PBLD-39

Topic:

Management of Intraoperative Bronchospasm

Moderator/Facilitator(s):

Renee M. Mapes, D.O.

Disclosure:
Dr. Mapes Does not have significant financial relationships with any commercial product, manufacturer or provider.
After participating in this program, the learner will:
Indentify causes of bronchospasm in the intraoperative period
Select an appropriate anesthetic plan for management of intraoperative bronchospasm;
Formulate a plan utilizing updated ventilator modalities to manage a patient with perioperative
bronchospasm
Case
A 46-year-old female is scheduled for exploratory laparoscopy under general anesthesia for removal of an ovarian mass.
Past Medical History: asthma, obesity, gastroesophageal reflux disease, hypertension, and chronic neck pain
secondary to motor vehicle accident.
Allergies: penicillin (rash)
Past Surgical History: anterior cervical discectomy & fusion of C5-C7, cesarean section
Medications: omeprazole, lisinopril, hydrocodone/acetaminophen, albuterol, fluticasone, montelukast
Vital Signs: BP 134/80, P 76, SPO2 96% RA, RR 20, T370C, BMI is 37.8 kg/m2.
Physical Exam: unremarkable except decreased neck range of motion
Intraoperative Events: In operating room, ASA monitors on with intravenous antibiotics flowing. Patient is
preoxygenated. Intravenous induction with fentanyl, lidocaine, propofol, defasiculating dose of rocuronium
and succinylcholine. Nurse anesthetist attempts direct laryngoscopy but is unsuccessful, he then proceeds
with video laryngoscopy but is unsuccessful. The airway assessment is noted to be a grade I view. The
anesthesiologist steps in with video laryngoscopy and as endotracheal tube is being advanced through glottic
opening, patient coughs and reflexively reaches for the endotracheal tube. Two-hand mask ventilation is
established with some difficulty, propofol is given, sevoflourane is turned up for two minutes and
succinylcholine is rebolused. Video laryngoscopy is attempted again with success. Hand ventilation is difficult
and breath sounds are nonexistent over the lungs and abdomen. Capnogram revealed no end tidal carbon
dioxide.
Guiding Questions
1. What actions can you take in the preoperative period to minimize the chances of intraoperative bronchospasm in a
patient with a history of asthma?
2. How would you tailor your anesthetic plan in a patient with asthma? Are there any drugs you would avoid?
3. How would you recognize and diagnose intraoperative bronchospasm during general anesthesia?
4. List the differential diagnosis of intraoperative bronchospasm and wheezing during anesthesia?
5. How would you manage intraoperative bronchospasm in a patient under general anesthesia?
6. How would you manage an asthmatic patient in the postoperative setting?
7. What is the recommended ventilation strategy to manage perioperative bronchospasm?
Discussion Outline:
Preoperative assessment and strategies to minimize intraoperative bronchospasm.
Drugs to consider and drugs to avoid in asthmatics.
Recognize & diagnose causes of intraoperative wheezing and bronchospasm.
Management of intraoperative bronchospasm.
Postoperative care of the asthmatic patient.
Ventilation modalities to manage perioperative bronchospasm.

Reference(s)::
1. Applegate R, et al. The perioperative management of asthma. J. Aller Ther 2013; S11:007.
2. Looseley A. Management of bronchospasm during general anaesthesia. Update in Anaesthesia 2011; 27 (1): 17-21.
Available from: http//www.anaesthesiologists.org/.
3. Dewachter P, et al. Case Scenario: Bronchospasm during anesthetic induction. Anesthesiology 2011; 114 (5): 12001210.
4. Woods, B.D, Sladen R.N. Perioperative considerations for the patient with asthma and bronchospasm. British
Journal of Anaesthesia 2009; 103: i57-i65.
5. Bateman ED, et al. Global strategy for asthma management and prevention: GINA executive summary. Eur Respir J
2008; 31: 143-78.
6. Epner DL, Castells MC. Anaphylaxis during the perioperative period. Anesth Analg 2003; 97:1381-95.