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Management of Bronchospasm
during General Anaesthesia
Chairperson: Dr. M.G. Dhorigol
Presenter: Dr. Ashwin Haridas
Article Details
 Author: Alex Looseley
 Journal: Update in Anaesthesia
 Volume 27,1
 Issue: October 2011
Introduction
 Bronchospasm during GA
 Isolated
 As part of anaphylaxis
 Characterized by
 Wheeze
 Prolonged expirati...
Bronchospasm
 Common feature of reactive airway disease
 COPD
 Asthma
 Hyper reactive airway response to mechanical an...
Bronchospasm
 Perioperative bronchospasm in patients with reactive airway disease is
relatively uncommon
 Incidence is 2...
Recognition of Bronchospasm
 Prolonged expiration
 Expiratory wheeze
 Movement of gas through narrowed airways
 Absent...
Other causes of wheeze
 Partial obstruction of tracheal tube (including ETT abutting the carina or
endobronchial intubati...
Causes of increased peak airway pressure during
IPPV
 Anaesthetic equipment
 Excessive tidal volume
 High inspiratory f...
Raised IPPV contd.
 Patient factors
 Obesity
 Head down position
 Pneumoperitoneum
 Tension pneumothorax
 Bronchospa...
Recognition contd.
 Capnography
 Delayed rise in end tidal CO2
 Shark-fin capnograph
Recognition contd.
 Prolonged expiration is required
 Breath stacking during IPPV
 Development of an intrinsic or auto ...
Differential Diagnosis
 Most common during induction and maintenance than in emergence and
recovery
 Induction: Usually ...
Differential Diagnosis contd.
 Mechanical obstruction
 Kinked, blocked, misplaced ETT
 A recent death which was initial...
Differential Diagnosis contd.
 Laryngospasm
 Non intubated patients
 Inspiratory stridor
 Increased respiratory effort...
Differential Diagnosis contd.
 Increased suspicion in h/o bronchial hyperreactivity
 Poorly controlled asthma and COPD
...
Pharmacological causes
 Isolflurane, desflurane
 NSAIDs, cholinesterase inhibitors
 Histamine releasing drugs
 Thiopen...
Airway soiling
 Unexplained
 No risk of airway hyper reactivity
 Secretions, regurgitation, aspiration
 LMA
 ETT – Un...
Prevention
 Asthma and COPD: Indicators of poor control
 Wheezing
 Increased sputum production
 Shortness of breath
 ...
Prevention contd.
 Preoperative bronchodilators
 Corticosteroids
 Chest physiotherapy
 Referral to a respiratory physi...
Prevention contd.
 URTI especially in children increases the risk significantly
 Postpone the surgery
 Complete resolut...
Management
 On suspecting bronchospasm
 Switch to 100% Oxygen
 Ventilate by hand
 Stop stimulation/surgery
 Consider ...
Management contd.
 Difficulty with ventilation or falling SpO2
 CALL FOR HELP
 Immediate management: prevent hypoxia and reverse bronchospasm
 Deepen anaesthesia
 If ventilation through ETT is diff...
Drug Therapy
 1st line is salbutamol
 MDI: 6-8 puffs repeated as necessary(using in line adapter or 60ml syringe
with tu...
Drug Therapy contd.
 2nd line
 Ipratropium bromide: 0.5mg nebulized 6th hourly
 Magnesium sulphate: 50mg/kg IV over 20 ...
Secondary Management
 Consider transfer to HDU/ICU
 Optimise mechanical ventilation
 Reconsider allergy/anaphylaxis: ex...
Notes on the Algorithm
 Increasing the inspired concentration of all volatile anaesthetic agents will
produce bronchodila...
Notes contd.
 Salbutamol can be repeated many times or given ‘back to back’
 Administer downstream of HMEF
 Hypercapnia...
Notes contd.
 Optimise ventilation – prevent barotrauma
 Prolong expiratory time
 Minimizing intrinsic PEEP: slow rate,...
References
1. Olsson GL. Bronchospasm during anaesthesia. A computer-aided
incidence study of 136,929 patients. Acta Anaes...
References contd.
6. Dudzińska K, Mayzner-Zawadzka E. Tobacco smoking and the
perioperative period. Anestezjol Intens Ter ...
THANK YOU
Management of Bronchospasm during General Anaesthesia
Management of Bronchospasm during General Anaesthesia
Management of Bronchospasm during General Anaesthesia
Management of Bronchospasm during General Anaesthesia
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Management of Bronchospasm during General Anaesthesia

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This was presented in the journal club at JNMC, Belagavi. This is based on an article by Alex Looseley.

