intraoperative bronchospasm

BRONCHOSPASM DURING INDUCTION

WHAT SHALL I DO..?

PRAY GOD THAT THIS SITUATION DOESN’T ARISE….

IN WHICH PATIENTS IT CAN OCCUR..?

BRONCHIAL ASTHMA

COPD

URI – esp IN CHILDREN

SMOKERS

Non allergic etiology – 79%Allergic cause - 21%

IN WHICH SITUATIONS IT CAN OCCUR…?

UNDER PREPARED PATIENTS WITH WHEEZING

GASTRIC ASPIRATION

LIGHTER PLANE – PREMATURE ATTEMPT

ANAPHYLAXIS

HOW TO DIAGNOSE….?

TIGHT BAG

FALLING OXYGEN SATURATION

FALLING EtCO2 LEVEL

NORMAL/REDUCED/NO CHEST MOVEMENT

WHEEZE / NO BREATH SOUNDS

HOW TO DIAGNOSE..?

COVER - WESTHORPE

C1 – COLOUR, CUTANEOUS MANIFESTATION FOR ALLERGYC2 – CAPNOGRAPHYO1 – LOW SpO2, CHECK ROTA METER,O2 SOURCEV1 - VENTILATION BY HAND, OBSERVE COMPLIANCE AND AUSCULTATEV2- CHECK VAPORISER FOR FLUID LEVEL, GAS LEAKSE1 – CHECK E.T.TE2 – EQUIPMENT RELATED CAUSESR1 – REVIEW ALL MONITORS

WHY BRONCHOSPASM IS FEARED..?

The narrowing of airway is so much that air entry sometimes become impossible….

1.Rapid de-saturation2.Increasing airway resistance3.Worsening lung compliance4.Decreased venous return5.Falling cardiac output6.Severe hypotension and collapse

WHAT SHOULD BE DONE..?

ASSESS THE SITUATION

ASSESSING THE SITUATION:ELECTIVE SURGERY:

MILD SPASM SEVERE SPASM

TREAT & PROCEEDTREAT AND POSTPONE THE SURGERY

CONSIDER EXTUBATION

EMERGENCY SURGERY

MILD SPASM SEVERE SPASM

TREAT AND PROCEEDWITH THE SURGERY

ASSESSING THE SITUATION:

HOW TO TREAT…?100% OXYGEN – Switch to Bain circuit

INHALED β2 AGONIST –Salbutamol Nebulizer, metered dose inhaler5 mg ( 5ml of 0.5%) or 8 to 10 puffs

INTRAVENOUS DRUGS – ETOPHYLLINE?AMINOPHYLLINE

STEROIDSMethyl prednisolone ( 1 mg / kg)

NEBULISED IPRATROPIUM 0.5 mg in 5 ml

How to attach the nebuliser to the Breathing circuit….?

A simple way of attaching the nebulizer circuit if T adaptor is not available….

TREATMENT – contd….

Whether to deepen the anaesthesia withinhalational agent or lighten the patient..?

STABLE HAEMODYNAMICS:

Give Halothane/isoflurane/sevoflurane

If spasm is severe- go for intravenous anaestheticsketamine/propofol

TREATMENT – contd…

TREATMENT – contd….

ROLE OF ADJUVANTS:

oKETAMINE – 10 -20 mg bolus , 1to 3mg/kg/hour

oMAGNESIUM – 50 mg/kg to a maximum of 2G

oXYLOCARD – 100mg bolus

o? ADRENALINE – useful in anaphylaxis

Consider extubation in resistant cases as a treatment modality….

HOW TO PREVENT SPASM DURING INDUCTION..?

NO ELECTIVE SURGERY IN A PATIENT WITH WHEEZE

ADEQUATE PREPARATION

STOP SMOKING

IF POSSIBLE – SELECT REGIONAL ANAESTHESIA

ROLE OF STEROIDS

44% of bronchospasm incidence occur during intubation – Westhorpe et al

HOW TO PREVENT SPASM DURING INDUCTION..?GIVE A GOOD PRE-MEDICATIONALWAYS USE ATROPINE/GLYCOPYROLATEANXIOLYTICS IN THE WARD OXYGEN SUPPLEMENTATIONINDUCTION- SMOOTH BY USING LIBERAL DOSESWITCH ON INHALATIONAL AGENT FROM THE BEGINNINGUSE XYLOCARD?XYLOCAINE SPRAYPROPOFOL or KETAMINE INDUCTION

HOW TO PREVENT SPASM DURING MAINTENANCE…?

REGIONAL ANAESTHESIA WITH G.A

CONSIDER SIMPLE NERVE BLOCKS

WOUND INFILTRATION

ADEQUATE ANALGESIA

36% bronchospasm incidence occur during maintenance phase - Westhorpe

HOW TO PREVENT SPASM DURING EXTUBATION..?

Tricky situationIf the type of surgery permits,

deeper plane of extubationXylocard, low dose ketamineGood post-operative analgesia and

oxygenation

The rest of 20% of cases occur during this phase of anaesthesia

Summary:Bronchospasm during induction can occur because of 2 reasons

1.Non-allergic airway hyperreactivity 2.As a part of anaphylactic syndrome

Needs urgent intervention as the vitals will deteriorate rapidly

A systematic approach helps in the early diagnosis

Inhalational β2 agonists is the mainstay of treatment

Summary..:

In resistant cases, adjuvants like ipratropium, magnesium have a role to play

As lighter plane of anaesthesia triggers spasm, patient has to be in deeper plane

Inhalational agents like halothane,sevoflurane possess broncho-dilating property

Adequate preparation, good analgesia and depth of anaesthesia help in avoiding this situation

Concluding…..

Prevention is better than cure

Thank you

dr.r.selvakumarprofessor of anaesthesiologyk.a.p.viswanatham govt medical collegetrichy