Company

Anesthesia in patient with

respirator disease
respiratory
Namthip Ditphu MD

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Contents

Introduction

Upper
pp respiratory
p
y tract infection

Asthma

COPD

Introduction
Risk of perioperative respiratory
complications
P t
Postoperative
ti pulmonary
l
complications
Morbidity
Mortality
Increase hospital length of stay

Modification of disease severity and

patient optimization preoperative

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Acute upper respiratory

tract infection
(Acute URI)

Acute URI
Uncomplicated URI (common cold
syndrome)
Infectious nasopharyngitis (95%)
Virus (rhinovirus
(rhinovirus, influenzavirus)
Bacteria

Noninfectious nasopharyngitis
Allergy
Vasomotor

Acute URI
Signs and symptoms

Sneezing
Runny nose
History of allergy
F
Fever
Purulent nasal discharge
Productive cough
Malaise
Tachypneic or wheezing

Acute URI
Diagnosis
Clinical signs and symptoms
Laboratory
y tests

Acute URI
Management of anesthesia
Preoperative
Intraoperative
Postoperative

Preoperative
High risk childs for respiratory
complications
Copious secretions
E d t
Endotracheal
h l
intubation
Prematurity
g
Parental smoking

Nasal congestion
R
Reactive
ti airway
i
disease
Airway surgery

Preoperative
Signs of infection
Elective surgery (esp. airway surgery)
Consultation with surgeon
Urgency of case
Delay surgery
Economic and practical aspects

How long to delay surgery?

Preoperative

Preoperative
Adverse respiratory events does not
reduce if anesthesia is administered
within 4 wks of URI
Airway hyperreactivity require 6 wk or
more to heal

Preoperative
Viral infections (infectious phase)
Morphologic & functional changes in
respiratory epithelium
Mucociliary flow & bactericidal activity
Spreading
S
di infection
i f ti by
b PPV
Immune response

Intraoperative
Adequate hydration
Reduce secretions
Limit manipulation of sensitive airway
ETT versus LMA
Prophylactic bronchodilator

Postoperative
Adverse respiratory events

Bronchospasm
Laryngospasm
Airway obstruction
P ti t b ti
Postintubation
croup
Desaturation
Atelectasis

Supplemental oxygen for intraop and

immediate postop hypoxemia

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Asthma

Definition
GINA updated 2007
A chronic inflammatory
y disorder of the
airways
Airway hyperresponsiveness that leads to
recurrent episodes of acute attack
Variable airflow obstruction

Diagnosis
Medical history

Clinical symptoms -episodic breathlessness

-wheezing
-cough
-chest
chest tightness

Episodic symptoms after allergen exposure

or seasonal variability of symptoms

Positive family history of asthma and atopic

disease

Diagnosis
Common signs

Severe signs

wheezing
g on
auscultation
difficulty speaking
use of accessory
muscles

poor
p
air entry
y
intercostal
retraction
cyanosis
d
drowsiness
i
tachycardia
hyperinflated chest

Pathophysiology
Pathophysiology

Ai
Airway
inflammation
i fl
ti

Airway hyperresponsiveness (AHR)

Airway remodeling

Pathophysiology
Airway hyperresponsiveness

Results
R
lt iin airway
i
narrowing
i in
i response to
t
stimulus

Linked to both inflammation and repair of the

airways

Global strategy for asthma management and

prevention (updated
p
( p
2007))

Pharmacology in asthma
Controller drugs
g
Inhaled corticosteroids (ICS)
Systemic
y
corticosteriods ((SCS))
Leucotriene modifiers
Long-acting inhaled
g
(
) +/B2agonists(LABA)
combination with inhaled
glucocorticosteroids
Theophyline (sustained release)
Cromones
Anti-IgE
Other controller therapies ;
low dose methotrexate,
cyclosporine , gold,
macrolide
lid or allergenll
specific immunotherapy

Reliever drugs
g
Rapid-acting inhaled B2 agonists
Inhaled anticholinergics
Theophyline (short-acting)
Short-acting oral B2 agonists
Magnesium sulphate
Oth ; Heliox
Other
H li

