Perioperative Management of Asthma in Cesarean Section

8/14/2019 Perioperative Management of Asthma in Cesarean Section

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PERIOPERATIVEPERIOPERATIVE

MANAGEMENT OFMANAGEMENT OF

ASTHMAASTHMA ININCESAREANCESAREAN

SECTIONSECTION

Houman Teymourian, M.DHouman Teymourian, M.D..Assistant professor, Department ofAssistant professor, Department ofAnesthesiology and Critical Care,Anesthesiology and Critical Care,

Shahid Beheshti MedicalShahid Beheshti MedicalUniversityUniversity


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ASTHMAASTHMA

Asthma is a very common chronic diseaseAsthma is a very common chronic disease

150 million people worldwide are affected150 million people worldwide are affected

The most common respiratory disease inThe most common respiratory disease in

women of childbearing agewomen of childbearing age 4% of all pregnancies are complicated by4% of all pregnancies are complicated by

asthmaasthma


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DEFINITION &DEFINITION &

PATHOPHYSIOLOGYPATHOPHYSIOLOGY It is a chronic inflammatory diseaseIt is a chronic inflammatory disease

of the airways involving multipleof the airways involving multiplecomponents of immune systemcomponents of immune system (mast(mast

cells, eosinophils,cells, eosinophils,neutrophils, T cell lymphocytesneutrophils, T cell lymphocytes& cysteinyl leukotrienes& cysteinyl leukotrienes))

Is associated with :Is associated with : acuteacutebronchoconstriction , airway edema , mucus plugbronchoconstriction , airway edema , mucus plug

formation ,& airway wall remodelingformation ,& airway wall remodeling Hyper reactivity ,Hypertrophy,Hyper reactivity ,Hypertrophy,

Autonomic dysfunction, InflammationAutonomic dysfunction, Inflammation

secretion & edemasecretion & edema


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CLASSIFICATIONCLASSIFICATION

1.1. Childhood-onset asthma (extrinsic)Childhood-onset asthma (extrinsic)

2.2. Adult-onset asthma (intrinsic)Adult-onset asthma (intrinsic)

or traditionally:or traditionally: Mild , Moderate , SevereMild , Moderate , Severe Women with severe asthma tends toWomen with severe asthma tends to

have more pronounced exacerbations ofhave more pronounced exacerbations ofdisease during pregnancydisease during pregnancy


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CLASSIFICATION OFCLASSIFICATION OF

ASTHMA SEVERITYASTHMA SEVERITY

STEP 1 (mild intermittent)STEP 1 (mild intermittent)Symptoms:Symptoms: 80% predicted

STEP 2 (mild persistent)STEP 2 (mild persistent)Symptoms:Symptoms: >2 times a weak but2 times a weak but 2 times a month> 2 times a month

Lung function:Lung function: FEV1 >80% predictedFEV1 >80% predicted


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STEP 3 (moderate persistent)STEP 3 (moderate persistent)Symptoms:Symptoms: daily , daily use of inhaled short actingdaily , daily use of inhaled short acting

22 agonists, exacerbations affect activity andagonists, exacerbations affect activity and

are >2 time a weak , may last daysare >2 time a weak , may last days

Nighttime symptoms:Nighttime symptoms: > 1 time a weak> 1 time a weak

Lung function:Lung function: FEV1 >60 -60 -


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PHYSIOLOGIC CHANGES OFPHYSIOLOGIC CHANGES OF

PREGNANCYPREGNANCY

Cardiovascular:Cardiovascular: HR, SV , CO ,BP ,SVR , PVRHR, SV , CO ,BP ,SVR , PVR Respiratory:Respiratory: MV , VT ,FRC , & RR remainsMV , VT ,FRC , & RR remains

unchanged, CO2 production but PaCO2unchanged, CO2 production but PaCO2

capillary engorgement of mucosa and edema ofcapillary engorgement of mucosa and edema ofthe oropharynx ,larynx ,and tracheathe oropharynx ,larynx ,and trachea

Hematologic:Hematologic: Blood volume 45%, red cellBlood volume 45%, red cell30%30%


