Would you choose general anesthesia (with endotra-cheal intubation, with a laryngeal mask airway) or a neuraxial block for this patient?

Would you choose general anesthesia (with endotra-cheal intubation, with a laryngeal mask airway) or a neuraxial block for this patient?

Regional anesthesia would be preferable since airway instrumentation can be avoided. However, a reduction in risk has been shown only for patients with ongoing bronchospasm. Groebel et al. (1994) reported that high thoracic epidural did not alter airway resistance and did attenuate the response to provocation tests in patients with bronchial hyperreactivity.

One concern with neuraxial block is the change in pul-monary function due to high block, but the reduction in expiratory reserve volume usually does not impair breath-ing. A theoretical concern is sympathetic blockade with unopposed vagal action and bronchospasm. However, no difference was found between parturients anesthetized with high epidurals (T₂–T₄) and those receiving general anesthesia with ketamine and isoflurane.

The main issue with regional anesthesia is the risk for failed block and the need for emergent intubation. Preparations should be made for general anesthesia induction and intubation, and a difficult airway should be recognized in advance. All attempts should be made, if this situation arises, to obtain a deep plane of anesthesia before intubation to prevent bronchospasm.

Laryngeal mask airway (LMA) insertion has been shown to increase airway resistance less than endotracheal intubation and might be preferable. However, the LMA does not protect against aspiration of gastric contents, and administration of positive pressure ventilation through an LMA is controversial.

Propofol appears to have a bronchodilator effect and is currently the preferred agent for induction in asthmatics, provided they are not allergic to eggs or soy. Ketamine is also among the first choices for induction because of its sympathetic-stimulating action. Lidocaine 1.5 mg/kg IV administered 1–3 minutes before intubation prevents reflex bronchoconstriction. Intratracheal lidocaine may trigger bronchospasm and should be avoided. All volatile anesthetics are bronchodilators. A recent study suggests that halothane and sevoflurane are better bronchodilators than isoflurane at doses <1.7 MAC, but the clinical signifi-cance is unclear.