[Crisis Management] Sudden bronchospasm during perianaesthesia

[Crisis management] Sudden bronchospasm during peri-anesthesia 1.
Occurrence and harm of peri-anesthesia bronchospasm Peri-anesthesia bronchospasm refers to the spastic contraction of bronchial smooth muscle due to various reasons during anesthesia
.

In the case of hypersensitivity of bronchial smooth muscle, external stimuli such as endotracheal intubation, reflux aspiration, and sputum suction can all cause bronchospasm
.

Surgical stimulation can also cause reflex bronchospasm
.

Anesthetic drugs can release histamine from tracheal and bronchial mast cells, and can also cause bronchospasm
.

Bronchospasm is one of the common complications of perianesthesia, with an incidence of 0.
6%-0.
8%
.

The main clinical manifestations of bronchospasm are bronchial smooth muscle spasmodic contraction, airway narrowing, sudden increase in ventilation resistance, expiratory dyspnea, causing hypoxia and carbon dioxide accumulation; wheezing sounds in the lungs, or disappearance of breath sounds on auscultation: Airway Resistance and peak pressure increased; oxygen saturation decreased continuously; PaO2 decreased and PETCO2 increased
.

Once severe bronchospasm occurs, if it is not treated in time, it is often life-threatening due to respiratory and circulatory failure caused by severe hypoxia and carbon dioxide retention
.

Although the level of anesthesia technology has been greatly improved in the past decade, the incidence of intraoperative bronchospasm has not been significantly reduced
.

For patients with a current history of asthma, the incidence of intraoperative bronchospasm is about 10%; for patients with currently asymptomatic asthma, the probability of intraoperative respiratory complications is very low
.

Once the patient develops bronchospasm during the peri-anesthesia period, it is very dangerous
.

If rescue is not timely, the mortality rate is as high as 70%
.

Therefore, patients with bronchospasm during the peri-anesthesia period need to be quickly identified, diagnosed, and managed, otherwise the patient will experience respiratory cardiac arrest within minutes, leading to death
.

Due to the existence of individual differences in patients, different types of diseases, and differences in age, gender, past history, etc.
, the objects of bronchospasm are also different
.

During clinical anesthesia, young children are most prone to bronchospasm, especially those with pulmonary infection
.

Once bronchospasm occurs, it should be detected and dealt with immediately; if the rescue is not timely, it will cause the patient's death or irreversible organ function damage; Damage to many vital organ systems and functions of the human body
.

2.
Challenges brought about by sudden bronchospasm during the peri-anesthesia period 1.
Challenges to the safety of patients Bronchospasm is a common clinical complication during the peri-anesthesia period
.

Its incidence is increasing year by year worldwide
.

Especially in patients with a history of asthma attacks in the past two years, the probability of intraoperative asthma attacks was significantly increased, and the closer the time was, the higher the incidence of intraoperative and postoperative bronchospasm
.

For asthma during pregnancy, if regional anesthesia is not appropriate or if prostaglandins are used for miscarriage or childbirth, the risk of asthma-induced asthma is significantly increased
.

The incidence of stridor during induction of general anesthesia in smoking patients was 8%, and the relative risk of bronchospasm was 5.
6 times that of non-smokers.
Smoking cessation can reduce respiratory secretions and promote ciliary transport
.

A variety of factors during anesthesia surgery can induce asthma attacks, leading to bronchospasm, which directly threatens the life safety of surgical patients
.

2.
Challenges to medical staff At present, asthma is no longer considered to be a simple acute bronchospasm, but a chronic allergic inflammation of the airways, and it has become a clinical phenomenon because asthma is prone to recurrence and is difficult to cure.
One of the more difficult diseases to treat
.

Asthma patients suffer from the dual effects of surgery and anesthesia in the perioperative period, increasing the probability of asthma attacks, and even endangering the patient's life if not handled properly
.

Due to the involvement of surgery and anesthesia factors, there is no guideline for the diagnosis and treatment of intraoperative asthma attacks, but the international guidelines for the diagnosis and treatment of asthma patients have been revised for many times
.

First of all, when encountering such an airway crisis, it is necessary to deal with it calmly
.

