What are the management strategies for a patient with Allergic Bronchopulmonary Aspergillosis (ABPA) undergoing Coronary Artery Bypass Grafting (CABG)?

Management of ABPA Patients Undergoing CABG

For patients with Allergic Bronchopulmonary Aspergillosis (ABPA) undergoing Coronary Artery Bypass Grafting (CABG), optimization of ABPA control before surgery and careful perioperative management are essential to reduce respiratory complications and improve surgical outcomes.

Preoperative Management

ABPA Control Before Surgery

• Assess ABPA status and optimize control before elective CABG
  • Evaluate symptoms, serum total IgE levels, and chest imaging 1
  • Aim for clinical remission or stable disease before elective surgery
  • Consider delaying elective CABG if ABPA is in acute exacerbation phase

Medication Management

• Continue or initiate appropriate ABPA therapy:

  • For stable ABPA: Maintain current therapy regimen
  • For symptomatic ABPA: Consider oral prednisolone 0.5 mg/kg/day for 2-4 weeks before surgery 2
  • If steroids are contraindicated: Consider itraconazole 200 mg twice daily 2

• Antiplatelet therapy considerations:

  • Administer aspirin (100-325 mg daily) preoperatively 1
  • Discontinue clopidogrel and ticagrelor at least 5 days before elective CABG 1
  • Discontinue prasugrel at least 7 days before surgery 1
  • For urgent CABG, discontinue clopidogrel and ticagrelor for at least 24 hours 1

• Statin therapy:

  • Continue statin therapy throughout the perioperative period 1
  • Do not discontinue statins before or after CABG 1

Respiratory Optimization

• Optimize underlying asthma control:

  • Ensure appropriate use of inhaled corticosteroids (ICS) and long-acting beta-agonists (LABA) 2
  • Consider adding long-acting muscarinic antagonists (LAMA) for severe asthma 2
  • Address any active bronchospasm or airway inflammation

• Bronchiectasis management:

  • Implement airway clearance techniques 1
  • Consider nebulized hypertonic saline (3-7%, 4-5 mL) to reduce sputum viscosity 1
  • Administer nebulized salbutamol before hypertonic saline to prevent bronchospasm 1

Intraoperative Management

Anesthetic Considerations

• Bronchospasm prevention:

  • Consider pre-induction bronchodilator administration
  • Avoid histamine-releasing anesthetic agents
  • Maintain adequate hydration to prevent mucus impaction

• Glucose management:

  • Aim for intraoperative blood glucose <180 mg/dL 1
  • Consider continuous intravenous insulin if needed 1

Surgical Considerations

• Minimize cardiopulmonary bypass time to reduce inflammatory response
• Careful handling of the lungs during internal mammary artery harvesting
• Consider off-pump CABG if technically feasible to reduce respiratory complications 3

Postoperative Management

Immediate Postoperative Care

• Respiratory support:

  • Early extubation when feasible
  • Aggressive pulmonary toilet and secretion clearance
  • Early mobilization to prevent atelectasis

• Medication management:

  • If aspirin was not initiated preoperatively, start within 6 hours postoperatively 1
  • Resume ABPA therapy as soon as clinically stable 1
  • Maintain continuous intravenous insulin to achieve blood glucose ≤180 mg/dL 1

ABPA-Specific Considerations

• Monitor for exacerbations:

  • Watch for increased sputum production, wheezing, or new infiltrates
  • Monitor serum total IgE levels if exacerbation suspected 1

• Treatment options for post-CABG ABPA exacerbation:

  • Oral prednisolone 0.5 mg/kg/day for 2-4 weeks, then taper over 4 months 2
  • Consider itraconazole 200 mg twice daily for 4 months 2
  • For treatment-dependent ABPA: Consider nebulized amphotericin B 1, 4

Long-term Management

• Regular follow-up:

  • Monitor clinical symptoms, serum total IgE levels, and lung function tests every 3-6 months 1
  • Adjust therapy based on clinical response

• Maintenance therapy options:

  • Long-term itraconazole (200 mg daily) for treatment-dependent ABPA 1
  • Nebulized liposomal amphotericin B (25 mg weekly) 1, 4
  • Consider biological agents (omalizumab, mepolizumab, benralizumab) for steroid-dependent patients 1, 2

Special Considerations

Management of Pleural Effusions

• Pleural effusions are common after CABG (especially left-sided) 5
• Monitor for dyspnea and perform therapeutic thoracentesis if significant 5
• Distinguish between post-CABG effusions and those related to ABPA exacerbation

Potential Complications and Pitfalls

• Drug interactions:

  • Monitor for interactions between azoles and statins
  • Caution with azithromycin and itraconazole combination (QTc prolongation) 1

• Respiratory complications:

  • Higher risk of postoperative respiratory complications in ABPA patients 3
  • Early recognition and aggressive management of atelectasis, pneumonia, or ABPA exacerbation

• Therapeutic drug monitoring:

  • Maintain itraconazole trough levels ≥0.5 mg/L 2
  • Monitor for hepatotoxicity with antifungal therapy 2