What is the intraoperative management of bronchospasm during emergence and extubation?

Intraoperative Management of Bronchospasm During Extubation

When bronchospasm occurs during emergence and extubation, immediately deepen anesthesia with propofol 1-2 mg/kg IV, administer 100% oxygen with continuous positive airway pressure (CPAP), and deliver inhaled beta-2 agonists (albuterol 10-15 puffs via MDI with spacer) through the endotracheal tube before attempting extubation. 1, 2, 3

Immediate Pharmacological Management

First-Line Bronchodilator Therapy

• Administer inhaled albuterol 10-15 puffs (90 mcg per puff) via metered-dose inhaler with spacer device through the endotracheal tube, as this effectively reduces resistive airway pressure in mechanically ventilated patients within minutes 3
• Titrate dosing based on clinical response; doses up to 15 puffs are effective, with further doses (beyond 30 cumulative puffs) providing no additional benefit 3
• Consider adding ipratropium bromide 120 mcg aerosolized through the endotracheal tube, which relieves wheezing in approximately 11 minutes and significantly decreases peak inspiratory pressure within 5 minutes 4

Anesthetic Depth Adjustment

• Deepen anesthesia with propofol 1-2 mg/kg IV to suppress airway reactivity and reduce bronchospasm triggered by airway stimulation 1, 2
• Avoid premature extubation attempts during active bronchospasm, as airway stimulation worsens and prolongs the episode 2
• Consider remifentanil infusion to suppress cough reflex without causing excessive respiratory depression 5

Ventilatory Support Strategies

Optimize Oxygenation and Ventilation

• Provide 100% oxygen with CPAP to maintain oxygen saturation while treating the underlying bronchospasm 1, 2
• Monitor peak inspiratory pressure (PIP) and resistive pressure (PIP minus plateau pressure) as objective measures of bronchospasm severity and treatment response 3
• Avoid excessive positive pressure ventilation that may cause barotrauma; allow permissive hypercapnia if necessary while treating bronchospasm 3

Alveolar Recruitment Considerations

• Perform sustained inflation maneuvers to expel secretions and potentially reduce breath-holding, though these should be used cautiously during active bronchospasm 5
• Maintain PEEP to prevent alveolar collapse, but recognize that PEEP alone does not reverse existing atelectasis 5

Rescue Therapies for Refractory Bronchospasm

Escalation to Systemic Medications

• Administer intramuscular epinephrine 0.3-0.5 mg if bronchospasm persists despite inhaled bronchodilators and deepening anesthesia 1
• Consider intravenous corticosteroids (methylprednisolone 125 mg or equivalent) for anti-inflammatory effects, though onset is delayed 6

Advanced Rescue Options

• For life-threatening refractory bronchospasm, consider endotracheal epinephrine 0.5 mg of 1:10,000 solution in 10 mL normal saline, which provides immediate bronchodilation when standard therapies fail 6
• Inhaled volatile anesthetic gas (sevoflurane or isoflurane) delivered via conserving device provides bronchodilation through direct smooth muscle relaxation in severe cases 7
• Administer succinylcholine 1 mg/kg IV only if progressive hypoxia develops despite all other measures, as this allows complete vocal cord relaxation and ventilation 1, 2

Timing of Extubation

Delay Extubation Until Resolution

• Do not attempt extubation until bronchospasm has completely resolved, as evidenced by normalized peak inspiratory pressures, absence of wheezing, and adequate tidal volumes 3, 4
• Ensure patient is breathing spontaneously with regular pattern and adequate minute ventilation before considering extubation 5
• Verify return of protective airway reflexes if performing awake extubation 5

Extubation Technique After Bronchospasm Resolution

• Pre-oxygenate with FiO2 1.0 to maximize oxygen stores before extubation 5
• Position patient head-up 30 degrees to optimize respiratory mechanics 5
• Suction oropharynx under direct vision with laryngoscopy to remove secretions without traumatizing airway 5
• Insert bite block to prevent tube occlusion during emergence 5
• Extubate at peak inspiration with simultaneous cuff deflation to generate passive exhalation that expels secretions 5

Critical Pitfalls to Avoid

Common Errors That Worsen Outcomes

• Never delay escalation of treatment if initial bronchodilators fail, as bronchospasm can rapidly progress to complete airway obstruction and hypoxic cardiac arrest 2
• Avoid unnecessary airway stimulation (suctioning, tube manipulation) during active bronchospasm, as this worsens and prolongs the episode 1, 2
• Do not routinely suction the tracheal tube immediately before extubation, as this reduces lung volume and may trigger further bronchospasm 5
• Avoid turning off the ventilator to allow CO2 accumulation for spontaneous breathing, as the apnoeic period with zero PEEP causes alveolar collapse 5

Post-Extubation Monitoring

• Monitor for post-obstructive pulmonary edema, which develops in approximately 4% of severe bronchospasm cases and presents with dyspnea, pink frothy sputum, and hypoxemia 2
• Maintain supplemental oxygen to keep SpO2 >94% while investigating underlying causes 5
• Consider prophylactic CPAP in recovery to reduce atelectasis, though evidence for routine use is limited 5