713

Paediatric Asthma and Anaesthesia

A Rudra
1
, S Sengupta
2
, S Chatterjee
3
, S Ghosh
4
, A Ahmed
5
, S Sirohia
6
Summary
Asthma in children is a complex disease with several aetiopathogenic factors, is difficult to diagnose and the
incidence is on the increase. More such children need anaesthetic interventions today. Anaesthesiologists need to be
aware of the triggering factors, pharmacotherapy of the disease including the possible drug interactions. Successful
outcome will depend upon thorough preoperative assessment and optimization of the pharmacotherapy. Prudent
judgment in the preoperative period is needed to understand which patients with asthma need to be postponed prior to
an elective procedure keeping in mind best clinical outcome. Children with asthma who come in for surgical proce-
dure may be appropriately taken up for either inhalation or intravenous anaesthesia. Adequate, depth of anaesthesia
is vital to avoid critical perioperative events. Smooth emergence from anaesthesia minimizes the risk of postoperative
bronchospasm. The scientific literature till date is inadequate to provide guidelines for postoperative pain relief for
these children afflicted with asthma.
Key words Anaesthesia; Asthma; Pathology; Treatment
1. Hon. Consultant, Anaesthesiologist, Apollo Gleneagles Hospital, Kolkata, 2. Consultant Anaesthesiologist, Apollo Gleneagles
Hospital, Kolkata, 3. Assistant Professor of Anaesthesiology, Medical College & Hospital, Kolkata, 4. DNB student, Apollo
Gleneagles Hospital, Kolkata, 5. DNB student, Apollo Gleneagles Hospital, Kolkata, 6. Consultant Anaesthesiologist, Apollo
Gleneagles Hospital, Kolkata, Correspondence to: A Rudra, 1, Shibnarayan Das Lane, Kolkata-700006
Email:sumanc_24@yahoo.co.in
Indian Journal of Anaesthesia 2008;52:Suppl (5):713-724
Introduction
Asthma in children is the most common chronic
inflammatory lung disease and is a major health prob-
lem showing steady increase in prevalence both in de-
veloped and developing countries. The incidence of
asthma in Asian countries varies between 5.2 percent
in Taipei to 10 17 percent in other countries. In Ban-
galore, a metropolitan city in India, asthma increased
from 9 percent in 1979 to 29.5 percent in the last 25
years correlating to the demographic changes in the
city
1
. Even with greater understanding of the pathol-
ogy, the fundamental factors underlying the develop-
ment of asthma remain unknown. The increase in preva-
lence of asthma has been attributed to hygiene theory,
dietary habits, western lifestyle of living, and air pollu-
tion. Furthermore, genetic predisposition, atopy, and
parental all appear to influence the development of
asthma
2
. The rising prevalence of asthma in childhood
means that the anaesthesiologists with increasing fre-
quency are encountering children with asthma sched-
uled for surgery. Moreover, increase in the volume of
day case surgery has limited the time available for the
assessment of both childs medical condition and pos-
sible anaesthetic risk. In this article, the literature rel-
evant to the child with asthma and progress through
preoperative and postoperative care is reviewed.
Definition
1
In the light of the current knowledge, the defini-
tion of asthma is a lung disease with following charac-
teristics :
A. Airway obstruction, which is reversible either
spontaneously, or with treatment (reversibility may not
be complete in some patients)
B. Airway inflammation
C. Airway hypersensitivity to a variety of stimuli
Epidemiololgy
1
Genetic predisposition and atopy are contribut-
714
Indian Journal of Anaesthesia, October 2008(P.G.Issue)
ing factors in the development of reactive airway dis-
ease, as is respiratory syncytial virus infection in infancy.
However, children migrate to urban area from rural ar-
eas begin to experience a much higher prevalence of
asthma when followed over a period than similar chil-
dren who remain in the rural areas. The urbanized en-
vironment increase exposure to new allergens and irri-
tants.
