based on new infiltrates on chest x-ray along with signs of infection. Treatment involves oxygen, empiric antibiotics targeting likely pathogens, and treating predisposing conditions. Monitoring includes following vitals, labs, imaging and oxygenation to ensure response to therapy. The patient case involved an elderly man with post-op ileus who developed aspiration pneumonia responding well to broad-spectrum IV antibiotics.
General anesthesia involves inducing a state of unconsciousness and loss of protective reflexes through administration of anesthetic agents. While effective for surgery, general anesthesia can cause various complications. Complications range from minor issues like nausea and vomiting to more serious problems involving the respiratory, cardiovascular and neurological systems. It is important for anesthesiologists to carefully monitor patients during and after surgery to promptly identify and address any complications in order to minimize negative outcomes.
This document provides information about asthma, including:
1) Asthma is a chronic inflammatory pulmonary disease characterized by recurrent episodes of wheezing, coughing, and dyspnea in response to triggers like allergens or stress.
2) It affects millions of people in the US and rates have been increasing, especially in children.
3) Symptoms include breathlessness, chest tightness, wheezing, and coughing. Tests like spirometry are used for diagnosis and classification as mild, moderate, or severe.
4) Treatment involves avoiding triggers, using inhaled corticosteroids and bronchodilators, and managing exacerbations with quick-relief medications. Proper dental care and management
Status asthmaticus is a life-threatening episode of severe asthma where symptoms are resistant to initial bronchodilator therapy. It is characterized by chest tightness, shortness of breath, cough, and wheezing. Treatment involves aggressive bronchodilator therapy with beta-2 agonists, supplemental oxygen, systemic corticosteroids, and potentially aminophylline for patients not responding to initial treatments. The severity is staged based on blood gas levels, with stages 3-4 requiring intensive care admission and mechanical ventilation.
Most about status asthmaticus, you will find from etiology to treatment and ventilator management. This presentation is made with thanks to medscape and other resources.
Anaphylactic shock is a severe, potentially life-threatening allergic reaction that can occur within minutes of exposure to an allergen. Symptoms involve multiple body systems and can progress rapidly to circulatory collapse and death. Common causes include medications like penicillin, insect bites, foods, and other allergens. Treatment involves stopping exposure to the allergen, administering epinephrine, and managing airway obstruction and circulatory shock through intubation or other interventions. Proper management and treatment are crucial as anaphylactic reactions can be fatal if not addressed promptly.
This document provides information on bronchial asthma, including:
- Asthma is a chronic inflammatory airway disease characterized by wheezing, breathlessness, and coughing.
- It affects over 350 million people globally and causes nearly 400,000 deaths per year, most in developing countries.
- Long-term treatment involves inhaled corticosteroids to reduce inflammation. Other treatments include oral corticosteroids, leukotriene modifiers, and long-acting beta-2 agonists.
- Triggers include infections, allergens, exercise, air pollution, weather changes, drugs, stress, and smoking. Proper management is needed to prevent complications and control symptoms.
(1) Postoperative nausea and vomiting (PONV) is a common complication following anesthesia and surgery, with incidence rates of 22-38% for nausea and 12-26% for vomiting. (2) The vomiting center located in the brainstem plays a key role in coordinating the vomiting reflex in response to various emetogenic stimuli. (3) Identifying patient, anesthesia, and surgery risk factors can help determine those at higher risk of PONV and guide prophylaxis.
This document provides guidelines for managing acute asthma exacerbations. It outlines that severe asthma exacerbations are medical emergencies requiring close supervision. The initial treatment involves administering supplemental oxygen and repetitive doses of a short-acting beta-2 agonist such as albuterol via a nebulizer every 15-30 minutes or continuously for one hour. Patients should be monitored for signs of deterioration and those with severe or life-threatening features require immediate hospital admission.
