Perioperative Bronchospasm Management

Algorithm Steps

1. ▶

   Start

   Bronchospasm Suspected

   Signs of airway reactivity during anesthesia

   1. ●

      Action

      Recognition of Bronchospasm

      Clinical and ventilator signs

      • CLINICAL SIGNS:
      • Expiratory wheezing (may be silent if severe)
      • Prolonged expiratory phase
      • Increased work of breathing (if spontaneous)
      • Hypoxemia, cyanosis
      • VENTILATOR SIGNS:
      • Increased peak inspiratory pressure (PIP)
      • Plateau pressure often normal (PIP-Pplat gap)
      • Decreased tidal volume (if pressure mode)
      • Upsloping capnography waveform ('shark fin')
      • Air trapping, auto-PEEP
      1. ◆

         Decision

         Rule Out Mechanical Causes

         FIRST: Exclude non-bronchospasm etiologies

         • CHECK:
         • ETT kinked or malpositioned?
         • ETT too deep (mainstem)?
         • Mucus plug or blood in ETT?
         • Circuit obstruction or disconnect?
         • Light anesthesia (coughing/bucking)?
         • Tension pneumothorax?
         • Anaphylaxis? (check BP, skin)
         1. ●

            Action

            Initial Management

            Immediate actions

            • Increase FiO2 to 100%
            • Deepen anesthesia (volatile or IV)
            • Sevoflurane: bronchodilator properties
            • Propofol: preferred over ketamine initially
            • Hand ventilate to assess compliance
            • Extend expiratory time (lower RR, I:E 1:3-1:4)
            • Reduce tidal volume if needed
            • Consider switching to pressure control
            1. ●

               Action

               Bronchodilator Therapy

               Beta-2 agonist - first-line pharmacotherapy

               • INHALED (via ETT):
               • Albuterol 4-8 puffs via MDI with spacer
               • OR Albuterol 2.5-5 mg nebulized inline
               • If inadequate IV access or severe:
               • Salbutamol IV 100-250 mcg slow bolus
               • Then infusion 5-20 mcg/min
               • Note: Much drug lost in circuit - use higher doses
               1. ◆

                  Decision

                  Response to Treatment?

                  Assess improvement in PIP, wheezing, oxygenation

                  1. ●

                     Action

                     Bronchospasm Resolved

                     Post-event management

                     • Continue bronchodilators
                     • Steroids for 24-48 hours
                     • Consider extubation readiness carefully
                     • Pretreat before extubation (lidocaine, bronchodilator)
                     • Extended PACU monitoring
                     • Optimize chronic asthma/COPD management
                     1. ✓

                        Outcome

                        Bronchospasm Managed

                        Continue monitoring, document event

                  2. ●

                     Action

                     Second-Line Therapies

                     For refractory bronchospasm

                     • ANTICHOLINERGIC:
                     • Ipratropium 4-8 puffs via MDI
                     • Glycopyrrolate 0.2 mg IV
                     • MAGNESIUM SULFATE:
                     • 2g IV over 20 minutes
                     • (smooth muscle relaxation)
                     • HYDROCORTISONE:
                     • 100-200 mg IV
                     • (delayed onset but give early)
                  3. ⚠

                     Warning

                     ⚠️ Refractory/Severe Bronchospasm

                     Escalating therapy

                     • EPINEPHRINE:
                     • 10-100 mcg IV boluses (titrate)
                     • OR 0.3-0.5 mg IM (if no IV)
                     • Infusion: 1-10 mcg/min
                     • KETAMINE:
                     • 0.5-1 mg/kg IV bolus
                     • Then 0.5 mg/kg/hr infusion
                     • (bronchodilator + maintains drive)
                     • VOLATILE ANESTHETICS:
                     • Sevoflurane or isoflurane at higher MAC
                     • Potent bronchodilators
                     • (Avoid desflurane - airway irritant)
                     1. ⚠

                        Warning

                        ⚠️ Life-Threatening Hypoxia

                        Cannot ventilate adequately

                        • Call for help
                        • Consider ECMO if available and appropriate
                        • Aggressive epinephrine infusion
                        • Manual ventilation with prolonged expiration
                        • Accept permissive hypercapnia
                        • If cardiac arrest: prolonged CPR, correct hypoxia