Seventy-four percent of asthma attacks experi-
enced in children less than 5 years of age and 26 per-
cent in less than 1 year of age. Male to female ratio is
2:1.
Triggering factors
Asthma triggering factors include: respiratory in-
fections (especially viral), aeroallergen (dust), air pol-
lutants (cigarette smoke), temperature changes (par-
ticularly cold air), gastroesophageal reflux, exercise, and
anxiety.
The period before and during the induction of
anaesthesia is uniquely suited to trigger bronchospasm
in susceptible individuals because of the patients emo-
tional stress, fear, and excitement. There is resultant
hyperventilation with mouth breathing of dry anaesthetic
gas mixtures, airway irritation by volatile anaesthetics,
and mechanical stimulation of the pharyngeal and la-
ryngeal mucosa by laryngoscopy and endotracheal
tube.
Diagnosis
2
Asthma in children is a notoriously difficult condi-
tion to diagnose with confidence. There is no confir-
matory diagnostic blood test, or radiographic, or his-
topathologic investigation. The diagnosis of asthma is
based on clinical evidence of recurrent symptoms such
as wheezing, chest tightness, cough, and shortness of
breath, with increased airway hyper responsiveness to
various chemical, pharmacological, and physical stimuli.
The diagnosis is often difficult because the clinical pic-
ture is diverse and the possible pathophysiologic mecha-
nisms are numerous.
Differential diagnosis
Some features are uncharacteristic of asthma:
1. Unremitting wheeze or stridor is suggestive of
a fixed obstruction.
2. Persistent wet, productive cough is suggestive
of suppurative lung disease (cystic fibrosis, primary cili-
ary dyskinesia, immuno-deficiency, following infection).
3. Cough without wheeze is often a post-viral
bronchitis.
4. Intermittent wheeze since birth often due to
tracheomalacia or bronchomalacia.
Pharmacotherapy
Patients with asthma are believed to be at increased
risk for perioperative pulmonary complications and that
can lead to prolonged hospital stay.
Therefore, the goal of preparing a patient with
asthma for anaesthesia and surgery is to maximize the
patients pulmonary function. The anaesthesiologist must
consider the maintenance or addition of bronshospastic
drugs.
Bronchodilators
1. Beta adrenergic agonists, are commonly used
to provide rapid relief of acute bronchospasm and are
also used for chronic treatment. The inhaled beta-2-
adrenergic agents have a toxic dose that is an order of
magnitude greater than their therapeutic dose. These
drugs initiates their action on the receptor sites of air-
way smooth muscle cells and cause smooth muscle re-
laxation and bronchodilatation. Moreover, these agents
cause increased mucocilliary clearance by activating
adenyl cyclase to increase cAMP levels. Inhalation
administration provides faster peak bronchodilatation
and fewer systemic side effects than other routes of
delivery
3
. They may be also administered by oral or
intravenous routes.
715
Beta-2-agonists are the most potent
bronchodilators available and are the drugs of choice
for the treatment of acute exacerbation in mild asth-
matics and for maintenance therapy in severe reactive
airway disease. The recommended doses of commonly
used beta-2-agonists are :
Albuterol (salbutamol)
4
: 4-8 puffs through en-
dotracheal tube ; 1-2 puffs orally; metered dose in-
haler 0.01 ml / kg of 0.5 percent solution nebulized.
However, only 2.5 12 percent of delivered dose
reaches end of endotracheal tube when aerosolized at
endotracheal tube connector of 3-6 mm sizes.
Metaproterenol
4
: 2 puffs orally ; 0.01 mg / kg
of 0.5 percent solution nebulized. The duration of ac-
tion of this agent is less than albuterol.
Terbutaline
5
is a preferred agent for mild to
moderate asthmatic attacks. Terbutaline can be given
either by jet nebulizer (0.1% solution,3ml over 10
minutes)or by subcutaneous injection of 5 to 10 g.kg
-1
.
However, for patients with severe asthma
associatedwith severe respiratory failure, terbutaline can
be used intravenously. This should be done in an ICU
with continuous ECG and arterial pressure monitoring,
as arrhythmia and marked tacchycardia may result.