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Management of Bronchospasm during General Anaesthesia

  1. 1. Management of Bronchospasm during General Anaesthesia Chairperson: Dr. M.G. Dhorigol Presenter: Dr. Ashwin Haridas
  2. 2. Article Details  Author: Alex Looseley  Journal: Update in Anaesthesia  Volume 27,1  Issue: October 2011
  3. 3. Introduction  Bronchospasm during GA  Isolated  As part of anaphylaxis  Characterized by  Wheeze  Prolonged expiration  Increased peak airway pressures during IPPV
  4. 4. Bronchospasm  Common feature of reactive airway disease  COPD  Asthma  Hyper reactive airway response to mechanical and chemical stimuli  Bronchospasm  Mucosal oedema  Mucus hyper secretion
  5. 5. Bronchospasm  Perioperative bronchospasm in patients with reactive airway disease is relatively uncommon  Incidence is 2% in patients with well controlled asthma and COPD  Overall incidence during GA is 0.2%1  Risk  Exposure to tobacco smoke  URTI especially viral  History of atopy  Most patients have no history of reactive airway disease
  6. 6. Recognition of Bronchospasm  Prolonged expiration  Expiratory wheeze  Movement of gas through narrowed airways  Absent in severe spasm  Absent or reduced breath sounds  IPPV  Raised peak airway pressure  Reduced tidal volume*
  7. 7. Other causes of wheeze  Partial obstruction of tracheal tube (including ETT abutting the carina or endobronchial intubation)  Pulmonary oedema  Aspiration of gastric contents  Pulmonary embolism  Tension pneumothorax  Foreign body in the tracheobronchial tree
  8. 8. Causes of increased peak airway pressure during IPPV  Anaesthetic equipment  Excessive tidal volume  High inspiratory flow rates  Airway device  Small diameter ETT  Endobronchial intubation  Tube is kinked or blocked
  9. 9. Raised IPPV contd.  Patient factors  Obesity  Head down position  Pneumoperitoneum  Tension pneumothorax  Bronchospasm
  10. 10. Recognition contd.  Capnography  Delayed rise in end tidal CO2  Shark-fin capnograph
  11. 11. Recognition contd.  Prolonged expiration is required  Breath stacking during IPPV  Development of an intrinsic or auto PEEP  Raised intrathoracic pressure  Decreased venous return  Impaired cardiac output
  12. 12. Differential Diagnosis  Most common during induction and maintenance than in emergence and recovery  Induction: Usually airway irritation due to intubation  Maintenance  Anaphylaxis/allergic reaction  Drugs: Antibiotics, neuromuscular blockers  Blood products  Latex  Rash, urticarial, angioedema, tachy/bradycardia, hypotension etc.
  13. 13. Differential Diagnosis contd.  Mechanical obstruction  Kinked, blocked, misplaced ETT  A recent death which was initially treated as severe bronchospasm was found to be due to blockage of the breathing circuit from a protective cap of an IV set  Check the circuit before use  Ensure alternative means of ventilation(ambu)
  14. 14. Differential Diagnosis contd.  Laryngospasm  Non intubated patients  Inspiratory stridor  Increased respiratory effort  Tracheal tug  Paradoxical movement of chest and abdomen
  15. 15. Differential Diagnosis contd.  Increased suspicion in h/o bronchial hyperreactivity  Poorly controlled asthma and COPD  h/o URTI, atopy, exposure to tobacco smoke  Inadequate depth of analgesia  Anal or cervical dilation  Stripping of the long saphenous vein  Peritoneal traction  Often predictable and easily preventable
  16. 16. Pharmacological causes  Isolflurane, desflurane  NSAIDs, cholinesterase inhibitors  Histamine releasing drugs  Thiopentone, atracurium, mivacurium, morphine, d-Tc  Care should be taken in high risk patients
  17. 17. Airway soiling  Unexplained  No risk of airway hyper reactivity  Secretions, regurgitation, aspiration  LMA  ETT – Uncuffed, punctured or inadequately inflated cuff  h/o GERD  Sudden coughing in a spontaneously breathing patient
  18. 18. Prevention  Asthma and COPD: Indicators of poor control  Wheezing  Increased sputum production  Shortness of breath  Diurnal variability in PEFR  Continue medications till surgery
  19. 19. Prevention contd.  Preoperative bronchodilators  Corticosteroids  Chest physiotherapy  Referral to a respiratory physician  H/o drug allergies  Stop smoking – 6-8 weeks of abstinence significantly reduces respiratory complications including bronchospasm
  20. 20. Prevention contd.  URTI especially in children increases the risk significantly  Postpone the surgery  Complete resolution of symptoms correlates to decreased incidence of airway hyperreactivity  Pretreatment with inhaled/nebulized beta agonist  Induction with propofol  Adequate depth before airway instrumentation  LMA instead of intubation  Regional anesthesia
