BRONCHOSPASM

LOOK FOR (1)

Increasing circuit pressure
Desaturation
Wheeze (auscultate)
Rising ETCO2 and prolonged expiration
Reduction in tidal volumes

THINK OF (2)

Anaphylaxis/allergy to drugs/IV fluids/latex
Airway manipulation/irritation/secretions/regurgitation
Oesophageal/endobronchial intubation
Pneumothorax
Inadequate anaesthetic depth or failure of anaesthetic delivery system

EMERGENCY MANAGEMENT

100% Oxygen
Cease stimulation/surgery
Request immediate assistance
Deepen anaesthesia (3)
If intubated exclude endobronchial or oesophageal position (4)
If mask/LMA in use consider:
Laryngospasm / Airway Obstruction
Regurgitation / Vomit/Aspiration (5)
Give adrenaline or salbutamol (6)
If you cannot ventilate via an ETT consider:

Misplaced/kinked/blocked ETT, catheter mount, filter or circuit (See Check)
Pneumothorax
Aspiration
Consider possible obstruction distal to ETT
Try pushing a small tube past it, or push the obstruction down one bronchus and ventilate the other lung.

Consider Anaphylaxis
Consider Pulmonary oedema

FURTHER CARE:

Depends on patient's condition, and cause.
Bronchodilators as necessary
Chest X-ray
Admit to HDU/ICU if necessary

NOTES:
Top

The figures reported here are based on an analysis of 103 of the first 4000 AIMS anaesthesia incidents.

(1) 30% of 103 relevant incidents described increased peak inflation pressures, and a further 31% described "bronchospasm"/wheeze as the initial sign.
21% reported desaturation as the first sign.
3% reported rising ETCO2 and 1% revealed a flat capnogram indicating no gas flow.
(2) Allergy/anaphylaxis - 22/103 (21%) of incidents.
     Of the remaining 81 cases:
          42% occurred at induction and of these:
          64% were due to airway irritation
          17% were due to ETT misplacement
          11% were due to aspiration
          8% were due to other causes.
     36% occurred during maintenance and of these:
          31% were due to ETT problem
          14% were due to aspiration with an LMA
     20% occurred during emergence/recovery and of these:
          38% had no specific cause identified
          25% were due to pulmonary oedema
          18% were due to aspiration.
(3) 55% were of cases of bronchospasm at induction were idiopathic or presumed to be due to airway irritation from laryngoscopy and/or intubation.
(4) 12% were associated with oesophageal intubation and 2.5% with endobronchial intubation.
(5) 12% of cases were associated with aspiration
(6) Recommended dosages:
     Salbutamol 0.5% 1ml (5mg) saline solution nebulised (for an adult);
                        0.125% 1ml (1.25mg) saline solution (for a child. In severe cases use 0.5% solution neat).
      or aerosol puffer (spacer): For an adult (0.1 mg(100micrograms)/puff), 2 puffs;.
                                               For a child, 0.05 mg(50micrograms)/puff, 1-2 puffs.
      or For an adult, 0.1ml of a 0.5% solution (0.5mg) diluted to 1 ml, injected down ETT;
          For a child 0.01 mg/kg in 1 ml, single dose down ETT.
               [NOTE: Body weight calculation for unweighed children: (age x 2) + 9 (kgs) ]
      or as an IV infusion in adults, 6 mg/100ml (ml/hour = micrograms/minute). Start at 3 ml/hour;
                                       in children, 5 mcg/kg/minute, reducing to 1 mcg/kg/min after 60 minutes. If all else fails give
                                                        adrenalin nebulised or IV.

   Adrenaline 0.001 mg/kg slow bolus (which is 0.01 ml/kg of 1:10,000 solution) IV for adults. Repeat bolus,
                      or commence infusion 6mg in 100 ml burette (ml/hour = micrograms/minute),
                                                           start at 3 ml/hr(= 3 micrograms/minute) (adults)
                                                           0.0001 mg ( 0.1 micrograms) / kg / min (children)
                     Titrate to heart rate, blood pressure, and bronchodilator effect.
Top