Study Notes Essentials of Anesthesia Management in Children with Asthma

Asthma control should be optimized before anesthesia
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When possible, we evaluate patients with asthma one to two weeks before elective surgery to allow time to adjust treatment if necessary
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Patients should continue routine asthma treatment in the perioperative period
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● For children with severe, poorly controlled asthma requiring tracheal intubation and with risk factors for perioperative respiratory adverse events (PRAEs), a supplemental course of glucocorticoids is recommended (Grade 1B)
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Prednisone or prednisolone 1 mg/kg (maximum 50 mg) by mouth usually once daily for 4 days after consultation with an asthma specialist or primary care clinician
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● Tracheal intubation can easily induce bronchospasm, especially under light anesthesia
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When possible, avoid endotracheal intubation by administering general anesthesia using mask ventilation or laryngeal mask airway (LMA)
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● For most children with asthma, we recommend intravenous (IV) induction rather than inhalation induction (Grade 2B)
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For most hemodynamically stable children receiving general anesthesia, we suggest induction with propofol rather than other drugs (Grade 2B)
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For hemodynamically unstable patients, ketamine or etomidate may be the first choice
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Unlike etomidate, ketamine has bronchodilatory properties
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● For most children with asthma, general intravenous anesthesia or sevoflurane, isoflurane, or halothane can be used to maintain anesthesia
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Desflurane is an airway irritant and should not be used in children with asthma or at increased risk of PRAE (Grade 1B)
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● For children with asthma, neuromuscular blocking agents (NMBAs) that do not release large amounts of histamine (eg, rocuronium, pancuronium, and vecuronium) are preferred over those that release significant amounts of histamine (eg, atracurium and micuronium)
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Neostigmine, used to reverse muscle relaxants, rarely causes bronchospasm
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We recommend endotracheal intubation with NMBA rather than intubation without NMBA (Grade 2C) because intubation with NMBA is associated with fewer PRAEs
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● Morphine and pethidine release histamine when given in large doses or very rapidly
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Other synthetic opioids are preferred by asthmatics because they do not release clinically relevant amounts of histamine
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● Ventilation during anesthesia in patients with asthma should include controlled hypopnea, low respiratory rate, reduced inspiratory time, increased expiratory time, moderate tidal volume, and careful use of positive end-expiratory pressure to avoid hyperinflation, air entrapment, and Barotrauma
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● Intraoperative management of bronchospasm should include: • FiO2 100% • Careful hand ventilation (low frequency allows adequate exhalation) • Deep anesthesia Treatment with a potent beta2 agonist (eg, 8 to 10 doses of salbutamol by metered-dose inhaler or 2.
5 mg by nebulizer)
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More severe bronchospasm may require intravenous salbutamol, glycopyrrolate, or atropine, epinephrine, and steroids
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● Recovery from anesthesia
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Deep (relative to awake) removal of the airway device is recommended (Grade 2C)
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Patients with complex intraoperative procedures may benefit from continuous postoperative intubation and ventilation
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Postoperative noninvasive positive pressure ventilation can be used for extubated patients who require ventilatory support
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END