Correct and rapid diagnosis is the key, removing the inducement and adopting the correct treatment process to quickly solve the problem of airway crisis
.

The acute attack of bronchospasm often causes great psychological pressure to the clinical front-line doctors, and it is also a great challenge to the professional ability
.

3.
Challenges to clinical management Bronchospasm occurs during anesthesia, which can directly interfere with the process of anesthesia and surgery.
Sometimes the treatment is quite difficult, and it affects the postoperative recovery of patients and seriously threatens the safety of patients.
Therefore, prevention of bronchospasm is the focus
.

Higher requirements are put forward for various systems in the peri-anesthesia period, such as preoperative visit, evaluation, the responsibility system of the attending physician and the consultation of relevant departments (respiratory department) when necessary
.

In general, the incidence of intraoperative bronchospasm is affected by the physical condition of the patient before anesthesia
.

Patients with a high ASA class and a history of structural heart disease, respiratory tract infection, obstructive pulmonary disease, and airway obstruction had an increased incidence of bronchospasm
.

For high-risk patients, corresponding prevention strategies and treatment procedures should be established, so as to achieve pre-assessment and prevention.

.

Some studies have shown that the incidence of intraoperative bronchospasm is higher than that of general anesthesia without intubation and regional anesthesia.
and regional anesthesia are about 20%; preoperative prophylactic inhaled bronchodilator can help prevent the occurrence of intraoperative bronchospasm
.

To prevent acute bronchospasm, the most important principle is to adequately anesthetize the airway before endotracheal intubation
.

Immediately before induction of general anesthesia, inhalation of β2-receptor agonists or application of anticholinergic drugs is a feasible method; correct selection of anesthetic drugs such as propofol, ketamine and inhalation anesthetics for induction and maintenance, but propofol should be used with caution in those with allergic constitution.
Sodium thiopental, morphine, and succinylcholine are prohibited, and muscle relaxants that do not release histamine should be used as much as possible, and besylatracuramide should be used with caution; narcotic analgesics and lidocaine (1.
5-2 mg) are intravenously injected before intubation.
/kg) can reduce respiratory responsiveness
.

3.
Analysis of the causes of sudden bronchospasm during the peri-anesthesia period (1) Predisposing factors for bronchospasm during the peri-anesthesia period
.

Viral upper respiratory tract infection in normal organisms can lead to a marked increase in airway reactivity, which can last 3 to 4 weeks after infection
.

Therefore, when general anesthesia is required for emergency surgery in such patients, an appropriate amount of atropine or longtonine should be considered before induction
.

2.
Smoking Long-term smokers, especially those with cough and phlegm, have increased airway reactivity
.

Most of these may not be sufficient for the diagnostic criteria of bronchitis, and routine lung function may show mild abnormalities
.

3.
History of Asthma and Bronchospasm Many patients report a history of asthma exacerbations, which are not reliable predictors of reactive airway disease
.

Some patients may require a bronchial challenge test or spirometry to confirm the diagnosis
.

However, if the patient does not need medication at ordinary times, and the medical history, physical examination, and spirometry examination show no obvious abnormal respiratory function, then the anesthesia selection only needs to consider the anesthetic drugs used and the anesthesia method that is not easy to induce bronchospasm
.

For patients with recurrent bronchospasm, a decision should be made on the patient's preoperative medication, as well as intraoperative and postoperative treatment options
.

(B) the triggering factors of bronchospasm Many factors can promote bronchospasm in patients with obstructive airway disease
.

Bronchospasm can be induced in children with asthma, and airway edema and inflammation associated with exposure to antigens or viral infections
.

In adults with airway obstruction, allergic reactions are far less important than irritant reflex mechanisms
.

Irritant-induced bronchoconstriction is the most noteworthy problem in the anesthetic management of these patients
.

There are many predisposing factors for bronchospasm.
The main causes of bronchospasm during perianaesthesia are as follows
.

1.
Improper tracheal intubation, such as tracheal intubation and extubation under light anesthesia, stimulation of the tracheal mucosa, and deep tracheal intubation stimulation of the tracheal ridge and so on can cause postganglionic cholinergic nerve fibers to release acetylcholine, which is the main cause of bronchospasm.
precipitating factors
.

