Case Scenario: Bronchospasm during Anesthetic Induction

Abstract

BRONCHOSPASM, the clinical feature of exacerbated underlying airway hyperreactivity, has the potential to become an anesthetic disaster. During the perioperative period, bronchospasm usually arises during induction of anesthesia but may also be detected at any stage of the anesthetic course. Accordingly, prompt recognition and appropriate treatment are crucial for an uneventful patient outcome. Perioperative bronchospasm (i.e. , the clinical expression of exacerbated underlying airway reactivity) may be associated with type E immunoglobulin (IgE)-mediated anaphylaxis or may occur as an independent clinical entity, triggered by either mechanical and/or pharmacologic factors. Whatever the clinical circumstances, different triggers are identified in the occurrence of perioperative bronchospasm with asthma, a chronic inflammatory disorder of the airways frequently involved. The purpose of this clinical scenario is to discuss the key points of perioperative bronchospasm.A 25-yr-old woman with morbid obesity (body mass index: 54 kg/m2) and noninsulin-dependent diabetes was scheduled for cochlear implant surgery. She had two previous surgeries without incident during childhood. She denied any history of atopy or drug allergy. Chest auscultation was normal before anesthesia. She was premedicated with hydroxyzine (100 mg orally) the day before and 1 h before anesthesia, which was induced with sufentanil (20 μg intravenously) and propofol (350 mg intravenously). Tracheal intubation (Cormack and Lehane grade I) was facilitated with succinylcholine (130 mg intravenously). After tracheal intubation was performed, chest auscultation revealed a complete absence of bilateral breath sounds. Initial concentrations of end-tidal carbon dioxide (ETco2) were low. Because an esophageal intubation was suspected, the patient was immediately extubated and mask ventilation attempted. Mask ventilation was difficult to perform because of dramatically decreased lung compliance, whereas ETco2demonstrated a marked prolonged expiratory upstroke of the capnogram. Therefore, bronchospasm was considered. Rapid arterial oxygen desaturation (oxygen saturation measured by pulse oximetry [Spo2], 55%) followed by arterial hypotension (from 130/75 to 50/20 mmHg) associated with a moderate tachycardia (100 beats/min) occurred in less than 5 min after the onset of bronchospasm. Concomitantly, titrated epinephrine (two intravenous boluses of 100 μg each) along with fluid therapy with crystalloids (lactated Ringer's solution, 1,000 ml) corrected the cardiovascular disturbances (arterial blood pressure, 110/50 mmHg; heart rate, 110 beats/min) while at the same time ventilation became easier to perform along with the return of audible wheezing over both lung fields. As arterial blood pressure was restored, a localized (face and upper thorax) erythema occurred. Hydrocortisone (200 mg) was intravenously administered. A blood sample was obtained to measure serum tryptase concentrations, 40 and 90 min after the clinical reaction. Surgery was postponed, and the patient was transferred to the intensive care unit. No additional supportive vasopressor therapy was required. Respiratory symptoms resolved within 2 h after inhaled β2-agonist (salbutamol; i.e. , albuterol) and intravenous corticoids (hydrocortisone, cumulative dose: 800 mg over 24 h). Subsequent clinical outcome was uneventful, and the patient was discharged home the following day and returned 6 weeks later for allergologic assessment (see section III).Bronchospasm encountered during the perioperative period and especially after induction/intubation may involve an immediate hypersensitivity reaction including IgE-mediated anaphylaxis or a nonallergic mechanism triggered by factors such as mechanical (i.e. , intubation-induced bronchospasm) or pharmacologic-induced (via histamine-releasing drugs such as atracurium or mivacurium) bronchoconstriction in patients with uncontrolled underlying airway hyperreactivity.1,2Chest auscultation should be done to confirm wheezing, whereas decreased or absent breath sounds suggest critically low airflow.3The differential diagnosis includes inadequate anesthesia, mucous plugging of the airway, esophageal intubation, kinked or obstructed tube/circuit, and pulmonary aspiration.3Unilateral wheezing suggests endobronchial intubation or an obstructed tube by a foreign body (such as a tooth).3If the clinical symptoms fail to resolve despite appropriate therapy, other etiologies such as pulmonary edema or pneumothorax should also be considered.Immediate hypersensitivity is a clinical entity evoking allergy that varies in severity1and is subdivided into nonallergic hypersensitivity (called anaphylactoid reaction by the American Academy of Allergy Asthma and Immunology) where an immune mechanism is excluded, and allergic hypersensitivity (also called IgE-mediated anaphylaxis).4By definition, immediate hypersensitivity occurs within 60 min after the injection/introduction of the culprit agent.1The initial diagnosis remains presumptive, whereas the etiologic diagnosis is linked to a triad including clinical features (the description of the clinical features according to the adapted Ring and Messmer∥clinical severity scale); blood tests (tryptase level measurements, serum-specific IgEs); and postoperative skin tests with the suspected drugs or agents.1The