Asthma in childhood. implications for anesthethic procedures. Prof Marijke Proesmans Kinderpneumologie Uz Gasthuisberg Leuven

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1 Asthma in childhood implications for anesthethic procedures Prof Marijke Proesmans Kinderpneumologie Uz Gasthuisberg Leuven

2 Asthma in childhood asthma in adults Pathofysiology Natural course triggers Age specific subgroups or phenotypes Treatment responses

3 Definition ASTHMA = * repeated episodes of cough, wheeze and dyspnea - airway hyperresponsiveness - secundary to airway inflammation Diagnostic criteria 1) Signs of airway obstruction (peakflow, spirometry) 2) Significant improvement after bronchodilatation but.. 1) < 5-6 years: lung function not possible 2) Asthma in young children: atypical and heterogeneous

4 Not all that wheezes is asthma wheeze in young children Very frequent 1/3 at least one episode of wheeze May be in the context of: Bronchiolitis or other viral infections wheezy bronchitis, viral induced wheeze Severe diseases : cystic fibrosis, BPD etc

5 Asthma diagnosis: a challenge Clinical diagnosis Medical history Clinical examination Exclude other diseases!! Severe disease not to be missed Common infections : avoid overuse of asthma medication Childhood asthma: heterogenous group of diseases

6 Diagnosis of childhood asthma Signs/symptoms Wheeze Dry cough Shortness of breath BTS guidelines History and clinical examination Clinical clues Triggers, pattern Severity No Is this asthma? Most likely possible Investigations/referral Investigations? Start therapy Differential diagnosis Investigations Trial asthma therapy Not better Asthma action plan Improved Asthma likely Asthma unlikely

7 May not be asthma in case of. History Symptoms from birth, perinatal lung problem Family history of unusual lung disease Sever upper airway problems Symptoms and signs Productive cough Vomit, rerurgitation Swallow dysfunction Abnormal voice Crepitations on lung auscultation Clubbing, sputa Inspiratory stridor and wheeze Failure to thrive Possible diagnosis Cystic fibrosis; primairy ciliair dyskinesia, congenital lung malformation, BPD Cystic fibrosis; neuromusculair disease immunodeficiency CF, recurrent aspiration; immunodeficiency GOreflux ( aspiration) Aspiration with eating Laryngeal problems Bronchiectasis CF, bronchiectasis Disorder of trachea, larynx CF Thorax 2003; 58 (Suppl I): i1-i92

8 Asthma prevalence

9 Asthma prevalence age 8-13 years Toelle BG- BMJ 2004;328:386-7 Sang-Il Lee Allergy Asthma Immunol Res April; 2(2):

10 Asthma starts at a young age! median age of onset 4 years old > 20% of children develop symptoms within the first year of life McMillan J, Feigin, R, DeAngelis, C, Jones M, Oski s Pediatrics, 4th Edition, 2006, pp. 2405

11 genetic code omgeving timing Viral RTI Epigenetic changes outdoor pollution. 0 2 year Ig E sensitisatio n inflammation indoor pollution ASTHMA SYNDROME

12 ASTHMA TRIGGERS

13 Childhood asthma Treatment

14 ASTHMA: MEDICATION ANTI-INFLAMMATORY (chromoglycaten) (Lomudal) inhaled cortico steroids leukotrien-receptor antagonist systemic steroids BRONCHODILATORS short acting 2 mimetics SABA long acting 2 mimetics LABA anticholinergics (theophyllines)

15 Cornerstone: inhaled corticosteroids Very efficiënt for treating asthma Anti-inflammatory Effect increases over weeks, max effect after months Decreased asthma morbidity/mortality Mostly safe of dosing is correct Too often prescribed for unclear indications Side effects May decrease growth velocity Mostly transiënt No/minor effect on final height Cave: chronic high dosis may lead to adrenal suppression

16 ICS: Dose response, time response... Van Essen-Zandvliet 92

17 Leukotrienen receptor antagonisten Montelukast, Singulair Anti-inflammatory Fast effect Less potent compared to ICS Additive effect if combined with ICS (chewable) tablet

18 Step 5: Add systemic steroids : specialist referral Step 4: insufficient control increase ICS to 800mcg/day * Step 3: combination therapy 1. Long acting ß 2 agonist (LABA) 2. LTRA: first choice < 5 years of age Step 2: daily preventive therapy ICS mcg/day: according to severity (LTRA monotherapy) Step 1: mild intermittent asthma ß 2 agonist as needed Thorax 2003; 58 (Suppl I): i1-i92

19 Childhood asthma - anesthesia Risk for bronchospasm during/after anesthesia?

20 Consequences of acute bronchospasms circulatory Air trapping/hyperinflation Decrease venous return Systemic hypotention respiratory Small airway obstruction V/Q mismatch Hypoxia CO 2 retention (late)