Pharmacology in asthma
Inhale corticosteroid (ICS)
(
)

Most effective treatment for asthma

First-line treatment for children and adults with

persistent symptoms

S
Suppressing
i airway
i
inflammation
i fl
ti

Budesonide(Pulmicort) fluticasone(Flovent)
Budesonide(Pulmicort),

Pharmacology in asthma

Pharmacology in asthma
Systemic corticosteroid

Treated late allergen response, prevents relapse

and reduces mortality of the patient

The BTS guidelines ; prednisolone 40-60 mg or

100 mg of hydrocortisone iv or both in immediate
management of severe asthma

Following, oral prednisolone 40 mg daily and

stopped after 7-10 days without dose tapering

Pharmacology in asthma
Long
Long-acting
acting inhaled B2 agonists (LABA)

Formoterol and Salmeterol

Direct action on bronchial wall smooth muscle

(B2receptors),
t
) iinhibit
hibit mastt cell
ll mediator
di t release
l
and
d
plasma exudation

Most effective when combined with ICS

Fluticasone plus Salmeterol (Advair
Advair),
Budesonide plus formoterol (S
Symbicort
ymbicort)

Pharmacology in asthma
Rapid
Rapid-acting
acting inhaled B2 agonists

For relief of bronchospasm during acute

exacerbation

S lb t
Salbutamol,
l terbutaline,
t b t li
f
fenoterol,
t
l

Combivent (salbutamol
(salbutamol+ipratropium
ipratropium bromide)

Berodual (fenoterol+ipratropium bromide)

Onset of action 5 min and duration of action 6 hr

Pharmacology in asthma
Leucotriene modifiers

Cysteinyl-leukotriene1 receptor antagonists

(montelukast,
montelukast pranlukast,
pranlukast and zafirlukast)
zafirlukast
5-lipoxygenase
p yg
inhibitor (zileuton)

Reduce symptoms (cough), improve lung

function & reduce airway inflammation

Small and variable bronchodilator effect

Pharmacology in asthma
Alternative treatment for adult patients with
mild persistent asthma and add-on therapy
to moderate to severe asthma

Pharmacology in asthma
Theophylline

Phosphodiesterase inhibition increases in

intracellular levels of cyclic AMP

Bronchodilator and improve diaphragmatic

endurance, stimulation of ventilatory drive and
di
direct
t anti-inflammatory
ti i fl
t
effect
ff t

A second line agent or add-on

add on therapy

Pharmacology in asthma

The BTS guideline: loading 5 mg/kg iv over 20 min

,followed by infusion of 0.5 mg/kg/h may help
patients with life-threatening

S/E: GI symptoms (loose stools), cardiac

arrhythmia, seizure, and even death

Nausea and vomiting are most common

Pharmacology in asthma
Inhaled anticholinergic

Ipratropium bromide and Oxitropium bromide

Compete with acetylcholine to bind airway

muscarinic
i i receptors
t
and
d decrease
d
bronchial
b
hi l
vagal tone

Less effective reliever medication than rapidacting inhaled B2 agonists

Pharmacology in asthma
Magnesium sulphate

Calcium antagonist

Smooth muscle relaxation ,inhibit histamine

release and acetylcholine release from nerve
endings

Augment
g
B-agonist
g
effects in the airway
y

Pharmacology in asthma

Most beneficial in severe attacks (PEF < 30

40% predicted) and failed initial conventional
treatment

BTS/SIGN guideline recommends

using single IV bolus of 1.22.0 g of MgSO4
as an infusion over 20 min

Pharmacology in asthma
Heliox

Mixture of helium (60-80%) and oxygen

(20-40%)

Reduce density and resistance to flow

Decrease WOB and improve gas exchange

Preoperative evaluation and preparation

Well-controlled asthmatics tolerate

Wellanesthesia and surgery well

Poorly controlled asthmatics at risk of

perioperative respiratory problems

Elective surgery should take place when

the patient is optimally controlled

History and Physical exam

Determine severity of disease and current

conditions

Triggering agents

Past admissions to the hospital

Pharmacological therapy

Hi t
History
off anesthesia
th i

Signs of acute asthma on physical exam

Global strategy for asthma management and

prevention ((updated
p
p
2007))

