Management of intraoperative bronchospasm

A basic overview on the management of intra-operative bronchospasm: the risk factors, triggers, diagnosis, prevention and management. Includes a case scenario – discussion.

1. Management of
Intra-operative
Bronchospasm

2. •Introduction
•Risk factors
•Triggers
•Diagnosis
•Prevention
•Management
•Case scenario – discussion
•Summary and conclusion
Contents

3. •Spasm of bronchial
smooth muscle, producing
narrowing of the bronchi

•Clinical feature of
exacerbated underlying
airway hyper reactivity

Introduction

4. •May be associated with IgE –
mediated anaphylaxis

•Or may occur as an independent
clinical entity, triggered by either
mechanical (by ETT or Suction catheter)

•and / or pharmacologic factors (drugs
causing histamine release – ex: Adenosine)
Forsythe, P., McGarvey, L.P.A., Heaney, L.G., MacMahon, J. and Ennis, M., 1999. Adenosine induces
histamine release from human bronchoalveolar lavage mast cells. Clinical Science, 96(4), pp.349-355.
Introduction
ETT – Endotracheal tube

5. •Hyper-reactive airway responses
to mechanical and chemical
irritants

•Incidence is ~ 2%

•H/o smoking, atopy and viral
URTI → increase the risk of
bronchospasm during anesthesia
Intra-operative bronchospasm
Risk factors
Looseley, A., 2011. Management of bronchospasm during general
anaesthesia. Clinical Overview Articles. Update in Anaesthesia, pp.17-21.
URTI – Upper respiratory tract infection

6. •Airway irritation
•Anaphylaxis
•Misplacement of ETT
•Aspiration of gastric contents
•Pulmonary edema
•Unknown, possibly allergy
Intra-operative bronchospasm
Triggers - Induction phase

7. •Allergy
•Aspiration
•Acute exacerbation of asthma
•Airway irritation
Intra-operative bronchospasm
Triggers - Intraoperative

8. •Pulmonary edema
•Anaphylaxis / allergy
•Inadvertent extubation
•Extubation spasm
•Aspiration
Intra-operative bronchospasm
Triggers - During Extubation

9. •Rash
•Wheeze (Expiratory) / silent chest
•Increased peak airway pressure during IPPV
•Hypotension due to development of auto PEEP.
•Falling oxygen saturation
•Increased ET CO
2
•Capnography change: ‘shark fin’ appearance
Intra-operative bronchospasm
Signs and symptoms
IPPV - Intermittent positive pressure ventilation
PEEP - Positive end-expiratory pressure

10. Bronchospasm during
anaesthesia usually
manifests as prolonged
expiration with wheeze
Signs and symptoms
Wheeze (Expiratory) / silent chest
Causes of wheeze during
general anaesthesia

•Partial obstruction of tracheal
tube (including ETT abutting
the carina or endobronchial
intubation)
•Bronchospasm
•Pulmonary oedema
•Aspiration of gastric contents
•Pulmonary embolism
•Tension pneumothorax
•Foreign body in the
tracheobronchial tree

11. With IPPV, peak airway
pressures are increased
and tidal volume reduced.
Signs and symptoms
Increased peak airway pressure during IPPV
Causes of increased peak
airway pressure during IPPV

•Anaesthetic equipment
Excessive tidal volume
High inspiratory flow rates
•Airway device
Small diameter tracheal tube
Endobronchial intubation
Tube kinked or blocked
•Patient
Obesity, Head down position,
Pneumo-peritoneum, Tension
pneumothorax, Bronchospasm

12. Signs and symptoms
Hypotension due to development of auto PEEP
Accumulation of air in alveoli if breath is delivered
before complete exhalation of previous breath
Positive airway pressure at the end of Expiration
Over expansion of lungs leading to dynamic
hyperinflation of lungs
Increase intrathoracic pressure → decrease
venous return and impair cardiac output
Hypotension

13. Signs and symptoms
Hypotension due to development of auto PEEP
Singer, B.D. and Corbridge, T.C., 2009. Basic invasive
mechanical ventilation. South Med J, 102(12), pp.1238-1245.

