Medical emergency when bronchospasm is refractory to bronchodilator and steroids in the ED.
- Previous severe exacerbation (e.g., intubation or ICU admission for asthma)
- Two or more hospitalizations for asthma in the past year
- Three or more ED visits for asthma in the past year
- Hospitalization or ED visit for asthma in the past month
- Using >2 canisters of short-acting beta-2-agonist per month
- Attack while under systemic steroids, or recent discontinuation of steroids
- Difficulty perceiving asthma symptoms or severity of exacerbations, noncompliance
Table 205-1 Special Considerations for Anesthesia |Favorite Table|Download (.pdf)
Table 205-1 Special Considerations for Anesthesia
|Emergent surgery||Aggressive O2, beta-2-agonist, IV steroid therapy|
- Sedate with benzodiazepines
- Anticholinergic only if profuse secretions or using ketamine
- Avoid H2 antagonist due to unopposed H1-triggered bronchospasm
- Propofol and ketamine are bronchodilators
- Sevoflurane is the most potent bronchodilator among volatile agents (but clinical significance unclear)
- Avoid atracurium, mivacurium, morphine, meperidine (histamine release)
- Bronchospasm due to intubation, high spinal, pain, surgical stimulus
- Assess: wheezes, high peak pressure, low exhaled VT, rising ETCO2
- Deepen anesthesia: IV propofol, increase volatile agent concentration
- Rule out other causes: tube kinking, secretions, bronchial intubation, pulmonary edema, embolism, or pneumothorax
- Beta-2-agonist MDI in the inspiratory limb of the breathing circuit
- IV steroids
- Anticholinergic agent prevents bronchospasm before anticholinesterase
- Deep extubation (consider Bailey maneuver [replacement of ETT by LMA in patient under GA breathing spontaneously] if no risk of regurgitation) and lidocaine IV 1–2 mg/kg to prevent bronchospasm on emergence
- Cyanosis, profuse sweating, mental status changes
- Bradycardia, hypotension, pulsus paradoxus >15 mm Hg
- Accessory muscle use, silent chest, difficulty speaking, inability to lie down
- Peak expiratory flow rate (PEFR) <200 L/min and/or <40% predicted/usual value
- FEV1 <40% of predicted is an ominous sign in an adult
- Room air SpO2 <92%, PaO2 <60 mm Hg, Paco2 >45 mm Hg
See Table 205-2 for drug dosages.
- Oxygen: keep SaO2 ≥92% (>95% in pregnancy)
- Inhaled nebulized beta-2-agonist: albuterol
- Inhaled nebulized anticholinergic agent: ipratropium bromide, along with albuterol
- Steroids: methylprednisolone, dexamethasone, or hydrocortisone, IV, IM, or even PO:
- Give steroids early as peak action delayed by 3–4 hours
- Monitor K; replete as needed: both beta-agonists and steroids cause hypokalemia
- If high-risk predictors, signs of severity, no improvement after first treatment, transfer to ICU
- Magnesium sulfate IV if no resolution after 1 hour of continuous nebulization and steroids, or as first line if signs of severity
- Terbutaline or epinephrine (never both) after 1 hour of nebulization and steroids
- Heliox-driven albuterol nebulization after 1 hour of continuous nebulization and steroids. It decreases work of breathing and improve ventilation (but may lower O2)
- Ketamine is sometimes helpful when everything else fails before intubation
- Intubate with rapid sequence if:
- Unable to maintain airway
- Slow respiratory rate
- PCO2 normal or high
- If intubated:
- Vt 5–7 mL/kg, RR 6–8/min, I:E 1:3 ...
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