Bronchospasm Suspected
Signs of airway reactivity during anesthesia
All Pathways
AnesthesiologyEmergency
Perioperative Bronchospasm Management
Perioperative Bronchospasm Management: Bronchospasm Suspected → Recognition of Bronchospasm → Rule Out Mechanical Causes → Initial Management → Bronchod...
Pathway Overview
11 steps
Algorithm Steps
11 total
01Start 02Action 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
03Decision 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)
04Action 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
05Action 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
06Decision Response to Treatment?
Assess improvement in PIP, wheezing, oxygenation
07Action 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
08Outcome Bronchospasm Managed
Continue monitoring, document event
09Action 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)
- Path rejoins step 06Shared downstream outcome
10Warning ⚠️ 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)
11Warning ⚠️ 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
- Path rejoins step 07Shared downstream outcome
- Path rejoins step 07Shared downstream outcome
Guideline Source
Perioperative Care and Algorithm for Treatment of Intraoperative Bronchospasm
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- Rule out mechanical causes first
- Anaphylaxis may present similarly
- Patient history (asthma/COPD) affects management
- Some agents have cardiac effects
Applicable Regions
USEUglobal
Global: Based on JAA 2023 and international consensus
Version 1Next review: 2027-01-01
Next steps
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Related Resources
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 Perioperative Care and Algorithm for Treatment of Intraoperative Bronchospasm.
What guideline is the Perioperative Bronchospasm Management based on?
This algorithm is based on Perioperative Care and Algorithm for Treatment of Intraoperative Bronchospasm (DOI: 10.2147/JAA.S414026).
What are the limitations of the Perioperative Bronchospasm Management?
Known limitations include: Rule out mechanical causes first; Anaphylaxis may present similarly; Patient history (asthma/COPD) affects management; Some agents have cardiac effects. Individual patient factors may require deviation from these recommendations.
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