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EFFECTS OF ASTHMA ONEFFECTS OF ASTHMA ON

PREGNANCYPREGNANCY The rate of prematurity ,pregnancyThe rate of prematurity ,pregnancy

induced hypertension , perinatal mortalityinduced hypertension , perinatal mortality

, low birth weight are increased, low birth weight are increased (particularly in(particularly in

steroid dependents)steroid dependents) Pre & post partum hemorrhage, pretermPre & post partum hemorrhage, preterm

labor , premature rupture of membraneslabor , premature rupture of membranes

Neonatal tachycardia & transientNeonatal tachycardia & transient

tachypneatachypnea Increase in need to induce labor & theIncrease in need to induce labor & the

rate of cesarean sectionrate of cesarean section


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TREATMENT OF ASTHMATREATMENT OF ASTHMA

Removal of triggers , monitoring ,patientRemoval of triggers , monitoring ,patient

educationeducation

STEP 1 (mild intermittent):STEP 1 (mild intermittent):

Inhaled short actingInhaled short acting2-2-agonist ( e.g. albuterol )agonist ( e.g. albuterol )

STEP 2 (mild persistent):STEP 2 (mild persistent):

step 1 +anti inflammatory (Inhaled steroid or cromolyn sodium) +step 1 +anti inflammatory (Inhaled steroid or cromolyn sodium) +possible use of sustained-release theophyllinepossible use of sustained-release theophylline

STEP 3 ( moderate persistent):STEP 3 ( moderate persistent):long actinglong acting 2-2-agonistagonist (e.g. salmeterol) + Inhaled steroid(e.g. salmeterol) + Inhaled steroid

STEP 4 (severe persistent):STEP 4 (severe persistent):all above + systemic steroidall above + systemic steroid


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TREATMENT OF ASTHMATREATMENT OF ASTHMA

DURING PREGNANCYDURING PREGNANCY

Poor treatment of asthma duringPoor treatment of asthma during

pregnancy contribute significantly topregnancy contribute significantly to

adverse outcomeadverse outcome

The risk of untreated asthma farThe risk of untreated asthma far

exceeds the risk of the medicationsexceeds the risk of the medications

Use ofUse of2-2-agonistsagonists is safe.is safe.

Use of oral corticosteroids isUse of oral corticosteroids is

associated with pregnancy-inducedassociated with pregnancy-induced

hypertension & weakly with low-birthhypertension & weakly with low-birth

weight & cleft palateweight & cleft palate


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Anti cholinergics (Ipratropium) mayAnti cholinergics (Ipratropium) may

be useful.be useful.

During delivery ,During delivery , InhaledInhaled

2-2-agonists +agonists +

steroidsteroid++ supplemental Osupplemental O22 should beshould beused forused for anyany level of asthmalevel of asthma

Leukotriene modifiers are safe duringLeukotriene modifiers are safe during

pregnancy (zafirlukast ,montelukast)pregnancy (zafirlukast ,montelukast)

Zileuton is associated with IUGR,Zileuton is associated with IUGR,

cleft palate, & long bonecleft palate, & long bone

abnormalitiesabnormalities


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Status AsmathicusStatus Asmathicus

Severe bronchospasm unresponsiveSevere bronchospasm unresponsive

to systemic steroids &to systemic steroids & 2-2-agonists thatagonists thatrequires mechanical ventilation & sedationrequires mechanical ventilation & sedation

& may be muscle relaxants & volatile& may be muscle relaxants & volatileanestheticsanesthetics

Use permissive hypercarbia ,Use permissive hypercarbia ,

anticholinergics , heliox , methyl xantinesanticholinergics , heliox , methyl xantines


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STATUS ASTHMATICUS INSTATUS ASTHMATICUS IN

PREGNANTSPREGNANTS In pregnants permissive hypercarbiaIn pregnants permissive hypercarbia

cannot be achievedcannot be achieved

PPV may make the decrease in cardiac outPPV may make the decrease in cardiac out

put even more pronouncedput even more pronounced Position is important( aortocavalPosition is important( aortocaval

compression )compression )

