Bronchospas

m
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 Outline
Objective

Introduction

Anatomy and innervation of bronchial smooth

muscles
Pathophysiology and causes of bronchospasm

Risk Factors

Differential diagnosis and Clinical Features

Management
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 Objective
At the end of this discussion students will be able to;

Know the anatomy and innervation of bronchial

smooth muscles

understand causes and risk factors of

bronchospasm

identify DDX and clinical features of bronchospasm

practice or apply management of bronchospasm

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 Introduction
Bronchospasm is one of the common features of reactive

airways disease.

patients with bronchial asthma and some with chronic

obstructive pulmonary disease (COPD) show hyper reactive

airway responses to mechanical and chemical irritants.

Results in constriction of bronchial smooth muscle, mucosal

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 Cont
Perioperative bronchospasm in patients with reactive

airways disease is however relatively uncommon.

In patients with well-controlled asthma and COPD the

incidence is approximately 2%.

The overall incidence of bronchospasm during general

anesthesia is approximately 0.2%.

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 Bronchospasm
Definition:
Bronchospasm is a temporary narrowing of
the bronchi (airways into the lungs)
caused by contraction of the muscles in
the lung walls, by inflammation of
the lung lining, or by a combination of
both.

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 Arterial supply:
Right, one bronchial artery from 3rd
posterior intercostal artery.
Left,two bronchial arteries from
descending thoracic aorta.
Venous drainage: mostly from
pulmonary veins, and bronchial veins.

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 Pathophysiology of bronchospasm
Bronchospasm or a bronchial spasm is a
sudden constriction of the muscles in the
walls of the bronchioles.
This is due to exaggerated response to
trigger;
airway edema

increased secretions
smooth muscle contractions
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 Cont
Airway inflammation increases bronchial hyper
responsiveness.
Anaphylaxis;releases histamine,leukotrienes
C4,D4,PGD2.
Allergic
As part of IgE mediated anaphylaxis

Latex, antibiotics

Nonallergic
Susceptible airways

Precipitating factors
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 Cont
Susceptible Airways
Asthma
smoking
Respiratory tract infection
Precipitating Factors

Airway irritation with inadequate depth of

anesthesia

Pharmacologicinduced histamine release

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 What causes
bronchospasm?
o Bronchospasm happens due to a number of

different factors; I.,MASA

Inflammation of the airways

Excessive mucus production

Allergens and Irritants

Emotional Stress

Anesthtetic agents

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 Risk factors
Having personal history of asthma, copd and
brochitis.
Upper respiratory infections.

Sudden increase in activity or exercise.

Air irritants, such as strong odors, smoke, air

pollution, cold or dry air .
Certain medications, such as, antihypertensives,
antibiotics, aspirin or NSAIDs.

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 Clinical presentation
Wheezing(expiratory)

Increase peak airway pressure

Decrease exhaled tidal volume

Desaturation

Prolonged expiration

Rash

hypotention due to development of auto PEEP

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 Characteristic shark fin appearance due to
bronchospasm in capnograph
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 Differential diagnosis
Bronchospasm occurs most commonly during the
induction and maintenance stages of anaesthesia.
and is less often encountered in the emergence
and recovery stages.
most common cause during induction is airway
irritation, often related to intubation.
During maintenance results from an anaphylactic
or serious allergic reaction.
Drugs , blood products and other allergens (latex)
are the agents commonly responsible.
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 Cont
Other features of allergic or anaphylactic
reaction includes;

cutaneous signs
rash, urticaria, angioedema
and cardiovascular signs
tachy/bradycardia
hypotension
circulatory collapse
When assessing bronchospasm there are other
important differential diagnoses and contributing
factors to consider:
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 DDX
Endobronchial intubation
Pneumothorax
Pulmonary edema
Esophageal intubation
Pulmonary aspiration
laryngospasm
mechanical obstruction
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 How to prevent
bronchospasm
Pretreatment with an inhaled/nebulised beta agonist, 30

minutes prior to surgery.

induction of anaesthesia with propofol and adequate

depth of anaesthesia before airway instrumentation

reduces the risk of bronchospasm.

The use of an LMA to reduce the incidence of

bronchospasm compared to tracheal intubation.

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 Cont
All patients should be counselled and encouraged to stop

smoking preoperatively.

Postpone surgery patients with URTI

Avoid anesthetic agents that causes bronchospasm.