This document summarizes information about two asthma case studies. It includes details about the patients' symptoms, examination findings, lab and imaging results, diagnoses, and treatment plans. The first case involves a 66-year-old man who had an asthma exacerbation after stopping his medications. The second case involves a 16-year-old girl with a history of asthma who presented with shortness of breath. The document also provides background information on asthma including definitions, pathophysiology, clinical assessment findings, diagnostic tests and their results, differential diagnosis, disease classification guidelines, and treatment approaches.
This document provides an overview of asthma including its definition, epidemiology, risk factors, pathogenesis, clinical features, diagnosis, status asthmaticus, and treatment. Asthma is a heterogeneous disease characterized by airway inflammation and affects approximately 300 million people worldwide. Key risk factors include atopy, genetic predisposition, infections, obesity, and air pollution. Clinical features include symptoms of wheezing, coughing, and shortness of breath. Diagnosis involves assessing symptoms and lung function tests. Treatment involves inhaled corticosteroids and bronchodilators, with status asthmaticus defined as an acute exacerbation not responding to standard treatment and requiring more intensive interventions.
Acute respiratory distress syndrome (ARDS) is an acute hypoxemic respiratory failure characterized by diffuse alveolar damage. It was first described in 1967 and definitions have since been refined. ARDS occurs in approximately 1 in 10 non-cardiothoracic ICU patients and has a mortality rate of 38-41% that increases with age over 70, multi-organ dysfunction, sepsis, and chronic liver disease. Risk factors include diffuse alveolar damage, pulmonary edema, and inflammatory infiltrate. Treatment involves identifying and treating the underlying cause, supportive care including mechanical ventilation with low tidal volumes, moderate PEEP levels, and prone positioning in moderate to severe cases.
This document discusses aspiration, its classification, risk factors, signs, and prevention. It defines aspiration as the inhalation of oropharyngeal or gastric contents into the larynx and lower respiratory tract. Aspiration can cause aspiration pneumonitis from gastric contents or aspiration pneumonia from oropharyngeal material. Risk factors for aspiration under anesthesia include obesity, impaired consciousness, and recent eating. Signs usually occur within 2 hours and include bronchospasm, hypoxia, and infiltrates on chest x-ray. Prevention methods discussed are using medications to reduce gastric volume or increase pH, as well as applying cricoid pressure during intubation.
1. Acute exacerbations (AEx) in idiopathic pulmonary fibrosis (IPF) patients occur in 5-10% of patients annually and are associated with high mortality.
2. The pathophysiology of AEx-IPF involves diffuse alveolar damage superimposed on the underlying usual interstitial pneumonia pattern. Several hypotheses exist for the triggers but occult infection is not commonly supported.
3. Risk factors for AEx-IPF include lower lung function and more severe fibrosis on imaging. Invasive procedures can precipitate events. Treatment of gastroesophageal reflux may reduce risk.
Status Asthmaticus in Children is a life-threatening form of asthma that is unresponsive to usual therapy. It involves a chronic inflammatory disorder of the small airways that causes recurrent wheezing, coughing, chest tightness and shortness of breath. Key treatments include delivering high flow oxygen, nebulized beta-agonists, systemic steroids, and ipratropium if beta-agonists are not effective. Clinical assessment is important to monitor for signs of impending respiratory failure like altered mental status or absent breath sounds.
This document discusses the case presentation, treatment, and management of acute severe asthma in children. It begins by describing a 2-year-old boy presenting with tight chest and wheezing who was cyanotic and in respiratory distress. He was treated with nebulized bronchodilators and steroids, but desaturated and required intubation. The document then discusses factors that define severe acute asthma attacks, common treatments including inhaled bronchodilators, systemic steroids, magnesium, and intubation in critical cases. It also reviews risks for fatal asthma and cardiopulmonary interactions in acute severe asthma.
The document discusses asthma triggers and diagnosing asthma. It provides information on the most common indoor asthma triggers like dust mites, pet dander, cockroaches, mold, and tobacco smoke. It notes that diagnosing asthma requires identifying recurrent symptoms like coughing, wheezing, and shortness of breath that are at least partially reversible with treatment. The diagnosis can be challenging for young children as lung function tests are difficult.
