What is the approach to perioperative assessment of a patient with asthma?

From the Guidelines

Perioperative assessment of a patient with asthma should prioritize reviewing the level of asthma control, medication use, and pulmonary function before surgery to reduce the risk of complications. This approach is crucial in minimizing the risk of acute bronchoconstriction, hypoxemia, and other respiratory complications during and after surgery 1.

Key Assessment Components

• Reviewing the patient's asthma control and medication use, especially oral systemic corticosteroids within the past 6 months, is essential in determining the risk of complications during surgery.
• Assessing pulmonary function through tests such as spirometry can help identify patients who may require preoperative optimization of lung function.
• Providing medications before surgery to improve lung function, such as a short course of oral systemic corticosteroids, may be necessary for patients with poorly controlled asthma.

Preoperative Management

• For patients receiving oral systemic corticosteroids during the 6 months before surgery, administering 100 mg hydrocortisone every 8 hours intravenously during the surgical period can help reduce the risk of complications, with the dose reduced rapidly within 24 hours after surgery 1.
• Ensuring the patient is on optimal controller therapy, including inhaled corticosteroids and long-acting beta-agonists, is vital in maintaining good asthma control.
• Considering a short course of oral corticosteroids preoperatively for patients with poorly controlled asthma can help optimize lung function before surgery.

Communication with Anesthesiologist

• Informing the anesthesiologist about the severity of asthma, recent exacerbations, and steroid use is crucial in guiding appropriate anesthetic management and avoiding triggers like endotracheal intubation when possible.
• Coordinating with the anesthesiologist to develop a perioperative plan that minimizes the risk of bronchospasm and respiratory complications is essential in ensuring a safe surgical outcome.

From the FDA Drug Label

When a clinical response to cromolyn sodium inhalation solution is evident, usually within two to four weeks, and if the asthma is under good control, an attempt may be made to decrease concomitant medication usage gradually If a patient is subjected to significant stress, such as a severe asthmatic attack, surgery, trauma or severe illness while being treated or within one year (occasionally up to two years) after corticosteroid treatment has been terminated, consideration should be given to reinstituting corticosteroid therapy

• Perioperative assessment of a patient with asthma should consider the potential for stress induced by surgery, which may require temporary increase in corticosteroids to regain control of the patient's asthma.
• It is essential to maintain close supervision of the patient, especially if cromolyn sodium inhalation solution is withdrawn, as there may be a sudden reappearance of severe manifestations of asthma.
• Corticosteroid therapy should be reinstituted if necessary, and the patient's asthma control should be closely monitored 2.

From the Research

Perioperative Assessment of a Patient with Asthma

To minimize the risks of perioperative respiratory complications in patients with asthma undergoing general anesthesia, a detailed preoperative assessment is crucial 3. The following steps can be taken:

• A specialized history and physical examination should be conducted to identify patients with a history of frequent exacerbations, aspirin-exacerbated respiratory disease, or recent airway infection, who have a severe risk of perioperative exacerbation 3, 4.
• Pulmonary function testing should be performed as part of the preoperative assessment 4.
• Preoperative intervention with anti-inflammatory and bronchodilatory medication should be considered if asthma is poorly controlled before surgery 3, 4.
• The use of systemic corticosteroids has not been shown to adversely affect wound healing or increase the rate of infections postoperatively, and may be used safely in the majority of patients to decrease asthma-related morbidity 4.

Anesthetic Planning and Management

Adequate anesthetic planning is essential to suppress or avoid bronchial constriction, including:

• Proper selection of anesthetic 3, 5.
• Appropriate depth of anesthesia at any time point during surgery 3.
• Avoiding potential trigger agents that may cause bronchospasm 5.
• Many routinely used anesthetic agents have an ameliorative effect on airway constriction, but acute bronchospasm can still occur, especially at induction and emergence, and should be promptly and methodically managed 5.

Intraoperative and Postoperative Management

Intraoperative bronchospasm must be managed promptly using:

• Bronchodilators 3.
• Steroid therapy 3, 5.
• Continuous observation and accurate diagnostic decision making are essential to prevent the untoward effects of acute asthma exacerbation during the perioperative experience 6.