Bronchospasm
Anesthesia Implications
Anesthesia Implications
Treatment
- 100% O2
- Manually ventilate (to assess pulmonary compliance and to assess any other possible reasons for high circuit pressure)
- Deepen sedation with volatile anesthetic, ketamine (e.g. 15 mg), propofol, or combination. Sevoflurane is usually best for its bronchodilating effects. Desflurane and isoflurane can be irritating
- Short acting B2 agonist (e.g. albuterol)
- Epinephrine
- For all doses, give judiciously: In small increments and wait for reaction (recommended ~ 5 minutes wait)
- Adult IV: 5-10 mcg/kg IV
- Adult Subcutaneous: 0.3 – 0.5 cc (300-500 mcg) of 1:1000 SQ
- PEDs Subcutaneous: 5-10 mcg/kg
- PEDs Emergency IV push: Dilute a 1mg vial in 10-ml syringe of crystalloid, give 1-2 mL (100-200 mcg) in increments. MAX dose: 5 mL or 500 mcg
- Corticosteroids(e.g. hydrocortisone 2-4 mg) – Corticosteroids should be considered for the long-term affects. These drugs will help very little in for acute/emergent situations
Symptoms
High PIP and airway resistance (manual ventilation will often feel like the air isn’t moving, you’re “hitting a wall”, or you’re not getting through at all), decreased exhalation on the flow-volume loop, wheezing, higher required pressure to deliver the same tidal volume, reduced dynamic compliance, normal ETCO2 until severe, and hypoxemia
Smokers that quit less than 2 months prior to surgery are 4 times more likely to experience pulmonary complications (bronchospasm included).
Jet ventilation during bronchospasm leaves the patient at high risk for hypoventilation.
Pediatric patients require quicker intervention for suspected bronchospasm.
Neuromuscular blockers will NOT help in resolution of an active bronchospasm
Differential diagnoses: Mechanical obstruction of ETT tube, light anesthesia, endobronchial intubation, pulmonary aspiration, pulmonary edema, pulmonary embolus, pneumothorax, acute asthma attack
Pathophysiology
Bronchospasm is a disorder of smooth muscle.
#1 cause for intraoperative bronchospasm is light sedation.
Other contributing causes include reactive airway disease, parasympathetic stimulation, sympathetic blockade, instrumentation of the airway, esophageal intubation, vigorous suctioning of the airway, inhaled absorbent dust, allergic reaction, or pneumothorax
Resources:
Surgeries that can induce bronchospasm
- Any surgery requiring manipulation/instrumentation of the airway
- Mediastinoscopy
- Endoscopy
Conditions that can precipitate bronchospasm
- Reactive airway disease
- Asthma
- Foreign body aspiration
- Carcinoid crisis
- Upper respiratory tract infection – especially in pediatric patients
- Hypocalcemia
Drugs that should be avoided in patients at risk
- Histamine 2 receptor blockers (such as cimetidine and ranitidine)
- Prostaglandins (e.g. ergonovine and other ergot derivatives)
- Succinylcholine
- Beta blockers – particularly those with strong b-2 blockade
- Opioids that release histamine (e.g. morphine, codeine, meperidine)
- IV anesthetics that release histamine (e.g. Atracurium, Mivacurium)
- Anything that would cause an increased histamine, serotonin, or bradykinin level
Hines. Stoelting’s anesthesia and co-existing disease. 7th edition. 2018. p.19
Nagelhout. Nurse anesthesia. 6th edition. 2018. p. 116, 190, 195, 271, 274, 318, 596, 620-625, 798, 962, 966, 1205