This resume is for K. Anand, who has over 7 years of work experience in sales and marketing roles. He has a diploma in electronics and communication engineering from Jay Polytechnic College and a B.Tech in information technology from Sakthi Engineering College. Additionally, he has an MBA in marketing management from Madras University. Anand is currently a senior sales executive at Honeywell Electricals, where he is responsible for sales, account management, handling government projects and tenders, and improving secondary sales. His objective is to build a career in a leading corporate environment where he can fully utilize his problem solving, communication, and people skills.
This marketing communication plan aims to increase awareness of the College of Business and Public Policy (CBPP) among non-CBPP students at the University of Alaska Anchorage (UAA). Currently, CBPP lacks awareness and has not previously reached out to these students. The plan recommends using social media marketing to build CBPP's Facebook and Instagram presence. Strategies include posting about events 2-3 times per week, acknowledging successful CBPP students, and offering free food for liking the CBPP page. The goal is to attract more students to enroll in CBPP's programs and courses.
El distrito de Independencia tiene una población de aproximadamente 216,426 habitantes, que representa el 2.18% de la población metropolitana de Lima. La población ha ido en aumento en los últimos nueve años de forma creciente. La mayoría de la población se dedica al comercio y los servicios. El nivel educativo promedio es la educación secundaria.
La meningoencefalitis vírica puede ser causada por varios virus, incluyendo el virus del herpes simple tipo 1 y 2, los cuales pueden permanecer latentes en los ganglios y reactivarse, infectando el cerebro. El virus de la rabia ingresa al cuerpo a través de una mordedura y viaja a través del sistema nervioso hasta el cerebro, causando inflamación y daño neuronal que conducen a síntomas como hidrofobia y parálisis. No existe tratamiento efectivo una vez que aparecen los síntomas neurológicos de la
This document discusses various types of water pollution including organic and inorganic pollutants, thermal pollution, and invasive species. It describes how pollution can influence biological systems and identifies common pollutants like nutrients, toxic metals, and pathogens. The text also discusses indicators of pollution like biochemical oxygen demand and biotic indices, and consequences of pollution like eutrophication and dead zones forming from lack of oxygen. Finally, it recommends various water management strategies to reduce pollution and restore ecosystems.
Every day in Maharashtra news papers carry articles on:
Farmer distress, Agri-product demand / supply inconsistencies, middle men centric trade, non-availability of bank credit, loan distress & farmer suicides etc.
Students from M.Tech (Project Mgmt) studied these phenomena and have suggested modifications to the APMC Supply Chain - as a part of their SCM course.
Este documento presenta una guía de análisis sobre los efectos del alcohol en el cuerpo humano y la sociedad. Incluye indicadores, videos de referencia, preguntas sobre el contenido de los videos, y preguntas para una apreciación crítica sobre temas como los accidentes de tránsito debido al alcohol, medidas para prevenirlos, adulteración de bebidas alcohólicas, y la importancia de informar a la población sobre los peligros del consumo de alcohol para la salud. El objetivo es analizar situaciones sociocientíficas rel
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The document provides information about a car show being held from 11:00AM to 3:00PM at the Lake Area Tech Automotive Department in Watertown, South Dakota. Pre-registration is available online and guarantees an indoor spot, while general registration will take place from 10AM to 11AM the day of the event. Proceeds will benefit Operation Black Hills Cabin.
Lake Area Tech is looking to improve campus security as they currently have no security measures in place. They are asking for help to create a safer campus environment for current and future students. Those interested in getting involved can contact Ashley or Abi for more details on how to help protect the future workforce at Lake Area Tech.
El documento describe el proceso de preparar un álbum de fotos de la experiencia del autor en La Marquesa. El autor pegó las fotos en el álbum y las decoró con brillo para que se vieran más bonitas. Finalmente, escribió debajo de cada foto y completó el álbum, listo para compartir su experiencia en La Marquesa.
