The patient refused to have “a needle stuck in her back”

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.