21 Pre-operative risk evalation Recent/current resp tract infection (RTI) Asthma control Medical history Asthma control test Lung function

22 Recent/current RTI

23 (upper) Respiratory tract infection For otherwise healthy children an URTI is not a strong contra indication for anesthesia However, the risk for broncospasm in asthmatic children is high If possible re-schedule operation 2-3 weeks after infection Tait et al Anesth Analg 2005; 100:59-65

24 Asthma under control? Aim= full asthma control No/minimal complaints during the day No/minimal complaints during the night No/minimal use of SABA No exacerabations No limits in activity including sports (near)normal longfunction No medication side effects Gina guidelines 2005

25 Uncontrolled asthma. Is my patient taking his medication?! 80 compliance % oral theophylline inhaled steroid inhaled cromolyn Kellaway 94

26 Evaluate Asthma control Medical history cough, wheeze, shortness of breath Need for SABA, oral steroids Emergency visits for asthma Extra attention: Active/passive smoke exposure Adolescents: compliance, underreporting Obese children: risk for asthma/bronchospasms Recent upper/lower airway infection But: Underreporting/overreporting Severity under/overestimated Beware of wrong diagnosis Townsend 1991, Lara 1998, Guyatt 1997, Nguyen 1996

27 (childhood) Asthma control test Validated questionnaire with 21 items Children 4-11 years old Has been validated /compared to Lung function Specialist evaluation Need for medication change score of 19 : insufficient control Liu A et all JACI 2007

28 Childhood asthma control test

29 Lung function and asthma control

30 The child with asthma: specific management? Avoid stress whenever possible Pre op midazolam is safe in children with asthma (Kill N et al 2003) maintenance therapy is well taken in the periode preceding the operation? Including the day of anesthesia Use salbutamol pre-induction Poorly controlled asthma (Pre-)treat with systemic steroids

31 Prevention of bronchospasm Tracheal intubation May provoke bronchospasms Alternatives if possible Laryngeal mask Locoregional anesthesia Lidocaine IV significantly increases the histamine threshold blocks the cough reflex may be given to decrease the airway responses associated with endotracheal intubation

32 Inhalational agents In general the anesthetics of choice in patients with airway hyperresponsiveness Desflurane not recommended Coughing, laryngospasms, bronchospasms Sevoflurane Mostly safe, may induce bronchospasm in asthmatics (conflicting data) Halothane (plus enflurane/isoflurane) potent bronchodilators decrease airway Effective in the treatment of status asthmaticus Ketamine bronchodilatory properties increases bronchial secretions must be given simultaneously with an anticholinergic drug such as glycopyrrolate or atropine

33 IV agents Propofol inhibits bronchoconstriction Increases airway dilation considered safe for patients with asthma Concern of cross reaction in patients allergic for egg, soybean, peanut? Opoid analgetics Morphine : potential histamine release Synthetic popoids (fenta, remy fenta): no significant histamine release

34 Specific issues with anesthetic medication in asthma Non histamine releasing neuromuscular blocking agents Acceptable for use in asthmatics Vecuronium, cisatracurium considered safe Mivacuronium dose dependent trigger of histamine release and bronchospasm Reversal of muscle relaxation Atracurium :use with caution in case of asthma Increase bronchial hyperreactivity and airway secretion Burburan 2007, Jooste 2007,Bishop 2003

35 In case of acute bronchospasms Increase, FiO2, increasing expiratory time and deepening the anaesthetic Inhaled salbutamol High dose, may be repeated every 20 minutes Delivery of inhaled medication via small ET tube is limited Systemic steroids Effect only after hours Magnesium sulphate If very severe: IV salbutamol

36 referenties Update on perioperative management of the child with asthma Dones F et al Pediatric Reports 2012 vol 4 e19 Lauer et al. Anaesthetic management of the child with co existing pulmonary disease

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39 Childhood asthma If a child has asthma Evaluate asthma control If insufficient refer for specialist advise Make sure controller medication is taken Use bronchodilators Postpone electve surgery in case of RTI BEWARE True asthmatics are often underdiagnosed Children with asthma label may have another lung/airway problem

40 Childhood asthma and anesthesia naamloos.png Lauer R et al British Journal of Anaesthesia ;

41 references Anaesthetic management of the child with co-existing pulmonary disease. Lauer et al British Journal of Anaesthesia 2012; 109:i47 Update on peri-operative management of the child with asthma. Dones F et al. Pediatric Reports 2012; volume 4:e19 Safety and ethics of bronchoscopy and endobronchial biopsy in difficult asthma. Payne D et al. Arch Dis Child 2001;84:423