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Bronchospam 

 

 

Signs ​

 

  • Wheezing on lung auscultation

  • Slow or incomplete expiration 

  • Change in EtCO2:

    • ​Upsloping waveform

    • Severe ↓ or absent waveform

  • ↓ tidal volume

  • ↓ oxygen saturation

  • ↑ peak airway pressure

 

 

Differential Diagnosis 

 

  • ↑ resistance:

    • Bronchial asthma

    • COPD with reversible component

    • Laryngospasm (if supraglottic airway)

    • Anaphylaxis

  • ↓ compliance:

    • Aspiration

    • Pulmonary edema

    • Pulmonary embolism/fat embolism/amniotic fluid embolism

    • Pneumothorax

    • Opioid-induced chest wall rigidity

    • Inadequate muscle relaxation

    • Circuit/machine problems

  • ETT/supraglottic airway:

    • Kinked

    • Malposition

    • Endobronchial/esophageal/submucosal

    • Herniated cuff

    • Foreign body/secretions

 

 

Management 

 

  • Adjust FiO2 as necessary, remove irritants, deepen anesthesia

  • Disconnect & hand-ventilate to assess compliance, rule out other possibilities

  • Beta 2 agonists are first line treatment:

    • Salbutamol 4-8 puffs via ETT OR 2.5-5mg via nebulizer q20min PRN

    • Epinephrine infusion 0.5-2mcg/min in severe, refractory cases 

  • Anticholinergics: ipratropium 4-8 puffs via ETT OR 0.5 mg via nebulizer q20min PRN 

  • Steroids: methylprednisolone 125mg IV OR dexamethasone 8mg IV 

  • Appropriate ventilation to avoid dynamic hyperinflation:

    • Longer expiratory time (I:E 1:3-1:5) 

    • Low/normal respiratory rates (8-12/min) 

    • Permissive hypercapnia

  • Adjuncts:

    • Bronchodilating anesthetics: volatiles > ketamine > propofol 

    • Magnesium sulfate 2g IV over 20min 

    • Heliox (does not reverse bronchospasm, but can be used as a temporizing measure)

    • Neuromuscular blocking drugs (may improve mechanics of ventilation & lower peak inspiratory pressures)

    • Extracorporeal membrane oxygenation (ECMO) if severe & refractory to all other treatments

 

 

 

 

 

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