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AnesthesiologyEmergency

Perioperative Bronchospasm Management

Perioperative Bronchospasm Management: Bronchospasm suspected under anaesthesia → Recognise bronchospasm → Call for help, give 100% oxygen, stop surgery...

Pathway Overview

17 steps

Algorithm Steps

17 total

  1. 01Start

    Bronchospasm suspected under anaesthesia

    Adult and child. Doses are adult unless marked Child.

  2. 02Action

    Recognise bronchospasm

    Can occur alone or as part of anaphylaxis

    • Expiratory wheeze; a silent chest can mean severe bronchospasm
    • High peak airway pressure; plateau pressure often less raised
    • Upsloping capnography trace; hypercapnia
    • Falling SpO2; low tidal volume in pressure modes
    • Prolonged expiration; air trapping (auto-PEEP)
  3. 03Action

    Call for help, give 100% oxygen, stop surgery

    Do these first, at the same time

    • Call for help; tell the theatre team
    • FiO2 100%
    • Stop surgery and other stimulation
    • Hand ventilate to feel compliance
    • Expose the chest; look, feel and listen on both sides
  4. 04Action

    Exclude mechanical causes and mimics; fix if found

    If signs persist after a fix, continue to the next step

    • Capnography trace absent: oesophageal tube; reintubate
    • Endobronchial tube: withdraw until both sides ventilate
    • Kinked, blocked or secretion-filled tube: suction; change the tube if needed
    • Circuit fault: check all hoses; hand ventilate with a self-inflating bag
    • Tension pneumothorax: decompress
    • Supraglottic airway or facemask: consider tracheal intubation
    • Aspiration: tracheal intubation, tracheal suction, nasogastric tube to empty the stomach
    • Mimics: light anaesthesia, laryngospasm, pulmonary oedema
  5. 05Decision

    Anaphylaxis suspected?

    Yes if hypotension, tachycardia or bradycardia, rash, or a recent trigger (antibiotic, NMBA, chlorhexidine, colloid, latex). Bronchospasm can be the only sign; no rash does not exclude it.

  6. If Yes
    1. Anaphylaxis suspected
    2. 06Warning

      Anaphylaxis: IV adrenaline first; do not deepen anaesthesia

      Cardiac arrest or systolic BP under 50 mmHg: start CPR now. Adrenaline IV (1 mg in 10 mL): adult 1 mg every 1-2 min; child 0.1 mL/kg = 10 microg/kg (max 1 mg) every 1-4 min; ALS. Otherwise never give 1 mg IV. Child doses: next step.

      • Adult IV adrenaline bolus (1 mg in 10 mL = 100 microg/mL) every 1-2 min: moderate 10-20 microg, life-threatening 50-100 microg; no response: 50 microg (moderate) or 200 microg (life-threatening)
      • No IV access: adrenaline IM 500 microg (0.5 mL of 1 mg/mL) lateral thigh; repeat every 5 min
      • Arrest or systolic BP under 50 mmHg: CPR; elevate legs; crystalloid 2 L (child 20 mL/kg)
    3. 07Action

      Anaphylaxis: infusion, fluids and resistant bronchospasm

      Follow ANZAAG-ANZCA perioperative anaphylaxis cards (Card 1 adult, Card 2 child)

      • Remove triggers: chlorhexidine (including coated lines), colloid, latex; use minimal volatile or TIVA
      • After 3 boluses: adrenaline infusion 3 mg in 50 mL saline; start 3 mL/h (3 microg/min), titrate to max 40 microg/min
      • Hypotension: elevate legs; crystalloid 500 mL (moderate) or 1000 mL (life-threatening); child 20 mL/kg; repeat as needed
      • Resistant hypotension (adult): more fluid; add noradrenaline 3-40 microg/min and/or vasopressin 1-2 units IV then 2 units/h
      • Resistant bronchospasm: continue adrenaline; salbutamol MDI 12 puffs (1200 microg); magnesium 2 g (8 mmol) IV over 20 min
      • On beta-blockers and not responding: glucagon 1-2 mg IV every 5 min (child 40 microg/kg, max 1 mg)
      • Child IM adrenaline (1 mg/mL): under 6 years 150 microg (0.15 mL); 6-12 years 300 microg (0.3 mL); over 12 years adult dose
      • Child IV adrenaline bolus (1 mg in 50 mL = 20 microg/mL) every 1-2 min: moderate 2 microg/kg, life-threatening 4-10 microg/kg; not more than the adult dose
      • Child infusion and refractory doses: ANZAAG-ANZCA Card 2 and Card 4
    4. 08End

      Continue perioperative anaphylaxis management

      Tryptase at once, then 1 h, 4 h and after 24 h. Plan ICU or HDU care. Refer to an anaesthetic allergy clinic.

    If No
    1. No anaphylaxis
    2. 09Action

      No anaphylaxis: deepen anaesthesia if BP adequate; set ventilation

      Do not deepen anaesthesia if hypotensive: think anaphylaxis

      • Sevoflurane: a bronchodilator; light anaesthesia can cause bronchospasm
      • Avoid isoflurane or desflurane if possible: airway irritants when increased quickly
      • Lengthen expiration: lower rate, shorter inspiration, smaller tidal volume
      • Watch for breath stacking (auto-PEEP): BP falls
      • Pressure control may be better; accept permissive hypercapnia
    3. 10Action

      Salbutamol: first-line drug

      Inhaled into the circuit. Severe (silent chest, cannot ventilate): give IV adrenaline now (see below)

      • Adult MDI (100 microg/puff): 12 puffs (1200 microg) via spacer or adaptor into the circuit
      • OR nebulised 5 mg in-line (remove HME filter or nebulise downstream)
      • Much drug is lost in the tube; repeat if still wheezing and heart rate allows
      • Child MDI: 6 puffs under 6 years; 12 puffs 6 years or older
      • Child nebulised: 2.5 mg under 5 years; 5 mg 5 years or older
    4. 11Decision

      Improving after salbutamol?

