Before surgery, a thorough evaluation of pulmonary risk factors is essential to identify potential complications related to asymptomatic or poorly controlled airway hyper-reactivity. It is well established that perioperative and postoperative outcomes are closely linked to the severity of asthma at the time of surgery, the type of surgery being performed, and the anesthesia techniques employed.
Patients with asthma, particularly those with a history of uncontrolled use of inhaled corticosteroids and β2-agonists, recent systemic corticosteroid use, recent exacerbations, emergency department visits, hospitalizations, or previous intubations, should be assessed for poor asthma control. Signs such as wheezing, coughing, increased sputum production, shortness of breath, and diurnal variability in peak expiratory flow rate also indicate the need for further evaluation and potential for case cancellation or delay. These guidelines emphasize the importance of optimizing asthma management before surgery, as asthma is a leading cause of bronchoconstriction during surgery. Patients should be adequately managed and their medications should be continued up until the time of surgery.
For all patients, particularly those with asthma, smoking cessation should be encouraged before surgery. If a patient presents with an upper respiratory tract infection, particularly in pediatric cases, surgery should be postponed until complete resolution of symptoms is achieved. This is particularly important as children have an increased risk of bronchospasm. In such cases, postponing surgery for two to three weeks after symptom resolution may be necessary.
To reduce the risk of bronchospasm, pretreatment with a β2-agonist 30 minutes before surgery is recommended. Using propofol for induction and ensuring an adequate depth of anesthesia before airway manipulation can also lower the risk. Patients with significant bronchial hyperreactivity benefit from receiving steroids before anesthesia and surgery. Combining steroids with β-agonists is more effective than using either agent alone. For patients undergoing general anesthesia, potent inhalational agents at or above one minimum alveolar concentration (MAC) are essential, as they effectively reduce airway resistance and are central to the anesthetic management of these patients. Regional anesthesia techniques and the use of general anesthesia with a laryngeal mask airway (LMA) can help minimize the risk of bronchospasm by avoiding direct airway manipulation, when indicated.
This comprehensive approach to preoperative assessment and management helps mitigate the risks associated with bronchospasm during surgery, ensuring safer outcomes for patients with pulmonary risk factors.
