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      Severe bronchospasm in a premature infant during induction of anesthesia caused ventilation failure

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          Abstract

          A 3-month-old (39 weeks postconceptual age) male infant weighing 2.9 kg was scheduled for laser photocoagulation with a diagnosis of retinopathy of prematurity. He was born at 27 weeks gestation with a birth weight of 970 g. He had been mechanically ventilated from birth for 20 days for respiratory insufficiency due to respiratory distress syndrome (RDS) and bronchopulmonary dysplasia (BPD). A chest X-ray performed before the subsequent ligation of the patent ductus arteriosus showed bilateral haziness in the entire lung field due to the RDS and BPD during tracheal intubation. The infant required ventilation with a high concentration of oxygen and received surfactant therapy. Twenty days after birth, patent ductus arteriosus (PDA) ligation was done under general anesthesia in which induction was achieved with inhalation of sevoflurane and 1 mg of rocuronium. The operation proceeded uneventfully and the extubation was performed five days after the surgery. After extubation, the infant was able to breathe spontaneously with an incubator oxygen supply, and the oxygen saturation was maintained above 90%. After PDA ligation, the infant was diagnosed with retinopathy of prematurity, and he was then scheduled for laser photocoagulation. On the chest X-ray, improvement of haziness was observed from five days before the operation. After consultation with pediatrics, the decision was made to operate. Upon arrival in the operating room, electrocardiography, pulse oximetry, and noninvasive blood pressure were monitored, and the patient's vital signs were stable. Induction of anesthesia was achieved with thiopental (15 mg), rocuronium (2 mg), and sevoflurane. The tracheal intubation was performed with an uncuffed 3.5 mm internal diameter endotracheal tube, but there was no capnogram trace after three breaths. At this time, the oxygen saturation rapidly dropped to below 80%. The endotracheal tube was removed because the anesthesiologist suspected esophageal intubation and the patient was ventilated with 100% oxygen via face mask. Mask ventilation was not performed well, and peak inspiratory pressure was revealed to be above 25 mmHg. The anesthesiologist suspected stiff lungs, which suggested bronchospasm. Hydrocortisone sodium succinate (Solu-Cortef®, Pfizer Inc., New York, NY, USA) 20 mg was intravenously injected. Five minutes later, oxygen saturation slowly increased up to 99% and reintubation was attempted. Although it was confirmed by direct laryngoscopy that the tube had passed between the vocal cords, proper ventilation of the lungs was not achieved. No expired carbon dioxide was noted on the capnograph, and chest auscultation was equivocal. The oxygen saturation was then in the low sixties. After sevoflurane was administered by inhalation, a slight chest movement was noted, and oxygen saturation increased up to 80%. During that time, a portable chest radiograph was taken which revealed severe consolidation with air bronchograms (Fig. 1A). Despite ventilatory support for 10 minutes, the oxygen saturation failed to increase beyond 80%. Hydrocortisone sodium succinate 20 mg was then intravenously injected once more. Afterwards, SaO2 was maintained at 88-93%. The surgery was cancelled, and glycopyrrolate 0.2 mg and pyridostigmine 0.2 mg were intravenously administered. The intubated patient was transferred to the neonatal intensive care unit (NICU) with Ambu bag ventilation for further management. While in transit to the NICU, the patient's vital signs were stable, and oxygen saturation was maintained above 90%. In the NICU, another chest radiograph was taken after the patient was stabilized, and this showed an improved state of consolidation (Fig. 1B). After the patient's spontaneous breathing completely returned and became regular, extubation was performed. The patient recovered without complications. We experienced a case in which severe bronchospasm caused ventilation failure in a 3-month-old premature pediatric patient with a previous history of mechanical ventilation and incompletely resolved consolidation with underlying bronchopulmonary dysplasia. In this case, the onset of symptoms was rapid, including extreme stiffness of the lungs, and there was an absence of the end-tidal carbon dioxide trace noted immediately after intubation. During the event, the chest radiography revealed severe consolidation with air bronchograms. Fatal contraction of airway smooth muscle can be observed spontaneously or by agonist. Thus, even within the first days of life, bronchospasm can occur in preterm infants [1]. Bronchospasm associated with anesthesia presents with an expiratory wheeze with/without auscultation, prolonged expiration and rising end-tidal carbon dioxide, increasing circuit pressure, increased pressures of inflation during positive pressure ventilation, and/or desaturation [2]. Wheeze cannot be audible either with or without auscultation because it is caused by gas flow in the patient's airways. Thus, in cases of severe bronchospasm such as our case, the chest may be silent or equivocal on auscultation and the diagnosis may be delayed on appropriate assessment of increased inflation pressures. However, wheeze may occur as bronchospasm but can be heard with a misplaced endotracheal tube, such as in bronchial or esophageal intubation, and with acute respiratory distress syndrome or pulmonary edema. We also make a wrong diagnosis because the patient had no detectable end-tidal carbon dioxide or chest movement. Thus, extubation was conducted and optimal management was delayed. In the same way, wheezing was not a typical symptom for diagnosis of bronchospasm, and the wheezing of our patient was not distinct because the patient underwent severe airway obstruction. Increased inspiratory pressures may develop not only with bronchospasm but also with obstruction of a natural airway or any component of a breathing circuit and decreased compliance of the lungs or chest such as atelectasis, hemo-pneumothorax, or fentanyl induced rigidity [2]. Accordingly, the anesthesiologist takes a systematic approach to the diagnosis and treatment of bronchospasm in relation to anesthesia. In our case, airway irritation from direct laryngoscopy and passage of the endotracheal tube is suspected to have caused bronchospasm during intubation. This procedure is noted for profoundly painful stimuli and is related to bronchospasm and/or laryngospasm. In particular, a patient who has a previous respiratory history is closely connected to an increased risk for perioperative desaturation, bronchospasm, laryngospasm, or airway obstruction [3]. Furthermore, our patient underwent long-term mechanical ventilation. Therapy with high inspired oxygen concentrations or mechanical ventilation with high positive airway pressures leads to inflammation, fibrosis, or smooth muscle hypertrophy in the airways of premature infants [4], which might result in our patient having an increased vulnerability to bronchospasm. We suggest that the anesthesiologist should carefully consider respiratory complications such as bronchospasm during the induction of anesthesia with a premature infant who has a previous history of mechanical ventilation and underlying respiratory diseases. In addition, we keep in mind the respiratory complications throughout general anesthesia.

