The patient refused to have “a needle stuck in
her back”. Induction of general anesthesia and intubation were uneventful.
During the procedure, the peak airway pressures suddenly rise, and wheezes are
heard on auscultation. What would you do?
·
Rule out
mechanical causes, such as an endotracheal tube positioned against the carina
or endobronchially, kinked, or obstructed by secretions. Consider a
pneumothorax, which while only rarely causing actual wheezing, can
significantly increase insufflation pressures and confuse the diagnosis.
·
Deepen
the plane of anesthesia (propofol, ketamine, sevoflurane) and obtain adequate
neuromuscular blockade. Even if the blood pressure is dropping, deepening the
plane of anesthesia might relieve the increased intrathoracic pressure, thus
increasing venous return and decreasing pulmonary vascular resistance, which
may result in improved hemo-dynamics.
·
Increase
the percent oxygen delivered. Unless the arterial oxygen tension (PaO2)
drops significantly, nitrous oxide can be used.
·
Administer
inhaled β2-agonists.
Two to four puffs are commonly given. However, Manthous et al. (1995) suggest
that the optimal dose may be 15 puffs of albuterol with a spacer. These agents
are very safe and can be administered in high doses with minimal side-effects.
Do not use salmeterol, a long-acting β2- agonist, because of its delayed onset of 20 minutes.
·
Administer
steroids (e.g., hydrocortisone 200–500 mg IV or methylprednisolone 60–125 mg
IV). Their effect might take up to 6 hours to manifest itself, but if the
bronchospasm persists, it will be a good thing to have started steroids early.
Consider
bringing in an intensive care unit ventilator. Higher inspiratory flows allow
for shorter inspira-tory time, longer expiratory time, and lower auto-PEEP. The
only downside is the need to switch from inhaled to intravenous anesthetics.
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