El documento describe el aprendizaje autónomo, que permite a los estudiantes decidir qué y cómo aprender, evaluar su propio desarrollo educativo, y buscar estrategias para mejorar su rendimiento. Implica auto disciplina, dedicación de tiempo y recursos, y aprovechar diversas fuentes de información para lograr objetivos planteados. Las tecnologías de la información han facilitado el aprendizaje autónomo al dar acceso a material didáctico y apoyar la educación en línea, donde los estudiantes deciden cuándo estudiar.
Dokumen tersebut membahas tentang menulis sastra anak-anak. Terdapat beberapa poin penting yaitu genre sastra anak-anak meliputi fiksi, tradisional, biografi, informasional, puisi. Perlu memperhatikan umur anak sasaran, bahasa yang sederhana, dan plot yang menarik seperti misteri atau petualangan. Penulis perlu melakukan riset pasar dan memahami minat serta gaya hidup anak saat ini.
This case report describes a 25-year-old morbidly obese woman with diabetes who experienced bronchospasm during induction for cochlear implant surgery. Initial signs included absent breath sounds, low end-tidal carbon dioxide, and bronchospasm. Treatment included epinephrine, fluids, bronchodilators, and steroids. Further workup ruled out allergic reaction but found previously undiagnosed asthma. Obesity can precipitate rapid desaturation in asthma patients. Uncontrolled asthma is a risk factor for perioperative bronchospasm.
This case report describes a 25-year-old woman who experienced bronchospasm during anesthetic induction for cochlear implant surgery. After intubation with succinylcholine, she developed difficulty breathing, low carbon dioxide levels, and arterial desaturation. Epinephrine and fluids stabilized her cardiovascularly while wheezing and ventilation improved with bronchodilators and steroids. Testing ruled out allergy to induction agents but a possible non-IgE mediated reaction to succinylcholine. She recovered fully with treatment.
This document provides information about Kartagener syndrome, a rare genetic disorder characterized by situs inversus, chronic sinusitis, and bronchiectasis due to immotile cilia. It causes infertility in men due to immotile sperm flagella. The syndrome is caused by mutations in genes encoding dynein motor proteins essential for proper cilia function. Patients typically present with chronic respiratory symptoms from poor mucociliary clearance and recurrent lung infections leading to bronchiectasis. Diagnosis involves imaging to detect organ-situs abnormalities and evaluation of cilia function. Management focuses on airway clearance and pulmonary infections treatment/prevention to preserve lung function.
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Anaphylaxis is an acute, multi organ, life threatening allergic reaction. Initial symptoms may look like a normal allergy with runny nose or rash and usually occur within minutes of exposure to an allergen. Within a few minutes, symptoms get more severe and can be deadly if not treated. Anaphylaxis requires immediate medical attention.
The document provides information on the management of intra-operative bronchospasm, including risk factors, triggers, diagnosis, prevention, and treatment approaches. Bronchospasm can be caused by airway irritation or anaphylaxis and presents with signs of wheezing, increased airway pressures, and falling oxygen saturation. Differential diagnoses must be ruled out. Management involves deepening anesthesia, administering bronchodilators, optimizing ventilation, and considering anaphylaxis or postponing surgery. A case example demonstrates treatment of bronchospasm potentially caused by succinylcholine-induced anaphylaxis.
This document provides information on bronchial asthma, including its definition, epidemiology, etiology, provoking factors, pathology, symptoms, physical exam findings, laboratory/diagnostic findings, classification by severity, and treatment approaches. Bronchial asthma is a chronic inflammatory airway disease characterized by reversible airway obstruction and bronchial hyperresponsiveness. It has a prevalence of 5-15% worldwide and is caused by genetic and environmental factors like allergens. Symptoms include wheezing, chest tightness, cough, and dyspnea. Treatment involves controllers like inhaled corticosteroids and relievers like short-acting bronchodilators.
