Asthma and consultation Prof Dr Berrin Ceyhan Dept of Pulmonary Medicine Marmara University School of Medicine ISTANB

1. Asthma and consultationProf Dr Berrin CeyhanDept of Pulmonary MedicineMarmara University School of MedicineISTANBUL

3. Operation in patients with asthma Pts with asthma are thought to be at high risk for pulmonary complications to develop during the periop and postop period and these complications may lead to serious morbidity Patients with untreated bronchial obstruction and hyperreactivity are at higher risk for periop complications Neverthelss how long a patient should be treated before undergoing airway instrumentation and surgery and whether this should include systemic corticosteroids is unknown

4. LITERATURE The low frequency of adverse outcomes in anesthesia practice limits the ability of researchers to conduct prospective randomized controlled trials to identify best practices Bronchospasm severe enough to require treatment probably occurs in the range of 1 in 250 patients anesthesized however 4 % incidence of asthma in general population makes asthma a significant risk factor for an adverse outcome It is unknown whether asthma can be linked to the rare severe outcome attributed to bronchospasm

5. Periop respiratory complications in patients with asthmaBetween 1979-1991, in Mayo Clinics Cohort study706 patients with asthma receive surgical procedurePerioperative bronchospasm and laryngospasm was surprisingly low (12pts , 1.7%, one of them developped postop respiratory failure)The risk increased in older pts and in those with active disease Warner DO Anesthesiology 1996; 460

6. ASA database declared 88 bronchospasm in 3533 closed claims during 1975-1994, it has showed 28 (32%) of pts who experienced a morbid event had a history of asthma and 10 more (11%) had a history of COPD or smoking. 90% bronchospasm was associated with intubation Cheney et al 1991; 932 Univ of Washington Med Center 70 (0.23%) in 30654 consecutive anesthetic pts had clinically significant bronchospasm, 10% of these pts had a history of asthma Postner KL, Am j Med Qual1994;129 In Japan, 105 pts with reactive airway disease, the incidence of intra or postop bronchospasm was not associated with duration of asthma, severity of disease, duration of the anesthesia and operation or FEV1. Intubation and the proximity of the latest asthmatic attack to the operation date were related Kumeta Y et al Masui 1995;396

14. Preop corticosteroid? Between 1986-2002, 190 asthmatics who underwent 249 procedures treated with preoperative corticosteroids/compared with general surgical population in the same hospital 14 (5.6%) postop bronchospasm 9(3.6%) postop infection 4(1.6%) wound infection There was no statistical difference between groups Su FW J Allergy Clin Immunol 111 (2): s127 In a retrospective cohort design of 71 asthmatics, 3 pts (4.5%) developed mild postoperative bronchospasm, five (5.6%) developed postoperative infections Kabalin et a lArch Intern Med. 1995;155:1379.

15. Preop corticosteroid? Between 1973-1986, 68 asthmatics underwent 92 surgical procedures,(68 were on inhled/oral corticosteroids) All of them administered 100 mg hydrocortisoneX3 day before surgery 41 of them administered outpatient prednisone on a daily basis for 1 week before surgery 9.7% postop complication (asthma+infection) Overall no statistically significant difference when compared with all surgical patients Pien LC et al J All Clin Immunol 1988;82:696

16. Systemic cs are safe? In a meta analysis, no increase in complication rate in 2500 pts undergoing surgery with preop 15-30 mg/kg methylprednisolone, Decrease of pulmonary complications , mainly in trauma patients Sauerland et al Drug Safe 2000; 119. No increased incidence of postop infection or delayed wound healing in 89 patients with asthma treated with cs in 3-7 preop days Kaballu et al Ann Intern Med

17. Preop cs vs beta agonist 41 patients with reversible airway obstruction (newly diagnosed or not received therapy for at least 1 month) were studied 3x2 puffs salbutamol for 5 days 3x2 puffs salbutamol+ Methylprednisolone 40mg/day for 5 days 2 puffs salbutamol preinduction Both salbutamol groups improved lung function to a similar extent (within 24 hours).However, the only group receiving steroids had a much lower incidence of wheezing after intubation Silvanus et al Anesthesiology 2004; 1052

