Transcript of Bronchospasm during induction
- 1. Pascale Dewachter, Claudie Mouton-Faivre, Charles W.
Emala,Sadek Beloucif Anesthesiology 2011; 114:1200 10 DR. RISHABH
MITTALMODERATOR DR. AVNISH BHARADWAJ
- 2. Case Report A 25-yr-old woman Body mass index: 54 kg/m2 (
morbidly obese) Noninsulin-dependent diabetes Scheduled for
cochlear implant surgery. h/o 2 previous surgeries without incident
during childhood. NO history of atopy or drug allergy Normal Chest
auscultation before anaesthesia.
- 3. Case Report Anaesthetic coursePremedication Tab. Hydroxyzine
(100 mg) the day before and 1 h before inductionInduction - Inj.
sufentanil (20 g I.V) + Inj. propofol (350 mg I.V) Tracheal
Intubation (Cormack and Lehane grade I) - Inj. succinylcholine (130
mg I.V). Chest auscultation -complete absence of bilateral breath
sounds. End-tidal carbon dioxide (ETCO2) - Low. initially
- 4. What had happened?? SUSPECTED -Esophageal intubation ??
Patient immediately extubated Mask ventilation attempted -
difficult to perform Dramatically decreased lung compliance ETCO2 -
marked prolonged expiratory upstroke of the capnogram Bronchospasm
!!!!!!!!
- 5. What was DONE?? WITHIN FIVE MINUTES SpO2 55%, Arterial
hypotension ( From 130/75 to 50/20 mmHg), Moderate tachycardia (100
beats/min) Titrated epinephrine (two I.V boluses of 100 g each) ,
Ringer lactate- 1000 ml Blood pressure, 110/50 mmHg; heart rate,
110 beats/min), Ventilation became easier to perform Audible
wheezing over both lung fields. A localized (face and upper thorax)
erythema - Hydrocortisone(200 mg) I.VBlood sample 40 and 90 min
after the clinical reaction- to measure serum tryptase
concentrations
- 6. And then.. Surgery was postponed Patient was transferred to
the intensive care unit. Inhaled 2-agonist (salbutamol) I.V
corticoids (hydrocortisone, cumulative dose: 800 mg over24 h)
Respiratory symptoms resolved within 2 h h/o wheezing induced by
cold and exercise was elicited No additional supportive vasopressor
therapy was required Patient discharged home the following day
Allergologic assessment - after 6 wk
- 7. Bronchospasm?? Is defined as constriction of bronchi and
bronchioles Clinical feature of exacerbated underlying airway
hyper- reactivity symptoms include difficulty in breathing,
wheezing, coughing, and dyspnea. Chest auscultation wheezing
decreased or absent breath sounds - critically low airflow.
- 8. Peri-operative bronchospasm.. Usually arises during
induction of anesthesia May be detected at any stage of the
anaesthetic course. Bronchoconstriction due to - Immediate
hypersensitivity reaction EVOKING ALLERGY I. IgE-mediated
anaphylaxis II. Anaphylactoid reaction Non immune Mechanism
Non-allergic mechanism triggered by I. Mechanical factors (
intubation-induced bronchospasm) II. Pharmacologic factors (via
histamine-releasing drugs such as atracurium or mivacurium )
- 9. D/D of Intra-operative Bronchospasm Esophageal intubation
Inadequate anaesthesia Mucous plugging of the airway Kinked or
obstructed tube/circuit, Pulmonary aspiration. Unilateral wheezing
suggests endobronchial intubation or an obstructed tube by a
foreign body (such as a tooth). If the clinical symptoms fail to
resolve despite appropriate therapy, pulmonary edema or
pneumothorax should be considered.
- 10. Periop. Immediate Hypersenstivity Reaction Clinical entity
evoking allergy that varies in severity Occurs within 60 min after
the injection/introduction of the culprit agent Diagnosis is linked
to a triad including - 1. Clinical features ( Graded acc. to Ring
and Messmer clinical severity scale) 2. Blood tests (Tryptase level
measurements, serum-specific IgEs) 3. Postoperative skin tests with
the suspected drugs or agents
- 11. Ring and Messmer clinical severity scale Grade I: Erythema,
urticaria with or without angioedema Grade II: Cutaneous-mucous
signs hypotension tachycardia dyspnea gastrointestinal disturbances
Grade III: Cardiovascular collapse tachycardia or bradycardia
cardiac dysrythmia bronchospasm cutaneous-mucous signs
gastrointestinal disturbances; Grade IV: Cardiac arrest
- 12. Etiology in the Current Case Clinical diagnosis initially
suggested drug-induced anaphylactic reaction (allergic
bronchospasm) Sudden occurrence of bronchospasm after induction
Cardiovascular disturbances Cutaneous signs Succinylcholine-induced
anaphylaxis was suggested as the most likely etiology at first
sight. Neuromuscular blocking agents are the most frequent agents
involved in perioperative anaphylaxis in adults
- 13. Etiology in the Current Case How can we differentiate
between allergic and non- allergic bronchospasm clinically??
