Should budesonide (corticosteroid) be continued before undergoing general anesthesia in patients with asthma or Chronic Obstructive Pulmonary Disease (COPD)?

Budesonide Should Be Continued Prior to General Anesthesia

Patients with asthma or COPD should continue their regular inhaled budesonide therapy through the perioperative period, including on the day of surgery. 1

Rationale for Continuation

Guideline-Based Recommendations

The American Academy of Allergy, Asthma, and Immunology explicitly recommends continuing regular asthma medications through the perioperative period, including on the day of surgery. 1 This approach prioritizes maintaining optimal airway control and minimizing the risk of perioperative bronchospasm, which directly impacts morbidity and mortality outcomes.

Inhaled corticosteroids like budesonide are safe at recommended doses and do not cause clinically important adverse effects on cortisol production or glucose metabolism that would necessitate perioperative discontinuation. 1

Risk Mitigation Strategy

Continuing budesonide serves multiple protective functions:

• Reduces perioperative bronchospasm risk: Patients with poorly controlled asthma face increased risks of bronchospasm, hypoxemia, hypercapnia, atelectasis, and respiratory infections during the perioperative period. 1

• Maintains baseline airway stability: Discontinuing inhaled corticosteroids can lead to disease exacerbation, as demonstrated in studies where stopping budesonide resulted in loss of asthma control in 67% of patients. 2

• Prevents inflammatory airway edema: While steroids are effective for inflammatory airway edema from direct airway injury during intubation and anesthesia, maintaining baseline therapy is preferable to rescue treatment. 3

Preoperative Optimization

Assessment Requirements

Before proceeding with surgery, clinicians should:

• Review asthma control status: Assess medication use, symptom frequency, and recent exacerbations, particularly any oral corticosteroid use within the past 6 months. 1

• Measure pulmonary function: Check spirometric parameters, especially in patients with suspected COPD or poorly controlled disease. 1

• Consider postponement: For elective procedures in patients with poorly controlled asthma, delay surgery until better control is achieved through medication optimization. 1

Additional Perioperative Measures

Beyond continuing budesonide:

• Premedicate with bronchodilators: Administer short-acting beta-agonists before the procedure. 1

• Consider supplemental systemic steroids: If asthma is not well controlled despite inhaled therapy, a short course of oral corticosteroids may be necessary preoperatively. 1

• Maintain continuous monitoring: Use pulse oximetry throughout the procedure and recovery period, maintaining oxygen saturation ≥90%. 1

Intraoperative and Postoperative Considerations

Airway Management

• Extubate while awake: Unless medically contraindicated, patients with asthma should be extubated while fully awake to minimize bronchospasm risk. 1

• Avoid hypothermia: Postoperative hypothermia can trigger bronchospasm and must be prevented. 1

• Continue monitoring: Maintain oxygen saturation monitoring throughout the recovery period. 1

Common Pitfalls to Avoid

Do not discontinue inhaled corticosteroids perioperatively based on concerns about systemic effects. The evidence over 25 years demonstrates that inhaled budesonide at recommended doses carries minimal risk of adrenal suppression, and the benefits of maintaining airway control far outweigh theoretical systemic risks. 4, 5

Do not confuse the perioperative management of GLP-1 receptor agonists or SGLT2 inhibitors with inhaled corticosteroid management. While recent guidelines recommend specific timing adjustments for these newer diabetes medications, 3 no such restrictions apply to inhaled corticosteroids for respiratory disease.

Evidence Quality Note

The recommendation to continue inhaled corticosteroids perioperatively is based on high-quality guideline evidence from the American Academy of Allergy, Asthma, and Immunology. 1 This is supported by extensive safety data demonstrating that budesonide maintains excellent airway efficacy with minimal systemic effects, 4, 5 and by evidence that discontinuation leads to loss of disease control. 2