Preoperative Preparation and Perioperative Management of a 50-year-old Female with Bronchial Asthma for Elective Laparoscopic Cholecystectomy

Why This Patient Requires Special Attention

1. Bronchial asthma - increases the risk of perioperative bronchospasm, laryngospasm, and postoperative pulmonary complications (PPCs)
2. Laparoscopic surgery - CO2 pneumoperitoneum raises intra-abdominal pressure, elevates the diaphragm, reduces FRC, and increases peak inspiratory pressures, all of which can worsen airway reactivity

PREOPERATIVE PREPARATION

1. Preoperative Evaluation

2. Investigations

• Pulmonary Function Tests (PFTs): FEV1, FEV1/FVC, FEF 25-75%, Peak Expiratory Flow Rate (PEFR). These assess severity and reversibility after bronchodilator administration. Serial comparisons with previous values are invaluable.
• Chest X-ray: Look for hyperinflation (flattened diaphragm, hyperlucent fields, small-appearing heart), air trapping, or concurrent infection
• ABG (if severe): Hypoxemia and hypercapnia indicate severe disease; even mild hypercapnia suggests significant air trapping and impending respiratory failure
• Routine bloods: CBC, serum electrolytes, renal function, coagulation profile, blood sugar
• ECG: In a 50-year-old female; assess for cor pulmonale if long-standing severe asthma
• Pulmonary consultation: Recommended in patients with severe asthma, to help optimize management and plan postoperative disposition - Barash Clinical Anesthesia, 9e

3. Medication Optimization

• Patients on >5 mg/day prednisone (or equivalent) require perioperative glucocorticoid supplementation
• Patients who have received oral steroids within 6 months, or are on high-dose ICS, should be considered for stress dose steroids (e.g., hydrocortisone 50-100 mg IV q8h perioperatively), tapered back to baseline within 1-2 days - Morgan & Mikhail, 7e; Berek & Novak's Gynecology

4. Drugs to AVOID in Premedication

• H2 blockers (ranitidine, famotidine): Theoretically detrimental - H2 activation normally causes bronchodilation; blocking it leaves H1-mediated bronchoconstriction unopposed if histamine is released. Reserve aspiration prophylaxis to antacids or proton pump inhibitors instead.
• Aspirin / NSAIDs: Can precipitate aspirin-exacerbated respiratory disease in susceptible patients
• Morphine, meperidine, atracurium: Cause histamine release; best avoided entirely

• Benzodiazepine (e.g., oral midazolam) for anxiolysis - anxiety itself can precipitate bronchospasm
• Proton pump inhibitor (e.g., omeprazole) for aspiration prophylaxis
• Nebulized salbutamol just prior to transfer to the OT

INTRAOPERATIVE MANAGEMENT

5. Monitoring

• ECG, SpO2, EtCO2 (capnography - especially important here)
• Non-invasive blood pressure
• Airway pressure monitoring (peak and plateau pressures)
• Temperature
• Neuromuscular blockade monitoring

6. Regional vs. General Anesthesia

7. Airway Management

• Additional bolus of induction agent
• Ventilate with 2-3 MAC volatile agent for 5 minutes
• IV lidocaine 1.5-2 mg/kg before intubation (also useful at extubation)
• Ensure adequate depth of anesthesia before laryngoscopy

8. Induction

• Propofol: First choice - attenuates airway reflexes, causes bronchodilation, smooth induction
• Ketamine: Second choice (especially if hemodynamically unstable) - causes bronchodilation via catecholamine release; however, increases secretions, so co-administer an anticholinergic (glycopyrrolate)
• Etomidate: Suitable when cardiovascular stability is paramount but lacks bronchodilating properties

9. Maintenance

• Volatile anesthetics are the mainstay - all share potent bronchodilating properties. Sevoflurane is the preferred agent (smooth bronchodilation, minimal airway irritation). Isoflurane and especially desflurane are more irritant to airways and can cause cough/bronchospasm; avoid desflurane for maintenance in asthmatics.
• TIVA with propofol infusion is an excellent alternative if bronchospasm risk is very high.
• Ventilate with warmed, humidified gases whenever possible.