2.
Insufficient depth of anesthesia As mentioned above, the neurohumoral reflexes caused by endotracheal tubes or surgical stimulation cannot be effectively suppressed
.

3.
Improper choice of drugs, such as curare, morphine or rapid input of low molecular weight dextran, can provoke mast cells to release histamine
.

4.
Stimulation of the airway by secretions In addition, the epidural block plane is too wide (sympathetic nerve block, the vagus nerve is relatively excited), blood transfusion, cardiopulmonary bypass after opening the aorta, surgical stimulation, etc.
can induce airway spasm
.

5.
Affected by the physical condition of patients undergoing surgery before anesthesia, such as high ASA grade, organic heart disease, respiratory tract infection, obstructive pulmonary disease and mechanical operation of the throat, the incidence of airway hyperresponsiveness during anesthesia is high.
, the incidence of bronchospasm will be greatly increased
.

4.
Coping strategies for sudden bronchospasm during peri-anesthesia (1) Timely identification of sudden bronchospasm during peri-anesthesia.
In severe cases, cyanosis occurs, and ventilation resistance increases significantly under general anesthesia with endotracheal intubation.
Extensive wheezing in both lungs can be heard on auscultation, which is more pronounced during exhalation.
PETCO2 or PaCO2 can decrease slightly, and in severe cases, wheezing decreases , PETCO2 or PaCO2 increased significantly, SpO2 or PaO2 decreased significantly
.

Stridor episodes during anesthesia are not uncommon, may be due to causes other than bronchospasm, and must be identified
.

(2) Differential diagnosis of sudden bronchospasm during peri-anesthesia period 1.
Improper position of the tracheal tube.
When the tracheal tube is inserted into one bronchus, the airway pressure may be significantly increased.
When the tracheal tube is located in the carina, it may also stimulate the sensitivity of the site.
Irritant receptors, producing reflex bronchospasm
.

Persistent cough and muscle tension are more common clinically with this irritation
.

Administration of muscle relaxants can be differentiated from bronchospasm
.

2.
Duct obstruction Excessive pulmonary ventilation pressure may also be due to mechanical obstruction of the tracheal tube, such as tube twisting, thick secretions or over-inflated balloon
.

This obstruction is generally audible during both the inspiratory and expiratory phases of ventilation
.

Failure of the suction tube to pass through the endotracheal tube may suggest the diagnosis, but it may only be confirmed by fiberoptic bronchoscopy
.

3.
Pulmonary edema In the early stage of pulmonary edema, plasma fluid accumulates in a cuff-like manner around the bronchioles
.

This phenomenon is generally believed to be the cause of increased airway resistance during pulmonary congestion, which can cause stridor, mainly near the end of expiration
.

This stridor is the main early sign of pulmonary edema in surgical patients
.

Effective treatment, including correction of heart failure and/or noncardiac etiologies, rather than bronchiectasis, must be pursued
.

4.
Tension pneumothorax The clinical signs of tension pneumothorax may also resemble bronchospasm, and many patients with pneumothorax have chronic obstructive airway disease
.

The stridor in pneumothorax may be due to compression of the bronchioles due to decreased lung volume on the diseased side
.

Hypotension and tachycardia are early signs of pneumothorax and may help in identification
.

Diagnosis and treatment depend on chest X-ray or large needle puncture of the anterior thoracic second intercostal space with gas escaping
.

5.
Stomach contents Inhalation of gastric contents into the tracheobronchial tree is also one of the causes of bronchospasm
.

Inhaled substances can excite irritant receptors, leading to constriction of the large airways
.

Airway constriction is self-limiting in most patients, and the goal of therapy is to correct abnormal gas exchange
.

6.
Pulmonary embolism It is generally believed that stridor in pulmonary embolism is caused by bronchoconstriction caused by the release of amines into the surrounding airways
.

Stridor as a major sign of pulmonary embolism is still controversial
.

(3) Prevention and treatment of sudden bronchospasm during peri-anesthesia period Bronchospasm is one of the common complications during peri-anesthesia period.
Any factor that causes bronchial smooth muscle contraction may induce bronchospasm
.

