Unexpected Bronchospasm Spinal Anesthesia
during
Edward K. McGough, MD,* Jerry A. Cohen, MDT Department of Anesthesiology, University of Florida College of Medicine, Gainesville. FL.
Asthma and bronchospastic disease are common in patients presenting for anesthesia. Intraoperative bronchospasm can be a @e-threatening problem. One approach to these patients is to we regional anesthesia because it is believed that this will reduce the complication rate. Presented here is a case of bronchospasm occurring during regional anesthesia that was unresponsive to beta agonists. The use of atropine in the treatment of bronchospasm also i.s discussed. Keywords: Anesthesia, spinal; complications, asthma, bronchospasm; lung, asthma; parasympathetic nervous system, atropine.
Introduction Patients undergoing anesthesia often have a history of bronchospasm. One way to reduce the risk of bronchospasm during anesthesia is to use regional anesthesia.’ This case report, however, describes severe bronchospasm during spinal anesthesia. *Resident in Anesthesiology tAssistant Professor in Anesthesiology Address reprint requests to Dr. Cohen at the Department of Anesthesiology, Box J-254, J. Hillis Miller Health Center, Gainesville, FL 32610-0254, USA. Received for publication March 9, 1989; cepted for publication June 14, 1989. 0 1990 Butterworth
Publishers
revised manuscript
ac-
Case Report A 63-year-old man with renal calculi presented for cystoscopic stone basketing. He had a 20-year history of hypertension and a IO-year history of disabling chronic obstructive pulmonary disease. He had frequent attacks of severe bronchospasm as well as chronic bronchitis and limitations to his activities because of shortness of breath. Medications included hydrochlorothiazide (25 mg/day), triamterene (50 mg/day), theophylline (300 mg twice daily), metaproterenol by metered dose inhaler every 3 to 4 hours, and beclomethasone inhaler every 6 hours. He received all his medications while hospitalized. The patient’s physical examination showed no wheezing, electrocardiogram (EKG) was normal, and chest radiograph showed hyperinflation. Preoperative theophylline blood level, determined the night before surgery, was 16 pg/ml. The day before this procedure, the patient had undergone extracorporeal shock-wave lithotripsy with spinal anesthesia (maximal sensory level of anesthesia, T4, by pinprick). No signs or symptoms of bronchospasm had occurred. Two hours before arriving in the operating room, the patient was premeditated orally with 15 mg of diazepam as well as his usual dose of diuretic and theophylline. In the operating room, a pulse oximeter, EKG, automated blood pressure (BP) cuff, and axillary temperature probe were positioned. With the patient in the sitting position and using a 25-gauge needle, a lumbar puncture was performed at the L34 interspace, and 12 mg of tetracaine in dextrose with 0.1 mg of epinephrine was injected for spinal anesJ. Clin. Anesth., vol. 2, Jan/Feb
1990
35
Case Reports
thesia. The patient then was placed supine and given oxygen via nasal cannula at the rate of 3 L/min; oxygen saturation was 97%. A T7 sensory level to pinprick was obtained. The patient was then placed in the lithotomy position and was given 2.5 mg of midazolam intravenously (IV). Approximately 90 minutes after the operation began, the patient complained of mild shortness of breath. No wheezing was heard from the precordial stethoscope. Oxygen saturation was 95%. The patient was given two puffs of metaproterenol, and the shortness of breath was resolved. Surgery ended 1 hour later, at which time the patient had a TlO sensory level of anesthesia. On arrival in the recovery room, he again complained of shortness of breath. Auscultation showed bilateral diffuse wheezing. Over the next 90 minutes, the patient was given nebulized terbutaline and metaproterenol, and an IV aminophylline infusion (4 mg/kg/h) was started, all of which provided little relief. Next, 1 mg of nebulized atropine was administered, which promptly relieved bronchospasm. There was no change in the patient’s heart rate (HR) or BP with the inhaled atropine. He was observed for another 2 hours and then sent to the ward. He had no further wheezing for the rest of his hospitalization.
