Preoperative Asthma Optimization for Coronary Artery Bypass Grafting
Administer prednisone 40 mg once daily for five days before surgery to optimize this patient's severe persistent asthma and reduce perioperative pulmonary complications.
Clinical Reasoning
This patient presents with severe persistent asthma that is poorly controlled despite maximum maintenance therapy (budesonide-formoterol and montelukast), evidenced by:
- Daily symptoms with minimal exertion requiring reliever therapy three times daily 1
- Activity limitation and wheezing on examination 1
- Multiple exacerbations in the past year 1
The scattered wheezes bilaterally indicate active bronchospasm, placing him at high risk for perioperative bronchospasm, prolonged mechanical ventilation, and respiratory complications during major cardiac surgery 2.
Why Systemic Corticosteroids Are Essential
Preoperative systemic corticosteroids are specifically indicated for patients with COPD or severe asthma undergoing CABG, as they significantly reduce ICU stay (p ≤ 0.001 for <24 hours stay) and total hospital length of stay (p = 0.013) 2. While this study examined COPD patients, the pathophysiology of airway inflammation and perioperative risk applies equally to severe persistent asthma 2.
The British Thoracic Society guidelines recommend prednisolone 30-60 mg for uncontrolled asthma, and this patient's clinical picture—requiring frequent rescue therapy with ongoing symptoms—meets criteria for acute treatment escalation 1.
Specific Dosing and Timing
Prednisone 40 mg once daily for 5 days preoperatively is the optimal approach because:
- Five days allows adequate time for anti-inflammatory effects to stabilize airway hyperreactivity 1
- This duration matches established protocols for acute asthma exacerbations requiring systemic steroids 1
- The dose of 40 mg falls within the recommended 30-60 mg range for moderate-to-severe asthma 1
- Starting 5 days before surgery provides sufficient lead time without excessive steroid exposure 2
Why Other Options Are Inadequate
Continuing current medications alone (Option A) is inappropriate because the patient demonstrates clear treatment failure with frequent rescue inhaler use and ongoing symptoms despite guideline-directed therapy 1.
Single-dose intraoperative hydrocortisone 100 mg (Option B) is insufficient because:
- It provides only acute coverage during surgery without addressing preoperative airway inflammation 1
- The British Thoracic Society recommends 200 mg hydrocortisone for acute severe asthma, not 100 mg 1
- Single intraoperative dosing misses the critical preoperative optimization window 2
Adding a long-acting antimuscarinic (Option D) addresses only one component of the problem and does not provide the broad anti-inflammatory effects needed to stabilize severe asthma before major surgery 3. While ipratropium can be added for acute exacerbations, systemic corticosteroids remain the cornerstone for severe persistent asthma 1.
Critical Perioperative Considerations
Monitor for adrenal suppression given chronic inhaled corticosteroid use, though the short 5-day course minimizes this risk 4. The patient may require stress-dose steroids intraoperatively (hydrocortisone 100 mg every 8 hours) if he has been on high-dose inhaled steroids long-term 4.
Continue all maintenance asthma medications (budesonide-formoterol and montelukast) throughout the perioperative period 4, 3. Abrupt withdrawal of inhaled corticosteroids can precipitate acute exacerbations 4.
Ensure availability of rescue bronchodilators and consider nebulized therapy immediately preoperatively if any bronchospasm is detected 1.
Postoperative Management
After surgery, continue systemic steroids for at least 3-5 additional days with gradual taper while monitoring peak expiratory flow and symptoms 1. The patient should be weaned from mechanical ventilation as rapidly as possible to minimize airway irritation 2.
Arterial graft spasm is a specific concern in asthma patients undergoing CABG, particularly with radial artery grafts, and may require immediate revision if hemodynamic instability occurs 5. This underscores the importance of optimal preoperative bronchodilation and anti-inflammatory therapy 5.