Bronchospasm During Induction: a Moment of Sheer Terror
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Consider the following dilemma during induction of anesthesia: intravenous induction, tracheal intubation, no breath sounds on auscultation and end-tidal carbon dioxide levels are low. Is this an esophageal intubation? The endotracheal tube was seen advancing beween the vocal chords. Should the endotracheal tube be removed? The differential diagnosis includes bronchospasm. Certainly, the treatment of bronchospasm is different than esophageal intubation.
In this month’s education case scenario, entitled, “Bronchospasm during Anesthetic Induction“, a case report of a patient with suspected bronchospasm is followed by a detailed discussion:
1. Diagnosis and differential diagnosis of intraoperative wheezing/bronchospasm. Possibilities include esophageal intubation, aspiration, and obstruction of the breathing circuit.
2. Bronchospasm can represent either an anaphylactoid reaction or IgE-mediated anaphylaxis. Neuromuscular blocking agents are the most common drugs involved in perioperative anaphylaxis.
3. Determination of the pathophysiologic mechanism. Symptoms that might help determine the cause: symptom duration, possible trigger, and clinical signs, e.g., erythema, though many clinical signs including erythema are non-specific. Tryptase increase is specific for mast cell activation. Skin tests for medications received as well as for latex can help determine mechanism.
4. Asthma is under-diagnosed and can be responsible for airway responsiveness that leads to bronchospasm. Control of asthma before surgery can help reduce bronchoconstriction during surgery. The lungs of all patients should be auscultated before surgery to help determine if there is a preoperative element of wheezing/asthma.
5. Asthmatics and smokers are at greater risk for perioperative bronchospasm.
6. Bronchospasm can be life-threatening and and is one of the reasons related to perioperative brain damage and death.
7. Once bronchospasm occurs: increase oxygen to 100%; consider manual bag ventilation; increase anesthesia depth; administer short-acting β2-selective agents; and consider the use of systemic glucocorticosteroids, though their anti-inflammatory effect is not immediate.
The article goes into much more detail and should be read by all. This topic is certain to be discussed during board exams and the article is particularly useful for those who are about to take the test.
Though bronchospasm can be a moment of sheer terror, for me, even without these moments of terror, anesthesia is never hours of boredom.
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