For a 62‑year‑old man with coronary artery disease, hypertension, severe persistent asthma (on inhaled budesonide and frequent short‑acting bronchodilator use, no chronic oral steroids) scheduled for coronary‑artery bypass grafting, what is the appropriate pre‑operative medication plan?

Pre-operative Steroid Management for Severe Persistent Asthma Before CABG

For this patient with severe persistent asthma requiring frequent rescue inhaler use and recent exacerbations, administer oral prednisone 40 mg daily for 5 days before surgery (Option C) to reduce perioperative bronchospasm risk and inflammatory cytokine production.

Rationale for Systemic Corticosteroid Supplementation

Evidence Supporting Pre-operative Oral Steroids

• Patients with severe persistent asthma requiring frequent rescue therapy (≥3 times daily) and recent exacerbations within 2 months represent high-risk candidates for perioperative bronchospasm 1

• Preoperative corticosteroid administration (20 mg prednisolone for 2 days before surgery) completely suppresses inflammatory cytokine production (IL-5 and TNF-alpha) at the mRNA level in asthmatic lung tissue, which is the primary mechanism for preventing perioperative asthma attacks 2

• British Thoracic Society guidelines recommend prednisolone 30-40 mg daily for acute exacerbations until lung function returns to baseline, with treatment duration of 7-21 days depending on severity 1

Why Inhaled Corticosteroids Alone Are Insufficient

• This patient's current budesonide regimen is clearly inadequate, as evidenced by daily symptoms with minimal exertion, frequent rescue inhaler use (3 times daily), and multiple exacerbations in the past year 1

• The surgical stress response will further increase airway hyperresponsiveness, and inhaled corticosteroids cannot provide the rapid, systemic anti-inflammatory effect needed for major surgery 2

Why Not the Other Options

Option A (Continue Current Regimen) - Inadequate

• Continuing the current medication regimen would leave this patient at unacceptably high risk for life-threatening perioperative bronchospasm, given the severity markers: daily symptoms, activity limitation, frequent rescue use, and recent exacerbations 1

Option B (Intravenous Hydrocortisone Intraoperatively Only) - Insufficient Timing

• While intravenous hydrocortisone 200 mg is appropriate for acute severe asthma during surgery, administering steroids only at the time of surgery misses the critical 2-5 day preoperative window needed to suppress inflammatory cytokine production at the transcriptional level 2

• Preoperative steroid administration for 2 days before surgery is specifically supported by research showing complete suppression of IL-5 and TNF-alpha mRNA expression, which cannot be achieved with intraoperative dosing alone 2

Option D (Inhaled Anticholinergic) - Adjunctive Only

• Ipratropium bromide is recommended as an adjunct to beta-agonists in acute severe asthma but does not address the underlying inflammatory process that drives perioperative bronchospasm risk 1

Optimal Pre-operative Protocol

Steroid Dosing Strategy

• Administer prednisone 40 mg orally once daily for 5 days before elective CABG 1

• This 5-day preoperative course allows adequate time for transcriptional suppression of inflammatory cytokines while minimizing hyperglycemia risk in the perioperative period 2

Intraoperative Supplementation

• Add intravenous methylprednisolone 80 mg immediately before and after surgery to maintain corticosteroid coverage during the peak stress response 2

Continuation of Inhaled Therapy

• Continue budesonide and formoterol throughout the perioperative period, as inhaled corticosteroids should not be discontinued before or after surgery 3

• Ensure proper inhaler technique and consider using a spacer device to maximize drug delivery in the postoperative period 1

Critical Safety Considerations

Glucose Management

• Use continuous intravenous insulin to maintain blood glucose ≤180 mg/dL while avoiding hypoglycemia, as this reduces deep sternal wound infection risk after CABG 1

• The patient's BMI of 35 and likely insulin resistance increase infection risk, making tight glycemic control essential when administering systemic corticosteroids 1

Monitoring Requirements

• Monitor peak expiratory flow and respiratory symptoms daily during the preoperative steroid course 1

• Ensure oxygen saturation remains >90% and respiratory rate <25 breaths/minute before proceeding with surgery 1

Common Pitfalls to Avoid

• Do not delay surgery indefinitely waiting for "perfect" asthma control—5 days of oral prednisone provides adequate preparation for most patients with severe persistent asthma 1, 2

• Do not rely solely on inhaled corticosteroids for perioperative management in patients with severe persistent asthma and recent exacerbations, as they lack the systemic anti-inflammatory potency needed 2

• Do not withhold systemic corticosteroids due to concerns about wound healing or infection—the risk of perioperative bronchospasm and respiratory failure far outweighs these concerns in severe persistent asthma 1, 4

• Do not taper the short preoperative steroid course—oral corticosteroids used for ≤2 weeks can be stopped abruptly without tapering 1