2. Methylxanthines
Methylxanthines (e.g. theophylline) produce
bronchodilatation by inhibiting adenosine-induced
bronchoconstriction in asthmatic patients
6
. It is used
for prophylaxis against acute attacks in the severe asth-
matic and in the prevention of nocturnal episodes of
bronchospasm. Theophylline has a very low therapeu-
tic index and toxic effects can be seen at levels below
maximal therapeutic effects. Side effects include nau-
sea, irritability, learning difficulties in children and head-
ache
7
. The great variability of drug metabolism and the
necessity for monitoring of blood levels is one reason
the use of theophylline has declined.
Dose : (a) oral solution 10 mg / kg / day; (b) im-
mediate release tablet may be given upto 16 mg / kg /
day ( > 1 year) ; (c) sustained release capsule upto 5
mg / kg/ day + 0.2 mg (age in weeks) (< 1 year).
3.Anticholinergics
Anticholinergics are less effective bronchodilators
than the beta-adrenergic agonists or the xanthines, and
should be viewed as adjunctive agents. They produce
bronchodilatation by inhibiting cholinergic activation of
airway smooth muscle (inhibiting mucous hypersecre-
tion and decreasing reflex bronchoconstriction)
8
.
Ipratropium bromide is a quarternary ammonium
compound with no significant systemic absorption or
side effects and is available as a metered-dose inhaler
and as a nebulizable solution. It has a slower onset of
action than beta-2-agonists, but the duration of action
is longer (up to 8 hours). The optimal dose is 50 to 125
mcg
9
. However, anticholinergics may have a limited role
in paediatric patients due to their central not peripheral
airway effects.
Anti-inflammatory drugs
1. Corticosteroids
Corticosteroids are initiated earlier in treatment
for their anti-inflammatory properties because reactive
airway disease has a significant inflammatory compo-
nent. Inhaled corticosteroids have reduced systemic side
effects, compared with oral steroids. Regular use of an
inhaled corticosteroid allows effective control of symp-
toms and improvement in lung function; reduces air-
way inflammation, and results in a gradual reduction in
airway hyperactivity
10,11
. Onset of benefit is within a
few hours (maximum effect 12 to 36 hours) making
intravenous steroids useful as a preoperative medica-
tion in patients with moderate to severe asthma
12
. Oral
or parenteral corticosteroids are most effective for acute
exacerbations of asthma unresponsive to maximal bron-
chodilator therapy
13
. The preparation used most fre-
quently is hydrocortisone 1 to 3 mg / kg intravenously.
The onset of action is 1 to 2 hours after administration.
Methylprednisolone 1 to 2 mg/kg is an alternate choice,
A Rudra. Paediatric asthma
716
Indian Journal of Anaesthesia, October 2008(P.G.Issue)
with less mineralocorticoid effect. Corticosteroid ad-
ministration improves oxygenation and peak flow
rates
14
. Oral or parenteral corticosteroids are most ef-
fective for acute exacerbations of asthma unresponsive
to maximal bronchodilator therapy.
2. Cromolyn sodium
Cromolyn sodium is used prophylactically to re-
duce the incidence of asthma attacks. It attenuates
bronchoconstriction caused by allergen, exercise, and
bronchial challenge
15
. It prevents release of mediators
from pulmonary mast cells and is frequently given in
aerosol form for treatment of chronic asthma. It is rela-
tively free of side effects and has no known interac-
tions with drugs used in anaesthesia. Therefore, it can
be given until the time of induction of anaesthesia
16
.
Cromolyn sodium may take 2 to 4 weeks to produce a
clinical change. It has no place in the treatment of acute
asthma. However, maintenance therapy with cromolyn
is recommended in children with moderate to severe
asthma.
3. Leukotriene pathway modifiers
These are the first new drugs for the treatment of
asthma to be introduced in more than 20 years.
