Should fluticasone (inhalation corticosteroid) be continued or initiated prior to general anesthesia in patients with asthma or Chronic Obstructive Pulmonary Disease (COPD)?

Fluticasone Prior to General Anesthesia

Inhaled corticosteroids including fluticasone should be continued through the day of surgery in all patients with asthma or COPD who are currently using them, and short-term initiation may be considered in symptomatic COPD patients with bronchial hyperreactivity undergoing non-cardiac surgery. 1

Continuation of Existing Therapy

For Patients Already on Inhaled Corticosteroids

• Continue fluticasone and all bronchodilators until the day of surgery in patients with asthma or COPD 1
• Beta-adrenergic agonists and anticholinergic agents should be maintained through the morning of surgery in all symptomatic patients with bronchial hyperreactivity 1
• The 2014 ESC/ESA guidelines explicitly state that bronchodilators should be continued until the day of surgery, and this recommendation extends to inhaled corticosteroids as part of standard maintenance therapy 1

Rationale for Continuation

• Patients with asthma are at increased risk for acute bronchoconstriction triggered by intubation, hypoxemia, impaired cough effectiveness, atelectasis, and respiratory infection during and after surgery 1
• COPD patients face significant post-operative pulmonary complications that result in substantial mortality and morbidity 1
• Abrupt discontinuation of inhaled corticosteroids can precipitate exacerbations and worsen perioperative outcomes 2

Short-Term Initiation Prior to Surgery

When to Consider Starting Fluticasone

• In symptomatic COPD patients with bronchial hyperreactivity who are not already on inhaled corticosteroids, short-term systemic or inhaled steroids may be considered as part of pre-operative optimization 1
• For patients with poorly controlled asthma, medications should be provided before surgery to improve lung function, which may include a short course of oral systemic corticosteroids if necessary 1

Pre-operative Optimization Period

• The pre-operative period should be used for optimization, ideally including cessation of smoking for at least 2 months before surgery, chest physiotherapy instruction, and lung expansion maneuvers 1
• Review the level of asthma control, medication use, and pulmonary function before surgery 1
• If lung function is not well controlled, provide medications to improve it prior to the procedure 1

Perioperative Corticosteroid Coverage

Systemic Steroid Supplementation

• For patients receiving oral systemic corticosteroids within the 6 months before surgery, or selected patients on long-term high-dose inhaled corticosteroids, give 100 mg hydrocortisone intravenously every 8 hours during the surgical period 1
• Reduce the hydrocortisone dose rapidly within 24 hours after surgery 1
• This recommendation addresses the risk of adrenal suppression from chronic corticosteroid use 1

Patients on High-Dose Inhaled Corticosteroids

• While systemic exposure to inhaled fluticasone is generally low, patients on high doses (>800 μg daily) may have increased systemic exposure and warrant consideration for perioperative stress-dose coverage 3, 4
• The pharmacokinetics of inhaled fluticasone differ between COPD patients and healthy subjects, with COPD patients showing lower systemic absorption and less hypothalamic-pituitary-adrenal suppression 3

Evidence Quality and Clinical Considerations

Guideline Strength

• The recommendation to continue bronchodilators and inhaled corticosteroids comes from high-quality European cardiovascular and anesthesiology guidelines 1
• The asthma guidelines from the National Asthma Education and Prevention Program provide Grade B evidence for perioperative management 1

Common Pitfalls to Avoid

• Do not discontinue inhaled corticosteroids in the perioperative period - this is a common error that can lead to bronchospasm and respiratory complications 1
• Do not assume that patients on inhaled corticosteroids automatically need stress-dose systemic steroids - this is primarily indicated for those on oral steroids within 6 months or very high-dose inhaled therapy 1
• Ensure proper inhaler technique is maintained even on the day of surgery, as patients may be NPO but can still use inhalers 1

Special Populations

• For COPD patients, the benefit of inhaled corticosteroids is most evident in those with FEV1 <50% predicted and history of frequent exacerbations (≥2 per year) 1
• Asthma patients benefit from inhaled corticosteroids across all severity levels, with budesonide being the preferred agent during pregnancy but fluticasone being acceptable 1