Investigations
Imaging : CXR , CT scan

Pulmonary function tests : PEF , FEV1

Pulse oximetry (SpO2)
ABG

Premedications

Inhaled B2-agonists
agonists prior to the OR

Other maintenance drugs should

continue preoperatively

Corticosteroids p
prevent perioperative
p
p
bronchospasm

Premedications

Anxiolytic drugs can use safely

Avoids aspirin and NSAIDs

Perioperative recommendations for

asthma medications
Class of drug
2 agonists
i
Anticholinergic
drugs
g
Inhaled steroids

Examples
Salbutamol,
t b t li
terbutaline,
salmeterol
Ipratropium
Beclomethas
one,
budesonide,
fluticasone

Perioperative
recommendation
Convert to nebulised
form

Continue inhaled
formulation

If patient on >1500 mcg/day of

beclomethasone, adrenal suppression
may be present

Continue as IV
hydrocortisone until
taking orally (1 mg
prednisolone equivalent
to 5 mg hydrocortisone)

If >10 mg/day, adrenal suppression

likely

Oral steroids
Leukotriene
inhibitor (antiinflammatory
effect)

Montelukast
, zafirlukast

Restart when taking oral

medications

Mast cell
stabilizer

Disodium
cromoglycate

Continue by inhaler

Aminophylline

High doses may lower K+. Causes

tachycardia and tremor

Convert to nebulised
form

Prednisolon
e

Phosphodiestera
se inhibitor

Notes

Continue where
possible

Effectiveness in asthma debated. In

severe asthma consider converting to an
infusion perioperatively (checking levels
12-hrly)

Suggested Protocol: Pre op assessment

& preparation
Use of systemic steroid within the past
6 months
Regimen: Hydrocortisone 100mg q8h iv
Startt ttime:
Sta
e 1-2 days p
prior
o to su
surgery
ge y
End time: within 24 hours after surgery

Suggested Protocol: Pre op assessment

& preparation
PFT: FEV1 < 80% of personal best
Regimen: Prednisolone 40-60 mg/day po
Start time: 1-2 days prior to surgery
End time: within 24 hours after surgery

No need of tapering dose

Suggested Protocol: Pre op assessment

p p
& preparation
Wheezing before operation
Inhaled B2 agonist & corticosteroid

If no improvement

Delay elective surgery

Suggested Protocol: Pre op assessment

p p
& preparation
Reversible airway obstruction
or severe bronchial hyperactivity
Regimen:
g
Methylprednisolone
y
0.5-1.0 mg/kg
g g po
and Salbutamol 3x2 puffs
Start time: 48 hours prior to surgery

Intraoperative management

Ch i off anesthesia
Choice
th i

Regional anesthesia

General anesthesia

Regional anesthesia
Spinal or epidural anesthesia and
peripheral nerve blocks
Targeted sensory level below T4
T4
Epidural
p
: less motor block of respiratory
p
y muscles
sufficient systemic absorption of LA
/epinephrine to protect against
bronchospasm

Peripheral nerve blocks : minimal changes in

pulmonary
l
function
f
ti

General anesthesia
General anesthesia and endotracheal
intubation increased risk of bronchospasm
To minimize risk of bronchospasm
Avoid
A oid air
airway
a instr
instrument
ment
GA under mask with inhalation anesthesia

Need airway instrument

LMA
ETT

Induction of anesthesia
Inhalation induction
Bronchodilatation
Sevoflurane is less p
pungent
g
and less irritant
than isoflurane
Desflurane is more pungent and can irritated
airway
i