Leukotrienes were isolated from leukocytes and stimu-
late airway smooth muscle contraction by a non-hista-
mine mechanism. Leukotrienes and other products of
the 5-lipoxygenase pathway induce pathophysiologic
responses similar to those associated with asthma
oedema, migration of eosinophils, and stimulation of
airway secretions. These drugs are particularly useful
in two areas (i) exercised-induced asthma and (ii) as-
pirin-induced asthma. Oral administration of any of these
drugs in patients with chronic asthma decreases (a) the
need for rescue beta agonists, (b) decreases the fre-
quency of exacerbations of asthma requiring oral glu-
cocorticoid therapy, (c) and decreases the dose of in-
haled glucocorticoid required to maintain control of
asthma. Thus, leukotriene pathway modifiers exert a
glucocorticoidsparing effect
17,18
.
Severity of asthma
It is important to establish both the severity of the
disease and the quality of control, as two aspects are
closely linked. Mild asthma that is poorly controlled
may appear severe in terms of frequent or persistent
symptoms. Whereas a child with severe asthma may
have well controlled symptoms but require high doses
of inhaled corticosteroids. The severity of asthma has
been defined by British Thoracic Society and the Na-
tional Heart, Lung and Blood Institute
19,20
in a five step
scale dependent upon the amount of treatment required
to control symptoms.
Step 1: Occasional use of a short acting beta-2-ago-
nist
Step 2: Addition of inhaled steroids 400 mcg of
beclamethasone diproprionate or equivalent per day.
Step 3 : Addition of long acting beta-2-agonist or
leukotriene receptor agonist to obviate the need for
an increase in inhaled steroids.
Step 4 : Cautious increase of inhaled steroid
(beclamethasone diproprionate) to a maximum 800
mcg per day.
Step 5 : Oral steroid, high dose of inhaled steroid >
1000 mcg per day or systemic steroid sparing agent
(aminophylline).
Most children will be on the first two steps of treat-
ment protocol. However, extra cautions must be taken
while anaesthetizing children on step four and five.
Perioperative assessment
In children with asthma, it is important to estab-
lish both how severe the disease is and how well it is
controlled currently. The two aspects are closely linked.
Mild asthma, which is poorly controlled, may appear
severe in terms of frequent and persisting symptoms.
In contrast, a child with severe asthma may have well
controlled symptoms, but require high doses of inhaled
717
corticosteroids to maintain control. Poorly controlled
asthma is defined by various features such as frequency
of symptoms and use of reliever medication. Frequent
emergency attendances, hospital admissions or use of
oral steroids also indicate inadequate control. In addi-
tion, a small group of children may have life-threaten-
ing asthma .These children may have poorly controlled
asthma, or brittle asthma with sudden onset of as-
phyxiating or anaphylactic-type asthmatic attacks. A
previous history of severe or life threatening exacerba-
tions, especially if requiring intensive care is indicative
of a particular vulnerable group of children. Sudden
asphyxiating asthma may also be precipitated by non-
steroidal analgesics or irritant gases (both used in ana-
esthesia)
21
.
Therefore, preoperative assessment of the patient
with asthma should include a thorough preoperative
history and physical examination with a focus on the
patients pulmonary status to determine the level of res-
piratory dysfunction and to assess the effectiveness of
current therapy. Objective testing is not diagnostic but
can support a clinical diagnosis. Most tests have a rea-
sonable positive predictive value but a poor predictive
negative value. Some tests may also help in assessing
current control or severity of airways inflammation.
Laboratory evaluation may include spirometry to as-
sess the presence and degree of airway obstruction,
and reversibility with bronchodilators. Oxymetry may
provide information with regards to desaturation with
exertion. A chest radiograph is rarely useful unless a
condition other than asthma is felt to be present in an
acute exacerbation. In patients with mild or intermittent
disease, there is no significant benefit of obtaining pul-
monary function tests, oxymetry, or chest x-ray; how-
ever, patients with more moderate to severe symptoms
may require these evaluations to adequately assess their
pulmonary risk.
