Asthma and consultation Prof Dr Berrin Ceyhan Dept of Pulmonary Medicine Marmara University School of Medicine ISTANBUL. Operation in patients with asthma.
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AsthmaandconsultationProf Dr Berrin CeyhanDept of PulmonaryMedicineMarmara UniversitySchool of MedicineISTANBUL
Perioprespiratorycomplications in patientswithasthmaBetween 1979-1991, in Mayo ClinicsCohortstudy706 patientswithasthmareceivesurgicalprocedurePerioperativebronchospasmandlaryngospasmwassurprisinglylow (12pts , 1.7%, one of themdeveloppedpostoprespiratoryfailure)The risk increased in olderptsand in thosewithactivediseaseWarner DO Anesthesiology 1996; 460
Cheney et al 1991; 932
Postner KL, Am j Med Qual1994;129
Kumeta Y et al Masui 1995;396
Postoperative pulmonary complications (PPC)
Bronchospasm(History of asthma is not predictive for bronchospasm)
Excessive bronchial secretion
PPC occured more frequently than cardiac complications (9.6% vs 5.7%)
Lawrence WA J Gen Intern Med 1995;671.
How can we prevent peri- and postoperative pulmonary complications in asthma?
Preop evaluation of ashmatics
Suboptimal antiinflammatory therapy
Side effects of treatments
Aspirin /NSAID intolerance
Recent RTI (not related with recent URTI, Warner O Anesthesioloy 1996)
Prior severe attack (intensive care, mechanical ventilation)
To detect acute bronchospasm
To detect active lung infection
To detect chronic lung disease and right heart failure
Woods BD Br J Anesthesia 2009
Assessment of risk
(The degree of airway obstruction assessed by FEV1 is not a significant independent risk factor for the development of postop respiratory failure after abdominal surgery. It should be viewed as management tool to optimize preoperative pulmonary function not to assess risk)
Preparation of patients with asthma for surgery.
*It should be tailored to the needs of the individual patient
*Symptoms should be optimally controlled in patients with asthma in elective surgery
*Premedication alloys anxiety, improves work of breathing, averts the induction of bronchospasm. Benzodiazepins are safe and do not alter bronchial tone (midazolam)
*In pts first evaluated immediately before operation steroid+ beta2 agonists+anticholinergics
Warner DO Anesthesiology 2000; 1467
*Allpatientsshould be encouragedtoquitsmoking, risk factorforPPCs (withinapproximately 2 monthsbeforesurgery)
*Smokingcessation (at least 4 wks) resulted in a relative risk reduction of 41% postopcomplications (Woundhealingandpulmonarycomplications)
Mills E Am J Med 011;124:144
Therewas no statisticaldifferencebetweengroups
Su FW J AllergyClinImmunol 111 (2): s127
Kabalin et a lArchInternMed. 1995;155:1379.
Between 1973-1986, 68 asthmaticsunderwent 92 surgicalprocedures,(68 were on inhled/oral corticosteroids)
All of themadministered 100 mg hydrocortisoneX3 daybeforesurgery
41 of themadministeredoutpatientprednisone on a dailybasisfor 1 weekbeforesurgery
9.7% postopcomplication (asthma+infection)
Overall no statisticallysignificantdifferencewhencomparedwithallsurgicalpatients
Pien LC et al J AllClinImmunol 1988;82:696
Decrease of pulmonarycomplications , mainly in traumapatients
Sauerland et al DrugSafe 2000; 119.
Kaballu et al AnnInternMed
3x2 puffssalbutamolfor 5 days
3x2 puffssalbutamol+ Methylprednisolone 40mg/dayfor 5 days
Silvanus et al Anesthesiology 2004; 1052
Theadministration of systemiccorticosteroids is recommended
Treatment:100 mg hydrocortisone (20 mg methylprednisoloneor 25 mg prednisolone)x3 taperdosebyhalfperdaytomaintenancelevel
Anxietyorpainduringregionalanesthesia can precipitatebronchospasm!!!!