Clinical variables predicting IgE mediated anaphylaxis Presence of
any cutaneous symptoms ( 7times) Shock (cardiovascular collapse)
HALLMARK (27 t1mes) Episodes of desaturation (22 times) Prolonged
duration of clinical features (longer than 60 min) Cardiovascular
collapse -usually the inaugural clinical event , occur within
minutes after the drug challenge May occur either before or after
instrumentation of the airway
- 14. Etiology in the Current Case Non-allergic bronchospasm
Immediately follows nonspecific stimuli (irritation by ETT, suction
catheter) Usually not associated with cardiovascular symptoms but..
PEEP with severe bronchospasm may lead to a decrease in venous
return & hence cardiac output. Hypoxia and respiratory failure
from inadequate ventilation may lead to cardiovascular collapse
(occurs late after bronchospasm) Cutaneous signs may be
observed
- 15. Etiology in the Current CaseIn the current case Skin
testing remained negative in response to propofol, sufentanil,
succinylcholine, and latex solutions. Tryptase level were unchanged
(N less than 13.5 g/l.) - specific for mast cell activation
Serum-specific IgEs against succinylcholine and latex were not
detectable. Basophil activation test- Succinylcholine induced
neither CD63 nor CD203c up-regulation. Succinylcholine-induced
anaphylaxis was ruled out
- 16. Etiology in the Current Case Bronchospasm triggered by
endotracheal tube insertion and followed by cardiovascular collapse
(hypoxemia) suggests non-allergic bronchospasm Erythema may also be
observed during non-allergic bronchospasm. Morbid obesity of the
patient -precipitating factor of rapid arterial desaturation
Uncontrolled Asthma -main trigger of this non-allergic bronchospasm
(h/o wheezing induced by cold and exercise elicited from patient in
post-op period)
- 17. What is ASTHMA??Asthma is a chronic disorder of the airway
in which many cells and cellular elements play a role. The chronic
inflammation is associated with airway responsiveness that leads to
recurrent episodes of wheezing, breathlessness, chest tightness and
coughing, particularly at night or in the early morning. These
episodes are usually associated with widespread, but variable
airflow obstruction within the lung, that is often reversible
either spontaneously or with treatment. (2008)
- 18. ASTHMA Two main phenotypes:- Allergic Non-allergicOverlap
may occur within these groups Allergic Rhinitis and Allergic Asthma
Belong to the Same Airway Disease -More than 80% of asthmatic
individuals have rhinitis, and 1040% of patients with rhinitis have
asthma
- 19. Allergic Asthma Onset occurs primarily in early childhood
Results from immunologic reactions, mostly initiated by IgE
antibodies Atopy - (Genetic predisposition for the development of
an IgE- mediated response to common aeroallergens) - strongest
identifiable predisposing factor Triggers- Environmental factors -
tobacco smoke, air pollutants, and exposure to allergens Obesity,
diet, and hygiene hypothesis ATOPY + TRIGGERS ALLERGIC ASTHMA
- 20. Non-allergic Asthma: Aspirin-induced Asthma Widely under
diagnosed condition Not seen in childhood Inhibition of
cyclooxygenase enzymes by aspirin-like drugs in the airway of
sensitive patients Characterized by eosinophilic rhinosinusitis,
nasal polyposis, senstivity to aspirin or NSAIDs and asthma
Rhinorrhea, nasal congestion, and anosmia are the first clinical
features Asthma and sensitivity to aspirin appear approximately 15
yr after the onset of rhinitis
- 21. Perioperative Bronchospasm & AsthmaWesthorpe RN,
Ludbrook GL, Helps SC: Crisis management during anaesthesia:
Bronchospasm. Qual Saf Health Care 2005; 14:e7In a study conducted
by Westhorpe RN et al (103 cases)PERIOPERATIVE BRONCHOSPASM
Allergic (21%) / Non-allergic mechanism(79%) Of Non-allergic cases,
44% during induction, 36% during maintenance phase, and 20% during
emergence/recovery stage. Major causes during - Induction - airway
irritation (64%), tube misplacement (17%), aspiration (11%), and
other pulmonary edema or unknown causes (8%). Maintenance -allergy
(34%), endotracheal tube malposition (23%), airway irritation
(11%), aspiration with a laryngeal mask airway(9%)
- 22. Perioperative Bronchospasm & Asthma Bronchospasm
induced by airway irritability occurred more frequently in patients
who had one or more predisposing factors such as asthma, heavy
smoking, or bronchitis. Previous history of asthma was present in
50% cases of Non-allergic Bronchospasm 60% patients with allergic
bronchospasm Uncontrolled asthma/chronic obstructive pulmonary
disease is frequently involved with both allergic and non-allergic
bronchospasm, regardless of the stage of anesthesia (induction or
maintenance)
- 23. Mechanisms of Reflex-induced Bronchoconstriction Irritation
of the upper airway by a foreign body Afferent sensory
pathwaysStimulatory - Glutamate++ Nucleus of solitary Tract
Inhibitory- aminobutyric acid - -Glutamate++ Airway-related Vagal
Pre- ganglionic Neurons Airways via Vagus nerve Acetylcholine
release ++ Bronchoconstriction (M3 muscarinic receptor)
- 24. Reflex-induced Bronchoconstriction Non-adrenergic
non-cholinergic nerves (releasing tachykinins, vasoactive
intestinal peptide, and calcitonin gene-related peptide) may
participate in this reflex arc and/or locally release the pro-
contractile neurotransmitters via activation of inter-neurons in
the airway. Since Acetylcholine acting on M3 muscarinic receptors
on airway smooth muscle is a key component in mechanism, use of
antimuscarinic - inhaled medications (e.g., ipratropium or
tiotropium) should be advantageous to prevent /treat it.
