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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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Operation in patients with asthma

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Operation in patients with asthma

AsthmaandconsultationProf Dr Berrin CeyhanDept of PulmonaryMedicineMarmara UniversitySchool of MedicineISTANBUL

Operation in patients with asthma

Operation in patients with asthma

  • Ptswithasthmaarethoughtto be at high risk forpulmonarycomplicationstodevelopduringtheperiopandpostopperiodandthesecomplicationsmayleadtoseriousmorbidity

  • Patientswithuntreatedbronchialobstructionandhyperreactivityare at higher risk forperiopcomplications

  • Neverthelsshowlong a patientshould be treatedbeforeundergoingairwayinstrumentationandsurgeryandwhetherthisshouldincludesystemiccorticosteroids is unknown



  • Thelowfrequency of adverseoutcomes in anesthesiapracticelimitstheability of researcherstoconductprospectiverandomizedcontrolledtrialstoidentifybestpractices

  • Bronchospasm severe enoughtorequiretreatmentprobablyoccurs in therange of 1 in 250 patientsanesthesizedhowever 4 % incidence of asthma in general populationmakesasthma a significant risk factorfor an adverseoutcome

  • It is unknownwhetherasthma can be linkedtotherare severe outcomeattributedtobronchospasm

Operation in patients with asthma

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

Operation in patients with asthma

  • ASA databasedeclared 88 bronchospasm in 3533 closedclaimsduring 1975-1994, it has showed 28 (32%) of ptswhoexperienced a morbidevent had a history of asthmaand 10 more (11%) had a history of COPD orsmoking. 90% bronchospasmwasassociatedwithintubation

    Cheney et al 1991; 932

  • Univ of Washington MedCenter 70 (0.23%) in 30654 consecutiveanestheticpts had clinicallysignificantbronchospasm, 10% of thesepts had a history of asthma

    Postner KL, Am j Med Qual1994;129

  • InJapan, 105 ptswithreactiveairwaydisease, theincidence of intraorpostopbronchospasmwas not associatedwithduration of asthma, severity of disease, duration of theanesthesiaandoperationor FEV1. Intubationandtheproximity of thelatestasthmaticattacktotheoperationdatewererelated

    Kumeta Y et al Masui 1995;396

Operation in patients with asthma

  • Vener et al reported periop bronchospasm in 23 , postop respiratory complications in 7% of 206 children with asthma (not related to asthma severity or chronic use of bronchodilators)

  • Vener et al Can J Anesthesiol 1991;A55.

  • Olsson et al reported 0.80 % intraop bronchospam in 3210 pts with asthma vs 0.16% in nonasthmatics

  • Olsson et al Acta Anesthesiol Scand 1987;344.

  • In a retrospective study, 0.81% frequency of bronchospasm in 486 asthmatics and 0.13% in 16535 nonasthmatics

  • Forrest et al Anesthesiology 1992;3

  • In a blinded auscultation 25% of asthmatics wheezed after iv induction anesthesia

  • Pizov Anesthesiology 1995;111

Operation in patients with asthma

Postoperative pulmonary complications (PPC)


Bronchospasm(History of asthma is not predictive for bronchospasm)

Unexplained fever

Excessive bronchial secretion


Respiratory failure

PPC occured more frequently than cardiac complications (9.6% vs 5.7%)

Lawrence WA J Gen Intern Med 1995;671.

Operation in patients with asthma

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)

Frequent exacerbations

Hospital visits

Prior severe attack (intensive care, mechanical ventilation)

Physical examination

To detect acute bronchospasm

To detect active lung infection

To detect chronic lung disease and right heart failure

Woods BD Br J Anesthesia 2009

Operation in patients with asthma





Chest X-Ray

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)

Operation in patients with asthma

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

Operation in patients with asthma

*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

Operation in patients with asthma

  • Ourgoal is topreventbronchoconstriction

  • *Preinductionadministration of beta agonistsandanticholinergicjustbeforesurgeryreducesthe risk of intraoperativebronchospasm

  • Inhaledalbuterol (4 puffs 15-20 min) protectsagainstintubation-inducedbronchoconstriction in asthmaticscurrentlyreceivingtreatment but intravenouslidocaine (15 mg/kg 3 minbeforetrachealintubation) ?

  • Aslow et al Anesthesiology 2000;1198

Preop corticosteroid


  • Between 1986-2002, 190 asthmaticswhounderwent 249 procedurestreatedwithpreoperativecorticosteroids/comparedwith general surgicalpopulation in thesamehospital

  • 14 (5.6%) postopbronchospasm

  • 9(3.6%) postopinfection

  • 4(1.6%) woundinfection

    Therewas no statisticaldifferencebetweengroups

    Su FW J AllergyClinImmunol 111 (2): s127

  • In a retrospectivecohortdesign of 71 asthmatics, 3 pts (4.5%) developedmildpostoperativebronchospasm, five (5.6%) developedpostoperativeinfections

    Kabalin et a lArchInternMed. 1995;155:1379.