14. Narrowed airways and prolonged expiration result in
a delayed rise in end-tidal carbon dioxide, producing
a characteristic ‘shark fin’ appearance
Signs and symptoms
Capnography change: ‘shark fin’ appearance

15. Signs of intraoperative bronchospasm
•Wheezing or silence on auscultation
•Decrease of the slope of the expiratory CO
2 curve
•Increasing peak and plateau airway pressure

Subsequent symptoms
•Desaturation
•Hypercapnia
•Haemodynamic depression (due to high intra-thoracic pressure)
Intraoperative bronchospasm
Diagnosis

16. Rule out:
•Mechanical obstruction due to kinking, secretions,
over-inflation of tracheal tube cuff
•Laryngospasm
•Esophageal / endo-bronchial intubation
•Inadequate depth of anesthesia
•High intra-abdominal pressure (laparoscopy)
•Obstruction of tube by foreign body, mucus plug
•Pulmonary aspiration / edema / embolus
•Pneumothorax
•Extreme head-down position & bowel packing
•Pharmacological causes

Intraoperative bronchospasm
Differential diagnosis

17. To rule out almost all of the alternative causes:

•Knowledge of the patient’s history
•Check of the tubing and anaesthesia machinery
•Auscultate the patient
•Endotracheal suction
•Control of the surgical site
Intraoperative bronchospasm
Ruling out differential diagnosis

18. •A kinked / blocked (mucous plug, cuff herniation) or misplaced
(endobronchial, oesophageal) tracheal tube or occlusion in the
breathing circuit can mimic severe bronchospasm
•Unless rapidly recognised and corrected this can have disastrous
consequences

→ A death in the UK (initially treated as severe bronchospasm) was found
to be due to blockage of the breathing circuit with the protective cap from
an IV giving set
Ruling out the differential diagnosis
Kinking of endotracheal tube
Looseley, A., 2011. Management of bronchospasm during general
anaesthesia. Clinical Overview Articles. Update in Anaesthesia, pp.17-21.

19. In non-intubated patients acute laryngospasm can produce
upper airway noise (usually inspiratory), reduced breath
sounds and difficulty in ventilation.
Ruling out the differential diagnosis
laryngospasm
Bronchospasm Laryngospasm
Expiratory and accompained
by a wheeze or croup
Inspiratory usually
accompained by a stridor
Accessory muscles of
respiration
Indrawing of the intercostals
suprasternal notch present
Expiration is prolonged Not prolonged
Cyanosis is slow to develop Develops rapidly

20. •Manipulation of the airway or surgical stimulation under light
anaesthesia increases the risk of bronchospasm

•Surgical procedures triggering bronchospasm:
- Anal or cervical dilatation
- Stripping long saphenous vein – varicose vein surgery
- Traction on the peritoneum

→ can be prevented or countered by an intravenous bolus of
opioid and/or IV anaesthetic agent such as propofol.
Ruling out the differential diagnosis
Inadequate depth of anaesthesia

21. •Volatile anaesthetic agents (isoflurane, desflurane) if
introduced quickly can trigger bronchospasm.

•β-blockers, prostaglandin inhibitors (NSAIDs) and
cholinesterase inhibitors (neostigmine)

•Thiopentone, atracurium, mivacurium, morphine, d-
tubocurarine → Hisamine release → bronchospasm

Care should be taken with these drugs in high risk patients.
Ruling out the differential diagnosis
Pharmacological causes

22. •For COPD pts: stop smoking, infection control, chest
physiotherapy, use of bronchodilators and steroids

•Asthma: Evaluate the patient over the past half year.
Improve lung function to predicted values before surgery
(consider short course of oral steroids)

•URTI in children increases the risk of bronchospasm
→ postpone surgery till complete resolution of symptoms
(approximately 2 weeks)
→ correlates well with a decreased incidence of airway hyper
reactivity
Steps to prevent intra-op bronchospasm
Preoperative assessment – Patient factors

23. •Pretreatment with an inhaled/nebulised beta agonist – 30
minutes prior to surgery

•Induction of anaesthesia with propofol and adequate depth
of anaesthesia before airway instrumentation

•LMA cause less airway resistance increase than ETT.
.



