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Pharmacology of the Airways

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Principles and Practice of Anesthesia for Thoracic Surgery

Abstract

Short-acting beta-2 adrenergic agonists are administered for the acute relief of bronchospasm, wheezing, and airflow obstruction. Long-acting beta-2 adrenergic agonists are for long-term control of symptoms. Inhaled anticholinergics are first-line therapy in COPD. They are useful for both maintenance therapy and in acute exacerbations. Inhaled corticosteroids are used to control inflammation in asthma and COPD. In asthma, they can be used as monotherapy. In COPD, they are used in conjunction with long-acting beta-adrenergic agonists and long-acting antimuscarinic antagonists. Systemic corticosteroids are used for the reduction of inflammation in asthma and COPD exacerbations and are not typically prescribed as maintenance therapy. Phosphodiesterase 4 inhibitors can be used in patients with severe COPD who have a history of bronchitis and exacerbations. Leukotriene modifiers, mast cell stabilizers, and methylxanthines are alternative therapies used in asthma when symptoms are not well-controlled on first-line therapy. Volatile and intravenous anesthetics provide a degree of bronchodilation that may be useful in treating intraoperative bronchoconstriction. Helium/oxygen mixtures, antihistamines, and magnesium sulfate are alternative therapies used when bronchospasm does not respond to conventional therapies.

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Author information

Authors and Affiliations

  1. Department of Anesthesiology, University of Cincinnati, Cincinnati, OH, USA

    Cassandra Bailey, Paul J. Wojciechowski & William E. Hurford

Authors
  1. Cassandra Bailey
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  2. Paul J. Wojciechowski
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  3. William E. Hurford
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Corresponding author

Correspondence to Cassandra Bailey .

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Editors and Affiliations

  1. Department of Anesthesiology, University of Toronto, Toronto, ON, Canada

    Peter Slinger

Clinical Case

Clinical Case

A 65-year-old-man with COPD who quit smoking 2 years ago now presents to the preoperative clinic for evaluation before a right upper lobe lobectomy for a lung nodule. The patient has no other medical history and a recent cardiac stress test is normal.

Questions

Preoperative evaluation:

  • How often does he need rescue inhalers? Has the frequency increased recently?

  • When was the last time he was in the hospital with a COPD exacerbation?

  • What medications for the treatment of COPD is the patient receiving?

  • When was the last time he needed systemic corticosteroids for an exacerbation?

  • Has there been any recent change in sputum or use of antibiotics?

Intraoperative Management:

  • What medications will provide quickest relief of wheezing?

  • Are prophylactic systemic corticosteroids indicated?

  • What role do helium/oxygen mixtures and magnesium sulfate play in the management of wheezing?

Answers

Preoperative evaluation:

  • Asking patients about the use of rescue inhalers gives some indication of how well their symptoms are controlled at baseline. Any increase in frequency of inhaler use may indicate disease progression or potential acute exacerbation.

  • Inquiring about previous hospitalizations and the extent of illness (i.e., intubation, ICU admission) is important in determining the severity of disease.

  • This patient will likely present on an IC and long-acting beta-adrenergic agonist combination along with an antimuscarinic such as ipratropium.

  • The most recent use of systemic corticosteroids not only provides information as to how well the disease is being controlled but also gives the evaluator an idea if the patient is prone to adrenal suppression during surgical stress.

  • Discussing the use of antibiotics and changes in sputum allows the evaluator to know if the patient is experiencing an exacerbation or if the patient is at risk for infection with multidrug-resistant bacteria.

Intraoperative management:

  • Intraoperative wheezing can be due to endotracheal intubation, light anesthesia, or allergic reaction. Short-acting beta-2 adrenergic agonists, followed by inhaled anticholinergics, will give the most prompt relief. The additional use of intravenous and inhaled anesthetics may also be an effective treatment of bronchoconstriction. Epinephrine may be used for severe bronchoconstriction.

  • Prophylactic IV corticosteroids are not indicated. Steroids should be given if the patient has recently received steroids and stress doses are needed or the patient experiences an allergic reaction and steroids are administered to reduce the inflammatory response associated with the exposure.

  • Helium/oxygen mixtures and magnesium sulfate are only indicated when the patient fails to adequately respond to maximum conventional therapy.

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Bailey, C., Wojciechowski, P.J., Hurford, W.E. (2019). Pharmacology of the Airways. In: Slinger, P. (eds) Principles and Practice of Anesthesia for Thoracic Surgery. Springer, Cham. https://doi.org/10.1007/978-3-030-00859-8_8

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