Anesthetic considerations

1

• Anesthetic considerations
• in asthmatics
• by R2
  ???

2
Anesthetic considerations in
asthmatics

• A. Introduction
• B. Preoperative evaluation
• C. Perioperative management
• D. Postoperative management

3
Introduction

• 1. What is the etiology of asthma ?
• the asthmatic diathesis is a nonspecific
• hyperirritability of the
  tracheobronchial
• tree.
• 2. What are the predisposing factors of
  asthmatic attacks ?
• Allergens. Pharmacologic stimuli.
• Infections. Exercise. Emotional stress
  .

4
Preoperative evaluation

• Frequency and interval of asthmatic
• attacks
• How long would you postpone electi-ve surgery if
  the patient had a recent upper respiratory tract
  infection?
• Cohen MM, Cameron CB. Should you cancel the
  operation when a child has an upper respiratory
  infection ? Anesth Analg 199172282-288

5
Perioperative management

• 1.How would you induce anesthesia?
• a. Principlesto block airway reflexes before
  laryngoscopy and intubation, to relax airway
  smooth muscle, and to prevent release of
  biochemical mediators.
• b. Would you use lidocaine for intubation ?
• c. Would you use propofol , etomidate, or
  ketamine for induction instead of pentothal ?

6

• Barash PG, Cullen BF, Stoelting RK, eds. Clinical
  anesthesia,
• 4th ed. Philadelphia Lippincott Williams
  Wilkins, 2001603-
• 604.
• Bishop MJ. Bronchospasm successful management.
  ASA Ann-
• ual Meeting Refresher Course Lectures. Park
  Ridge, ILAmeric-
• an Society of Anesthesiologists, 2002411
• Martin DE, Rosenberg H, Aukburg 5J, et al.
  Low-dose fentanyl blunts circulatory responses to
  tracheal intubation. Anesth Analg 198261680.
• Eames WO, Rooke GA, et al. Comparison of the
  effects of etomidate, propofol, and thiopental on
  respiratory resistance following tracheal
  intubation. Anesthesiology 1996841307-
• 1311
•  

7

• d. Which muscle relaxants would you
• use?
• e. What is your choice of agents for
• maintenance of anesthesia?

8

• Kingston HGG, Hirshman CA. Perioperative
  management of the patient with asthma. Anesth
  Analg 198463844.
• Basta SJ. Modulation of histamine release by
  neuromuscular blocking drugs. Curr Opin Anesth
  19925572.

9
 
10

• 2. In the middle of surgery, the patient
  developed a severe wheezing attack. How do you
  manage it?
• a. deepen the level of anesthesia and
• increase FIO2
• b. Relieve mechanical stimulation
• c. Medical intervention is necessary if the
• previously mentioned treatment
• cannot break the bronchospasm

11

• Barnes PJ. A new approach to the treatment of
  asthma. N Engl J Med 19893211517-1527.
• Bishop MJ. Bronchospasm successful management.
  ASA Annual Meeting Refresher Courses. Park Ridge,
  IL American Society of Anesthesiologists,
  2002411.

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• 3. How would you administer aminophyl-
• line?How does aminophylline relieve
• bronchospasm?
• The usual intravenous loading dose is
• 6.0 mg/kg given slowly, followed by a
• continuous infusion of 1.0 mg/kg per
• hour for smokers, 0.5 mg/kg per hour
• for nonsmokers .
• It was thought that aminophylline increases
  intracellular cAMP through inhibition of the
  enzyme phosphodiesterase (PDE), which inactivates
  cAMP .
• The use of aminophylline in the therapy of
  bronchospasm appears to be declining .

13

• Braunwald E, Fauci AS, Kasper DL, et aI, eds,
  Harrison's principles of internal medicine, 15th
  ed, New York McGraw-Hill, 20011456-1462.
• Hirshman CA, Airway reactivity in humans
  anesthetic implications. Anesthesiology
  198358170.

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• 4. Would you like to reverse the muscle relaxant
  when the operation was completed ?

15

• Gal TJ. Reactive airway disease anesthetic
  perspectives. International Anesthesia Research
  Society Review Course Lectures. Cleveland, OH
  International Anesthesia Research Society,
  200245-53.

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D. Postoperative Management

• 1.Would you extubate the asthmatic patient
  while he or she was deeply anesthetized?
• 2. When the patient cannot be extubated
  immediately following surgery , how would you
  keep the endotracheal tube in place without
  causing bronchoconstriction?
• 3. In asthmatic patients, are narcotics
  contraindicated for postoperative pain control?

17

• Lien CAt Kaff H, Malhotra V, et al. Emergence and
  extubation a systemic approach. Anesth Analg
  1997851177.
• Miller KH, Harkin CP Bailey PL. Postoperative
  tracheal extubation. Anesth Analg
  199580148-172.
•