Therefore, how to better prevent and urgently deal with this symptom is a common concern of anesthesiologists and surgeons
.

1.
Preventive measures for bronchospasm during peri-anesthesia Careful preoperative assessment of the risk of bronchospasm in peri-operative patients is very important for formulating a reasonable anesthesia plan, and prevention should be the first priority
.

Patients with airway hyperresponsiveness should quit smoking for at least 1 week before surgery, and take routine oxygen inhalation, anti-inflammatory, antispasmodic, and antiasthmatic treatment to prevent and control respiratory inflammation
.

Actively improve the general condition and choose the best time for surgery
.

Emergency patients should also be treated appropriately to improve hypoxia
.

For patients with airway hyperresponsiveness, local anesthesia or spinal anesthesia should be used as much as possible
.

When using spinal anesthesia, the plane should not exceed the T6 level
.

Mask and nasal cannula oxygen should be listed as routine measures, and pure oxygen should be inhaled when necessary
.

The addition of 1:200,000 to 600,000 epinephrine to local anesthesia, intravenous administration of steroids, and some sedation and postoperative analgesia can help prevent bronchospasm during and after regional anesthesia
.

To prevent acute bronchospasm, the most important principle is to adequately anesthetize the airway before endotracheal intubation
.

Inhalation of β2-receptor agonists or anticholinergic drugs before induction of general anesthesia is a feasible method: correct selection of anesthetic drugs such as propofol, ketamine and inhalation anesthetics for induction and maintenance, but propofol should be used with caution in those with allergic constitution.
Sodium thiopental, morphine, and succinylcholine are contraindicated, and muscle relaxants that do not release histamine should be used as much as possible.
Besulfatracuramide should be used with caution: intravenous injection of narcotic analgesics and lidocaine (1.
5~ 2 mg/kg) can reduce airway reactivity, but there are also reports that intravenous administration of 1.
5 mg/kg lidocaine 3 minutes before intubation does not inhibit bronchoconstriction in patients with asthma, while inhalation of salbutamol 15 to 20 minutes before intubation can.
Effective inhibition; intratracheal injection of lidocaine can avoid bronchospasm; intubation should not be too deep; general anesthesia should be maintained at a sufficient depth; adequate crystalloid solution during surgery: avoid the use of PEEP; use neostigmine with caution, suction A certain depth of anesthesia should be maintained during extubation, and lidocaine can be instilled continuously for extubation
.

2.
The treatment of bronchospasm in the peri-anesthesia period is first to diagnose correctly and quickly, remove the incentive, and secondly, pressurized oxygen to avoid hypoxia
.

For regional anaesthesia, muscle relaxants can help differentiate ventilation difficulties from bronchospasm from respiratory muscle tension or cough
.

Most bronchospasm can be relieved by deepening anesthesia (increasing the concentration of inhaled anesthetics, giving ketamine, propofol, etc.
), and for those that cannot be relieved, intravenous or inhaled sympathomimetic drugs and anticholinergics can be administered
.

in use
.

Antiarrhythmics such as lidocaine should be routinely reserved for receptor agonists; severe bronchospasm is not suitable for high-concentration inhalation anesthetics because the drug is difficult to transport in the airways and may have been compromised before the desired bronchodilator effect has been achieved.
Severe hypotension occurs; correct and rapid injection of glucocorticoids, preferably hydrocortisone sodium succinate 100~200mg intravenously, but anti-infective treatment of hormones cannot immediately relieve symptoms; patients with hypotension are given ephedrine, Epinephrine 0,1 mg intravenously in emergencies; aminophylline should be used with caution, it is not recommended to use it with β-receptor agonists, inhalation anesthesia can increase the concentration of theophylline in plasma, which can cause arrhythmia, and can be divided if necessary Small doses (<50mg each time, total 250mg); adjust respiratory parameters to ensure effective tidal volume, and manual ventilation if necessary; Lidocaine (5mg/kg) aerosol inhalation can inhibit histamine-induced bronchoconstriction, but The disadvantage is that there is a process of irritating the airway and causing the airway tension to increase.
The combined inhalation of lidocaine and salbutamol (1.
5mg) can provide better airway protection, and the effect is better than that of lidocaine or salbutamol alone.
inhalation
.