sudden occurrence of bronchospasm after anesthetic induction, with cardiovascular disturbances and cutaneous signs, clinically suggested a drug-induced anaphylactic reaction. Succinylcholine-induced anaphylaxis was the most likely etiology, because neuromuscular blocking agents are the most frequent agents involved in perioperative anaphylaxis in adults.1,5Skin testing remained negative in response to propofol, sufentanil, succinylcholine, and latex solutions (Allerbio, Varennes en Argonne, France and Stallergènes, Antony, France). Tryptase levels (ImmunoCAP, Phadia SAS, Uppsala, Sweden) were unchanged (5.4 μg · l−1and 4.3 μg · l−1; N less than 13.5 μg · l−1) in blood samples obtained 40 and 90 min, respectively, after the onset of the reaction. Serum-specific IgEs (ImmunoCAP) against succinylcholine and latex were not detectable. Specific serum IgE against quaternary ammonium was slightly increased (2.08 kU/L, N less than 0.1). A basophil activation test was also performed and analyzed using a FACSCanto II flow cytometer (Becton-Dickinson, Rungis, France). Succinylcholine induced neither CD63 nor CD203c up-regulation.The chronology of evolving clinical features is crucial to understand the pathophysiologic mechanism of an immediate hypersensitivity reaction.Cardiovascular disturbance is the hallmark of severe IgE-mediated anaphylaxis. In patients with neuromuscular blocking agent-induced perioperative anaphylaxis, cardiovascular signs are usually the inaugural clinical event and occur within minutes after the drug challenge. These cardiovascular signs may be associated with or followed by bronchospasm in 19–40% of patients, more likely in those with underlying asthma or chronic obstructive pulmonary disease.1Drug-induced anaphylactic bronchospasm may occur either before or after instrumentation of the airway2(fig. 1).Latex-induced anaphylaxis typically occurs in patients with a history of atopy.6Because atopy is the strongest identifiable predisposing factor for the development of asthma,7severe clinical features occurring during latex-induced anaphylaxis usually involve cardiovascular signs followed by or associated with bronchospasm and cutaneous signs.8As latex proteins are slowly absorbed, latex-induced anaphylaxis usually occurs up to 30–60 min after the beginning of surgery (i.e. , mucous membrane exposure).8Acute increases in airway responsiveness may also occur in the absence of an antigen challenge and result from irritation of the well-innervated upper airway by a foreign body (e.g. , endotracheal tube or suction catheter).2Thus, nonallergic bronchospasm immediately follows nonspecific stimuli and usually is not associated with cardiovascular symptoms2(fig. 1). Nevertheless, positive end-expiratory pressure with severe bronchospasm may lead to a decrease in venous return and hence of cardiac output. In addition, the association of hypoxia and respiratory failure from inadequate ventilation may lead to cardiovascular collapse.9Four clinical variables were identified as independent predictors of allergic compared with nonallergic perioperative bronchospasm: the presence of any cutaneous symptoms; shock; episodes of desaturation; and the prolonged duration of clinical features (longer than 60 min).2Compared with that of patients who did not present with these “predictive” signs as part of the clinical syndrome, the occurrence of hypotension or episodes of oxygen desaturation were 27 and 21 times, respectively, more likely to be associated with IgE-mediated anaphylaxis. In addition, symptom duration longer than 60 min or the presence of skin changes was two and seven times, respectively, more likely to be associated with IgE-mediated anaphylaxis.2In the current case, inaugural severe bronchospasm triggered by endotracheal tube insertion and followed by cardiovascular collapse, likely related to subsequent hypoxemia after the patient's extubation, yields clinical insight into the pathophysiologic mechanism of the reaction and suggests nonallergic bronchospasm. Cutaneous signs, such as erythema, are not specific for IgE-mediated anaphylaxis per se and may also be observed during nonallergic bronchospasm.2The morbid obesity of the patient is of clinical interest and could also have been a precipitating factor of rapid arterial desaturation despite appropriate preoxygenation.A tryptase increase is specific for mast cell activation such as that occurring during IgE-mediated anaphylaxis.1Increased tryptase levels appear to distinguish clearly between allergic and nonallergic perioperative bronchospasm.2Thus, Fisher2suggested that an allergologic assessment is unnecessary in patients with isolated bronchospasm occurring after airway instrumentation without an increase in tryptase. In the current case, allergic mast cell activation was ruled out because tryptase levels measured within the recommended time frame remained unchanged. Skin tests were negative in response to the medications received (i.e. , propofol, sufentanil, and succinylcholine) as well as latex. These results were corroborated by basophil activation tests showing an absence of CD63 and CD203c up-regulation with succinylcholine, ruling out basophil sensitization by specific IgE toward succinylcholine and undetectable specific serum IgEs against succinylcholine. Serum IgEs against quaternary ammonium was slightly increased (2.08 kU/L, N less than 0.1), but these assays appear to be less