Operation in patients with asthma

1. AsthmaandconsultationProf Dr Berrin CeyhanDept of PulmonaryMedicineMarmara UniversitySchool of MedicineISTANBUL

3. Operation in patients with asthma • Ptswithasthmaarethoughtto be at high risk forpulmonarycomplicationstodevelopduringtheperiopandpostopperiodandthesecomplicationsmayleadtoseriousmorbidity • Patientswithuntreatedbronchialobstructionandhyperreactivityare at higher risk forperiopcomplications • Neverthelsshowlong a patientshould be treatedbeforeundergoingairwayinstrumentationandsurgeryandwhetherthisshouldincludesystemiccorticosteroids is unknown

4. LITERATURE • Thelowfrequency of adverseoutcomes in anesthesiapracticelimitstheability of researcherstoconductprospectiverandomizedcontrolledtrialstoidentifybestpractices • Bronchospasm severe enoughtorequiretreatmentprobablyoccurs in therange of 1 in 250 patientsanesthesizedhowever 4 % incidence of asthma in general populationmakesasthma a significant risk factorfor an adverseoutcome • It is unknownwhetherasthma can be linkedtotherare severe outcomeattributedtobronchospasm

5. Perioprespiratorycomplications in patientswithasthmaBetween 1979-1991, in Mayo ClinicsCohortstudy706 patientswithasthmareceivesurgicalprocedurePerioperativebronchospasmandlaryngospasmwassurprisinglylow (12pts , 1.7%, one of themdeveloppedpostoprespiratoryfailure)The risk increased in olderptsand in thosewithactivediseaseWarner DO Anesthesiology 1996; 460

6. ASA databasedeclared 88 bronchospasm in 3533 closedclaimsduring 1975-1994, it has showed 28 (32%) of ptswhoexperienced a morbidevent had a history of asthmaand 10 more (11%) had a history of COPD orsmoking. 90% bronchospasmwasassociatedwithintubation Cheney et al 1991; 932 • Univ of Washington MedCenter 70 (0.23%) in 30654 consecutiveanestheticpts had clinicallysignificantbronchospasm, 10% of thesepts had a history of asthma Postner KL, Am j Med Qual1994;129 • InJapan, 105 ptswithreactiveairwaydisease, theincidence of intraorpostopbronchospasmwas not associatedwithduration of asthma, severity of disease, duration of theanesthesiaandoperationor FEV1. Intubationandtheproximity of thelatestasthmaticattacktotheoperationdatewererelated Kumeta Y et al Masui 1995;396

7. Vener et al reported periop bronchospasm in 23 , postop respiratory complications in 7% of 206 children with asthma (not related to asthma severity or chronic use of bronchodilators) • Vener et al Can J Anesthesiol 1991;A55. • Olsson et al reported 0.80 % intraop bronchospam in 3210 pts with asthma vs 0.16% in nonasthmatics • Olsson et al Acta Anesthesiol Scand 1987;344. • In a retrospective study, 0.81% frequency of bronchospasm in 486 asthmatics and 0.13% in 16535 nonasthmatics • Forrest et al Anesthesiology 1992;3 • In a blinded auscultation 25% of asthmatics wheezed after iv induction anesthesia • Pizov Anesthesiology 1995;111

8. Postoperative pulmonary complications (PPC) Pneumonia Bronchospasm(History of asthma is not predictive for bronchospasm) Unexplained fever Excessive bronchial secretion Atelectasis Respiratory failure PPC occured more frequently than cardiac complications (9.6% vs 5.7%) Lawrence WA J Gen Intern Med 1995;671.

