Asthma is a chronic respiratory disease characterized by reversible airway obstruction, inflammation, and bronchial hyperreactivity. The global prevalence of asthma continues to rise, with about 4.3% of the population affected worldwide and an estimated 8.4% of the U.S. population being diagnosed (1). Patients with asthma face increased risks during surgery, such as bronchospasm, hypoxemia, and other perioperative respiratory complications. Careful optimization of asthma patients is essential to reduce the risk of complications during surgery and anesthesia.
The optimization of patients with asthma should begin with a thorough evaluation before surgery to assess the severity of the disease, the degree of asthma control, and the patient’s history of exacerbations. Uncontrolled asthma, marked by frequent symptoms, hospitalizations, or prior need for intubation, significantly increases perioperative risks. Studies show that patients with poorly controlled asthma are at a higher risk of experiencing bronchospasm, postoperative pneumonia, and other complications compared to those whose asthma is well managed (2).
During preoperative evaluation, clinicians should gather a detailed history of recent asthma symptoms, such as wheezing, chest tightness, or shortness of breath. The patient’s use of medications, such as inhaled corticosteroids or beta-2 agonists, should be reviewed to confirm adherence. Patients presenting for surgery should have their asthma stabilized before proceeding. Elective surgeries should be postponed until asthma control is optimized. Preoperative spirometry or pulmonary function tests may be useful, but they are not always necessary, as recent research indicates they may not correlate strongly with the risk of perioperative respiratory adverse events (3).
Pharmacologic optimization for asthma patients prior to surgery typically involves the administration of bronchodilators and corticosteroids. For patients with asthma exacerbations, systemic corticosteroids combined with beta-2 agonists (such as albuterol) may be prescribed. A five-day course of systemic corticosteroids before surgery has been shown to reduce the risk of bronchospasm after endotracheal intubation (1). When systemic steroids have been administered for more than two weeks in the preceding six months, patients may require supplemental doses during surgery to prevent adrenal insufficiency. Intravenous hydrocortisone can help mitigate this risk (2).
During surgery, anesthesia providers should aim to minimize triggers of bronchospasm as part of the optimization of asthma patients. Intubation may precipitate bronchospasm if anesthesia depth is insufficient. Inhalational anesthetics such as sevoflurane or isoflurane, which possess bronchodilating properties, are often preferred in asthmatic patients. However, desflurane should be avoided due to its potential to increase airway resistance at high concentrations (4). Propofol is another excellent choice due to its ability to reduce airway reactivity. Ketamine, while also effective as a bronchodilator, can cause increased secretions, complicating airway management (5).
Postoperative care focuses on maintaining adequate oxygenation and preventing bronchospasm. Patients should resume their asthma medications promptly after surgery. If necessary, bronchodilator therapy should be continued in the postoperative period. Extubation should be performed carefully, ideally under deep anesthesia, to reduce the risk of bronchospasm triggered by the endotracheal tube (5).
In summary, the optimization of asthma patients before surgery involves a comprehensive evaluation of disease control, the use of bronchodilators and corticosteroids, and careful management during anesthesia. By following these strategies, the risk of perioperative respiratory complications can be minimized, and patient outcomes improved.
References
1. Bayable SD, Melesse DY, Lema GF, Ahmed SA. Perioperative management of patients with asthma during elective surgery: A systematic review. Ann Med Surg (Lond). 2021;70:102874. Published 2021 Sep 20. doi:10.1016/j.amsu.2021.102874
2. Kamassai JD, Aina T, Hauser JM. Asthma Anesthesia. [Updated 2022 Oct 24]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK537327/
3. Perez MF, Coutinho MT. An Overview of Health Disparities in Asthma. Yale J Biol Med. 2021;94(3):497-507. Published 2021 Sep 30.
4. von Ungern-Sternberg BS, Saudan S, Petak F, Hantos Z, Habre W. Desflurane but not sevoflurane impairs airway and respiratory tissue mechanics in children with susceptible airways. Anesthesiology. 2008;108(2):216-224. doi:10.1097/01.anes.0000299430.90352.d5
5. Juang J, Cordoba M, Ciaramella A, et al. Incidence of airway complications associated with deep extubation in adults. BMC Anesthesiol. 2020;20(1):274. Published 2020 Oct 29. doi:10.1186/s12871-020-01191-8