  21. 21. Management  On suspecting bronchospasm  Switch to 100% Oxygen  Ventilate by hand  Stop stimulation/surgery  Consider allergy/anaphylaxis; stop administration of suspected drugs/blood products
  22. 22. Management contd.  Difficulty with ventilation or falling SpO2  CALL FOR HELP
  23. 23.  Immediate management: prevent hypoxia and reverse bronchospasm  Deepen anaesthesia  If ventilation through ETT is difficult/impossible  Check tube position  Exclude blocked/misplaced tube  Eliminate breathing circuit occlusion with self inflating bag  In non intubated patients consider laryngospasm and aspiration
  24. 24. Drug Therapy  1st line is salbutamol  MDI: 6-8 puffs repeated as necessary(using in line adapter or 60ml syringe with tubing or down ETT directly)  Nebulised: 5mg (1ml 0.5%) repeated as necessary  IV: 250mcg slow then 5mcg/min up to 20mcg/min
  25. 25. Drug Therapy contd.  2nd line  Ipratropium bromide: 0.5mg nebulized 6th hourly  Magnesium sulphate: 50mg/kg IV over 20 min (max 2g)  Hydrocortisone: 200mg IV 6th hourly  Ketamine: Bolus 10-20mg, infusion 1-3mg/kg/h  IN EXTREMIS: Adrenaline  Nebulised: 5ml 1:1000  IV: 10mcg (0.1ml 1:10000) 100mcg (1ml 1:10000) titrated to response
  26. 26. Secondary Management  Consider transfer to HDU/ICU  Optimise mechanical ventilation  Reconsider allergy/anaphylaxis: expose and reexamine  If no improvement consider pulmonary oedema/pneumothorax/pulmonary embolus/foreign body  Consider abandoning or aborting surgery  Request & review CXR
  27. 27. Notes on the Algorithm  Increasing the inspired concentration of all volatile anaesthetic agents will produce bronchodilation and deepen anesthesia  Delivery will be difficult in severe bronchospasm  Consider IV agents especially ketamine  Exclude oesophageal/endobronchial intubation  Suction catheter may be passed to assess patency and clear secretions
  28. 28. Notes contd.  Salbutamol can be repeated many times or given ‘back to back’  Administer downstream of HMEF  Hypercapnia is tolerated as long as oxygenation is maintained, as long as acidosis does not develop (pH<7.15)  If indication for surgery is not life threatening consider abandoning
  29. 29. Notes contd.  Optimise ventilation – prevent barotrauma  Prolong expiratory time  Minimizing intrinsic PEEP: slow rate, I:E at least 1:2  Very severe bronchospasm: only 3-4 breaths per minute may be possible if complete expiration is allowed  Auscultate or listen to disconnected ETT  Rarely, to facilitate this, use external pressure to chest  No consensus on application of external PEEP  Many advocate trying to match applied PEEP to the estimated iPEEP
  30. 30. References 1. Olsson GL. Bronchospasm during anaesthesia. A computer-aided incidence study of 136,929 patients. Acta Anaesthesiol Scand 1987; 31: 244-52. 2. Pepe PE, Marini JJ. Occult positive end-expiratory pressure in mechanically ventilated patients with airflow obstruction: the auto- PEEP effect. Rev Respir Dis 1982; 126: 166-70. 3. Westhorpe RN, Ludbrook GL, Helps SC. Crisis management during anaesthesia: bronchospasm. Qual Saf Health Care 2005; 14: e7. 4. Department of Health 2004. Protecting the Breathing Circuit in Anaesthesia--Report to the Chief Medical Officer of an Expert Group on Blocked Anaesthetic Tubing Available from: www.dh.gov.uk 5. Szczeklik A, Stevenson D. Aspirin-induced asthma: Advances in pathogenesis, diagnosis, and management. J Allergy Clin Immunol 2003; 111: 913–21.
  31. 31. References contd. 6. Dudzińska K, Mayzner-Zawadzka E. Tobacco smoking and the perioperative period. Anestezjol Intens Ter 2008; 40: 108-13. 7. Nandwani N, Raphael JH, Langton JA. Effects of an upper respiratory tract infection on upper airway reactivity. Br J Anaesth 1997; 78: 352- 5. Szczeklik A, Stevenson D. Aspirin-induced asthma: Advances in pathogenesis, diagnosis, and management. J Allergy Clin Immunol 2003; 111: 913–21 8. Kim ES, Bishop MJ. Endotracheal intubation, but not laryngeal mask airway insertion, produces reversible bronchoconstriction. Anesthesiology 1999; 90: 391-4. 9. Dikmen Y, Eminoglu E, Salihoglu Z, Demiroluk S. Pulmonary mechanics during isoflurane, sevoflurane and desflurane anaesthesia. Anaesthesia 2003; 58: 745–48.
  32. 32. THANK YOU
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This was presented in the journal club at JNMC, Belagavi. This is based on an article by Alex Looseley.

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