What is the most appropriate preoperative management for a patient with well-controlled asthma using a short-acting beta-agonist (SABA) (albuterol) twice daily, scheduled for laparoscopic cholecystectomy?

Preoperative Management for Well-Controlled Asthma Before Laparoscopic Cholecystectomy

This patient can proceed directly with surgery (Option A) without additional preoperative interventions, as her asthma is well-controlled with no recent exacerbations. 1

Clinical Assessment and Rationale

The patient's current asthma status indicates adequate control:

• Using SABA (albuterol) twice daily only
• No recent exacerbations
• No mention of symptoms at rest or nocturnal awakening
• Scheduled for elective laparoscopic procedure

According to the National Asthma Education and Prevention Program (NAEPP) Expert Panel Report 3, the key preoperative action is to assess asthma control before surgery. 1 When lung function is well controlled, patients can proceed to surgery with continuation of their current medications. 1

Why Other Options Are Not Indicated

Postponing Surgery (Option B)

• There is no indication to delay surgery in a patient with well-controlled asthma. 1
• Postponement would only be warranted if the patient had poorly controlled asthma, recent exacerbations, or evidence of active bronchospasm. 2

Pulmonary Function Testing (Option C)

• Routine preoperative PFTs are not required for patients with well-controlled asthma undergoing elective surgery. 1
• PFTs would be considered if asthma control were questionable or if there were signs of deterioration, but this patient demonstrates stable disease. 2

Intravenous Steroids (Option D)

• IV corticosteroids are reserved for specific high-risk scenarios, not routine well-controlled asthma. 1
• The NAEPP guidelines specify that for patients receiving oral systemic corticosteroids during the month before surgery, or for selected patients on high-dose inhaled corticosteroids, 100 mg hydrocortisone IV should be given during the surgical period with rapid dose reduction within 24 hours after surgery. 1
• This patient is only using SABA therapy, not chronic corticosteroids, so prophylactic IV steroids are not indicated. 1

Appropriate Perioperative Management

The patient should continue her albuterol inhaler through the perioperative period. 1 Key perioperative considerations include:

• Albuterol is the preferred SABA for perioperative use and should be available throughout the surgical period. 1
• Ensure the patient has access to her inhaler up until surgery and immediately postoperatively. 1
• Laparoscopic cholecystectomy actually offers improved pulmonary function compared to open technique, with postoperative FVC at 73% versus 52% of baseline. 3
• Potential bronchospasm triggers during anesthesia should be identified and avoided. 2

Common Pitfalls to Avoid

• Do not discontinue the patient's SABA therapy preoperatively - maintenance of bronchodilatory regimens through the perioperative period is essential. 2
• Do not assume all asthma patients need stress-dose steroids - this is only for those on chronic systemic or high-dose inhaled corticosteroids. 1
• Do not order unnecessary testing - well-controlled asthma does not require routine PFTs before elective surgery. 1
• Recognize that using SABA more than twice daily for symptom relief (not prevention) would indicate inadequate control and warrant optimization before surgery. 1 However, this patient is using it twice daily, which is acceptable. 1