Bronchospasm: It ll Take Your (Patient s) Breath Away. Presenter: Raymond Panketh, MD Mentor: Nabi Khatibi, MD
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1 Bronchospasm: It ll Take Your (Patient s) Breath Away Presenter: Raymond Panketh, MD Mentor: Nabi Khatibi, MD
2 None Disclosures
3 Case Presentation Case Progression Objectives Signs and Differential Diagnosis of Bronchospasm Pathophysiology of Bronchospasm Management of Bronchospasm Role of ETT depth in Bronchospasm Case Management Summary
4 Case Presentation of Patient JB HPI: 68 y.o. male with gross hematuria found to have a 1.3cm bladder stone and 1.0cm right kidney stone presenting for bilateral utereroscopy with laser lithotripsy. PMH: paf, OSA treated with CPAP, HTN (130s/70s in clinic), DMII (glucose: 133 that AM), GERD, OA, obesity (BMI: 33) PSH: Left adrenalectomy for adrenal mass, tonsillectomy, cystoscopy and lithotripsy Allergies: Latex (mild rash), lidocaine, equine containing products (respiratory difficulty) Meds: Citalopram, Eliquis, Losartan, Metoprolol, Metformin, Pantoprazole, h/o indomethacin FH: Non-contributory SH: Never smoker, rare EtOH, no illicit drug use
5 Case Presentation of Patient JB PE: Vitals: BP: 139/70 Pulse: 63 Temp: 36.7 C (98 F) SpO2: 96% on RA Ht 170 cm (5 7") Wt 99.6 kg (220 lbs) BMI kg/m2 GEN: NAD PULM: CTAB, no increased WOB CV: RRR without MRG NEURO: A&Ox3, no focal deficits AIRWAY: Multiple intact crowns, Mallampati II, otherwise unremarkable EKG: SR at 62 with moderate intraventricular delay QRS: 113ms
6 Case Progression Pre-induction: 2mg midazolam IV and standard denitrogenation followed by 100mcg fentanyl IV. Induction: 150mg propofol IV and 160mg succinylcholine IV. Intubation: Grade I view orally intubated with Mac 3 with a 7.5mm ETT taped at 24 cm at the teeth.
7 Case Progression
8 Case Progression
9 Differential Diagnosis Causes of increased peak airway pressure during IPPV: Anesthetic equipment Excessive tidal volume High inspiratory flow rates Airway device Endobronchial intubation Tube kinked or blocked Small diameter tracheal tube Patient Obesity Head down positioning Pneumoperitoneum Tension pneumothorax Bronchospasm
10 Causes of Bronchospasm Patient Increased secretions Vagal-sympathetic tone imbalance Acute respiratory infection Pre-existing COPD, asthma, active smoking Environmental Tobacco Cold Air Air pollution, dust, dander Medications NMBs, antibiotics, beta blockers, protamine, non-synthetic opioids, drug preservatives, ester local anesthetics, carboprost (Hemabate) Hospital Materials Latex Invasive ventilatory devices
11 Signs of Bronchospasm Wheezing on auscultation Slow or incomplete expiration Changes in capnography Upsloping waveform shark fin Severely decreased or absent waveform Decreased tidal volume Increased peak airway pressure Decreased oxygen saturation HR of anesthesia provider > SpO2 of patient High sensitivity / Low specificity
12 Differential Diagnosis Causes of wheeze during GA: Bronchospasm Pulmonary edema Aspiration of gastric contents Pulmonary embolism Tension pneumothorax Foreign body (such as a tooth)
13 Causes of Bronchospasm
14 Pathophysiology of Reflex Bronchospasm Irritation of the upper airway/ Noxious stimuli Afferent sensory pathways via vagus nerve Solitary nucleus Efferent vagus nerve pathways Bronchiolar smooth muscle contraction
15 Crisis Management of Bronchospasm
16 Crisis Management of Bronchospasm
17 Secondary Management of Bronchospasm Steroids: methylprednisolone 125mg IV OR dexamethasone 8mg IV Appropriate ventilation to avoid dynamic hyperinflation: Longer expiratory time (I:E 1:3-1:5) Low/normal respiratory rates (8-12/min) Permissive hypercapnia Adjuncts: Bronchodilating anesthetics: volatiles, ketamine, propofol Magnesium sulfate 2g IV over 20min Heliox (does not reverse bronchospasm, but can be used as a temporizing measure) Neuromuscular blocking drugs (may improve mechanics of ventilation & lower peak inspiratory pressures) Extracorporeal membrane oxygenation (ECMO) if severe & refractory to all other treatments
18 ETT: How Far is Too Far?
19 ETT: How Far is Too Far?
20 ETT: How Far Is Too Far?
21 ETT: How Far is Too Far?
22 ETT: Changes in Positioning
23 Case Management Patient was given 100% oxygen, 100mg IV propofol, isoflurane was increased and albuterol administered via the ETT. There were no clinical signs of anaphylaxis and the patient remained hemodynamically stable. Magnesium 2g IV was given over 20 minutes and 30mg of rocuronium was given with appropriate decrease in peak inspiratory pressures. Patient was reversed with sugammadex followed by uneventful extubation and PACU stay and was discharged home.
24 Summary of Important Points CALL FOR HELP EARLY the differential for bronchospasm can be complex, and requires extra eyes and hands! Although we all strive to have the perfect wake-ups, prematurely lightening the patient while surgery is going on may put our patient s at higher risk for bronchospasm. The silver standard should be a combination of observing chest movement, auscultation, and importantly observing tube depth. The gold standard being bronchoscopy. The optimal depth insertion is about 20cm in women and 22 cm in men and clinicians should be concerned if depth varies much from this, especially in range heights between 150cm and 180cm.
25 References Stoelting s Pharmacology and Physiology 5 th edition Morgan and Mikhail s Clinical Anesthesiology 5 th edition Goodman LR, Conrardy PA, Laing F, Singer MM. Radiographic evaluation of endotracheal tube position. Am J of Roe 1976; 127: Roberts JR, Spadafora M, Cone DC. Proper depth placement of oral endotracheal tubes in adults prior to radiographic confirmation. Acad Emerg Med 1995; 2: Warner DO, Warner MA, Barnes RD, et al. Perioperative Respiratory Complications in Patients with Asthma. Anesthesiology 1996; 85: Olsson GL. Bronchospasm during anaesthesia. A computer-aided incidence study of 136,929 patients. Acta Anaesthesiol Scand 1987; 31: Westhorpe RN, Ludbrook GL, Helps SC. Crisis management during anaesthesia: bronchospasm. Qual Saf Health Care 2005; 14: e7. Cherng CH, Wong CS, Hsu CH, Ho ST. Airway length in adult: estimation of optimal tube length for orotracheal intubation. J Clin Anes 2002; 14: Varshney M, Sharma K, Kumar R, Varshney PG. Appropriate Depth of placement of oral endotracheal tube and its possible determinants in Indian adult patients. Indian J Anest : Sitzwohl C, Angelika L, Schober A, et al. Endobronchial intubation detected by insertion depth of endotracheal tube, bilateral auscultation, or observation of chest movement: randomised trial. BMJ : c5943 Kim JT, Kim HJ, Ahn W, et al. Head rotation, flexion, extension alter endotracheal tube position in adults and children. Can J Anaesth : Caplan RA, Posner KL, Ward RJ, Cheney FW. Adverse Respiratory Events in Anesthesia: A Closed Claims Analysis. Anesthesiology :
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