Should nasal sprays, such as fluticasone propionate (fluticasone), be continued in patients with asthma or Chronic Obstructive Pulmonary Disease (COPD) undergoing general anesthesia?

Nasal Corticosteroid Sprays Should Be Continued Perioperatively in Asthma and COPD Patients

Patients with asthma or COPD who are on nasal corticosteroid sprays (such as fluticasone propionate) should continue these medications through the perioperative period, as there is no evidence of harm and abrupt discontinuation may worsen underlying respiratory disease control.

Rationale for Continuation

No Contraindication to Perioperative Use

• The available guidelines do not identify nasal corticosteroid sprays as medications requiring discontinuation before general anesthesia 1.
• Nasal corticosteroids work topically with minimal systemic absorption, making perioperative risks negligible 1.

Risk of Discontinuation Outweighs Benefits

• Abrupt cessation of nasal corticosteroids can lead to rebound inflammation and worsening of upper airway symptoms, which may complicate perioperative respiratory management 1.
• In patients with coexisting chronic rhinosinusitis (common in asthma patients), nasal corticosteroids significantly improve quality of life and symptoms, with effects demonstrated across multiple delivery methods including sprays 1.

Disease-Specific Considerations

Asthma Patients

• Patients with asthma and nasal polyposis benefit significantly from nasal corticosteroids, with fluticasone propionate demonstrating improved health-related quality of life when continued regularly 2.
• The combination of upper and lower airway inflammation is common in asthma; maintaining nasal corticosteroid therapy helps optimize overall respiratory status perioperatively 2, 3.

COPD Patients

• While the primary evidence focuses on inhaled bronchodilators and corticosteroids for COPD management, nasal corticosteroids for concurrent rhinosinusitis should not be discontinued 1.
• Regular use of corticosteroid therapy (including fluticasone propionate) in COPD is associated with improved outcomes and should be maintained 4.

Practical Management Algorithm

Preoperative Assessment

• Verify the patient is using their nasal spray correctly (proper technique with head positioning) 1.
• Confirm the medication regimen and dosing schedule 1.
• Document any recent changes in respiratory symptoms or nasal obstruction 1.

Perioperative Instructions

• Instruct patients to use their morning dose of nasal corticosteroid spray on the day of surgery 1.
• Resume normal dosing schedule as soon as the patient can self-administer medications postoperatively 1.
• If the patient cannot self-administer immediately postoperatively, resume within 24 hours 1.

Important Caveats

Distinguish from Systemic Corticosteroids

• This recommendation applies specifically to topical nasal corticosteroid sprays, not systemic corticosteroids which require different perioperative management 1.
• Nasal sprays have minimal hypothalamic-pituitary-adrenal axis suppression compared to systemic steroids 1.

Not a Substitute for Bronchodilator Optimization

• Continuation of nasal sprays does not replace the need for optimizing inhaled bronchodilators and systemic medications for asthma/COPD 1.
• Ensure nebulized bronchodilators are available perioperatively for acute exacerbations 1.

Delivery Method Considerations

• Standard nasal sprays are appropriate for perioperative continuation 1.
• More complex delivery systems (nebulizers, irrigations) may need to be temporarily simplified to standard sprays during the immediate perioperative period for practical reasons 1.