Induction of anesthesia

Intravenous induction

Ketamine

bronchodilator effect

inhibition of vagal
agal pathways
path a s

augmentation
g
of catecholamine release

Propofol

producing less bronchoconstriction than

other agents such as barbiturates

Induction of anesthesia

Barbiturates

sometimes provoke bronchospasm

Etomidate

low risk of anaphylaxis and cardiovascular

side effects

BZD

can use safely

Induction of anesthesia
Adjuvants to increase the depth of
anesthesia and blunt airway reflexes
before intubation
additional dose of thiopental
p
(1-2
(
mg/kg)
g g)
ventilating the patients with a 2-3 MAC of
volatile agent for 5 min
opioids or lidocaine IV or IT (1-2 mg/kg)

Maintenance of anesthesia
Volatile anesthetics are useful
because of excellent bronchodilating
properties
Possible exception of Desflurane

Neuromuscular blocking agent

Avoid histamine release drugs

Airway constriction is dose-dependent
Low dose
Not
N t significant
i ifi
t iinduce
d
b
bronchospasm
h

Reversal drug
Anticholinesterases
Neostigmine
g
impair metabolism of Ach at nerve terminals
activate muscarinic receptors on airway smooth
muscle

Anticholinergic drug
Atropine

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Opioid
Short acting & low histamine release
Short-acting
alfentanil or fentanyl

In well controlled asthmatics

morphine

Monitoring
Standard monitoring
Capnometry esp. delayed rise pattern

Airway pressure

Drugs considered safe for asthmatics

Induction : Propofol, etomidate,
ketamine, midazolam
Opioids : Fentanyl, alfentanil
NMBAs : Vecuronium, rocuronium,
pancuronium, cisatracurium
Volatile agents : Halothane, isoflurane,
sevoflurane, N2O

Mechanical ventilation
To prevent dynamic hyperinflation,
hyperinflation
barotrauma and hemodyamic
compromise
p
pressure limitation
low tidal volume
slow RR with prolong expiratory time

Intraoperative complications
Bronchospasm
Anaphylaxis
Adrenal crisis

Bronchospasm
Preventions
Optimize preoperative symptom control
Adequate
Ad
t preoperative
ti anxiolytic
i l ti
Inhale 2-agonists/anticholinergic
immediately before induction
g
anesthesia
Regional

Bronchospasm
Minimize airway instrument
g
(propofol,
(p p
ketamine, volatile))
Induction agent
Use volatile early & often (avoid desflurane)
Adequate depth of anesthesia before airway
instrument
IV lidocaine & opioid as adjunct for intubation

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Bronchospasm
Differential Diagnosis of Intraoperative
Bronchospasm and Wheezing
Mechanical obstruction of endotracheal tube
Kinking
Secretions
Overinflation of the tracheal tube cuff

Inadequate depth of anesthesia

Endobronchial intubation

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Bronchospasm
Differential Diagnosis of Intraoperative
Bronchospasm and Wheezing
Pulmonary aspiration

Pulmonary edema
Pulmonary embolus
eu ot o a
Pneumothorax
Acute asthmatic attack

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Bronchospasm
C fi
Confirmation
ti diagnosis
di
i

Most likely causes

anaphylactoid reactions to drugs
airway
i
instrumentation
i t
t ti
with
ith inadequate
i d
t
depth of anesthesia

Bronchospasm
Treatments
Increase anesthetic depth by volatile anesthetic
Consider
C
id propofol
f l to
t further
f th deepen
d
anesthesia
th i
(severe bronchospasm)
Inhaled 2-agonists
(prevent recurrence))
IV corticosteroids (p
IV adrenergic agonists such as epinephrine
(severe bronchospasm)
Avoids aminophylline
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ASA Refresher Courses in Anesthesiology

2007

Postoperative care
Emergence
Presence of ETT stimulate reflex-induced
bronchospasm
Deep extubation
B
B-adrenergic
adrenergic agonists and/or cholinergic
antagonists
Intravenous lidocaine

Postoperative care
Adequate pain control
Regional analgesia
Multimodal therapy
py
Avoid NSAID in severe asthmatics

Postoperative care
Reevaluation of respiratory system after
operation
left ventricular failure
pulmonary emboli
fluid overload
pneumothorax
regular nebulizer therapy with additional
bronchodilators as needed