Discussion Asthma and bronchoreactive disorders are very common and affect 2% to 4% of the general population. Bronchospasm during anesthesia can be difficult to treat and even life threatening. Many physicians have suggested that regional anesthesia is the method of choice for patients with a history of bronchospasm. In a 1961 review of 687 patients with a history of bronchospasm, the frequency of intraoperative bronchospasm was 3.9%.’ In patients who underwent regional anesthesia, the frequency of bronchospasm was I .9%, which was significantly lower than the 6.4% frequency in patients who were intubated and underwent general anesthesia. The frequency of bronchospasm was similar in those patients who had regional anesthesia (1.9%) and in those who were not intubated but had general anesthesia (1.6%). This finding would indicate that the need for intubation, not the choice of anesthetic, plays a bigger role in the pathogenesis of bronchospastic complications. The treatment of bronchospasm has traditionally involved beta-adrenergic receptor agonists, such as terbutaline or isoproterenol, which decrease bronchial motor tone.2 Because of the bronchodilator effects of the sympathetic nervous system, a sympathectomy caused by spinal or epidural anesthesia may worsen bronchospasm and may not be tol36
J. Clin. Anesth., vol. 2, Jan/Feb
1990
erated by patients with bronchospastic disease. In the past, sympathetic blockade in the form of stellate ganglion block has been suggested as treatment for bronchospastic disorders.3 In patients with a history of asthma who underwent spinal anesthesia, the frequency of intraoperative respiratory complications was 3.8%.” In the present case, the patient underwent an uncomplicated spinal anesthetic the previous day with a maximal sensory level higher than that noted when bronchospasm developed (T4 US T7). In some patients, such as this one, aggressive therapy with sympathomimetic agents fails to relieve bronchospasm. In these instances, anticholinergics such as atropine may be helpful. Vagal stimulation also may produce bronchoconstriction.’ The use of anticholinergic agents to treat bronchospasm has a long history (e.g., the use of cigarettes containing atropine). However, the use of anticholinergic agents has not been widespread because enteral and parenteral anticholinergic drugs all have important side effects, such as tachycardia and dry mouth. Until recent approval of ipratropium, no inhalable anticholinergic preparation was available. In the past, clinicians have been forced to nebulize parenteral anticholinergic preparations, such as we did with atropine, to provide inhaled anticholinergic therapy for bronchospasm. Despite these difficulties, inhaled anticholinergic drugs remain a powerful tool in fighting bronchospasm. In summary, bronchospasm is a common medical condition that can occur unexpectedly during anesthesia. Regional anesthesia has been reported to reduce the occurrence of intraoperative bronchospasm, but in this case, the patient had severe bronchospasm during spinal anesthesia even though he had undergone a similar procedure the day before without incident.
Acknowledgments The authors thank Jerome H. Modell, M.D., for his review of the manuscript, and Lynn Dirk for her editorial assistance.
References Shnider SM, Papper EM: Anesthesia for the asthmatic patient. Anesthesiology 1961;22:886-92. Aviado DM: Regulation of bronchomotor tone during anesthesia. Anesthesiology 1975;42:68-80. Moore DC: Asthma. In: Moore DC, ed. Stellute Ganglion Block Techniques-Indications-Uses. Springfield, IL: Charles C. Thomas, 1954: 179-8 1. Converse JG, Smotrilla MM: Anesthesia and the asthmatic. Anesth Analg 1961;40:336-42.
during
Edward K. McGough, MD,* Jerry A. Cohen, MDT Department of Anesthesiology, University of Florida College of Medicine, Gainesville. FL.
Asthma and bronchospastic disease are common in patients presenting for anesthesia. Intraoperative bronchospasm can be a @e-threatening problem. One approach to these patients is to we regional anesthesia because it is believed that this will reduce the complication rate. Presented here is a case of bronchospasm occurring during regional anesthesia that was unresponsive to beta agonists. The use of atropine in the treatment of bronchospasm also i.s discussed. Keywords: Anesthesia, spinal; complications, asthma, bronchospasm; lung, asthma; parasympathetic nervous system, atropine.
Introduction Patients undergoing anesthesia often have a history of bronchospasm. One way to reduce the risk of bronchospasm during anesthesia is to use regional anesthesia.’ This case report, however, describes severe bronchospasm during spinal anesthesia. *Resident in Anesthesiology tAssistant Professor in Anesthesiology Address reprint requests to Dr. Cohen at the Department of Anesthesiology, Box J-254, J. Hillis Miller Health Center, Gainesville, FL 32610-0254, USA. Received for publication March 9, 1989; cepted for publication June 14, 1989. 0 1990 Butterworth
Publishers
revised manuscript
ac-
