This was presented in the journal club at JNMC, Belagavi. This is based on an article by Alex Looseley.

1. Management of Bronchospasm
during General Anaesthesia
Chairperson: Dr. M.G. Dhorigol
Presenter: Dr. Ashwin Haridas

2. Article Details
 Author: Alex Looseley
 Journal: Update in Anaesthesia
 Volume 27,1
 Issue: October 2011

3. Introduction
 Bronchospasm during GA
 Isolated
 As part of anaphylaxis
 Characterized by
 Wheeze
 Prolonged expiration
 Increased peak airway pressures during IPPV

4. Bronchospasm
 Common feature of reactive airway disease
 COPD
 Asthma
 Hyper reactive airway response to mechanical and chemical stimuli
 Bronchospasm
 Mucosal oedema
 Mucus hyper secretion

5. Bronchospasm
 Perioperative bronchospasm in patients with reactive airway disease is
relatively uncommon
 Incidence is 2% in patients with well controlled asthma and COPD
 Overall incidence during GA is 0.2%1
 Risk
 Exposure to tobacco smoke
 URTI especially viral
 History of atopy
 Most patients have no history of reactive airway disease

6. Recognition of Bronchospasm
 Prolonged expiration
 Expiratory wheeze
 Movement of gas through narrowed airways
 Absent in severe spasm
 Absent or reduced breath sounds
 IPPV
 Raised peak airway pressure
 Reduced tidal volume*

7. Other causes of wheeze
 Partial obstruction of tracheal tube (including ETT abutting the carina or
endobronchial intubation)
 Pulmonary oedema
 Aspiration of gastric contents
 Pulmonary embolism
 Tension pneumothorax
 Foreign body in the tracheobronchial tree

8. Causes of increased peak airway pressure during
IPPV
 Anaesthetic equipment
 Excessive tidal volume
 High inspiratory flow rates
 Airway device
 Small diameter ETT
 Endobronchial intubation
 Tube is kinked or blocked

9. Raised IPPV contd.
 Patient factors
 Obesity
 Head down position
 Pneumoperitoneum
 Tension pneumothorax
 Bronchospasm

10. Recognition contd.
 Capnography
 Delayed rise in end tidal CO2
 Shark-fin capnograph

11. Recognition contd.
 Prolonged expiration is required
 Breath stacking during IPPV
 Development of an intrinsic or auto PEEP
 Raised intrathoracic pressure
 Decreased venous return
 Impaired cardiac output

12. Differential Diagnosis
 Most common during induction and maintenance than in emergence and
recovery
 Induction: Usually airway irritation due to intubation
 Maintenance
 Anaphylaxis/allergic reaction
 Drugs: Antibiotics, neuromuscular blockers
 Blood products
 Latex
 Rash, urticarial, angioedema, tachy/bradycardia, hypotension etc.

13. Differential Diagnosis contd.
 Mechanical obstruction
 Kinked, blocked, misplaced ETT
 A recent death which was initially treated as severe bronchospasm was
found to be due to blockage of the breathing circuit from a protective cap
of an IV set
 Check the circuit before use
 Ensure alternative means of ventilation(ambu)

14. Differential Diagnosis contd.
 Laryngospasm
 Non intubated patients
 Inspiratory stridor
 Increased respiratory effort
 Tracheal tug
 Paradoxical movement of chest and abdomen

15. Differential Diagnosis contd.
 Increased suspicion in h/o bronchial hyperreactivity
 Poorly controlled asthma and COPD
 h/o URTI, atopy, exposure to tobacco smoke
 Inadequate depth of analgesia
 Anal or cervical dilation
 Stripping of the long saphenous vein
 Peritoneal traction
 Often predictable and easily preventable

16. Pharmacological causes
 Isolflurane, desflurane
 NSAIDs, cholinesterase inhibitors
 Histamine releasing drugs
 Thiopentone, atracurium, mivacurium, morphine, d-Tc
 Care should be taken in high risk patients

17. Airway soiling
 Unexplained
 No risk of airway hyper reactivity
 Secretions, regurgitation, aspiration
 LMA
 ETT – Uncuffed, punctured or inadequately inflated cuff
 h/o GERD
 Sudden coughing in a spontaneously breathing patient

18. Prevention
 Asthma and COPD: Indicators of poor control
 Wheezing
 Increased sputum production
 Shortness of breath
 Diurnal variability in PEFR
 Continue medications till surgery