Potentialadvantages of epidural (ratherthanspinal) includesless motor block of respiratorymuscles
Combo (Epiduralpostopanesthesia +general anesthesia) …reduction of postopcomplicationsbecause of earlierextubation, bettermobilisationandcoughingandimproveddiaphragmaticfunction
Acute intraoperative bronchospasm
Signs of acute bronchospasm(wheezing or silent chest)
Peak insp pressure elevation
Decrease of the slope of the expiratory CO2 curve
Prolonged expiratory phase
Visible slowing or lack of chest fall
The patient should immediately be switched to bag ventilation, compliance can be assessed (the bag will not fill on exhalation)
Differential diagnosis includes
1-mucous plugging or kinking of endotracheal tube
4- unilateral wheeze ( unilateral intubation or foreign body)
Woods BD Br J Anesthesia 2009
Deepining of anesthesia (Increased concentration of volatile anesthetic gases (isoflurane and sevoflurane), light anesthesia can trigger autonomic reflexes
Beta 2 agonist inhalation in larger doses (8-10 puffs followed by 2 puffs every 10 min)
Cs (1-2 mg/kg methylprednisolone)
Ipratropium bromide ( 6 puffs followed by 2 puffs every 10 min)
If it remains refractory epinephrine 1/1000 0.5 mg sc
Heliox (%21-30 O2)
Mgsulphate 1.2-2 g iv
Lidocain 1.5- 2 mg/kg iv
Emergence and postop care
Repeat beta 2 agonist before emergence if wheezing persists
Reversal of neuromuscular block (neostigmin increases bronchospasm and causes bradycardia and increases secretion)
Extubation when still deeply anesthesized
Woods BD Br J Anesthesia 2009
PostopperiodPaincontrol (Opiates/opioids)BronchodilatortherapyIncentivetherapyDeepbreathingexerciseEarlymobilizationChestphysiotherapyControl of refluxNIPV forasthmaticswhohavepersistentbronchospasmWarner DO Anesthesiology 2000; 1467Woods BD Br J Anesthesia 2009
GINA guidelineFEV1<80% personalbest, briefcourse of oral steroid (Evidence C)Ptswhohavereceivedsystemiccorticosteroidswithinpast 6 months100 mg hydrocortisone x3 iv reduced 24 hrsfollowingsurgery.Cstherapymayinhibitwoundhealing (Evidence C)
She has had asthma since childhood, wheezind and dyspnea in association with URTI, smoking (+)
Last episode of wheezing, dyspnea and cough 1 week before surgery
House dust mite, URTI
No previous admission
Inhaled corticosteroids with prn short acting beta 2 agonists no previous use of systemic steroids
Wheezing but she denies recent URTI
Next step ?
D-All of them
They do not alter anesthetic management in an asymptomatic stable asthmatic patients
However, in acute asthma
*Chest X-Ray would be useful to determine a cause for acute bronchospasm such as infection
*PFT would be useful to determine the degree of airway obstruction and response to further bronchodilator therapy
*ABG most frequently shows hypoxemia and hypocarbia in acute attack, hypercarbia indicates severe or longstanding airway obstruction and increases risk for pulmonary complication during surgery
Pharmacologic therapy is appropriate?
Primary goal is to decrease the risk of intra operative bronchospasm
Which ones sould be added?
E- Beta agonists?
Beta adrenergic agonists
In the middle of the operation , with the trachea intubation and anesthesia with halothane 0.5%+ nitrous oxide (66%),
Ayse begins to wheeze.
Anesthezist assumed that wheezing is related to light anesthesia and increased halothane to 1%
The wheezing subsided but then recurred after 20 minutes
In Ayse’s case, wheezing is relieved after administration of aerosols of albuterol and ipratropium bromide
In Ayse’s case, the recent intra operative bronchospasm might increase the likelihood of wheezing during emergence
What can be done?