Consider ketamine because of bronchodilator effects .

avoid non-selective Beta blockers.
Use lidocaine 1.5 mg/kg 1-3 min before intubation.

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 Cont
Intraoperative
Minimize airway instrumentation
If possible, use local or regional anesthesia
If possible, consider face mask > LMA > ETT
Ensure adequate depth of anesthesia before
airway instrumentation
Intubation
Deep extubation
Topical lidocaine to the airway
Consider not using muscle relaxant
Potential allergic reactions
Problems from reversal agents

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 Cont
If bronchospasm occurs
100% O2

Deepen anesthesia
Manual ventilation to assess
compliance
Provide adequate expiratory time

Avoid PEEP

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 Cont
If there is Difficulty with ventilation/falling SpO2;

CALL FOR HELP

Immediate management; prevent hypoxia & reverse bronchoconstriction

Deepen anaesthesia

If ventilation through ETT difficult/impossible, check tube

position and exclude blocked/misplaced tube

If necessary eliminate breathing circuit occlusion by using self-

inflating bag

DRUG THERAPY

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 Secondary management
provide ongoing therapy and address underlying
causes

Optimise mechanical ventilation

Reconsider allergy/anaphylaxis - expose and examine the
patient, review medications

If no improvement consider pulmonary

oedema/pneumothorax/pulmonary embolus/foreign body

Request & review chest X-ray

transfer to a critical care area for ongoing investigations
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 Classes of bronchodilators
1.Sympathomimetic agents ;
are the most commonly used for acute
exacerbations.
produce bronchodilation via 2-agonist activity.

Activation of 2-adrenergic receptors on bronchiolar

smooth muscle stimulates the activity of adenylate
cyclase, which results in the formation of intracellular
cyclic adenosine monophosphate (cAMP) .example
Terbutaline
Albuterol
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2.Phosphodiesterase inhibitors;
this enzyme is responsible for breakdown of cAMP.

This enzyme is inhibited by methylxanthines

(theophyline,aminophyline)which results in bronchial
relaxation.

3. Anticholinergic agents;
Anticholinergics act by blocking the cholinergic nerves,
which lead to dilatation of the airways.
The chemicals which are released from these nerves
cause tightening of the muscles which line the airways.
E.g. tiotropium, ipratropium,

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 Cont
first line therapy
o salbtamol
Metered Dose Inhaler: 6-8 puffs repeated as
necessary (using in-line adaptor/barrel of 60ml
syringe with tubing or down ETT directly)
Nebulised: 5mg (1ml 0.5%) repeated as
necessary
Intravenous: 250mcg slow IV then 5mcg.min-1 up
to 20mcg.min-1
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 Figure 3. A metered dose inhaler (MDI)
adaptor fitted in the breathing circuit, on the
patient side of the heat and moisture
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 Figure 4. An MDI canister can be placed in the
barrel of a 60ml syringe and a 15cm length of IV
tubing attached via the Luer lock. Feed the tubing
down the ETT and press the plunger to administer
the drug, then reconnect the breathing circuit and
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ventilate.
 Cont
Second line drug therapy
Ipratropium bromide: 0.5mg nebulised 6 hourly
Magnesium sulphate: 50mg.kg-1 IV over 20min
(max 2g)
Hydrocortisone: 200mg IV 6 hourly
Ketamine: Bolus 10-20mg. Infusion 1-3mg.kg-1.h-
1
IN EXTREMIS: Epinephrine (Adrenaline)
Nebulised: 5mls 1:1000
Intravenous: 10mcg to 100mcg tirtrated to
response

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 Summary
Bronchial smooth muscle tone is
predominantly controlled or innervated by
parasympathetic nervous system.

The overall incidence of bronchospasm during general

anesthesia is approximately 0.2%.

Bronchospasm is a relatively common event

during general anaesthesia.
Management begins with swicthing to 100%O2
and calling for help early.
Stop all potential precipitants and deepen
anaesthesia.
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 Cont
Exclude mechanical obstruction or
occlusion of the breathing circuit.
Aim to prevent and corret hpoxaemia and
reverse bronchoconstriction.
Consider a wide range of differential
diagnoses including anaphylaxis,
aspiration or acute pulmonary oedema.

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 Reference
Update in anesthesia
Journal of American
Anesthesiologists
Morgan 5th edition

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 Thank You

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