What is the most appropriate preoperative management for a patient with asthma who is scheduled for laparoscopic cholecystectomy and is currently stable on inhaler therapy with no recent exacerbations?

Proceed with Surgery for This Stable Asthmatic Patient

For a patient with well-controlled asthma on regular inhaler therapy with no recent exacerbations, you should proceed directly with laparoscopic cholecystectomy without delay or additional preoperative testing. 1

Rationale for Proceeding

This patient demonstrates good asthma control based on:

• Regular maintenance therapy (inhaler twice daily) 1
• Absence of recent exacerbations 1
• No symptoms suggesting poor control 2

The American Academy of Allergy, Asthma, and Immunology explicitly states that postponing elective procedures should only be considered for patients with poorly controlled asthma, which does not apply to this patient. 1

Preoperative Optimization (Not Postponement)

Rather than delaying surgery, implement these immediate perioperative measures:

Medication Management

• Continue all regular asthma medications through the perioperative period, including on the day of surgery 1
• Premedicate with a bronchodilator (SABA) before the procedure 1
• Maintain baseline inhaled corticosteroid therapy, which is preferable to rescue treatment for preventing inflammatory airway edema from direct airway injury during intubation 1

Steroid Coverage Assessment

• For patients receiving oral systemic corticosteroids within the past 6 months, give 100 mg hydrocortisone intravenously during the surgical period 2
• Selected patients on high-dose inhaled corticosteroids may also require stress-dose steroids 2
• This patient on regular inhaler therapy likely does not require additional steroid coverage unless on high-dose ICS 1

Why Additional Testing Is Unnecessary

Pulmonary Function Testing Not Indicated

Routine preoperative pulmonary function testing is not recommended for patients with well-controlled asthma undergoing elective surgery. 1 PFTs should be reserved for:

• Patients with suspected COPD (not applicable here) 1
• Patients with poorly controlled asthma where optimization is needed 2
• When there is uncertainty about current asthma control 1

Chest X-Ray Not Indicated

CXR provides no actionable information for well-controlled asthma and does not predict perioperative risk in this population. 1

Intraoperative Considerations

Anesthetic Technique

• Consider regional anesthesia techniques when appropriate, though general anesthesia is acceptable for laparoscopic cholecystectomy 1
• General anesthesia with a secure airway is preferable to deep sedation for procedures that may mechanically compromise the airway 1

Monitoring and Extubation

• Monitor oxygen saturation continuously via pulse oximetry 1
• Extubate while fully awake unless medically contraindicated 2, 1
• Place patient in semi-upright position for extubation and recovery 2

Common Pitfalls to Avoid

Do not unnecessarily postpone surgery in well-controlled asthmatics - this delays needed treatment without improving outcomes and may actually worsen asthma control if the underlying surgical condition (cholecystitis) causes systemic stress. 1

Do not withhold regular asthma medications perioperatively - modern inhaled corticosteroids are safe and should be continued to prevent inflammatory airway edema. 1

Do not assume all asthmatics need stress-dose steroids - only those on recent oral steroids or very high-dose inhaled steroids require supplementation. 2

Risk Stratification Context

Poor asthma control increases perioperative risk of bronchospasm, hypoxemia, hypercapnia, atelectasis, and respiratory infections. 1 However, this patient's stable presentation with regular medication use and no recent exacerbations places them in a low-risk category suitable for proceeding with elective surgery. 1, 3