Extubate the trachea in the presence of a high exhaled concentration of a volatile anesthetic
Bronchodilator aerosols can be administered during emergence
A poorly controlled asthmatic patient on oral steroids presents for emergency manipulation of a fractured radius. He is slightly breathless and wheezy at rest.
Regionalanesthesiawithpreopnebulisedbronchodilators+ İv steroid
He/sherequiressteroid supplementation perioperativelyandmaintenance
Case-3A patient with symptomatic asthma is involved in a road traffic accident and requires an urgent laparotomy for abdominal surgery. There are 30 minutes available until the patient comes to theatre.Management of the patient. A-Oxygen, fluids and analgesia B-Salbutamol+ipratropiumbromidenebuliserC- Hydrocortisone 100 mg IV 8 hourly D-Magnesium 2g IV over 20 minutesAnesthesiaAvoiddrugsassociatedwithhistaminerelease (d-tubocurarine, mivacurium)Inwellcontrolledasthmatics, morphineandatracurium in routinedosesarelow risk Induction of anaesthesia should be with a rapid sequence using either ketamine, etomidate or propofol
. Analgesia in theatre can be with intravenous opioids and these should be prescribed postoperatively. Short-acting opioid analgesics (alfentanil or fentanyl) are appropriate for procedures with minimal postoperative pain
Drugs considered safe for asthmatics
Propofol, etomidate, ketamine, midazolamOpioidsPethidine, fentanyl, alfentanilMusclerelaxantsVecuronium, suxamethonium, rocuronium, pancuroniumVolatileagentsHalothane, isoflurane, enflurane, sevoflurane, ether (nitrousoxide)
PregnancyandasthmaPoorlycontrolledasthma can haveadverseeffect on fetus, resulting in increasedperinatalmortalityandlowbirthweight(Evidence B)Inhaledcorticosteroidshavebeenshowntopreventexacerbations of asthmaduringpregnancy (Evidence B)Thefocus of treatmentmustremain on control of symptomsandmaintenance of normal functionMurphy VE; ERJ 2005;25:731Acuteexacerbationsshould be treatedaggresively in ordertoavoidfetalhypoxiaNAEPP expert panel report. Managingasthmaduringpregnancy J AllergyClinImmunol 2005;34
SafedrugsBeta 2 agonistSteroidsIntranasalsteroidLTRAAntihistaminics (Loratadin, Setrizin)ContraindicateddrugsEpinephrin, adrenalinAlphaadrenergicsdrugsDecongestantTetracyclinSulphonamideCiprogloxacinİodineImmunotherapy (newstarterorchange of dose)
AsthmaticpregnantanddeliveryandanesthesiaSevere attacksusuallybetwen 24-36. wksAsthmaticpregnantemergencycare rate 11-18% 62% of theseadmittedtohospital90% of asthmaticshave normal deliveryAttack rate is not highafter C/S EpiduralorspinalanesthesiaarepreferredRegionalanesthesia is a choiceespeciallyprostaglandinsareadministeredProstaglandin E2 is choicefordeliveryinduction not prostaglandin F2 alpha
Nasalpolyps, asthmaandsurgery69-96% of aspirin intolerantpatientshavepolypsand 29-70% patientswithpolypsmayhaveasthma111 ptswithasthmaunderwent general anesthesiaPeriopasthmaticattack rate10.2%(5 in 49 cases) no treatment7.5% (3 in 40 cases) pretreatmentexceptsystemicsteroid4.5% (1 in 22 cases) systemicsteroidOtolaryngologicalsurgeryespeciallythosehavenasalpolyp had highperiopasthmaattackIe K Aerugi 2010 ;59:831
Celiker V AllergolImmunopatholMed 2004 ;64.45 ptswho had beendiagnosedwithanalgesicintoleranceunderwentsurgery%80 asthma%75 allergicrhinitis%46 polyp%64 ENT surgeryBenzodiaepinforpreopvecuroniumformusclerelaxationisofluarane, evofluaraneformaintenanceFentanylforearlypostoppainreliefNone of thepatients had analgesicrelatedallergic problem