9. How can we prevent peri- and postoperative pulmonary complications in asthma? Preop evaluation of ashmatics History Symptoms Suboptimal antiinflammatory therapy Side effects of treatments Aspirin /NSAID intolerance Recent RTI (not related with recent URTI, Warner O Anesthesioloy 1996) Frequent exacerbations Hospital visits Prior severe attack (intensive care, mechanical ventilation) Physical examination To detect acute bronchospasm To detect active lung infection To detect chronic lung disease and right heart failure Woods BD Br J Anesthesia 2009

10. Investigations PFT ABG ECG Chest X-Ray Assessment of risk PFT (The degree of airway obstruction assessed by FEV1 is not a significant independent risk factor for the development of postop respiratory failure after abdominal surgery. It should be viewed as management tool to optimize preoperative pulmonary function not to assess risk)

11. Preparation of patients with asthma for surgery. *It should be tailored to the needs of the individual patient *Symptoms should be optimally controlled in patients with asthma in elective surgery *Premedication alloys anxiety, improves work of breathing, averts the induction of bronchospasm. Benzodiazepins are safe and do not alter bronchial tone (midazolam) *In pts first evaluated immediately before operation steroid+ beta2 agonists+anticholinergics Warner DO Anesthesiology 2000; 1467

12. *Allpatientsshould be encouragedtoquitsmoking, risk factorforPPCs (withinapproximately 2 monthsbeforesurgery) *Smokingcessation (at least 4 wks) resulted in a relative risk reduction of 41% postopcomplications (Woundhealingandpulmonarycomplications) Mills E Am J Med 011;124:144

13. Ourgoal is topreventbronchoconstriction • *Preinductionadministration of beta agonistsandanticholinergicjustbeforesurgeryreducesthe risk of intraoperativebronchospasm • Inhaledalbuterol (4 puffs 15-20 min) protectsagainstintubation-inducedbronchoconstriction in asthmaticscurrentlyreceivingtreatment but intravenouslidocaine (15 mg/kg 3 minbeforetrachealintubation) ? • Aslow et al Anesthesiology 2000;1198

14. Preopcorticosteroid? • Between 1986-2002, 190 asthmaticswhounderwent 249 procedurestreatedwithpreoperativecorticosteroids/comparedwith general surgicalpopulation in thesamehospital • 14 (5.6%) postopbronchospasm • 9(3.6%) postopinfection • 4(1.6%) woundinfection Therewas no statisticaldifferencebetweengroups Su FW J AllergyClinImmunol 111 (2): s127 • In a retrospectivecohortdesign of 71 asthmatics, 3 pts (4.5%) developedmildpostoperativebronchospasm, five (5.6%) developedpostoperativeinfections Kabalin et a lArchInternMed. 1995;155:1379.

15. Preop corticosteroid? Between 1973-1986, 68 asthmaticsunderwent 92 surgicalprocedures,(68 were on inhled/oral corticosteroids) All of themadministered 100 mg hydrocortisoneX3 daybeforesurgery 41 of themadministeredoutpatientprednisone on a dailybasisfor 1 weekbeforesurgery 9.7% postopcomplication (asthma+infection) Overall no statisticallysignificantdifferencewhencomparedwithallsurgicalpatients Pien LC et al J AllClinImmunol 1988;82:696

16. Systemic cs are safe? • In a meta analysis, no increase in complication rate in 2500 ptsundergoingsurgerywithpreop 15-30 mg/kg methylprednisolone, Decrease of pulmonarycomplications , mainly in traumapatients Sauerland et al DrugSafe 2000; 119. • No increasedincidence of postopinfectionordelayedwoundhealing in 89 patientswithasthmatreatedwithcs in 3-7 preopdays Kaballu et al AnnInternMed

17. Preop cs vs beta agonist • 41 patientswithreversibleairwayobstruction (newlydiagnosedor not receivedtherapyfor at least 1 month) werestudied 3x2 puffssalbutamolfor 5 days 3x2 puffssalbutamol+ Methylprednisolone 40mg/dayfor 5 days 2 puffssalbutamolpreinduction • Bothsalbutamolgroupsimprovedlungfunctionto a similarextent (within 24 hours).However, theonlygroupreceivingsteroids had a muchlowerincidence of wheezingafterintubation Silvanus et al Anesthesiology 2004; 1052