Steps to prevent intra-op bronchospasm
Procedure considerations
LMA – Laryngeal mask airway

24. A.On suspecting bronchospasm

•Switch to 100% oxygen
•Ventilate by hand
•Stop stimulation / surgery
•Consider allergy / anaphylaxis; stop administration of
suspected drugs / colloid / blood products
•Thorough ETT suction after deepening of anesthesia.
Management
On suspecting bronchospasm

25. B. Immediate management – prevent hypoxia and
reverse bronchoconstriction

•Deepen anaesthesia
•If ventilation through ETT is difficult → check tube position
and exclude blocked/misplaced tube
•Eliminate breathing circuit occlusion → by using self
inflating bag
•In non-intubated patients: exclude laryngospasm and
aspiration
Management
Immediate management

26. Management
Drug therapy

27. Drug in bronchospasm
Drug dosage

28. C. Secondary management

•Optimize mechanical ventilation
•Reconsider allergy / anaphylaxis – expose and examine
the patient
•Review medications
•If no improvements – consider pulmonary edema /
embolus / pneumothorax / foreign body
•Consider aborting / abandoning surgery
•Request and review chest X-ray
•Consider transfer to critical care area for on-going
investigations and therapy
Management
Secondary management

29. •A 25-yr-old woman with morbid obesity (BMI: 54 kg/m
2
) and noninsulin-
dependent diabetes was scheduled for cochlear implant surgery
•No past history of any atopy or drug allergy
•Chest auscultation was normal before anesthesia
•Premedicated with hydroxyzine (100 mg orally) the day before and 1 h
before anesthesia, which was induced with sufentanil (20 g IV) and
propofol (350 mg IV)
•Tracheal intubation was facilitated with succinylcholine (130 mg IV)

After tracheal intubation was performed, chest auscultation revealed a
complete absence of bilateral breath sounds. Initial concentrations of
end-tidal carbon dioxide (ET
CO
2
) were low
Intraoperative bronchospasm
Case report
Dewachter, P., Mouton-Faivre, C., Emala, C.W. and Beloucif, S., 2011. Case scenario: bronchospasm during
anesthetic induction. The Journal of the American Society of Anesthesiologists, 114(5), pp.1200-1210.

30. What do we suspect?
•esophageal intubation was suspected, the patient was immediately
extubated and mask ventilation attempted.

→ Mask ventilation was difficult to perform because of dramatically
decreased lung compliance, whereas ET CO
2 demonstrated a marked
prolonged expiratory upstroke of the capnogram.

“Therefore, bronchospasm was considered”
What is the next move?
Case report
ET CO
2 – End tidal CO2 (partial pressure or maximal
concentration of CO2 at the end of an exhaled breath)

31. •Rapid arterial oxygen desaturation (SpO
2 55%) and hypotension (50/20
mm Hg)
•Moderate tachycardia (100 beats/min) occurred in less than 5 min after
the onset of bronchospasm.

What is our next move?

→ Epinephrine (100 μg IV bolus) along with Ringer’s lactate
(1000 ml) corrected the cardiovascular disturbances (arterial
blood pressure, 110/50 mmHg; heart rate, 110 beats/min)

ventilation became easier to perform along with the return of audible
wheezing over both lung fields.
How do we proceed from here?
Subsequent symptoms

32. •As arterial blood pressure was restored, a localized (face and upper
thorax) erythema occurred.

What is our next move?

→ Hydrocortisone (200 mg) was intravenously administered.
→ A blood sample was obtained to measure serum tryptase
concentrations, 40 and 90 min after the clinical reaction
→ Surgery was postponed, pt shifted to ICU for monitoring
How do we proceed from here?
Subsequent symptoms

33. •No additional supportive vasopressor therapy was required.

•Respiratory symptoms resolved within 2 h after inhaled β
2-agonist
(salbutamol) and IV corticoids (hydrocortisone, cumulative dose: 800
mg over 24 h).

•Subsequent clinical outcome was uneventful, and the patient was
discharged home the following day and returned 6 weeks later for
allergy assessment
Intraoperative bronchospasm
Case outcome

34. •Sudden occurrence of bronchospasm after anesthetic induction, with
cardiovascular disturbances and cutaneous signs,

→ clinically suggested a drug-induced anaphylactic reaction.


•Succinylcholine-induced anaphylaxis was the most likely etiology
→ neuromuscular blocking agents are the most frequent agents
involved in perioperative anaphylaxis in adults
Intraoperative bronchospasm
Case discussion

35. Stepwise approach to treatment
of perioperative bronchospasm
according to the clinical scenario

36. Thank you!

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Summary & conclusion
•Bronchospasm is a relatively common event during general anaesthesia.

•Management begins with switching to 100% oxygen and calling for help early.

•Stop all potential precipitants and deepen anaesthesia.

•Exclude mechanical obstruction or occlusion of the breathing circuit.

•Aim to prevent/correct hypoxaemia and reverse bronchoconstriction.

•Consider a wide range of differential diagnoses including anaphylaxis,
aspiration or acute pulmonary edema.

37. Thank
you