18. The administration of systemic corticosteroids is recommended To reduce airway hyperesponsiveness in severe asthmatic subjects In pts who are suffering from acute asthma just before surgery In patients who might have depressed adrenal-pituitary response (systemic cs -5-20 mg/day prednisone for greater than2-3 wks within the the last 6 months of patients or pts who have taken greater than the conventional recommended doses of inhaled cs) Treatment:100 mg hydrocortisone (20 mg methyl prednisolone or 25 mg prednisolone)x3 taper dose by half per day to maintenance level

28. Postop periodPain control (Opiates/opioids)Bronchodilator therapyIncentive therapyDeep breathing exerciseEarly mobilizationChest physiotherapyControl of refluxNIPV for asthmatics who have persistent bronchospasm Warner DO Anesthesiology 2000; 1467 Woods BD Br J Anesthesia 2009 

29. GINA guidelineFEV1<80% personal best, brief course of oral steroid (Evidence C)Pts who have received systemic corticosteroids within past 6 months 100 mg hydrocortisone x3 iv reduced 24 hrs following surgery. Cs therapy may inhibit wound healing (Evidence C)

30. CASE -1 Ayse K 42 year-old asthmatic patient Inpatient in Gynecology ward With abdominal hysterectomy indication Preop pulmonology consultation was indicated

38. Case-2

39. Case-3A patient with symptomatic asthma is involved in a road traffic accident and requires an urgent laparotomy for abdominal surgery. There are 30 minutes available until the patient comes to theatre.Management of the patient. A-Oxygen, fluids and analgesia B- Salbutamol+ipratropium bromide nebuliser C- Hydrocortisone 100 mg IV 8 hourly D-Magnesium 2g IV over 20 minutes Anesthesia Avoid drugs associated with histamine release (d-tubocurarine, mivacurium)In well controlled asthmatics, morphine and atracurium in routine doses are low risk Induction of anaesthesia should be with a rapid sequence using either ketamine, etomidate or propofol 

40. . Analgesia in theatre can be with intravenous opioids and these should be prescribed postoperatively. Short-acting opioid analgesics (alfentanil or fentanyl) are appropriate for procedures with minimal postoperative pain  

42. Pregnancy and asthmaPoorly controlled asthma can have adverse effect on fetus, resulting in increased perinatal mortality and low birth weight (Evidence B)Inhaled corticosteroids have been shown to prevent exacerbations of asthma during pregnancy (Evidence B)The focus of treatment must remain on control of symptoms and maintenance of normal function Murphy VE; ERJ 2005;25:731Acute exacerbations should be treated aggresively in order to avoid fetal hypoxia NAEPP expert panel report. Managing asthma during pregnancy J Allergy Clin Immunol 2005;34

43. Safe drugsBeta 2 agonistSteroidsIntranasal steroidLTRA Antihistaminics (Loratadin, Setrizin)Contraindicated drugsEpinephrin, adrenalinAlpha adrenergics drugsDecongestantTetracyclinSulphonamideCiprogloxacinIodineImmunotherapy (new starter or change of dose)

44. Asthmatic pregnant and delivery and anesthesiaSevere attacks usually betwen 24-36. wksAsthmatic pregnant emergency care rate 11-18% 62% of these admitted to hospital90% of asthmatics have normal deliveryAttack rate is not high after C/S Epidural or spinal anesthesia are preferred Regional anesthesia is a choice especially prostaglandins are administeredProstaglandin E2 is choice for delivery induction not prostaglandin F2 alpha 

45. Nasal polyps, asthma and surgery69-96% of aspirin intolerant patients have polyps and 29-70% patients with polyps may have asthma111 pts with asthma underwent general anesthesiaPeriop asthmatic attack rate10.2%(5 in 49 cases) no treatment7.5% (3 in 40 cases) pretreatment except systemic steroid4.5% (1 in 22 cases) systemic steroidOtolaryngological surgery especially those have nasal polyp had high periop asthma attack Ie K Aerugi 2010 ;59:831

46. Celiker V Allergol Immunopathol Med 2004 ;64.45 pts who had been diagnosed with analgesic intolerance underwent surgery%80 asthma%75 allergic rhinitis%46 polyp%64 ENT surgeryBenzodiaepin for preopvecuronium for muscle relaxationisofluarane, evofluarane for maintenanceFentanyl for early postop pain reliefNone of the patients had analgesic related allergic problem