19. Prevention contd.
 Preoperative bronchodilators
 Corticosteroids
 Chest physiotherapy
 Referral to a respiratory physician
 H/o drug allergies
 Stop smoking – 6-8 weeks of abstinence significantly reduces respiratory
complications including bronchospasm

20. Prevention contd.
 URTI especially in children increases the risk significantly
 Postpone the surgery
 Complete resolution of symptoms correlates to decreased incidence of
airway hyperreactivity
 Pretreatment with inhaled/nebulized beta agonist
 Induction with propofol
 Adequate depth before airway instrumentation
 LMA instead of intubation
 Regional anesthesia

21. Management
 On suspecting bronchospasm
 Switch to 100% Oxygen
 Ventilate by hand
 Stop stimulation/surgery
 Consider allergy/anaphylaxis; stop administration of suspected drugs/blood
products

22. Management contd.
 Difficulty with ventilation or falling SpO2
 CALL FOR HELP

23.  Immediate management: prevent hypoxia and reverse bronchospasm
 Deepen anaesthesia
 If ventilation through ETT is difficult/impossible
 Check tube position
 Exclude blocked/misplaced tube
 Eliminate breathing circuit occlusion with self inflating bag
 In non intubated patients consider laryngospasm and aspiration

24. Drug Therapy
 1st line is salbutamol
 MDI: 6-8 puffs repeated as necessary(using in line adapter or 60ml syringe
with tubing or down ETT directly)
 Nebulised: 5mg (1ml 0.5%) repeated as necessary
 IV: 250mcg slow then 5mcg/min up to 20mcg/min

26. Drug Therapy contd.
 2nd line
 Ipratropium bromide: 0.5mg nebulized 6th hourly
 Magnesium sulphate: 50mg/kg IV over 20 min (max 2g)
 Hydrocortisone: 200mg IV 6th hourly
 Ketamine: Bolus 10-20mg, infusion 1-3mg/kg/h
 IN EXTREMIS: Adrenaline
 Nebulised: 5ml 1:1000
 IV: 10mcg (0.1ml 1:10000) 100mcg (1ml 1:10000) titrated to response

27. Secondary Management
 Consider transfer to HDU/ICU
 Optimise mechanical ventilation
 Reconsider allergy/anaphylaxis: expose and reexamine
 If no improvement consider pulmonary
oedema/pneumothorax/pulmonary embolus/foreign body
 Consider abandoning or aborting surgery
 Request & review CXR

30. Notes on the Algorithm
 Increasing the inspired concentration of all volatile anaesthetic agents will
produce bronchodilation and deepen anesthesia
 Delivery will be difficult in severe bronchospasm
 Consider IV agents especially ketamine
 Exclude oesophageal/endobronchial intubation
 Suction catheter may be passed to assess patency and clear secretions

31. Notes contd.
 Salbutamol can be repeated many times or given ‘back to back’
 Administer downstream of HMEF
 Hypercapnia is tolerated as long as oxygenation is maintained, as long as
acidosis does not develop (pH<7.15)
 If indication for surgery is not life threatening consider abandoning

32. Notes contd.
 Optimise ventilation – prevent barotrauma
 Prolong expiratory time
 Minimizing intrinsic PEEP: slow rate, I:E at least 1:2
 Very severe bronchospasm: only 3-4 breaths per minute may be possible if
complete expiration is allowed
 Auscultate or listen to disconnected ETT
 Rarely, to facilitate this, use external pressure to chest
 No consensus on application of external PEEP
 Many advocate trying to match applied PEEP to the estimated iPEEP

34. References
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incidence study of 136,929 patients. Acta Anaesthesiol Scand 1987;
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2. Pepe PE, Marini JJ. Occult positive end-expiratory pressure in
mechanically ventilated patients with airflow obstruction: the auto-
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3. Westhorpe RN, Ludbrook GL, Helps SC. Crisis management during
anaesthesia: bronchospasm. Qual Saf Health Care 2005; 14: e7.
4. Department of Health 2004. Protecting the Breathing Circuit in
Anaesthesia--Report to the Chief Medical Officer of an Expert Group
on Blocked Anaesthetic Tubing Available from: www.dh.gov.uk
5. Szczeklik A, Stevenson D. Aspirin-induced asthma: Advances in
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35. References contd.
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36. THANK YOU