History
1. Current medications, including all bronchodilators
and steroids.
2. Response to previous anaesthesia.
3. Recent upper respiratory infections or episodes of
wheezing. Four to six weeks should be elapsed after
an episode of bronchospasm because of the risk of
exacerbation.
4. Assessment of patient regarding current status com-
pared with the baseline condition.
Physical examination
1. Degree of bronchospasm from the appearance of
patient (e.g. agitation, respiratory distress).
2. On auscultation of chest, wheezing is audible during
expiration.
3. Presence of cyanosis, intercostals retractions, and
use of accessory muscles due to severe bronchospasm.
4. Presence of pulsus paradoxus of greater than 24
mm Hg is often seen.
Pulmonary function testing
Preoperative spirometry may be useful for docu-
menting the extent of obstructive airway disease and,
more importantly, the potential for reversal with
bronchodilators. Comparing parameters of pulmonary
function against predicted values allows a classification
of clinical impairment
3
. (Table 1)
Improvement in pulmonary function parameters
after a trial of bronchodilators in a child with acute bron-
Table 1 Severity of expiratory airflow obstruction
FVC, FEV
1
FEF
25-75%
(% of predicted) (% of predicted)
Normal > 80 > 75
Mild 65 80 60 75
Moderate 56 64 45 59
Severe 35 55 30 44
Very Severe < 35 < 30
FVC = Forced Vital Capacity ; FEV
1
= Forced Expiratory Volume
in one second ; FEF = Forced expiratory flow.
A Rudra. Paediatric asthma
718
Indian Journal of Anaesthesia, October 2008(P.G.Issue)
chospasm implies a reversible component and suggests
that adjustments in bronchodilator therapy before elec-
tive surgery may be beneficial.
Inflammatory markers
Evidence of inflammation to help diagnose or
monitor asthma have been sought in blood (peripheral
blood eosinophillia
22
, eosinophilic cationic protein
23,24
),
urine(urinary leukotriene and eosinophil-derived pro-
tein X
25
) and exhaled air(exhaled air nitric oxide
26,27
).
However, these remain largely research tools.
Patients with mild to moderate symptoms do not
require further workup, but patients who are symp-
tomatic or who are deteriorated from their normal con-
dition should be postponed and optimized prior to elec-
tive surgery. Asthmatics should not be anaesthetized
for elective surgery during an acute viral respiratory in-
fection as the risk of bronchospasm is very high. They
should ideally be postponed 4-6 weeks after such an
event.
Preoperative arrangements
In addition to the concerns about lung function
and bronchospasm in children with asthma undergoing
anaesthesia, the anaesthesiologist must be aware of
other associated problems. In particular, atopic asth-
matics are prone to allergic reactions and may develop
anaphylaxis precipitated by allergens such has drugs,
drug excipients, or latex
28
. Potential allergies to drugs
such as antibiotics and previous anaesthetic agents
should be sought.
Preanaesthetic preparation and medication
The anaesthesiologist must get to know the asth-
matic child and his or her parents and gain their confi-
dence to minimize the childs anxiety before anaesthe-
sia induction. The child should be well sedated to avoid
struggle and hyperventilation, which can provoke ex-
ercise-induced asthma.
Preoperative preparation for mild asthma should
include an use of nebulized beta-2-adrenergic agonist
12 hours prior to surgery. For moderate asthma, ad-
ditional optimization with an inhaled anti-inflammatory
agent and regular use of nebulized beta-2-adrenergic
agonist one week prior to surgery can be instituted.
This may help abolish the increase in respiratory resis-
tance seen with some anaesthetic agents
29
. Severe asth-
matics may need addition of one of the following : oral
prednisolone 1 mg/kg/day (60 mg maximum) 35 days
before surgery; or oral dexamethasone 0.6 mg / kg
(16 mg maximum) or methylprednisolone 1 mg/kg for
48 hours prior to surgery
30
.
