From the Guidelines
The best next step for this 62-year-old man with severe persistent asthma, hypertension, and CAD scheduled for CABG is to administer prednisone, 40 mg once daily for five days before surgery to optimize his asthma control and reduce the risk of perioperative pulmonary complications. This recommendation is based on the guidelines for the diagnosis and management of asthma, which suggest that a short course of oral systemic corticosteroids may be considered to gain more rapid control for patients whose asthma frequently interrupts sleep or normal daily activities or who are experiencing an exacerbation at the time of assessment 1. Given the patient's severe persistent asthma, daily symptoms, and frequent need for reliever therapy, initiating a short course of oral corticosteroids is a reasonable step to quickly improve his asthma control before surgery. The patient's current medication regimen, including budesonide-formoterol and montelukast, should be continued without interruption, as abrupt cessation of these medications could worsen his asthma control 1. Additionally, pulmonary function testing should be performed to establish a baseline function, and the patient should be closely monitored for any changes in his asthma symptoms or lung function. Optimizing asthma control preoperatively is crucial, as poor control increases the risk of postoperative pulmonary complications, including bronchospasm during intubation and extubation, atelectasis, and respiratory failure, which are particularly dangerous in a patient undergoing cardiac surgery. It is also important to note that the patient's BMI of 35 may increase his risk of perioperative pulmonary complications, making optimal asthma control even more critical in this case. Overall, administering prednisone, 40 mg once daily for five days before surgery, is the best next step to optimize the patient's asthma control and reduce his risk of perioperative pulmonary complications.
From the Research
Patient Assessment
The patient is a 62-year-old man with severe persistent asthma, hypertension, and coronary artery disease (CAD) who is scheduled for coronary artery bypass grafting (CABG). He has been experiencing daily shortness of breath and frequent need for reliever therapy with budesonide-formoterol and montelukast.
Current Medication Regimen
The patient is currently taking budesonide-formoterol for both maintenance and reliever therapy and montelukast. He reports requiring his inhaler three times daily for reliever therapy.
Considerations for CABG
- The patient's severe persistent asthma and frequent need for reliever therapy may increase the risk of postoperative pulmonary complications 2.
- The use of corticosteroids in the perioperative period for patients undergoing cardiac surgery with cardiopulmonary bypass (CPB) is controversial, with some studies suggesting a reduction in biochemical inflammatory markers, but mixed results on clinical outcomes 3, 4, 5.
- The patient's BMI of 35 may not be a significant risk factor for postoperative complications, as studies have shown that patients with a BMI between 25 and 35 kg/m2 are not at elevated risk for most complications, except for infection 6.
Options for Next Step
- Continue current medication regimen: This option may not be sufficient to control the patient's asthma symptoms and prevent postoperative pulmonary complications.
- Administer hydrocortisone, 100 mg once intraoperatively: This option may help reduce the inflammatory response associated with CPB, but the evidence for its effectiveness is mixed 3, 4, 5.
- Administer prednisone, 40 mg once daily for five days before surgery: This option may help reduce airway inflammation and prevent postoperative pulmonary complications, but the evidence for its effectiveness in this setting is limited.
- Start a long-acting inhaled anti-muscarinic five days before surgery: This option may help control the patient's asthma symptoms and prevent postoperative pulmonary complications, but the evidence for its effectiveness in this setting is limited.
Best Next Step
Based on the available evidence, administering prednisone, 40 mg once daily for five days before surgery, may be the best next step to help control the patient's asthma symptoms and prevent postoperative pulmonary complications 2. However, the decision should be made on a case-by-case basis, taking into account the patient's individual risk factors and medical history.