sensitive than skin tests and do not prove that the drug/agent is responsible for the reaction.10Succinylcholine-induced anaphylaxis was therefore ruled out according to clinical, biologic, and allergologic evidence. This is of particular importance because succinylcholine is thereby allowed to be used for future anesthetics in this patient. In turn, uncontrolled asthma was suggested to be the main trigger of this nonallergic bronchospasm after endotracheal tube insertion. Wheezing induced by bronchial infection during childhood or triggered by cold weather and exercise in adulthood was elicited from the patient's history during the postoperative evaluation.Asthma is one of the most common chronic airway diseases worldwide, with a higher prevalence and incidence in the Western world.11The estimated annual death rate worldwide is 250,000.12However, this condition frequently remains underdiagnosed. In 2008, the following definition for asthma was suggested: “Asthma is a chronic disorder of the airway in which many cells and cellular elements play a role. The chronic inflammation is associated with airway responsiveness that leads to recurrent episodes of wheezing, breathlessness, chest tightness and coughing, particularly at night or in the early morning. These episodes are usually associated with widespread, but variable airflow obstruction within the lung, that is often reversible either spontaneously or with treatment.” 12This proposal was ratified in the United States.7Accordingly, a European and American Task Force issued by the corresponding Respiratory Societies suggested that the definition of asthma includes two domains (symptoms and variable airway obstruction) being assessed in clinical practice, with two additional domains inflammation and the underlying may have features of any or of these is induced by a of changes in the airway and by underlying airway the hallmark of a crucial in the to asthma was with a by the level of asthma or than asthma severity per se while the of asthma to asthma main of asthma, allergic and are most may occur within these in and is allergic allergic asthma is a chronic and often onset occurs in early childhood. more than of asthma is allergic in results from by IgE and is also called IgE-mediated allergic factors may the development of allergic asthma factors such as and to including , or may trigger and a may also trigger any potential factor with an underlying to result in the of the for the development of an IgE-mediated response to common is the strongest identifiable predisposing factor for factors such as and respiratory to be the most in the and the severity of allergic of allergic asthma should also be the of this disturbance with asthma remains is by symptoms including and/or of the is either or and is as or than of have and of patients with have A should be used to the upper and airway diseases is crucial but is the most therapy airway the presence of asthma be in patients with those with severe and/or uncontrolled allergic should be for asthma before other main of asthma in includes a not in such as asthma is by or drug and Asthma and to usually appear after the onset of and are usually the clinical features of This results from the of by drugs in the airway of sensitive patients and is not by an allergic is to be more in of issued from the European or the American has the perioperative of the patient. The this remains occurrence of perioperative bronchospasm has been in up to of patients anesthesia, after endotracheal tube also a with that of the of perioperative bronchospasm in higher in and in and is higher in patients with chronic than in the in of perioperative bronchospasm that an allergic mechanism was less frequently involved than a nonallergic mechanism these nonallergic occurred during the induction of anesthesia, during the and during the During induction of anesthesia, bronchospasm was related to airway irritation whereas were to tube and other pulmonary edema or During the stage of anesthesia, allergy endotracheal tube airway irritation and with a mask airway for of the of bronchospasm. During induction or of anesthesia, bronchospasm by airway irritation occurred more frequently in patients who had one or more predisposing factors such as asthma, or that an allergic mechanism for of the in patients bronchospasm during induction of previous history of asthma was present in and of patients with nonallergic and allergic uncontrolled obstructive pulmonary is frequently involved with either pathophysiologic of the stage of anesthesia or for of and death in the United this bronchospasm was in the other and to of respiratory In the United respiratory and airway for and respectively, of including severe and was not Nevertheless, airway to the with the and respiratory with the per of were to bronchospasm in bronchospasm remains a perioperative or death may be by care and/or inadequate and of perioperative bronchospasm should therefore be such as an anesthesia to for the low with which the severe bronchospasm during clinical of in bronchoconstriction are and involve airway and inflammatory bronchoconstriction induced by irritation of the upper airway by a foreign body such as an endotracheal tube is by of in the of the which to the The of the of the and whereas from the of the to the from the to the airway is in the and results in airway most the airway that airway the initial airway an to the in an