18. Theadministration of systemiccorticosteroids is recommended • Toreduceairwayhyperesponsiveness in severe asthmaticsubjects • Inptswhoaresufferingfromacuteasthmajustbeforesurgery • Inpatientswhomighthavedepressed adrenal-pituitaryresponse (systemiccs -5-20 mg/dayprednisoneforgreater than2-3 wkswithinthethelast 6 months of patientsorptswhohavetakengreaterthantheconventionalrecommendeddoses of inhaledcs) Treatment:100 mg hydrocortisone (20 mg methylprednisoloneor 25 mg prednisolone)x3 taperdosebyhalfperdaytomaintenancelevel

19. Theanesthetic plan • Bronchospam can be provokedbylaryngoscopy, trachealintubation, airwaysuctioning, coldinspiredgasesandtrachealextubation • Mechanicalairwayirritationbyendotrachealintubation in volunteermildasthmaticsresulted in morethan 50% reduction in FEV1 andlidocainand beta 2 agonistreducedthisresponseto %20 • Groeben et al Anesthesiology 2002; 579

20. Regionalanesthesia Spinalorepiduralanesthesia (toavoidtrachealintubation) Anxietyorpainduringregionalanesthesia can precipitatebronchospasm!!!! Potentialadvantages of epidural (ratherthanspinal) includesless motor block of respiratorymuscles Combo (Epiduralpostopanesthesia +general anesthesia) …reduction of postopcomplicationsbecause of earlierextubation, bettermobilisationandcoughingandimproveddiaphragmaticfunction

21. Intraoperativemanagement • Morphine can inducebronchospasmthroughhistaminerelease but not clinicallysignificantly • Propofolappearssuperiortothiopenthal • Eames et l Anesthesiology 1996, 1307 • Ketamine has excellentinductioncharacteristicsandinducesbronchodilatation, (possiblybyinterferingwiththeendothelinpathway, stimulatingsympatheticsystem, attenuatingvagalreflexes)

22. Topical anesthetics to the airways can provoke bronchospasm in asthmatics by stimulation of airway irritant receptors from the aerosol • Deep general anesthesia using a potent inhalational anesthetic provides excellent protection against bronchospasm. Potent inhalational agents produce dose dependent bronchodilatation (halothane is superior at lower concentrations). They directly attenuate airway reflexes in addition to directly relaxing airway smooth muscle • Lidocaine can prevent bronchospasm by attenuating sensory responses to airway instrumentation or irritation

23. Latex allergy • Anesthetic maintenance with isoflurane or sevoflurane have protective bronchodilation, but desflurane provokes bronchoconstriction in smokers • Ventilatory mode to avoid auto PEEP by using higher insp flow rates or smaller tidal volues than usual • Woods BD Br J Anesthesia 2009

24. Neuromusular blockade • D-tubocurarine, and atracurium provoke histamine release (administration the agent in divided doses or pretreatment with anti histamines) • Reversal of neuromuscular blockade is risk for provoking bronchspasm . Anticholinesterase might impair metabolism of acetylcholine at nerve terminal allowing activation of muscarinic receptor on airway smooth muscle (minimized with a muscarinic antagonist)

25. Acute intraoperative bronchospasm Signs of acute bronchospasm(wheezing or silent chest) Peak insp pressure elevation Decrease of the slope of the expiratory CO2 curve Prolonged expiratory phase Visible slowing or lack of chest fall The patient should immediately be switched to bag ventilation, compliance can be assessed (the bag will not fill on exhalation) Differential diagnosis includes 1-mucous plugging or kinking of endotracheal tube 2-pulmonary edema 3-tension pnx 4- unilateral wheeze ( unilateral intubation or foreign body) Woods BD Br J Anesthesia 2009

26. Treatment Deepining of anesthesia (Increased concentration of volatile anesthetic gases (isoflurane and sevoflurane), light anesthesia can trigger autonomic reflexes Beta 2 agonist inhalation in larger doses (8-10 puffs followed by 2 puffs every 10 min) Cs (1-2 mg/kg methylprednisolone) Ipratropium bromide ( 6 puffs followed by 2 puffs every 10 min) If it remains refractory epinephrine 1/1000 0.5 mg sc Heliox (%21-30 O2) Mgsulphate 1.2-2 g iv Lidocain 1.5- 2 mg/kg iv