Postoperative care
Lung expansion therapy
Deep breathing
Incentive
I
ti spirometry
i
t
CPAP

Encourage early ambulation

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Chronic obstructive
pulmonary disease
(COPD)

Definition
Progressive airflow limitation
Not fully reversible
Chronic bronchitis with small airway
obstruction
Emphysema
p y

Definition
Risk factors
Cigarette
g
smoking
g
Respiratory infection
Occupational exposure to dust
Genetic factors ( 1-antitrypsin deficiency)

Diagnosis
Signs and symptoms
Vary with severity
Early stage
Late stage

increase expiratory airflow obstruction

tachypnea
prolonged expiratory phase
decrease breath sound
expiratory wheezing

Diagnosis
Diagnosis
Persistent expiratory airflow obstruction
Chronic productive cough
Progressive exercise limitation

Long-term cigarette smoker

Chronic bronchitis or pulmonary emphysema
predominant
d i
t

Diagnosis
Advanced COPD Orthopnea
Infection sputum discoloration
Wheezing + mucus accumulation
mimic asthma
Chronic bronchitis + reversible
bronchospasm Asthmatic bronchitis

Investigations
CXR
Minimal abnormality even in severe COPD
Hyperlucency
yp
y and hyperinflation
yp
Flattening diaphragm with loss normal dome &
very
y vertical cardiac silhouette

Bullae
CT Chest is useful

Investigations
Arterial blood gas (ABG)
Pink Puffers
Blue Bloaters

Investigations
Pink Puffers

Blue Bloaters

PaO2 > 60 mmHg

PaO2 < 60 mmHg

PaCO2 normal

PaCO2 > 45 mmHg

Cough and sputum
production
Freq respiratory tract
infection
PHT
Recurrent cor pulmonale
2
2erythrocytosis
erythrocytosis

Thin
No signs of RV
failure
Severe emphysema

Treatments
Treatments
Cessation of smoking and supplemental
oxygen administration
Drug therapy
Bronchodilators

Lung volume reduction surgery

Emphysema (overdistended area)

Management of anesthesia
Preoperative
p
Preoperative PFT
Flow volume loop
Risk reduction strategies

Intraoperative
postoperative

Preoperative
Postop pulmonary complications
History
y & PE
Poor exercise tolerance
Chronic cough
Unexplained dyspnea
Decreased breath sound, wheezing &
prolonged expiratory phase

Preoperative
Preoperative preparation
Smoking
g cessation
Treatment of bronchospasm
Eradication of bacterial infection

Preoperative
Preoperative PFT
Clinical assessment
PFT / ABG
Simple spirometry
High risk ; FEV1 < 70% predicted
FEV1/FVC < 65%
ABG : PaCO2 > 45 mmHg

Preoperative
Indications for preoperative pulmonary
evaluation
Hypoxemia on room air or need home O2
therapy
HCO3 > 33 mEq/L or PCO2 > 50 mmHg
History of respiratory failure
Severe shortness of breath
Planned
a ed p
pneumonectomy
eu o ecto y

Preoperative
Difficult clinical assessment
Distinguish etiology
Determine response to bronchodilator
Suspected
S
t d pulmonary
l
hypertension
h
t
i

Advanced
d a ced pulmonary
pu o a y d
disease
sease
RV function
Echocardiography

Preoperative
Flow volume loop

Preoperative
Risk reduction strategies
Preoperative
Encourage cessation of smoking
Treat expiratory airflow obstruction
Treat respiratory infection
Patient education ((lung
g expansion
p
maneuver))

Preoperative
Risk reduction strategies
Intraoperative
Use minimally invasive surgery
Consider regional anesthesia
Avoid surgical time >3 hr

Postoperative
Lung volume expansion maneuvers
Maximize analgesia

Preoperative
Smoking cessation and pulmonary
complications
Predictive factors
Lower DLCO than predicted
p
Smoking history > 60 pack-years

Diminish
Di i i h symptoms
t
off chronic
h
i bronchitis
b
hiti
Eliminate accelerated loss of lung function