Hypersensitivity pneumonitis is a lung disease caused by inhalation of an antigen that the individual is sensitized to. It can present acutely following high dose exposure or chronically after long term low dose exposure. Common causes include moldy hay, grain, or bird droppings. Symptoms include breathlessness, cough, and fever occurring 4-8 hours after exposure. Chest imaging shows small nodules or infiltrates. Treatment involves avoiding the antigen and using corticosteroids. Prognosis depends on exposure type and duration, with acute cases often resolving but chronic exposure risking persistent symptoms.
This document provides information about asthma including its definition, incidence, triggers, pathophysiology, classification, clinical manifestations, complications, diagnostic evaluation, medical management including pharmacologic therapy, and nursing assessment and interventions. It defines asthma as a chronic inflammatory airway disease characterized by recurrent exacerbations of coughing, wheezing and shortness of breath. It notes that asthma affects over 25 million Indians and discusses common asthma triggers. The medical management section covers different classes of medications used to treat asthma including bronchodilators, anti-inflammatories, leukotriene modifiers and combinations. Nursing care involves assessing symptoms and lung sounds, monitoring for signs of anxiety or distress, educating patients about asthma self-management, and teaching techniques
This document provides information on anaphylaxis including its definition, clinical criteria, causes, pathophysiology, clinical features, diagnosis, differential diagnosis, and management. Anaphylaxis is defined as a serious allergic reaction that is rapid in onset and can cause death. It is caused by exposure to an allergen in sensitized individuals and involves the release of mediators from mast cells and basophils like histamine. Symptoms may include skin issues, low blood pressure, respiratory distress, and gastrointestinal symptoms. Epinephrine is the first line treatment to reverse its effects.
Dry cough – presentation, causes and managementSujay Iyer
This document provides an overview of cough, including its mechanism, classification, and various causes. It describes the cough reflex pathway involving afferent nerves, central processing, and efferent response. Dry cough is defined as non-productive and accounts for up to 46% of cough cases. Common causes of dry cough discussed include upper airway cough syndrome, cough variant asthma, gastroesophageal reflux disease, and medications like ACE inhibitors. Treatment depends on the identified cause and may include lifestyle changes, medications, and addressing underlying respiratory conditions.
This document discusses asthma, including its pathogenesis, triggers, symptoms, diagnosis and classification. It notes that asthma is a chronic inflammatory airway disease characterized by reversible bronchial constriction in response to multiple stimuli. Common symptoms include dyspnea, cough and wheezing. Diagnosis involves assessing symptoms, demonstrating reversibility of airflow obstruction via spirometry, and ruling out alternative diagnoses. Asthma is classified based on severity of symptoms and lung function.
Dry cough is one of the most common symptoms prompting patients to seek medical care. A systematic diagnostic approach is recommended to determine the underlying cause. Common causes of acute dry cough include upper respiratory infections, while chronic dry cough may be due to asthma, COPD, GERD, or postnasal drip. A careful history and physical exam can provide clues to the etiology, and initial tests may include a chest x-ray, spirometry, and trial treatments targeting suspected conditions. Management involves treating the identified cause through lifestyle changes, medications, or other therapies.
Bronchial asthma is a chronic inflammatory disorder of the airways that causes recurrent episodes of wheezing, breathlessness, chest tightness and coughing. These episodes are usually associated with widespread but variable airflow obstruction that is often reversible with treatment. Asthma is characterized by airway inflammation, airway hyperresponsiveness, and reversible airway obstruction. Common triggers include allergens, infections, exercise, and environmental factors. Diagnosis involves assessing symptoms, performing pulmonary function tests to check for reversibility of airway obstruction, and ruling out other conditions.
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This document summarizes several pulmonary emergencies: pneumothorax, hemoptysis, and status asthmaticus.