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          Most cited references4

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          Risk assessment for respiratory complications in paediatric anaesthesia: a prospective cohort study.

          Perioperative respiratory adverse events in children are one of the major causes of morbidity and mortality during paediatric anaesthesia. We aimed to identify associations between family history, anaesthesia management, and occurrence of perioperative respiratory adverse events. We prospectively included all children who had general anaesthesia for surgical or medical interventions, elective or urgent procedures at Princess Margaret Hospital for Children, Perth, Australia, from Feb 1, 2007, to Jan 31, 2008. On the day of surgery, anaesthetists in charge of paediatric patients completed an adapted version of the International Study Group for Asthma and Allergies in Childhood questionnaire. We collected data on family medical history of asthma, atopy, allergy, upper respiratory tract infection, and passive smoking. Anaesthesia management and all perioperative respiratory adverse events were recorded. 9297 questionnaires were available for analysis. A positive respiratory history (nocturnal dry cough, wheezing during exercise, wheezing more than three times in the past 12 months, or a history of present or past eczema) was associated with an increased risk for bronchospasm (relative risk [RR] 8.46, 95% CI 6.18-11.59; p<0.0001), laryngospasm (4.13, 3.37-5.08; p<0.0001), and perioperative cough, desaturation, or airway obstruction (3.05, 2.76-3.37; p<0.0001). Upper respiratory tract infection was associated with an increased risk for perioperative respiratory adverse events only when symptoms were present (RR 2.05, 95% CI 1.82-2.31; p<0.0001) or less than 2 weeks before the procedure (2.34, 2.07-2.66; p<0.0001), whereas symptoms of upper respiratory tract infection 2-4 weeks before the procedure significantly lowered the incidence of perioperative respiratory adverse events (0.66, 0.53-0.81; p<0.0001). A history of at least two family members having asthma, atopy, or smoking increased the risk for perioperative respiratory adverse events (all p<0.0001). Risk was lower with intravenous induction compared with inhalational induction (all p<0.0001), inhalational compared with intravenous maintenance of anaesthesia (all p<0.0001), airway management by a specialist paediatric anaesthetist compared with a registrar (all p<0.0001), and use of face mask compared with tracheal intubation (all p<0.0001). Children at high risk for perioperative respiratory adverse events could be systematically identified at the preanaesthetic assessment and thus can benefit from a specifically targeted anaesthesia management. Department of Anaesthesia, Princess Margaret Hospital for Children, Swiss Foundation for Grants in Biology and Medicine, and the Voluntary Academic Society Basel. Copyright 2010 Elsevier Ltd. All rights reserved.
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            Crisis management during anaesthesia: bronchospasm.