Case Report A 63-year-old man with renal calculi presented for cystoscopic stone basketing. He had a 20-year history of hypertension and a IO-year history of disabling chronic obstructive pulmonary disease. He had frequent attacks of severe bronchospasm as well as chronic bronchitis and limitations to his activities because of shortness of breath. Medications included hydrochlorothiazide (25 mg/day), triamterene (50 mg/day), theophylline (300 mg twice daily), metaproterenol by metered dose inhaler every 3 to 4 hours, and beclomethasone inhaler every 6 hours. He received all his medications while hospitalized. The patient’s physical examination showed no wheezing, electrocardiogram (EKG) was normal, and chest radiograph showed hyperinflation. Preoperative theophylline blood level, determined the night before surgery, was 16 pg/ml. The day before this procedure, the patient had undergone extracorporeal shock-wave lithotripsy with spinal anesthesia (maximal sensory level of anesthesia, T4, by pinprick). No signs or symptoms of bronchospasm had occurred. Two hours before arriving in the operating room, the patient was premeditated orally with 15 mg of diazepam as well as his usual dose of diuretic and theophylline. In the operating room, a pulse oximeter, EKG, automated blood pressure (BP) cuff, and axillary temperature probe were positioned. With the patient in the sitting position and using a 25-gauge needle, a lumbar puncture was performed at the L34 interspace, and 12 mg of tetracaine in dextrose with 0.1 mg of epinephrine was injected for spinal anesJ. Clin. Anesth., vol. 2, Jan/Feb
1990
35
Case Reports
thesia. The patient then was placed supine and given oxygen via nasal cannula at the rate of 3 L/min; oxygen saturation was 97%. A T7 sensory level to pinprick was obtained. The patient was then placed in the lithotomy position and was given 2.5 mg of midazolam intravenously (IV). Approximately 90 minutes after the operation began, the patient complained of mild shortness of breath. No wheezing was heard from the precordial stethoscope. Oxygen saturation was 95%. The patient was given two puffs of metaproterenol, and the shortness of breath was resolved. Surgery ended 1 hour later, at which time the patient had a TlO sensory level of anesthesia. On arrival in the recovery room, he again complained of shortness of breath. Auscultation showed bilateral diffuse wheezing. Over the next 90 minutes, the patient was given nebulized terbutaline and metaproterenol, and an IV aminophylline infusion (4 mg/kg/h) was started, all of which provided little relief. Next, 1 mg of nebulized atropine was administered, which promptly relieved bronchospasm. There was no change in the patient’s heart rate (HR) or BP with the inhaled atropine. He was observed for another 2 hours and then sent to the ward. He had no further wheezing for the rest of his hospitalization.
Discussion Asthma and bronchoreactive disorders are very common and affect 2% to 4% of the general population. Bronchospasm during anesthesia can be difficult to treat and even life threatening. Many physicians have suggested that regional anesthesia is the method of choice for patients with a history of bronchospasm. In a 1961 review of 687 patients with a history of bronchospasm, the frequency of intraoperative bronchospasm was 3.9%.’ In patients who underwent regional anesthesia, the frequency of bronchospasm was I .9%, which was significantly lower than the 6.4% frequency in patients who were intubated and underwent general anesthesia. The frequency of bronchospasm was similar in those patients who had regional anesthesia (1.9%) and in those who were not intubated but had general anesthesia (1.6%). This finding would indicate that the need for intubation, not the choice of anesthetic, plays a bigger role in the pathogenesis of bronchospastic complications. The treatment of bronchospasm has traditionally involved beta-adrenergic receptor agonists, such as terbutaline or isoproterenol, which decrease bronchial motor tone.2 Because of the bronchodilator effects of the sympathetic nervous system, a sympathectomy caused by spinal or epidural anesthesia may worsen bronchospasm and may not be tol36
J. Clin. Anesth., vol. 2, Jan/Feb
1990
erated by patients with bronchospastic disease. In the past, sympathetic blockade in the form of stellate ganglion block has been suggested as treatment for bronchospastic disorders.3 In patients with a history of asthma who underwent spinal anesthesia, the frequency of intraoperative respiratory complications was 3.8%.” In the present case, the patient underwent an uncomplicated spinal anesthetic the previous day with a maximal sensory level higher than that noted when bronchospasm developed (T4 US T7). In some patients, such as this one, aggressive therapy with sympathomimetic agents fails to relieve bronchospasm. In these instances, anticholinergics such as atropine may be helpful. Vagal stimulation also may produce bronchoconstriction.’ The use of anticholinergic agents to treat bronchospasm has a long history (e.g., the use of cigarettes containing atropine). However, the use of anticholinergic agents has not been widespread because enteral and parenteral anticholinergic drugs all have important side effects, such as tachycardia and dry mouth. Until recent approval of ipratropium, no inhalable anticholinergic preparation was available. In the past, clinicians have been forced to nebulize parenteral anticholinergic preparations, such as we did with atropine, to provide inhaled anticholinergic therapy for bronchospasm. Despite these difficulties, inhaled anticholinergic drugs remain a powerful tool in fighting bronchospasm. In summary, bronchospasm is a common medical condition that can occur unexpectedly during anesthesia. Regional anesthesia has been reported to reduce the occurrence of intraoperative bronchospasm, but in this case, the patient had severe bronchospasm during spinal anesthesia even though he had undergone a similar procedure the day before without incident.
Acknowledgments The authors thank Jerome H. Modell, M.D., for his review of the manuscript, and Lynn Dirk for her editorial assistance.
References Shnider SM, Papper EM: Anesthesia for the asthmatic patient. Anesthesiology 1961;22:886-92. Aviado DM: Regulation of bronchomotor tone during anesthesia. Anesthesiology 1975;42:68-80. Moore DC: Asthma. In: Moore DC, ed. Stellute Ganglion Block Techniques-Indications-Uses. Springfield, IL: Charles C. Thomas, 1954: 179-8 1. Converse JG, Smotrilla MM: Anesthesia and the asthmatic. Anesth Analg 1961;40:336-42.
