Perioperative Care of the Pediatric Patient and an Algorithm for the Treatment of Intraoperative Bronchospasm

Figures & data

Box 1 Preoperative Interventions for the Patient with Asthma

Consultation with pediatric pulmonary or allergy specialist. Maximize chronic medication regimens including inhaled corticosteroids and oral leukotriene antagonists. Avoid second-hand tobacco smoke. Ensure that there are no acute infectious concerns. Administration of a 5–7-day course of oral corticosteroids. Inhaled β-adrenergic agonist (albuterol) and anticholinergic agent (ipratropium) on the day of surgery.

Box 2 Intraoperative Considerations for the Patient with Asthma

Intravenous induction may be superior to inhalation induction. Intravenous induction agent: propofol or ketamine preferable to barbiturates or etomidate. Choice of airway: laryngeal mask airway or face mask preferred over endotracheal tube. If endotracheal intubation is necessary, consider use of a neuromuscular block agent. Consider adjunctive agents prior to endotracheal intubation such as an anticholinergic agent (glycopyrrolate) and lidocaine. Neuromuscular blocking agent: vecuronium or cis-atracurium may be preferred over rocuronium. Intraoperative administration of dexamethasone especially if oral corticosteroids were not administered preoperatively. Maintenance anesthesia: total intravenous anesthesia may be preferable to volatile agents. Sevoflurane preferred over desflurane. Reversal of neuromuscular blockade with sugammadex preferable to neostigmine. Avoid medications that cause histamine release such as morphine. Theoretical concerns suggest avoidance of non-steroidal anti-inflammatory agents including ketorolac.

Box 3 Acute Intraoperative Treatment of Bronchospasm

Manual ventilation with 100% oxygen. Ensure adequate exhalation time. Auscultation to ensure bilateral breath sounds are present. Must rule out that respiratory concern is due to bronchospasm and not ETT obstruction or kinking, mainstem intubation, ventilatory malfunction. Cessation of surgical or airway stimulation. Chest radiograph as clinically indicated. Identification of potential allergic reaction (anaphylactic or anaphylactoid). Inhaled albuterol delivered via metered-dose inhaler. Deepening the level of inhalational anesthesia or administration of a bolus dose of propofol. Intravenous epinephrine: bolus dose (1–2 µg/kg) and infusion (0.02–0.1 µg/kg/min). Alternatively may use intravenous β-adrenergic agonist such as terbutaline. Magnesium: bolus dose (25–50 mg/kg) followed by an infusion at 10–20 mg/kg/hour. Ketamine: bolus dose (0.5–1 mg/kg) followed by an infusion (0.5–1 mg/kg/hour). Corticosteroids (if not administered previously). Aminophylline.

Box 4 Postoperative Treatment of Bronchospasm

Auscultation to ensure bilateral breath sounds are present and rule out other causes of respiratory insufficiency. Treatment of emergence delirium with dexmedetomidine. Ensure adequate analgesia. Chest radiograph as clinically indicated. Inhaled albuterol delivered via metered-dose inhaler or aerosol. Continued dosing of inhaled anti-cholinergic agents. Follow same treatment pathway as intraoperative treatment including intravenous epinephrine bolus or infusion, magnesium, ketamine, corticosteroids, and aminophylline. Non-invasive ventilation with bilevel positive airway pressure (BiPAP). Identification of potential viral illnesses for diagnostic purpose – nasal swab for viral antigen identification (film array viral panel).