Anaesthesia for Obstructive Airway Disease Dr Prasanga Palihawadana (MD, FRCA) Consultant Anaesthetist General Hospital Ampara
Dec 17, 2015
Anaesthesia for Obstructive Airway DiseaseDr Prasanga Palihawadana (MD, FRCA)Consultant AnaesthetistGeneral Hospital Ampara
Areas coveredPathophysiologyMedical ManagementAssessment of Bronchial AsthmaPreparation Anaesthesia
Areas covered..Management of Acute Severe Asthma in OT
COPDPrinciples of MxPrevious exam questions
Bronchial AsthmaA chronic inflammatory condition of lungs.Common -10%
SymptomsCoughWheezeChest tightnessSOB
Characteristic featuresAirflow limitationAirway hyper responsivenessInflammation
CausesAtopy- Enviornmental Pollen Dust PollutionViral infections
CausesCold airEmotionsOccupationalDrugs - NSAIDS Beta blockers
PathophysiologyInflammation (Steroids)Bronchoconstriction (beta2 agonists)Cholinergic effect causing Bronchoconstriction(Ipratropium=atropine)
PathophysiologyHistamine H1=Bronchoconstriction(mast cell stabilisers)Leucotrines in aspirin induced asthma
Management of BA (WHO guidelines)Lifestyle modificationStepwise Rx with,Inhaled beta agonists sosRegular inhaled steroids Plus regular beta agonists
Drug Treatment (preferably as inhalers)Beta 2 agonists Salbutamol, Salmeterol, terbutalineSteroids- Beclamethasone etcMast cell stabilisers- Sodium chromoglycate
Treatment contd.Anticholinergics- Ipratropium Theophylline preparationsOral steroidsLeucotrine receptor antagonists
Assessment of BA Pts
DurationSymptomsPrecipitantsRx & Compliance
Assessment of BA patients..Effect on daily lifeAcute attacks- Nebulisations Hospitalisation ICU admissions, ventilationPrevious anaesthetics
Examination & InvestigationsGeneral examinationLung signsPEF and reversibility
Investigations
CXRAY if indicated
Lung function tests-FEV1/ FVC
Preparation and AnaesthesiaAllay anxietyContinue RX bring inhalers to OTOptimise medical Mx if not under control
Preparation & anaesthesiaTreat infectionsStop smokingNebulize before OTIV steroids- hydrocortisone 100mg
Choice of anaesthesia- GA vs RegionalNeed to have minimal lung signs for bothSpinal will avoid multiple drugs/ stimulation of airwayEpidural Avoid high blocks
GAHow the anaesthetic is given is more important than what the agent isSafe drugsPropofolKetamine(add atropine)EtomidateMidazolam
Safe drugs in BA..FentanylPethidineVecuroniumSuxVolatile agents
Possible precipitants?TPS? morphine? Atracurium
Possible precipitants..ProtamineNeostigmineDiclofenac/ aspirinAntibiotics
During anaesthesiaTry to avoid intubation- Face mask/ LMAMaintain adequate depthAvoid stimulation under light anaesthesia (ETT/surgery)Secretions may precipitate
Intra op management..Ventilate with- Slow RR/moderate Vt; I :E> 1:2 Monitor SPO2, ETCO2, AWPAvoid reversalDeep extubation
Asthmatic attack under GA
High AWPTight bagDesaturationUpsloping ETCO2
Possible causes..Anaphylaxis/ other hypersensitivity reactionAspirationPneumothoraxEndobronchial ETT/ circuit occlusion
Management
Increase oxygen flow while maintaining depthIncrease volatile agent (halothane)Remove precipitant
Management contd.Nebulise with -5mg salbutamol 0.5mg Ipratropium(need circuit adaptor/oxygen driven neb)Steroids- 200 mg Hydrocortisone IV
Drug RxAminophylline IV- 5mg/Kg bolus in dextrose/20 min(250 mg in a vial)Follow up infusion at 0.5mg/Kg per hourSalbutamol IV infusion
Second line drugs
Ketamine 0.5mg/Kg IVMGSO4- 2g IV/ 30min
COPDChronic bronchitis & emphysemaAbnormal lungsSmoking/ other factors
COPD..InfectionsHyperinflated lungsCor-pulmonale
Features of COPDPink puffers=compensatedBlue bloaters=decompensatedAirway obstruction is not completely reversibleRx- Beta 2 agonists/ steroids/ diuretics
Assessment
Functional capacityHow many pillowsCXRAYArterial blood gasesLFT
AnaesthesiaHigh riskAvoid elective surgery if not well controlledStop smokingRx InfectionSteam, Chest physio
Regionals when possible
GA= BA
Post op ICU
Controlled oxygen therapy
Exam QuestionsAnaesthetic management of BA patient for elective surgeryAcute asthmatic attack under GAShort notes on salbutamol/ aminophylline
Thank you!