Preop corticosteroid1

Preop corticosteroid?

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

Systemic cs are safe

Systemic cs are safe?

  • In a meta analysis, no increase in complication rate in 2500 ptsundergoingsurgerywithpreop 15-30 mg/kg methylprednisolone,

    Decrease of pulmonarycomplications , mainly in traumapatients

    Sauerland et al DrugSafe 2000; 119.

  • No increasedincidence of postopinfectionordelayedwoundhealing in 89 patientswithasthmatreatedwithcs in 3-7 preopdays

    Kaballu et al AnnInternMed

Preop cs vs beta agonist

Preop cs vs beta agonist

  • 41 patientswithreversibleairwayobstruction (newlydiagnosedor not receivedtherapyfor at least 1 month) werestudied

    3x2 puffssalbutamolfor 5 days

    3x2 puffssalbutamol+ Methylprednisolone 40mg/dayfor 5 days

    2 puffssalbutamolpreinduction

  • Bothsalbutamolgroupsimprovedlungfunctionto a similarextent (within 24 hours).However, theonlygroupreceivingsteroids had a muchlowerincidence of wheezingafterintubation

    Silvanus et al Anesthesiology 2004; 1052

Operation in patients with asthma

Theadministration of systemiccorticosteroids is recommended

  • Toreduceairwayhyperesponsiveness in severe asthmaticsubjects

  • Inptswhoaresufferingfromacuteasthmajustbeforesurgery

  • Inpatientswhomighthavedepressed adrenal-pituitaryresponse (systemiccs -5-20 mg/dayprednisoneforgreater than2-3 wkswithinthethelast 6 months of patientsorptswhohavetakengreaterthantheconventionalrecommendeddoses of inhaledcs)

    Treatment:100 mg hydrocortisone (20 mg methylprednisoloneor 25 mg prednisolone)x3 taperdosebyhalfperdaytomaintenancelevel

Operation in patients with asthma

  • Theanesthetic plan

  • Bronchospam can be provokedbylaryngoscopy, trachealintubation, airwaysuctioning, coldinspiredgasesandtrachealextubation

  • Mechanicalairwayirritationbyendotrachealintubation in volunteermildasthmaticsresulted in morethan 50% reduction in FEV1 andlidocainand beta 2 agonistreducedthisresponseto %20

  • Groeben et al Anesthesiology 2002; 579

Operation in patients with asthma


Spinalorepiduralanesthesia (toavoidtrachealintubation)

Anxietyorpainduringregionalanesthesia can precipitatebronchospasm!!!!

Potentialadvantages of epidural (ratherthanspinal) includesless motor block of respiratorymuscles

Combo (Epiduralpostopanesthesia +general anesthesia) …reduction of postopcomplicationsbecause of earlierextubation, bettermobilisationandcoughingandimproveddiaphragmaticfunction

Operation in patients with asthma

  • Intraoperativemanagement

  • Morphine can inducebronchospasmthroughhistaminerelease but not clinicallysignificantly

  • Propofolappearssuperiortothiopenthal

  • Eames et l Anesthesiology 1996, 1307

  • Ketamine has excellentinductioncharacteristicsandinducesbronchodilatation, (possiblybyinterferingwiththeendothelinpathway, stimulatingsympatheticsystem, attenuatingvagalreflexes)

Operation in patients with asthma

  • Topical anesthetics to the airways can provoke bronchospasm in asthmatics by stimulation of airway irritant receptors from the aerosol

  • Deep general anesthesia using a potent inhalational anesthetic provides excellent protection against bronchospasm. Potent inhalational agents produce dose dependent bronchodilatation (halothane is superior at lower concentrations). They directly attenuate airway reflexes in addition to directly relaxing airway smooth muscle

  • Lidocaine can prevent bronchospasm by attenuating sensory responses to airway instrumentation or irritation

Operation in patients with asthma

  • Latex allergy

  • Anesthetic maintenance with isoflurane or sevoflurane have protective bronchodilation, but desflurane provokes bronchoconstriction in smokers

  • Ventilatory mode to avoid auto PEEP by using higher insp flow rates or smaller tidal volues than usual

  • Woods BD Br J Anesthesia 2009

Operation in patients with asthma

  • Neuromusular blockade

  • D-tubocurarine, and atracurium provoke histamine release (administration the agent in divided doses or pretreatment with anti histamines)

  • Reversal of neuromuscular blockade is risk for provoking bronchspasm . Anticholinesterase might impair metabolism of acetylcholine at nerve terminal allowing activation of muscarinic receptor on airway smooth muscle (minimized with a muscarinic antagonist)

Operation in patients with asthma

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

2-pulmonary edema

3-tension pnx

4- unilateral wheeze ( unilateral intubation or foreign body)

Woods BD Br J Anesthesia 2009

Operation in patients with asthma


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

Operation in patients with asthma

Emergence and postop care


Airway obstruction



Poor ventilation


Repeat beta 2 agonist before emergence if wheezing persists

Adequate analgesia

Reversal of neuromuscular block (neostigmin increases bronchospasm and causes bradycardia and increases secretion)

