buteykobreathing.co.nz Melanie Kalmanowicz, MD Department of Anesthesia, Critical Care and Pain Medicine Beth Israel Deaconess Medical Center

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1 buteykobreathing.co.nz Melanie Kalmanowicz, MD Department of Anesthesia, Critical Care and Pain Medicine Beth Israel Deaconess Medical Center

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4 PMH: hypertension, hyperlipidemia, asthma, hypothyroidism PSH: tonsillectomy at age 7, Cesarean sectionx2 (under spinal anesthesia) Social history: never smoked, drinks occasionally alcohol, denies illicit drug use Allergies: NKDA Height: 62 in weight: 67 kg BMI: 27 Meds: Lisinopril, Advair, Albuterol, L-thyroxine, Simvastatin

5 Physical exam VS: BP 143/78, HR 86, O2 sat (room air) 96%, afebrile Gen: NAD Heart: RRR,nl S1/S2, no m/g/r Lungs: BIL exp wheezing (upon questioning pat states she did not use her inhalers today because she thought she is not allowed to take meds since she is NPO) Airway: MP II, HM>3, TM>6, neck: FROM, dentition: good

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7 Is the patient symptomatic (aka does she feel short of breath)? No, she is a little nervous because of the surgery, but otherwise feels well FYI: this is a good time to remind the patient that she can take her asthma medication perioperatively Did she have a recent URI? No, she feels great Does she have a recent CXR? Yes, they did one pre-op which was normal

8 Has she recently been on steroids for her asthma? No Has she ever been intubated and if so has she been told that it was difficult? The only time she was intubated was >50 years ago for her tonsillectomy; no known complications. Has she had pulmonary function tests? No, since her asthma was always reasonably controlled her doctor told her that s not necessary

9 When was the last time she had anything to eat or drink? She had pasta >6 hours ago, but since then is npo Careful: she is a trauma patient and thus per definition not npo (delayed gastric emptying) What is her exercise tolerance like? She does yoga with her best friend once a week and also goes to a spinning class 2-3 times a week.

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11 Since she has wheezing it s a good idea to give her some bronchodilator (e.g. Albuterol inhaler) prior to heading back to the OR. FYI: if she was symptomatic or cyanotic on exam it would be reasonable to get a room air/ baseline ABG; since our pat is doing great that s not necessary.

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13 1)Chronic inflammatory changes in the submucosa of the airway 2) airway hyperresponsiveness 3) reversible expiratory airway obstruction Clinical symptoms: episodic cough, SOB, wheezing some precipitating factors knowabouthealth.com

14 Treatment: Avoid triggers Beta agonists Steroids Antileukotriens Anticholinergics Theophylline Cromolyn poandpo.com Also see guidelines for stepwise approach of asthma therapy by the National Asthma Education and Prevention Program

15 Anesthetic considerations: continue pulmonary meds peri-operatively consider stress dose steroids if on chronic steroids consider extubating deep (if no contraindication) use drugs with bronchodilatatory effects adequate anesthetic depth prior to intubation healthtree.com

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17 goal is to depress airway reflexes in order to avoid bronchoconstriction use drugs with bronchodilatatory effects and avoid those that can cause bronchoconstriction or histamine release. Sufficient anesthetic depth should be established prior to intubation to minimize bronchoconstriction.

18 Induction agents (example): Propofol 2-2.5mg/kg IV Ketamine mg/kg IV (has bronchodilatatory properties, but can cause increased secretion) Opiates (example): Fentanyl 1.5-3mcg/kg Avoid morphine due to it s histamine release (e.g. Hydromorphone has less histamine release)

19 Muscle relaxants (example): Nondepolarizing NMBD: Rocuronium mg/kg IV Depolarizing NMBD: Succinylcholine mg/kg IV Avoid Artracurium due to it s histamine release Inhalational agent (example): Sevoflurane (MAC 2%) Isoflorane (MAC 1.2%) Avoid Desflurane since it can cause airway irritation

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22 emsresponder.com A) Normal A->B exhalation of gas in anatomic dead space B->C exhalation of gas from dead space and prox alveoli C->D alveolar gas D->E beginning of inspiration B) In obstructive pulmonary disease Slow rate of rise from C->D 2/2 airway obstruction ( shark fin appearance ) knol.google.com

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24 You first deepen the anesthetic by increasing the inhalational agent. Since this patient has a h/o asthma, bronchoconstriction is high up on your differential. Try an Albuterol inhaler via the endotracheal tube, if no improvement administer lidocaine, no change give epinephrine.

25 Although common things are common you should also exclude other possibilities, e.g.: make sure the anesthetic depth is adequate rule out mechanical obstruction (e.g. pat biting on tube, tube kinking etc.) do you see secretions in tube that would warrant endotracheal suctioning? Are you concerned about a pneumothorax? (You should always have that in the back of your mind, but it seems less likely in our patient, since the rest of her VS are stable, there was no central line placement and the surgery is far away from the chest )

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