      Lower airway pressure, less wheeze, better SpO2 and capnography

    5. If Yes
      1. Improved
      2. 12Action

        Once resolved: post-event care

        After bronchospasm settles

        • Continue inhaled salbutamol; give it before emergence
        • Plan extubation with a senior; bronchospasm may recur at emergence
        • Chest X-ray when safe
        • Recovery with close monitoring, or ICU/HDU if severe
        • Review asthma or COPD treatment before discharge
      3. 13Outcome

        Bronchospasm managed

        Document the event and tell the patient

      If No
      1. Not improving
      2. 14Action

        Not improving: IV salbutamol, magnesium, hydrocortisone

        Use when the inhaled route fails. Check potassium (more risk with digoxin) and lactate. Pregnancy or caesarean: IV salbutamol can relax the uterus and increase bleeding.

        • Salbutamol IV (500 microg/mL ampoule, diluted): adult 200-250 microg slowly, then 5-20 microg/min
        • Magnesium sulfate IV 2 g (8 mmol) over 20 min; can cause hypotension and prolong neuromuscular block
        • Hydrocortisone IV 200 mg; slow onset
        • Ipratropium nebulised 0.5 mg (child 2-12 years: 0.25 mg)
        • Child: magnesium 50 mg/kg (max 2 g) over 20 min; hydrocortisone 4 mg/kg (max 200 mg)
        • Child IV salbutamol bolus over 5 min: 1-23 months 5 microg/kg; 2-17 years 15 microg/kg (max 250 microg). Child infusion: local paediatric protocol
      3. 15Decision

        Still severe or getting worse?

        Rising airway pressure, falling SpO2 or BP, or cannot ventilate. Falling BP: think anaphylaxis and use the anaphylaxis doses.

      4. If Yes
        1. Still severe
        2. 16Warning

          Severe or not responding: IV adrenaline

          Never give 1 mg IV unless in cardiac arrest. Falling BP: treat as anaphylaxis (ANZAAG-ANZCA Card 1). Child: adrenaline 0.1-1 microg/kg IV slowly (not more than the adult dose).

          • Adult: adrenaline 10-100 microg IV slowly (1 mg in 10 mL = 100 microg/mL); titrate
          • Infusion: 3 mg in 50 mL; start 3 mL/h (3 microg/min); titrate to max 40 microg/min. No IV: IM 500 microg
          • Also: ketamine IV 20 mg (adult); more sevoflurane if BP allows
        3. 17Warning

          If cardiac arrest or life-threatening hypoxia

          Arrest: start CPR and ALS. Look for trapped gas (auto-PEEP) and tension pneumothorax.

          • Arrest: disconnect the tube and press on the chest to release trapped gas
          • Consider tension pneumothorax, which can be bilateral: decompress
          • Slow rate (under 10/min), small tidal volume; consider ECMO or ECPR if available
        4. Path rejoins step 12Shared downstream outcome
        If No
        1. Improving
        2. Path rejoins step 12Shared downstream outcome

Guideline Source

Association of Anaesthetists Quick Reference Handbook (QRH): 3-4 Bronchospasm

View Guideline

Clinical Safety Information

Clinical Decision Support — Not a Substitute for Clinical Judgment

Individual patient factors may require deviation from these recommendations.

Known Limitations

  • Adult doses unless marked Child; neonates are not covered
  • Bronchospasm can be the only sign of anaphylaxis: check before deepening anaesthesia
  • Weight-based child doses not listed here: see QRH 3-4 Box B or ANZAAG-ANZCA Card 2
  • IV salbutamol and ketamine doses vary between sources; titrate to response

Contraindicated Populations

Neonates (under 1 month): doses not covered

Applicable Regions

AUNZUKUSEUglobal

AU: Doses follow ANZAAG-ANZCA 2022 perioperative anaphylaxis cards and TGA product information (salbutamol injection 500 microg/mL; salbutamol MDI 100 microg/puff; adrenaline 1 mg/mL).

US: Salbutamol is albuterol; adrenaline is epinephrine.

Global: Based on Association of Anaesthetists QRH 3-4 (2023), ANZAAG-ANZCA 2022 and ANZCOR 11.10.

Version 2Next review: 2027-09-30

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Frequently Asked Questions

What is the Perioperative Bronchospasm Management?

The Perioperative Bronchospasm Management is a emergency clinical algorithm for Anesthesiology. It provides a structured decision tree to guide clinical decision-making, based on Association of Anaesthetists Quick Reference Handbook (QRH): 3-4 Bronchospasm.

What guideline is the Perioperative Bronchospasm Management based on?

This algorithm is based on Association of Anaesthetists Quick Reference Handbook (QRH): 3-4 Bronchospasm.

What are the limitations of the Perioperative Bronchospasm Management?

Known limitations include: Adult doses unless marked Child; neonates are not covered; Bronchospasm can be the only sign of anaphylaxis: check before deepening anaesthesia; Weight-based child doses not listed here: see QRH 3-4 Box B or ANZAAG-ANZCA Card 2; IV salbutamol and ketamine doses vary between sources; titrate to response. Individual patient factors may require deviation from these recommendations.

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