Extubation when still deeply anesthesized

Woods BD Br J Anesthesia 2009

Operation in patients with asthma

PostopperiodPaincontrol (Opiates/opioids)BronchodilatortherapyIncentivetherapyDeepbreathingexerciseEarlymobilizationChestphysiotherapyControl of refluxNIPV forasthmaticswhohavepersistentbronchospasmWarner DO Anesthesiology 2000; 1467Woods BD Br J Anesthesia 2009

Operation in patients with asthma

GINA guidelineFEV1<80% personalbest, briefcourse of oral steroid (Evidence C)Ptswhohavereceivedsystemiccorticosteroidswithinpast 6 months100 mg hydrocortisone x3 iv reduced 24 hrsfollowingsurgery.Cstherapymayinhibitwoundhealing (Evidence C)

Case 1


  • Ayşe K 42 year-oldasthmaticpatient

  • Inpatient in Gynecologyward

  • Withabdominalhysterectomyindication

  • Preoppulmonologyconsultationwasindicated

Operation in patients with asthma


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

Triggering factors

House dust mite, URTI


No previous admission

Pharmacological therapy

Inhaled corticosteroids with prn short acting beta 2 agonists no previous use of systemic steroids

Physical examination

Wheezing but she denies recent URTI

Operation in patients with asthma

Next step ?

A-Chest roentgenogram



D-All of them

Operation in patients with asthma

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

Operation in patients with asthma

Next concern

Pharmacologic therapy is appropriate?

Primary goal is to decrease the risk of intra operative bronchospasm

Which ones sould be added?


B-Xanthine deriatives?


D-Systemic corticosteroids?

E- Beta agonists?

Operation in patients with asthma

Pharmacologic therapy

Beta adrenergic agonists





Operation in patients with asthma

Intraoperative bronchospasm

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

Operation in patients with asthma


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

Case 2


A poorly controlled asthmatic patient on oral steroids presents for emergency manipulation of a fractured radius. He is slightly breathless and wheezy at rest.

Preop management

Regionalanesthesiawithpreopnebulisedbronchodilators+ İv steroid

He/sherequiressteroid supplementation perioperativelyandmaintenance

Operation in patients with asthma

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

Operation in patients with asthma

. 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

Operation in patients with asthma

Drugs considered safe for asthmatics


Propofol, etomidate, ketamine, midazolamOpioidsPethidine, fentanyl, alfentanilMusclerelaxantsVecuronium, suxamethonium, rocuronium, pancuroniumVolatileagentsHalothane, isoflurane, enflurane, sevoflurane, ether (nitrousoxide)

Operation in patients with asthma

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

Operation in patients with asthma

SafedrugsBeta 2 agonistSteroidsIntranasalsteroidLTRAAntihistaminics (Loratadin, Setrizin)ContraindicateddrugsEpinephrin, adrenalinAlphaadrenergicsdrugsDecongestantTetracyclinSulphonamideCiprogloxacinİodineImmunotherapy (newstarterorchange of dose)

Operation in patients with asthma

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

Operation in patients with asthma

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

Operation in patients with asthma

Celiker V AllergolImmunopatholMed 2004 ;64.45 ptswho had beendiagnosedwithanalgesicintoleranceunderwentsurgery%80 asthma%75 allergicrhinitis%46 polyp%64 ENT surgeryBenzodiaepinforpreopvecuroniumformusclerelaxationisofluarane, evofluaraneformaintenanceFentanylforearlypostoppainreliefNone of thepatients had analgesicrelatedallergic problem

Operation in patients with asthma


  • Meta analysisreviewing 222 articlesbetween 1995-2005

  • Foradequatesedation, benzodiazepinesaresafe

  • It is preferrabletoavoidairwayinstrumentationandregionalanesthesiashouldalways be considered.

  • Whenregionalanesthesia is not feasibleand general anesthesia is requiredprophylacticantiobstructivetreatment, volatileanesthetics, propofol, opioidsand an adequatechoice of musclerelaxants minimize the risk

  • • Intubation may provoke bronchospasm and should be carried out under adequate anaesthesia, usually with opioid cover.Theuse of facemasksandlaryngealmasksresult in lessairwayirritation

  • Forinhalationalanesthetics, halothan, sevofluraneandisofluranehavebeenrecommended not desflurane

Operation in patients with asthma

  • For intravenous anesthetics, ketamine has sympathomimetic bronchodilatory properties

  • Propofol, a widely used short-acting iv anesthetic, has a direct airway smooth muscle relaxant effect

  • Muscle relaxant type depending on muscarinic receptor type should be used carefully, the reversal of its effect by neostigmine should be avoided

  • Local anesthetics such as lidocaine (iv, inhalation) can block bronchoconstriction reflex

  • Burburan et al Minerva Anesth 2007; 357.

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