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Travel Clinic Cardiff offers comprehensive travel health services, including vaccinations, travel advice, and preventive care for international travelers. Our expert team ensures you are well-prepared and protected for your journey, providing personalized consultations tailored to your destination. Conveniently located in Cardiff, we help you travel with confidence and peace of mind. Visit us: www.nxhealthcare.co.uk
Co-Chairs, Val J. Lowe, MD, and Cyrus A. Raji, MD, PhD, prepared useful Practice Aids pertaining to Alzheimer’s disease for this CME/AAPA activity titled “Alzheimer’s Disease Case Conference: Gearing Up for the Expanding Role of Neuroradiology in Diagnosis and Treatment.” For the full presentation, downloadable Practice Aids, and complete CME/AAPA information, and to apply for credit, please visit us at https://bit.ly/3PvVY25. CME/AAPA credit will be available until June 28, 2025.
Travel vaccination in Manchester offers comprehensive immunization services for individuals planning international trips. Expert healthcare providers administer vaccines tailored to your destination, ensuring you stay protected against various diseases. Conveniently located clinics and flexible appointment options make it easy to get the necessary shots before your journey. Stay healthy and travel with confidence by getting vaccinated in Manchester. Visit us: www.nxhealthcare.co.uk
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Breast cancer in postmenopausal women with hormone receptor-positive (HR+) status is a common and complex condition that necessitates a multifaceted approach to management. HR+ breast cancer means that the cancer cells grow in response to hormones such as estrogen and progesterone. This subtype is prevalent among postmenopausal women and typically exhibits a more indolent course compared to other forms of breast cancer, which allows for a variety of treatment options.
Diagnosis and Staging
The diagnosis of HR+ breast cancer begins with clinical evaluation, imaging, and biopsy. Imaging modalities such as mammography, ultrasound, and MRI help in assessing the extent of the disease. Histopathological examination and immunohistochemical staining of the biopsy sample confirm the diagnosis and hormone receptor status by identifying the presence of estrogen receptors (ER) and progesterone receptors (PR) on the tumor cells.
Staging involves determining the size of the tumor (T), the involvement of regional lymph nodes (N), and the presence of distant metastasis (M). The American Joint Committee on Cancer (AJCC) staging system is commonly used. Accurate staging is critical as it guides treatment decisions.
Treatment Options
Endocrine Therapy
Endocrine therapy is the cornerstone of treatment for HR+ breast cancer in postmenopausal women. The primary goal is to reduce the levels of estrogen or block its effects on cancer cells. Commonly used agents include:
Selective Estrogen Receptor Modulators (SERMs): Tamoxifen is a SERM that binds to estrogen receptors, blocking estrogen from stimulating breast cancer cells. It is effective but may have side effects such as increased risk of endometrial cancer and thromboembolic events.
Aromatase Inhibitors (AIs): These drugs, including anastrozole, letrozole, and exemestane, lower estrogen levels by inhibiting the aromatase enzyme, which converts androgens to estrogen in peripheral tissues. AIs are generally preferred in postmenopausal women due to their efficacy and safety profile compared to tamoxifen.
Selective Estrogen Receptor Downregulators (SERDs): Fulvestrant is a SERD that degrades estrogen receptors and is used in cases where resistance to other endocrine therapies develops.
Combination Therapies
Combining endocrine therapy with other treatments enhances efficacy. Examples include:
Endocrine Therapy with CDK4/6 Inhibitors: Palbociclib, ribociclib, and abemaciclib are CDK4/6 inhibitors that, when combined with endocrine therapy, significantly improve progression-free survival in advanced HR+ breast cancer.
Endocrine Therapy with mTOR Inhibitors: Everolimus, an mTOR inhibitor, can be added to endocrine therapy for patients who have developed resistance to aromatase inhibitors.
Chemotherapy
Chemotherapy is generally reserved for patients with high-risk features, such as large tumor size, high-grade histology, or extensive lymph node involvement. Regimens often include anthracyclines and taxanes.
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.