in the and in the airway Because airway is a key of the of medications (e.g. , or should be to or this addition, and may in this and/or the activation of in the suggests that propofol airway in airway has been clinically that the of anesthesia the of but the pharmacologic by which this occurs are the anesthetics the of are to be clinically at bronchoconstriction or agents at has been that of to the from the of the and higher may be a mechanism by which anesthesia or both propofol and anesthetics have at the level of airway of the despite these of intravenous propofol and the induction used in the current case, bronchoconstriction in this patient who had and is as a body mass of at to asthma and airway in both and asthma and obesity are inflammatory development to be early in with this association not being turn, potential for the increase of asthma and obesity involve and factors. Accordingly, with common to obesity and asthma have been and decreased as a result of obesity result in of airway increased airway from obesity may trigger a condition was ruled out with an esophageal may also be involved as the of obesity asthma is in than addition, the by and that in the to immune cell and Serum levels in adulthood were to be higher in than with a higher prevalence of association between asthma and obesity may be of that changes in and are associated with both asthma and asthma or asthma ruling out the that this association be the result of by patients to is more in than in those without asthma, whereas and asthma common factors such as for the association between both remains in patients because respiratory symptoms are frequently to being as was the in patient. In such patients, underlying airway should be assessed during the (see section the current and after the clinical was also detected of airway inflammation and corresponding asthma symptoms are to perioperative and postoperative The Asthma and that the level of asthma within the 6 and pulmonary be before for Asthma suggest that perioperative and postoperative the severity of asthma at the time of the type of surgery and upper surgeries being at increased and of anesthesia anesthesia with tracheal intubation is at higher suggest that uncontrolled or asthma may be assessed the of asthma of inhaled of inhaled of of asthma or within the and potential or factors infection of the respiratory previous bronchospasm after intubation, pulmonary previous of a for severe asthma, associated or common key of these the level of asthma before uncontrolled asthma is to be the main factor for bronchoconstriction during clinical and are therefore crucial for pulmonary assessment to of underlying airway breath sounds as in decreased expiratory and prolonged expiratory as well as and/or frequent of respiratory symptoms including wheezing, exercise and should during the these different decreased breath to wheezing, and a prolonged expiratory an increase in the of perioperative pulmonary asthma usually perioperative pulmonary airway instrumentation may perioperative and prolonged intensive care asthma not additional therapy is used to and asthma Asthma is an inflammatory inhaled are the most drug for the treatment of asthma lung decrease airway hyperreactivity, airway and asthma and asthma should be used as therapy because these lung without clinical an increase in in patients to of by the United and that should be used without inhaled are most with inhaled fail to asthma increase the of and increase the of and response to turn, inhaled are used for of asthma are to and other agents are and to for the treatment of the presence of surgery should be The and corresponding clinical symptoms 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ventilation immediately to pulmonary and to of of a anesthetic is often the of because of airway particularly in anesthesia with an intravenous anesthetic may be because intubation-induced bronchospasm may be related to an inadequate of anesthesia agents using and are key drugs for the of onset of occurs within 5 min, is within 60 min, and duration of is should be immediately a to appropriate may be at to with a to the of the is in between and than of results in in and epinephrine has compared with or also a key drug in the treatment of bronchospasm because of by airway such as mg · are over because is more the is not of an inhaled (e.g. , has been to bronchoconstriction with to inhaled mg with a β2-agonist than a β2-agonist and may be used to bronchospasm or in those with a initial response to β2-agonist a in the treatment of asthma bronchial to the of intravenous of 2 over or inhaled from 110 mg to mg) in patients with severe bronchospasm that to be with in compared with that with 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occurring in patients (e.g. , patients and those with chronic obstructive pulmonary or and triggered either by or inflammatory (i.e. , factors. the of anesthesia in patients at for bronchoconstriction have not been the that intubation of the a higher of in the perioperative period compared with airway such as the mask are in the of the between airway and the of and other in the of airway the by which intravenous and inhaled anesthetics airway and airway likely involve of membrane membrane and but by the different corresponding anesthetic be to a of airway as well as key to patients at during the period and clinical and for assessment and and and for clinical