2-2-agonists & theophylline can causeagonists & theophylline can causeexcessive tachycardia in mother & atrialexcessive tachycardia in mother & atrial

arrhythmia in fetusarrhythmia in fetus

Heliox : only if adequate oxygenation canHeliox : only if adequate oxygenation can

be achieved with an FIO2 less than 0.4be achieved with an FIO2 less than 0.4


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Magnesium sulfate particularly inMagnesium sulfate particularly in

pregnancy-induced hypertension andpregnancy-induced hypertension and

asthmaasthma

There is some evidence that epiduralThere is some evidence that epiduralanesthesia alone can be efficacious inanesthesia alone can be efficacious in

termination of status asthmaticus in thetermination of status asthmaticus in the

parturientparturient

Early termination of pregnancy may beEarly termination of pregnancy may be

necessary to insure the survival of thenecessary to insure the survival of the

mother and may result in immediatemother and may result in immediate

improvement in the respiratory statusimprovement in the respiratory status


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ANESTHESIA FOR LABORANESTHESIA FOR LABOR


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ANESTHESIA FOR LABORANESTHESIA FOR LABOR

AND CESAREAN SECTION INAND CESAREAN SECTION IN

THE ASMATHIC PATIENTTHE ASMATHIC PATIENT Basic principles:Basic principles:

1.1. Optimization of pulmonary statusOptimization of pulmonary status

before anesthesiabefore anesthesia

2.2. Avoidance of bronchospasm inducingAvoidance of bronchospasm inducing

agents (histamine releasers)agents (histamine releasers)

3.3. Avoidance of airway irritation by anAvoidance of airway irritation by anendotracheal tube whenever possibleendotracheal tube whenever possible


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Neuraxial Anesthesia ForNeuraxial Anesthesia For

Cesarean SectionCesarean Section Epidural , Spinal , Combined spinal-Epidural , Spinal , Combined spinal-

epiduralepidural

Epidural anesthesia decreasesEpidural anesthesia decreases

catecholamine levels & Ocatecholamine levels & O22consumption , and may result inconsumption , and may result in

termination of the status asthmaticustermination of the status asthmaticus

Few cases of bronchospasm hasFew cases of bronchospasm has

been reported after spinal anesthesiabeen reported after spinal anesthesia

Patients on steroid therapy may bePatients on steroid therapy may be

at risk for infectionsat risk for infections


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No special considerations regardingNo special considerations regardingchoice of local anesthetics for thischoice of local anesthetics for thispopulationpopulation

Careful attention must be paid toCareful attention must be paid toavoidance of high block & respiratoryavoidance of high block & respiratoryfailurefailure

Maintenance of AdequateMaintenance of Adequateintravascular volume is importantintravascular volume is important If opioids are used either epidural orIf opioids are used either epidural or

intrathecally the patient must beintrathecally the patient must be

monitored carefully for respiratorymonitored carefully for respiratory


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GENERAL ANESTHESIAGENERAL ANESTHESIA

General anesthesia only if neuraxialGeneral anesthesia only if neuraxial

anesthesia is contraindicatedanesthesia is contraindicated

Risk of bronchospasm is high:Risk of bronchospasm is high:1.1. Tracheal intubationTracheal intubation

2.2. Rapid sequence inductionRapid sequence induction

3.3. Anesthetic level InsufficiencyAnesthetic level Insufficiency

Agents for induction: mostAgents for induction: mostcommonly thiopental, ketamin ,commonly thiopental, ketamin ,

propofolpropofol


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Ketamin : has mild bronchodilatoryKetamin : has mild bronchodilatoryaction due to release of endogenousaction due to release of endogenouscatecholaminescatecholamines

Propofol: efficacious in bluntingPropofol: efficacious in bluntingairway responces & has weakairway responces & has weakbronchodilatory action butbronchodilatory action buthemodynamic changes must behemodynamic changes must bemanaged appropriately andmanaged appropriately andaggressively in parturientaggressively in parturient