Pathophysiologic Change in Smoker

CVS
Physiology

Effect

cessation

-Carbonmonoxide
Carbonmonoxide

-COHb
COHb

-1-4
1 4 hr

-sympathetic
stimulation

-HR , BP ,Coronary
blood flow

-12-48 hr

-Arteroscolosis
Arteroscolosis

-Ischemic
Ischemic organ -unknown
unknown

-Production
Production of Hb ,
RBC , WBC ,
Fibrinogen, Plt

-Hct
Hct , Viscosity

-unknown
unknown

Respiratory
p
y system
y
Physiology

Effect

cessation

-Alveolar Macrophage

-infection

-unknown

-4wks
-Globet cell hyperplasia , -airway edema ,
epithelial
p
abnomally
y
mucous secretion , -2-6wks
COPD
-depletion
depletion of
cough , airway
-cough
neuropeptides for sensory reactivity
nerve

5 10days?
-5-10days?

-Cilia dysfunction

-2-6wks
-3months

-mucous
-Clearance

GI and Renal system

Physiology

Effect

-Gastroesophageal
sphincter

-reflux , pulmonary -minute after

aspiration
cessation

Renal
system
Effect
Physiology
y
gy
-irritate urinary
tract
-ADH

cessation

cessation

-micturation, nocturia

-unknown

-Dilutional hypoNa

-unknown

CNS & Wound healing

g
Physiology

Effect

-activate nAChRs
-addictive
-modulation of
-withdrawal
neurotransmitters release symptoms

Wound healing

Physiology

Effect

-peripheral vasoconstriction -wound

-impaired oxygen capacity
dehiscence and
infection ,
malunion bone

cessation
-unknown

cessation
-more than 4
wks

Nicotine replacement therapy

Telephone
p
Counselling
g
Group Meetings
Nicotine replacement therapy
Self adhesive patch
Chewing
Ch i gum
Microtabs

Conclusion for smoking cessation

Smoking invole every organ systems
Stop smoking > 4 wks is the best
Whenever patient stop,
stop Benefit get

Intraoperative
Regional anesthesia
Lower abdominal surgery
Extremities
E t
iti surgery

General anesthesia
Upper abdominal surgery
Intrathoracic surgery
Choice of anesthesia or drugs dose not alter
incidence of postop pulmonary complications

Intraoperative
Regional anesthesia
PNB lower risk than neuraxial block
Large dose of sedative drugs
High block (>T6) can impair ventilatory
f
functions
ti
Clinically inadequate cough

Intraoperative
General anesthesia
Volatile anesthetics base
Bronchodilation
Rapid elimination

Nitrous
Nit
oxide
id
Enlarge bullae tension pneumothorax
Low FIO2

Opioid
Less useful
Opioid+N
O i id N2O

Intraoperative
Endotracheal tube
Humidification
Low gas flow

Controlled mechanical ventilation

Large tidal volume (10-15 ml/kg)

Slow inspiratory flow rate
Slow RR (6-10 /min)
Aware barotrauma

Spontaneous breathing
Greater ventilatory depression

Postoperative
Postoperative
p
Maintain adequate lung volume (FRC)
Effective cough

Lung
g expansion
p
maneuvers

Deep breathing exercise

Incentive spirometry
Chest physiotherapy (CPT)
PPB

Postoperative
Mechanical ventilation
Continue during immediate postop
Severe COPD
Preop FEV1/FVC ratio <0.5
Preop
P
PCO2 > 50 mmHg
H

Quickly correct hypercarbiametabolic

alkalosis

Postoperative
Mechanical ventilation setting
FIO2 : maintain PaO2 60-100 mmHg
PCO2 : maintain pH 7.35-7.45

Take home messages

Respiratory disease
Optimized preoperative conditions
Well controlled
Treat infection
Patient education

Intraoperative management
Choice of anesthesia
Drugs & instruments

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Take home messages

Postoperative care
Oxygen supplement
Adequate
Ad
t analgesia
l
i
Lung expansion therapy

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