            Bronchospasm in association with anaesthesia may appear as an entity in its own right or be a component of another problem such as anaphylaxis. It may present with expiratory wheeze, prolonged exhalation or, in severe cases, complete silence on auscultation. To examine the role of a previously described core algorithm "COVER ABCD-A SWIFT CHECK", supplemented by a specific sub-algorithm for bronchospasm, in the diagnosis and management of bronchospasm occurring in association with anaesthesia. The potential performance of this structured approach for each of the relevant incidents among the first 4000 reported to the Australian Incident Monitoring Study (AIMS) was compared with the actual management as reported by anaesthetists involved. There were 103 relevant incidents among the first 4000 AIMS reports, 22 of which were associated with allergy or anaphylaxis. Common presenting signs, in addition to wheeze, were decreased pulmonary compliance and falling oxygen saturation. Of the non-allergy/anaphylaxis related incidents, 80% occurred during induction or maintenance of anaesthesia. Of these, the principal causes of bronchospasm were airway irritation (35%), problems with the endotracheal tube (23%), and aspiration of gastric contents (14%). It was considered that, properly used, the structured approach recommended would have led to earlier recognition and/or better management of the problem in 10% of cases, and would not have harmed any patient had it been applied in all of them. Bronchospasm may present in a variety of ways and may be associated with other life threatening conditions. Although most cases are handled appropriately by the attending anaesthetist, the use of a structured approach to its diagnosis and management would lead to earlier recognition and/or better management in 10% of cases.
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              Bronchopulmonary dysplasia. Unresolved neonatal acute lung injury.

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                Author and article information

                Journal
                Korean J Anesthesiol
                Korean J Anesthesiol
                KJAE
                Korean Journal of Anesthesiology
                The Korean Society of Anesthesiologists
                2005-6419
                2005-7563
                December 2013
                26 December 2013
                : 65
                : 6 Suppl
                : S84-S86
                Affiliations
                [1 ]Department of Anesthesiology and Pain Medicine, Seoul Paik Hospital, College of Medicine, Inje University, Seoul, Korea.
                [2 ]Department of Anesthesiology and Pain Medicine, College of Medicine, Korea University, Seoul, Korea.
                Author notes
                Corresponding author: Sung-Uk Choi, M.D., Ph.D., Department of Anesthesiology and Pain Medicine, College of Medicine, Korea University, 5, Anam-dong, Sungbuk-gu, Seoul 136-705, Korea. Tel: 82-2-920-5632, Fax: 82-2-928-2275, drchois@ 123456korea.ac.kr
                Article
                10.4097/kjae.2013.65.6S.S84
                3903874
                f4430f8b-8b5c-401d-8043-9b8b2ad78cde
                Copyright © the Korean Society of Anesthesiologists, 2013

                This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( http://creativecommons.org/licenses/by-nc/3.0/), which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

                Categories
                Letter to the Editor

                Anesthesiology & Pain management
                Anesthesiology & Pain management

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