Spinal anesthesia and Bronchospasm

[drlee]

---

Members don't see this ad.

1994 ITE Question 129 (K-type):

A patient with severe asthma is scheduled for an abdominal hysterectomy. Important considerations about anesthesia for this patient include:

1) Bronchospasm is less likely to occur with atracurium than with vecuronium
2) Topical application of lidocaine to the larynx will prevent bronchospasm
3) Ketamine will exacerbate bronchospasm
4) Spinal anesthesia to a T2 sensory level will exacerbate bronchospasm

Answer: D

How does spinal anesthesia exacerbate bronchospasm?? Spinal anesthesia is always preferred in severe asthmas over general anesthesia, since endotracheal intubation is avoided. What is the mechanism behind spinal-induced bronchospasm? 😕

 

[ZA_Gasman]

As far as I understand.... Higher spinal levels (T2-6) may knock out sympathetic supply to the lungs, leading to imbalance between PSNS and SNS tone --> Bronchospasm. Similar mechanism to the hypotension/bradycardia peri-arrest phenomenon we've all seen in obstetric spinal. Must confess, have never seen spinal induced bronchospasm, but always bug my residents with this when they choose spinal over GA for asthmatic patients.

Hope this helps

 

[jetproppilot]

As far as I understand.... Higher spinal levels (T2-6) may knock out sympathetic supply to the lungs, leading to imbalance between PSNS and SNS tone --> Bronchospasm. Similar mechanism to the hypotension/bradycardia peri-arrest phenomenon we've all seen in obstetric spinal. Must confess, have never seen spinal induced bronchospasm, but always bug my residents with this when they choose spinal over GA for asthmatic patients.

Hope this helps

man the stupid, I'll-never-see-this situation-question our elders are receiving Tenured Professor salaries for to dream up questions for the boards never ceases to amaze me.....I think if they actually did some cases the questions would be more clinically relevant...

 

[ZA_Gasman]

man the stupid, I'll-never-see-this situation-question our elders are receiving Tenured Professor salaries for to dream up questions for the boards never ceases to amaze me.....I think if they actually did some cases the questions would be more clinically relevant...

Agree 100%. But that is why we have to prepare the guys for this kind of rubbish question. You gotta play the game. You don't gotta like it, but you have to play to get the piece of paper. Doesn't make it right though....

 

[militarymd]

How do you tell the difference between someone who's numb up to the neck and can't move air because he's paraplzyed with someon who has bronchospasm and can't move air?












Ask an academic anesthesiologist.

 

[NaeBlis]

How do you tell the difference between someone who's numb up to the neck and can't move air because he's paraplzyed with someon who has bronchospasm and can't move air?




Ask an academic anesthesiologist.

Actually, this happened to me my first weekend on call after residency (pp btw). Woman with fairly well controlled asthma on the highest doses of advair discus presented for a C-sec for failure to progress. It was Sunday, and the previous day had gone well so I was feeling like a champ on my first weekend on call. Pop in the spinal, lay her down, get her in LLD, and as I am sorting out her monitors and IV she starts having difficulty breathing, it was pretty bad, could barely talk. The OB, yells out that its a high spinal and sort of throws the room into a panic, though I was sure almost right away that it was bronchospasm. She couldn't move air, but I could see from her chest wall and acc muscles it wasn't from lack of effort. She had also lifted her head and shoulders off the bed, and was gripping the side of the bed with her hand with good strength.

I'd never encountered bronchospasm that bad in pregnant woman before and I wasn't sure how handle it. I got out the albuterol and gave it to the nurse and told her to start pumping it and not to stop (I wasn't sure how much was going to get into her lungs when she was in that state), gave her 25mg of ephedrine. Next I gave a steroid bolus and 25mg of benedryl. I pulled out the epi but was reluctant to use it. I had earlier turned up O2 in her nasal canula, and was getting ready to use the mask/circuit to give pp ventilation with 100% O2 (I hadn't used the circuit yet because it would have been harder to give albuterol, but by then she had like 15 puffs). Fortunately the spam was starting to break by that point.

After I cleaned out my scrub pants we proceeded with the section and all went well. Baby was fine and the lowest pt sat was 90% and by then the spasm had broken.

I mentioned the case to my colleagues on Monday and asked them what they would have done differently, and most said they would have done the same. One said they would have done ppv with the mask and 100% O2 first and not worried about the albuterol, but most seemed to think the the albuterol first was worth while. They all agreed that Sunday was the worst time for that to happen because there is no help to call on.

I'd be interested to hear what you guys would have done differently and what you would have done if the spasm hadn't broken when it did.

Cases like these almost make me miss residency when you always had other people around to call for help.

 

[Planktonmd]

though I was sure almost right away that it was bronchospasm. She couldn't move air, but I could see from her chest wall and acc muscles it wasn't from lack of effort. She had also lifted her head and shoulders off the bed, and was gripping the side of the bed with her hand with good strength.

I'd be interested to hear what you guys would have done differently and what you would have done if the spasm hadn't broken when it did.

If a pregnant woman to whom I have given a spinal CAN NOT TALK anymore, she gets GA and a tube, I wouldn't even consider thinking about bronchospasm.
Can't talk = intubate.

 

[NaeBlis]

If a pregnant woman to whom I have given a spinal CAN NOT TALK anymore, she gets GA and a tube, I wouldn't even consider thinking about bronchospasm.
Can't talk = intubate.

Well, I didn't say she couldn't talk, I said she could barely talk. I used to have bad asthma myself when I was a teenager and I recall what it is like, you can talk, but it is tough. Not the same thing as high spinal can't talk.

Anyway, I did consider intubating her, but decided against it, she was moving some air and was awake and alert, and even that low sat of 90 I mentioned I think may have been a bad reading secondary to movement. Since she was awake and alert and moving air, I didn't think it was a good move to knock her out to try for a tube. Intubating probably would have been the next step if the spasm hadn't broken, and low dose epi as a last resort.

 

[Planktonmd]

Well, I didn't say she couldn't talk, I said she could barely talk. I used to have bad asthma myself when I was a teenager and I recall what it is like, you can talk, but it is tough. Not the same thing as high spinal can't talk.

Anyway, I did consider intubating her, but decided against it, she was moving some air and was awake and alert, and even that low sat of 90 I mentioned I think may have been a bad reading secondary to movement. Since she was awake and alert and moving air, I didn't think it was a good move to knock her out to try for a tube. Intubating probably would have been the next step if the spasm hadn't broken, and low dose epi as a last resort.

You know, I was not there, you were so all I can do is speculate.
I have to tell you though that I find it difficult to believe that a patient with asymptomatic asthma before a spinal could develop a severe asthma attack because of a spinal anesthetic, regardless of how significant the sympathetic blockade might have been.
Dyspnea caused by a high spinal is common and if they stop talking intubate them.