What peri‑operative precautions should be taken for a patient with asthma undergoing deep brain stimulation surgery under general anesthesia?

Perioperative Precautions for Asthma Patients Undergoing DBS Surgery with General Anesthesia

For asthma patients undergoing deep brain stimulation surgery under general anesthesia, optimize asthma control preoperatively with bronchodilators and consider stress-dose corticosteroids if the patient has used oral steroids within 6 months, secure the airway with endotracheal intubation rather than relying on sedation, minimize opioid use through multimodal analgesia, and extubate only when fully awake in a semi-upright position with continuous postoperative monitoring. 1

Preoperative Assessment and Optimization

Asthma Control Evaluation

• Review current asthma control status, medication regimen, and recent exacerbations before proceeding. 1 Well-controlled asthma (regular inhaler use without recent exacerbations) does not require surgery postponement. 1
• Postpone elective DBS surgery if asthma is poorly controlled (frequent rescue inhaler use >2 days/week, recent emergency care for exacerbation, or active symptoms). 1
• Obtain pulmonary function testing for patients with poorly controlled asthma to establish baseline and guide optimization. 1

Medication Management

• Continue all regular asthma medications through the perioperative period, including on the day of surgery. 1 This includes inhaled corticosteroids, which are safe and should not be discontinued. 1
• Administer bronchodilator premedication before the procedure to optimize lung function. 1
• For patients who received oral systemic corticosteroids within the past 6 months, give hydrocortisone 100 mg IV during surgery to prevent adrenal insufficiency. 1 This should be rapidly tapered within 24 hours postoperatively. 1
• Selected patients on high-dose inhaled corticosteroids may also require stress-dose steroids. 1

Difficult Airway Preparation

• Prepare for potential difficult airway management, as asthma patients may have airway challenges. 2 Have advanced airway equipment immediately available (video laryngoscope, fiberoptic bronchoscope, supraglottic devices). 3

Intraoperative Management

Anesthetic Technique Selection

• General anesthesia with a secured airway via endotracheal intubation is mandatory for DBS surgery rather than deep sedation, as the procedure mechanically compromises the airway with head frame placement. 2, 3
• Avoid preoperative sedatives or use minimal doses with continuous monitoring, as asthma patients are susceptible to respiratory depression from sedatives and opioids. 2

Airway Management

• Extubate only when the patient is fully awake unless medically contraindicated. 2, 1
• Verify complete reversal of neuromuscular blockade before extubation to ensure adequate respiratory muscle function. 2
• Position the patient semi-upright (30-45°) for extubation and recovery to optimize respiratory mechanics. 1, 3

Medication Selection During Surgery

• Minimize intraoperative opioids and employ multimodal analgesia (acetaminophen, NSAIDs when not contraindicated) to reduce respiratory depression risk. 3 Asthma patients may have heightened sensitivity to opioid respiratory effects. 2
• Titrate anesthetic gases carefully to avoid excessive respiratory depression while maintaining adequate anesthesia depth. 2, 3
• Avoid medications that trigger histamine release (morphine, atracurium, mivacurium) as they may precipitate bronchospasm. 3

Monitoring

• Monitor oxygen saturation continuously via pulse oximetry throughout the procedure. 1
• Use capnography monitoring if feasible to detect early respiratory compromise, as asthma patients have increased risk of undetected airway obstruction. 2
• Provide supplemental oxygen to maintain SpO₂ ≥90-95% while observing respiratory effort. 1, 3

Postoperative Management

Monitoring Requirements

• Continue continuous oxygen saturation and respiratory rate monitoring in the recovery period. 1
• Monitor patients for at least 3 hours longer than non-asthma counterparts before considering discharge from monitored settings. 2
• Observe patients in an unstimulated environment while appearing asleep to confirm they maintain baseline oxygen saturation on room air before discharge. 2

Respiratory Support

• Position patients semi-upright (30-45°) during recovery to optimize respiratory mechanics and reduce airway obstruction risk. 2, 3
• Consider incentive spirometry, chest physiotherapy, and early mobilization to prevent pulmonary complications. 1

Pain Management

• Prioritize non-opioid analgesics (acetaminophen, NSAIDs) as first-line postoperative pain control. 3
• If opioids are required, reduce doses to approximately 50% of usual amounts with extended monitoring due to heightened respiratory sensitivity. 3
• Maintain adequate analgesia, as inadequate pain control leads to shallow breathing and atelectasis. 1

Critical Pitfalls to Avoid

• Never proceed with elective DBS surgery during active asthma exacerbation or with poorly controlled disease without optimization. 1
• Avoid hypothermia in the postoperative setting, as it can trigger bronchospasm. 1
• Do not rely on pulse oximetry alone for respiratory monitoring—use capnography when available to detect early hypoventilation. 2, 3
• Never discontinue regular asthma medications perioperatively, as this increases exacerbation risk. 1
• Avoid excessive supplemental oxygen that masks hypoventilation—titrate to target SpO₂ while closely observing respiratory effort. 3