Melanie Kalmanowicz, MD

Department of Anesthesia, Critical Care and Pain Medicine

Beth Israel Deaconess Medical Center

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PMH: hypertension, hyperlipidemia, asthma, hypothyroidism

PSH: tonsillectomy at age 7, Cesarean sectionX2 (under spinal anesthesia)

Social history: never smoked, drinks occasionally alcohol, denies illicit drug use

Allergies: NKDA

Height: 62 in weight: 67 kg BMI: 27

Meds: Lisinopril, Advair, Albuterol, L-thyroxine, Simvastatin

Physical exam

VS: BP 143/78, HR 86, O2 sat (room air) 96%, afebrile

Gen: NAD

Heart: RRR ,nl S1/S2, no m/g/r

Lungs: BIL exp wheezing (upon questioning pat states she did not use her inhalers today because she thought she is not allowed to take meds since she is NPO)

Airway: MP II, HM>3, TM>6, neck: FROM, dentition: good

Is the patient symptomatic (aka does she feel short of breath)?

�No, she is a little nervous because of the surgery, but otherwise feels well

Did she have a recent URI?

�No, she feels great

Does she have a recent CXR?

�Yes, they did one pre-op which was normal

FYI: this is a good time to remind the patient that

she can take her asthma medication peri-

operatively

Has she recently been on steroids for her asthma?

� No

Has she ever been intubated and if so has she been told that it was difficult?

� The only time she was intubated was >50 years ago for her tonsillectomy; no known complications.

Has she had pulmonary function tests?

� No, since her asthma was always reasonably

controlled her doctor told her that’s not necessary

Careful: she is a trauma patient and thus

per definition not npo (delayed gastric

emptying)

When was the last time she had anything to eat or drink?

� She had pasta >6 hours ago, but since then is npo

What is her exercise tolerance like?

� She does yoga with her best friend once a week and also goes to a spinning class 2-3 times a

week.

Since she has wheezing it’s a good idea to give her some bronchodilator (e.g. Albuterol inhaler) prior to heading back to the OR.

FYI: if she was symptomatic or cyanotic on exam it would be reasonable to get a

room air/ baseline ABG;

since our pat is doing great that’s not necessary.

1)Chronic inflammatory changes in the submucosa of the airway

2) airway hyperresponsiveness

3) reversible expiratory airway obstruction

Clinical symptoms:

episodic cough, SOB, wheezing

some precipitating factors

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Treatment:� Avoid triggers

� Beta agonists� Steroids

� Antileukotriens� Anticholinergics� Theophylline

� Cromolyn

Also see guidelines for stepwise approach of asthma therapyby the National Asthma Education and Prevention Program

poandpo.com

Anesthetic considerations:

�continue pulmonary meds peri-operatively

�consider stress dose steroids if on chronic steroids

�consider extubating deep (if no contraindication)

�use drugs with bronchodilatatory effects

�adequate anesthetic depth prior to intubation

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� goal is to depress airway reflexes in order to avoid bronchoconstriction use drugs with bronchodilatatory effects and avoid those that can cause bronchoconstriction or histamine release.

� Sufficient anesthetic depth should be established prior to intubation to minimize bronchoconstriction.

Induction agents (example):

�Propofol 2-2.5mg/kg IV

�Ketamine 1-2.5 mg/kg IV (has bronchodilatatory properties, but can cause increased secretion)

Opiates (example):

�Fentanyl 1.5-3mcg/kg

Avoid morphine due to it’s histamine release (e.g. Hydromorphone has less histamine release)

Muscle relaxants (example):�Nondepolarizing NMBD: Rocuronium

0.6-1.2mg/kg IV�Depolarizing NMBD: Succinylcholine

0.5-1.5mg/kg IVAvoid Artracurium due to it’s histamine release

Inhalational agent (example):�Sevoflurane (MAC 2%)�Isoflorane (MAC 1.2%)Avoid Desflurane since it can cause airway irritation

A) Normal

A->B exhalation of gas in

anatomic dead space

B->C exhalation of gas from

dead space and prox

alveoli

C->D alveolar gas

D->E beginning of inspiration

B) In obstructive

pulmonary disease

Slow rate of rise from C->D

2/2 airway obstruction

(“shark fin appearance”)

emsresponder.com

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You first deepen the anesthetic by increasing the inhalational agent.

Since this patient has a h/o asthma, bronchoconstriction is high up on your differential.

Try an Albuterol inhaler via the endotracheal tube,

if no improvement � administer lidocaine,

no change� give epinephrine.

Although common things are common you should also

exclude other possibilities, e.g.:

�make sure the anesthetic depth is adequate

�rule out mechanical obstruction (e.g. pat biting on tube, tube kinking etc.)

�do you see secretions in tube that would warrant endotracheal suctioning?

�Are you concerned about a pneumothorax? (You should always have that in the back of your mind, but it seems less

likely in our patient, since the rest of her VS are stable, there was no central line placement and the surgery is far away

from the chest… )