27. Emergence and postop care Alertness!!! Airway obstruction Laryngospasm Bronchospasm Poor ventilation Hypoxemia Repeat beta 2 agonist before emergence if wheezing persists Adequate analgesia Reversal of neuromuscular block (neostigmin increases bronchospasm and causes bradycardia and increases secretion) Extubation when still deeply anesthesized Woods BD Br J Anesthesia 2009

28. PostopperiodPaincontrol (Opiates/opioids)BronchodilatortherapyIncentivetherapyDeepbreathingexerciseEarlymobilizationChestphysiotherapyControl of refluxNIPV forasthmaticswhohavepersistentbronchospasmWarner DO Anesthesiology 2000; 1467Woods BD Br J Anesthesia 2009

29. GINA guidelineFEV1<80% personalbest, briefcourse of oral steroid (Evidence C)Ptswhohavereceivedsystemiccorticosteroidswithinpast 6 months100 mg hydrocortisone x3 iv reduced 24 hrsfollowingsurgery.Cstherapymayinhibitwoundhealing (Evidence C)

30. CASE -1 • Ayşe K 42 year-oldasthmaticpatient • Inpatient in Gynecologyward • Withabdominalhysterectomyindication • Preoppulmonologyconsultationwasindicated

31. History She has had asthma since childhood, wheezind and dyspnea in association with URTI, smoking (+) Symptoms Last episode of wheezing, dyspnea and cough 1 week before surgery Triggering factors House dust mite, URTI Hospitalisation No previous admission Pharmacological therapy Inhaled corticosteroids with prn short acting beta 2 agonists no previous use of systemic steroids Physical examination Wheezing but she denies recent URTI

32. Next step ? A-Chest roentgenogram B-ABG C-PFT D-All of them

33. They do not alter anesthetic management in an asymptomatic stable asthmatic patients However, in acute asthma *Chest X-Ray would be useful to determine a cause for acute bronchospasm such as infection *PFT would be useful to determine the degree of airway obstruction and response to further bronchodilator therapy *ABG most frequently shows hypoxemia and hypocarbia in acute attack, hypercarbia indicates severe or longstanding airway obstruction and increases risk for pulmonary complication during surgery

34. Next concern Pharmacologic therapy is appropriate? Primary goal is to decrease the risk of intra operative bronchospasm Which ones sould be added? A-Anticholinergics? B-Xanthine deriatives? C-Antileukotrienes? D-Systemic corticosteroids? E- Beta agonists?

35. Pharmacologic therapy Beta adrenergic agonists Methylxanthines Anticholinergics Corticosteroids Antileukotrienes

36. Intraoperative bronchospasm In the middle of the operation , with the trachea intubation and anesthesia with halothane 0.5%+ nitrous oxide (66%), Ayse begins to wheeze. Anesthezist assumed that wheezing is related to light anesthesia and increased halothane to 1% The wheezing subsided but then recurred after 20 minutes In Ayse’s case, wheezing is relieved after administration of aerosols of albuterol and ipratropium bromide

37. Emergence In Ayse’s case, the recent intra operative bronchospasm might increase the likelihood of wheezing during emergence What can be done? Extubate the trachea in the presence of a high exhaled concentration of a volatile anesthetic Bronchodilator aerosols can be administered during emergence

38. Case-2 A poorly controlled asthmatic patient on oral steroids presents for emergency manipulation of a fractured radius. He is slightly breathless and wheezy at rest. Preop management Regionalanesthesiawithpreopnebulisedbronchodilators+ İv steroid He/sherequiressteroid supplementation perioperativelyandmaintenance

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+ipratropiumbromidenebuliserC- Hydrocortisone 100 mg IV 8 hourly D-Magnesium 2g IV over 20 minutesAnesthesiaAvoiddrugsassociatedwithhistaminerelease (d-tubocurarine, mivacurium)Inwellcontrolledasthmatics, morphineandatracurium in routinedosesarelow 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

