Proceed with Surgery
For this patient with well-controlled asthma (using inhaler twice daily with no recent exacerbations), the most appropriate management is to proceed with laparoscopic cholecystectomy (Option B) while ensuring proper perioperative optimization. 1, 2
Rationale for Proceeding
Well-controlled asthma does not require surgery postponement. The patient demonstrates good control with regular inhaler use and absence of recent exacerbations, which are key indicators that surgery can proceed safely. 1, 2
Routine pulmonary function testing is not mandatory for well-controlled asthma. PFTs are reserved for patients with poorly controlled asthma or when control status is uncertain. 2, 3 This patient's clinical presentation clearly indicates adequate control.
Chest X-ray has no role in preoperative assessment of controlled asthma. CXR does not predict perioperative risk or change management in stable asthmatic patients. 1
Required Preoperative Actions
Before proceeding to surgery, implement these specific measures:
Continue all regular asthma medications through the perioperative period, including on the day of surgery. This includes her current inhaler regimen. 2
Administer preoperative bronchodilator immediately before the procedure to prevent bronchospasm during intubation and anesthesia. 2, 4
Document medication history carefully, specifically asking about oral systemic corticosteroid use within the past 6 months. 1, 2 If she has received oral steroids in this timeframe, she will require stress-dose hydrocortisone (100 mg IV every 8 hours during surgery, rapidly tapered within 24 hours post-op). 1
Intraoperative Considerations
Ensure adequate depth of anesthesia before intubation to minimize airway reactivity and prevent reflex bronchoconstriction. 5, 6
Maintain continuous pulse oximetry and keep oxygen saturation ≥90% throughout the procedure. 2
Extubate while the patient is fully awake unless medically contraindicated, preferably in a semi-upright position. 2
Common Pitfalls to Avoid
Do not unnecessarily delay elective surgery in well-controlled asthmatics. Postponement is only indicated when asthma is poorly controlled or during active exacerbations. 2
Avoid hypothermia in the postoperative period, as this can trigger bronchospasm. 2
Do not withhold regular inhaled corticosteroids perioperatively. Maintaining baseline ICS therapy prevents inflammatory airway edema from direct airway injury during intubation. 2
When Surgery Should Be Postponed
Surgery postponement would be appropriate if the patient had:
- Active wheezing or respiratory symptoms at rest 6
- Recent asthma exacerbation requiring emergency care 1
- Frequent use of rescue inhaler (>2 days/week beyond exercise prevention) 1
- Poor symptom control despite current therapy 2
Since this patient demonstrates none of these concerning features, proceeding with surgery after appropriate preoperative optimization is the correct approach. 1, 2