Thiopental: can cause histamineThiopental: can cause histamine

release, doses which is safe for fetusrelease, doses which is safe for fetus


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Lidocaine: is useful as an adjuvant toLidocaine: is useful as an adjuvant to

thiopental induction (1 mg/kg isthiopental induction (1 mg/kg is

enough to attenuate both airway andenough to attenuate both airway and

hemodynamic responses) ,hemodynamic responses) ,Aerosolized lidocaine is airwayAerosolized lidocaine is airway

irritant and should not be usedirritant and should not be used


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MUSCLE RELAXANTSMUSCLE RELAXANTS

Succinylcholine can be used forSuccinylcholine can be used for

initial relaxationinitial relaxation

Rocuronium is a safe alternativeRocuronium is a safe alternativein asthmaticsin asthmatics

Atracurium & Rapacuronium canAtracurium & Rapacuronium can

worsen bronchospasm &worsen bronchospasm &histamine releasehistamine release

Cisatracurium also is a choiceCisatracurium also is a choice

REVERSAL OFREVERSAL OF


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REVERSAL OFREVERSAL OF

NEUROMUSCULARNEUROMUSCULAR

BLOCKADEBLOCKADE Neostigmine can exacerbate airflowNeostigmine can exacerbate airflowobstruction by increasing secretionsobstruction by increasing secretions

and bronchospasmand bronchospasm

Edrophonium is a better choice inEdrophonium is a better choice in

asthmatic patientsasthmatic patients

Use of atropine or glycopyrrolate canUse of atropine or glycopyrrolate can

attenuate these effectsattenuate these effects

Succinylcholine infusion may beSuccinylcholine infusion may be

used to avoid using reversal agentsused to avoid using reversal agents


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Maintenance ofMaintenance of

anesthesiaanesthesia Halogenated agents haveHalogenated agents have

bronchodialating properties :bronchodialating properties :

halothane, isoflurane , sevofluranehalothane, isoflurane , sevoflurane

Disadvantage: using high alveolarDisadvantage: using high alveolar

concentration (>1 1.5 MAC) forconcentration (>1 1.5 MAC) for

control of bronchospasm increasecontrol of bronchospasm increase

bleeding from uterine relaxationbleeding from uterine relaxation Halothane disadvantage : cardiacHalothane disadvantage : cardiac

irritability particularly in highirritability particularly in high

catecholamine state andcatecholamine state and


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Extubation take place when theExtubation take place when the

patient is fully awake & airwaypatient is fully awake & airway

obstruction controlledobstruction controlled

Patient should be treated duringPatient should be treated during

surgery with Steroids &surgery with Steroids & 2-agonist2-agonist

Lidocaine infusion decreases airwayLidocaine infusion decreases airwayreactivity during emergencereactivity during emergence

Post operative Mechanical ventilationPost operative Mechanical ventilation

may be necessary to controlmay be necessary to control

obstructionobstruction


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Postpartum HemorrhagePostpartum Hemorrhage

Is Increased in asthmatics due to:Is Increased in asthmatics due to: Abnormalities in smooth muscles andAbnormalities in smooth muscles and

neural regulation of contractionneural regulation of contraction

Peripartum use ofPeripartum use of2-agonists2-agonists Use of Oxytocin is valid inUse of Oxytocin is valid in

asthmaticsasthmatics

Use of Ergot alkaloid e.g.Use of Ergot alkaloid e.g.methylegonovinemethylegonovine

( methergine) & ergonovine( methergine) & ergonovine

(ergotrate) is relatively(ergotrate) is relatively


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Postpartum HemorrhagePostpartum Hemorrhage

Prostaglandins used for uterineProstaglandins used for uterine

atony :atony : E causes bronchodilatationE causes bronchodilatation

(only vaginal gel is available)(only vaginal gel is available) F2F2 causes bronchoconstrictioncauses bronchoconstriction

Severe bronchospasm might beSevere bronchospasm might bepreferable to cardiovascularpreferable to cardiovascular

collapsecollapse


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Perioperative Management of Asthma in Cesarean Section

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