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Anaesthesia for Obstructive

Airway Disease

Dr Prasanga Palihawadana (MD, FRCA)


Consultant Anaesthetist
General Hospital Ampara

Areas covered
Pathophysiology
Medical Management
Assessment of Bronchial Asthma
Preparation
Anaesthesia

Areas covered..
Management of Acute Severe Asthma in OT

COPD
Principles of Mx

Previous exam questions

Bronchial Asthma
A chronic inflammatory condition of lungs.
Common -10%

Symptoms
Cough
Wheeze
Chest tightness
SOB

Characteristic features
Airflow limitation
Airway hyper responsiveness
Inflammation

Causes
Atopy- Enviornmental

Pollen
Dust
Pollution
Viral infections

Causes
Cold air
Emotions
Occupational
Drugs - NSAIDS

Beta blockers

Pathophysiology
Inflammation

(Steroids)
Bronchoconstriction (beta2 agonists)
Cholinergic effect causing
Bronchoconstriction
(Ipratropium=atropine)

Pathophysiology
Histamine H1=Bronchoconstriction

(mast cell stabilisers)


Leucotrines in aspirin induced asthma

Management of BA (WHO
guidelines)
Lifestyle modification
Stepwise Rx with,
Inhaled beta agonists sos
Regular inhaled steroids
Plus regular beta agonists

Drug Treatment (preferably as


inhalers)
Beta 2 agonists Salbutamol,

Salmeterol, terbutaline
Steroids- Beclamethasone etc
Mast cell stabilisers- Sodium
chromoglycate

Treatment contd.
Anticholinergics- Ipratropium
Theophylline preparations
Oral steroids
Leucotrine receptor antagonists

Assessment of BA Pts
Duration
Symptoms
Precipitants
Rx & Compliance

Assessment of BA patients..
Effect on daily life
Acute attacks- Nebulisations

Hospitalisation
ICU admissions, ventilation
Previous anaesthetics

Examination & Investigations


General examination
Lung signs
PEF and reversibility

Investigations
CXRAY if indicated
Lung function tests-FEV1/ FVC

<60

Preparation and Anaesthesia


Allay anxiety
Continue RX bring inhalers to

OT
Optimise medical Mx if not
under control

Preparation & anaesthesia


Treat infections
Stop smoking
Nebulize before OT
IV steroids- hydrocortisone

100mg

Choice of anaesthesia- GA vs
Regional
Need to have minimal lung signs for

both
Spinal will avoid multiple drugs/
stimulation of airway
Epidural
Avoid high blocks

GA
How the anaesthetic is given is more important than
what the agent is

Safe drugs
Propofol
Ketamine(add atropine)
Etomidate
Midazolam

Safe drugs in BA..


Fentanyl
Pethidine
Vecuronium
Sux
Volatile agents

Possible precipitants
?TPS
? morphine
? Atracurium

Possible precipitants..
Protamine
Neostigmine
Diclofenac/ aspirin
Antibiotics

During anaesthesia
Try to avoid intubation- Face

mask/ LMA
Maintain adequate depth
Avoid stimulation under light
anaesthesia (ETT/surgery)
Secretions may precipitate

Intra op management..
Ventilate withSlow RR/moderate Vt; I :E> 1:2

Monitor SPO2, ETCO2, AWP


Avoid reversal
Deep extubation

Asthmatic attack under GA


High AWP
Tight bag
Desaturation
Upsloping ETCO2

Possible causes..
Anaphylaxis/ other hypersensitivity

reaction
Aspiration
Pneumothorax
Endobronchial ETT/ circuit occlusion

Management
Increase oxygen flow while

maintaining depth
Increase volatile agent (halothane)
Remove precipitant

Management contd.
Nebulise with -5mg salbutamol

0.5mg Ipratropium
(need circuit adaptor/oxygen driven
neb)
Steroids- 200 mg Hydrocortisone IV

Drug Rx
Aminophylline IV- 5mg/Kg bolus

in dextrose/20 min
(250 mg in a vial)
Follow up infusion at
0.5mg/Kg per hour
Salbutamol IV infusion

Second line drugs


Ketamine 0.5mg/Kg IV
MGSO4- 2g IV/ 30min

COPD
Chronic bronchitis &

emphysema
Abnormal lungs
Smoking/ other factors

COPD..
Infections
Hyperinflated lungs
Cor-pulmonale

Features of COPD
Pink puffers=compensated
Blue bloaters=decompensated
Airway obstruction is not completely

reversible
Rx- Beta 2 agonists/ steroids/
diuretics

Assessment
Functional capacity
How many pillows
CXRAY
Arterial blood gases
LFT

Anaesthesia
High risk
Avoid elective surgery if not well

controlled
Stop smoking
Rx Infection
Steam, Chest physio

Regionals when possible


GA= BA
Post op ICU
Controlled oxygen therapy

Exam Questions
Anaesthetic management of BA patient for

elective surgery
Acute asthmatic attack under GA
Short notes on salbutamol/ aminophylline

Thank you!