- 25. Reflex-induced Bronchoconstriction Propofol and volatile
inhalational anaesthetics (except desflurane) are clinically
effective Have activity at inhibitory GABA-A chloride channels Have
direct bronchodilatory effects at the level of airway smooth muscle
(via GABA-A channels/ modulating calcium sensitivity of the
contractile proteins) Propofol preferentially relaxes tachykinin-
induced airway constriction Deepening anesthesia Prevents /relieves
reflex-induced bronchoconstriction Modulation of GABA input to the
airway-related vagal preganglionic neurons from the nTS/ higher
centers
- 26. BUT. Despite these protective effects of intravenous
propofol and the adequate induction dose used in the current case,
reflex-induced bronchoconstriction developed in this patient who
had previously unrecognized and untreated asthma.
- 27. Obesity and Asthma: Is There Any Relationship? Obesity-
body mass index of at least 30 kg/m2 Both are systemic inflammatory
states Chromosomal regions with loci common to obesity and asthma
phenotypes have been identified Obesity FRC & TV contractile
responses of airway smooth muscle airway reactivity
- 28. Obesity and Asthma: Is There Any Relationship?
Gastroesophageal reflux resulting from obesity may potentially
trigger a latent asthmatic condition Hormonal influences- hormone
leptin produced by adipocytes has effects on immune cell function
and inflammation Recent changes in lifestyle and diet are
associated with both Asthma remains under diagnosed in obese
patients - respiratory symptoms are frequently attributed to being
overweight (current case) Sleep-disordered breathing is more
prevalent in asthmatic as well as obese individuals
- 29. Prevention of Perioperative Bronchospasm Acc. To Global
Initiative for Asthma guidelines - Perioperative and postoperative
complications rely on Severity of asthma at the time of surgery
Type of surgery (thoracic /upper abdominal surg risk) Modalities of
anesthesia (GA with intubation risk) Uncontrolled asthma is
considered to be the main risk factor for bronchoconstriction
during surgery.
- 30. Prevention of Perioperative BronchospasmHISTORY Poorly
controlled Asthma may be assessed through Degree of asthma control
(inc. Use of medications, recent exacerbations of symptoms,
hospital visit within the last months) Potential risks or
complication factors (recent respiratory tract inf., previous
bronchospasm / pulmonary complications during/after previous surg,
long-term use of a systemic corticosteroids, assso.
gastroesophageal reflux or smoking). Abstinence from smoking before
surgery reduces perioperative pulmonary complications
- 31. Prevention of Perioperative BronchospasmPreoperative
Clinical and Physical Examination Acc. To Smetana et al
perioperative pulmonary complications occur if preoperative
examination reveals - Decreased breath sounds Dullness to
percussion Wheezing Rhonchi Prolonged expiratory phase In the
presence of active bronchospasm, elective surgery should be
postponedSmetana GW: Preoperative pulmonary evaluation. N Engl J
Med 1999; 340:937 44
- 32. Prevention of Perioperative BronchospasmMeasurement of lung
function (PFT) FEV1 /PEFR -better indicators of the severity of
asthma exacerbation than clinical symptoms. FEV1/ FVC (normal >
75%) - sensitive measure of severity and control Reversibility with
the use of a bronchodilator defined as increase in FEV1 of at least
12% or 200 ml. Before surgery PEF or FEV1 >> 80% of the
predicted or personal best is recommended. If PEF or FEV1 is