41. Drugs considered safe for asthmatics Induction Propofol, etomidate, ketamine, midazolamOpioidsPethidine, fentanyl, alfentanilMusclerelaxantsVecuronium, suxamethonium, rocuronium, pancuroniumVolatileagentsHalothane, isoflurane, enflurane, sevoflurane, ether (nitrousoxide)

42. PregnancyandasthmaPoorlycontrolledasthma can haveadverseeffect on fetus, resulting in increasedperinatalmortalityandlowbirthweight(Evidence B)Inhaledcorticosteroidshavebeenshowntopreventexacerbations of asthmaduringpregnancy (Evidence B)Thefocus of treatmentmustremain on control of symptomsandmaintenance of normal functionMurphy VE; ERJ 2005;25:731Acuteexacerbationsshould be treatedaggresively in ordertoavoidfetalhypoxiaNAEPP expert panel report. Managingasthmaduringpregnancy J AllergyClinImmunol 2005;34

43. SafedrugsBeta 2 agonistSteroidsIntranasalsteroidLTRAAntihistaminics (Loratadin, Setrizin)ContraindicateddrugsEpinephrin, adrenalinAlphaadrenergicsdrugsDecongestantTetracyclinSulphonamideCiprogloxacinİodineImmunotherapy (newstarterorchange of dose)

44. AsthmaticpregnantanddeliveryandanesthesiaSevere attacksusuallybetwen 24-36. wksAsthmaticpregnantemergencycare rate 11-18% 62% of theseadmittedtohospital90% of asthmaticshave normal deliveryAttack rate is not highafter C/S EpiduralorspinalanesthesiaarepreferredRegionalanesthesia is a choiceespeciallyprostaglandinsareadministeredProstaglandin E2 is choicefordeliveryinduction not prostaglandin F2 alpha

45. Nasalpolyps, asthmaandsurgery69-96% of aspirin intolerantpatientshavepolypsand 29-70% patientswithpolypsmayhaveasthma111 ptswithasthmaunderwent general anesthesiaPeriopasthmaticattack rate10.2%(5 in 49 cases) no treatment7.5% (3 in 40 cases) pretreatmentexceptsystemicsteroid4.5% (1 in 22 cases) systemicsteroidOtolaryngologicalsurgeryespeciallythosehavenasalpolyp had highperiopasthmaattackIe K Aerugi 2010 ;59:831

46. Celiker V AllergolImmunopatholMed 2004 ;64.45 ptswho had beendiagnosedwithanalgesicintoleranceunderwentsurgery%80 asthma%75 allergicrhinitis%46 polyp%64 ENT surgeryBenzodiaepinforpreopvecuroniumformusclerelaxationisofluarane, evofluaraneformaintenanceFentanylforearlypostoppainreliefNone of thepatients had analgesicrelatedallergic problem

47. SUMMARY • Meta analysisreviewing 222 articlesbetween 1995-2005 • Foradequatesedation, benzodiazepinesaresafe • It is preferrabletoavoidairwayinstrumentationandregionalanesthesiashouldalways be considered. • Whenregionalanesthesia is not feasibleand general anesthesia is requiredprophylacticantiobstructivetreatment, volatileanesthetics, propofol, opioidsand an adequatechoice of musclerelaxants minimize the risk • • Intubation may provoke bronchospasm and should be carried out under adequate anaesthesia, usually with opioid cover.Theuse of facemasksandlaryngealmasksresult in lessairwayirritation • Forinhalationalanesthetics, halothan, sevofluraneandisofluranehavebeenrecommended not desflurane

48. For intravenous anesthetics, ketamine has sympathomimetic bronchodilatory properties • Propofol, a widely used short-acting iv anesthetic, has a direct airway smooth muscle relaxant effect • Muscle relaxant type depending on muscarinic receptor type should be used carefully, the reversal of its effect by neostigmine should be avoided • Local anesthetics such as lidocaine (iv, inhalation) can block bronchoconstriction reflex • Burburan et al Minerva Anesth 2007; 357.