10. Ventilation Strategy

11. Treatment of Intraoperative Bronchospasm

1. Increase volatile anesthetic concentration - take advantage of bronchodilating properties
2. Deepening anesthesia - propofol bolus or increase volatile
3. Inhaled beta-2 agonist - salbutamol MDI via circuit (5-8 puffs through an in-circuit adapter)
4. IV epinephrine - small doses (10-50 mcg IV) if severe bronchospasm with hemodynamic compromise
5. IV aminophylline - loading dose 5 mg/kg over 20-30 min (avoid if patient on theophylline)
6. IV hydrocortisone 100-200 mg IV (particularly in patients known to respond to glucocorticoids, or those on chronic steroids) - Morgan & Mikhail, 7e
7. IV magnesium sulfate - can enhance bronchodilation in combination with other agents
8. IV ketamine bolus 0.5-1 mg/kg if agent not already in use
9. Reduce IAP / consider temporary desufflation if severe

12. Reversal and Extubation

• Reverse neuromuscular blockade cautiously: Neostigmine/glycopyrrolate combination - neostigmine increases acetylcholine, which can cause bronchoconstriction, but glycopyrrolate blocks the muscarinic effect; use adequate glycopyrrolate (anticholinergic) before the anticholinesterase.
• Sugammadex is preferred for reversing rocuronium/vecuronium - avoids the cholinergic surge entirely. However, rare allergic reactions to sugammadex have been reported. - Morgan & Mikhail, 7e
• Deep extubation: Extubate before return of full airway reflexes (at deep plane of anesthesia) to reduce the stimulus of an awake extubation triggering bronchospasm
• IV lidocaine 1.5-2 mg/kg bolus before extubation blunts airway reflexes
• Administer pre-extubation nebulized salbutamol if any wheeze present
• Ensure the patient is wheeze-free before extubation

POSTOPERATIVE MANAGEMENT

13. Recovery Room (PACU)

• Supplemental O2 via face mask (target SpO2 >95%)
• Continuous monitoring: SpO2, ECG, RR, BP
• Keep patient in semi-recumbent (head-up) position - reduces diaphragmatic compression and improves FRC
• Continue bronchodilators via nebulization or MDI as soon as patient is awake
• Resume oral medications (including steroids) as soon as patient can swallow
• Monitor for residual bronchospasm, laryngospasm, and postoperative nausea/vomiting (PONV risk is high with laparoscopic cholecystectomy - use prophylactic ondansetron + dexamethasone; dexamethasone also has a mild anti-inflammatory benefit)

14. Analgesia

• Multimodal analgesia is preferred to minimize opioids (opioids can suppress respiratory drive and some cause histamine release):
  • Paracetamol (acetaminophen) regularly
  • Local anesthetic infiltration at port sites
  • Low-dose opioids if required (prefer fentanyl over morphine - less histamine release)
  • Avoid NSAIDs if history of aspirin-exacerbated asthma; if no such history, NSAIDs can be used cautiously
  • Consider TAP block or surgeon-performed intraperitoneal local anesthetic instillation
• Adequate pain control is itself protective against bronchospasm (pain and stress are triggers)

15. Steroid Supplementation

• Continue stress-dose steroids perioperatively if applicable; taper to baseline within 1-2 days post-procedure. - Morgan & Mikhail, 7e
• Resume inhaled corticosteroids as soon as the patient can use an inhaler

16. Postoperative Pulmonary Care

• Incentive spirometry and deep breathing exercises starting in the recovery room
• Early mobilization - reduces atelectasis and risk of DVT (also a concern with laparoscopy)
• DVT prophylaxis: sequential compression stockings and/or LMWH
• Chest physiotherapy if secretions are a concern
• Watch for shoulder-tip pain from residual CO2 under the diaphragm - this is a common post-laparoscopy complaint and may cause splinting (shallow breathing)

17. Discharge Criteria

• No bronchospasm or wheeze
• SpO2 >95% on room air
• Adequate pain control on oral medications
• Patient has resumed and can self-administer all their asthma medications
• Instructions given: continue ICS/LABA, use SABA rescue inhaler if needed, return if dyspnea or wheezing worsens

SUMMARY TABLE