5.
Thoughts on sudden bronchospasm during peri-anesthesia period The prevention and treatment of sudden bronchospasm during peri-anesthesia period is a complicated subject
.

There are many predisposing factors for sudden bronchospasm in the peri-anesthesia period, but most of them occur in patients with airway hyperresponsiveness.
Practice suggests that medical history and physical examination are the basis of preoperative evaluation
.

To identify and evaluate high-risk groups, pulmonary function testing and other auxiliary tests are necessary
.

In addition, in order to effectively prevent and reduce perioperative respiratory complications, smoking cessation must be reminded before surgery, active treatment of the primary disease, and pulmonary function exercise guidance for patients
.

Combining the type and scope of surgery to formulate an appropriate surgical method, select the correct anesthetics, and avoid the use of anesthetics that have a greater impact on the airway
.

Only in this way, it is possible to reduce the incidence of sudden bronchospasm in the perioperative period and improve the safety of surgery
.

In addition, the timing and skills of extubation are also issues worthy of consideration and attention
.

The "ideal" indication for extubation may lead to bronchospasm
.

Although there are differing views of "early" or "later" removal of the endotracheal tube, we do not think this is the crux of the matter
.

Because the timing of extubation should be within the control of the anesthesiologist
.

Bronchospasm is more difficult to control than insufficient respiratory muscle strength
.

For asthmatic patients, it is very important to maintain the "peace" of the airway before extubation, which can be achieved by using propofol, remifentanil, lidocaine, etc.
before extubation
.

Gradually restore the patient's respiratory function to an ideal state while maintaining the patient's airway "quiet".
After the patient has a slight physical movement, coughing, or swallowing, the tracheal tube is immediately removed, and a mask is given to inhale oxygen or moderately assisted ventilation
.

6.
Typical case sharing of sudden bronchospasm during peri-anesthesia The patient, female, 65 years old, 64kg, was diagnosed with right lung space-occupying lesions, and planned to undergo right lower lobectomy under general anesthesia
.

The patient has suffered from chronic obstructive pulmonary disease for 10 years, and the disease occurs 1 to 3 times a year, accompanied by frequent cough and sputum
.

Preoperative laboratory examinations and electrocardiograms were generally normal.
After entering the operating room, blood pressure was measured at 150/85 mmHg and heart rate was 90 beats/min.
General anesthesia was induced by intravenous injection of propofol 80 mg, fentanyl 0.
2 mg, and vecuronium bromide 8 mg.
, About 2 minutes later, a double-lumen endotracheal tube was inserted, and the double-lung isolation technique was implemented
.

About 1 minute after the intubation, the airway pressure was significantly increased (storage airbag assisted breathing).
It was initially believed that the double-lumen endotracheal tube was not in place, so the fiberoptic bronchoscope was used to reset it in place, but the mechanical ventilation alarm indicated that the airway pressure was high (45cmH2O).

.

), and there was wheezing and a small amount of moist rales in both lungs on auscultation.
At this time, the heart rate was 135 beats/min, blood pressure was 180/95 mmHg, SpO2 85%, and PETCO2 58 mmHg.
Therefore, it was determined that the patient had bronchospasm, and the anesthesia was immediately deepened (inhalation of high concentrations).
Isoflurane, intravenous dexmedetomidine 50ug, intravenous ketamine 60mg), and at the same time intravenous dexamethasone 10mg, 2% lidocaine 5mL was injected into the bronchus through a double-lumen endotracheal tube, and the heart rate was 89 beats/ Score, blood pressure 120/80mmHg, SpO2 97%, PETCO2 45mmHg.
Airway pressure dropped to 35cmH2O, half an hour later PETCO2 dropped to 39mmHg, airway pressure dropped to 25cmH2O
.

The anesthesia and operation of the patient went well, and the patient was sent back to the ICU for continued ventilator support.
After 2 hours, the patient was fully conscious, and the double-lumen endotracheal tube was pulled out normally with spontaneous breathing.
There was no abnormality in the patient thereafter
.

Notes/Hangbo Typesetting/Dingdang Maruko Ma