Premedication with oral midazolam 0.5 to 1 mg/
kg can be indicated since anxiety may precipitate acute
bronchospasm. Use of systemic corticosteroids in the
last 6 months is indication for stress dose coverage to
avoid the risk for adrenal suppression. Hydrocortisone
1-2 mg/kg every 6 to 12 hours is initiated 1 day before
surgery and is continued for at least 2 days postopera-
tively. The use of anticholinergic drugs should be indi-
vidualized, remembering that these drugs can increase
the viscosity of secretions, making it difficult to remove
them from the airway.
Agents to provide anaesthesia
Both intravenous and inhalational inductions of
anaesthesia are common in paediatric anaesthesia prac-
tice, and the choice of route or agent may be influ-
enced by a history of asthma. The goal during induc-
tion and maintainance of anaesthesia in children with
asthma is to depress airway reflexes with anaesthetic
drugs to avoid bronchoconstriction of the childs hy-
peractive airways in response to mechanical stimula-
tion. Stimuli that do not evoke airway responses in the
absence of asthma can precipitate life-threatening
bronchoconstriction in children with asthma.
A. Intravenous anaesthetics
Thiopentone
Thiopentone may release histamine. In addition
because it gives only a light level of anaesthesia, airway
719
instrumentation under thiopentone alone may cause
bronchospasm
31
. In practice, thiopentone has been used
frequently for successful induction of anaesthesia for
asthmatic patients
31
.
Propofol
Propofol appears to be a safe anaesthetic in asth-
matic patients. In adults, propofol has been shown to
provide more protection against bronchospasm induced
by tracheal intubation than an induction dose of thio-
pentone
32
. This may be due to the profound depres-
sion of airway reflexes. Propofol may also produce
bronchodilatation in patients with other types of airway
disease
33
. Propofol may be the agent of choice for in-
travenous induction in a haemodynamically stable pa-
tient.
Regardless of the drug chosen (thiopentone or
propofol), it is important to give sufficiently large intra-
venous dose to blunt the response and to start adding
potent volatile anaesthetic before the peak effect of in-
travenous agent is lost.
Ketamine
In the actively wheezing child or emergency sur-
gery, ketamine may be the induction agent of choice
34
,
because ketamine produces smooth muscle relaxation
and bronchodilatation both directly and via release of
catecholamines
35
. However, it may increase airway
secretions unless administered with an anticholinergic.
Etomidate
Etomidate does not seem to offer the protection
that propofol or ketamine does
30
.
B. Inhalational anaesthetics
Development of bronshospasm during induction
of anaesthesia may be prevented by the potent inhala-
tional anaesthetic agents (a) by blocking airway reflexes,
(b) by directly relaxing airway smooth muscles, (c) or
by inhibiting mediator release
36
. Lack of controlled
studies does not indicate what inhalational agent would
be most suitable for the child with asthma.
Halothane, was previously advocated when an-
aesthetizing children with asthma, but its use has de-
clined in popularity as it sensitizes the myocardium to
the cardiac dysrythmic effects of catecholamines.
Sevoflurane, is excellent for an inhalational induc-
tion having a decreased incidence of laryngospasm and
cardiac dysrhythmias but also bronchodilating effects.
At the present, sevoflurane must be considered as the
agent of choice for mask induction.
C. Muscle relaxants
Due to absence of histamine release vecuronium,
rocuronium, or cisatracurium are acceptable choices.
Neuromuscular blockade could be antagonized with
neostigmine. Neostigmine does not cause
bronshospasm if atropine or glycopyrrolate are admin-
istered concurrently.
Anaesthetic technique
Regional anaesthesia avoids airway manipulation
but regional anaesthesia only may not be feasible for
paediatric patients or site of surgery. However, regional
anaesthesia can be combined with inhalational anaes-
thesia with sevoflurane. Adolescents, however, are ac-
ceptable candidates for regional anaesthesia without
general anaesthesia in specific circumstances. In all situ-
ations where there is high risk of complications associ-
ated with the administration of a general anaesthetic, a
regional anaesthetic technique should be considered.
Avoiding intubation by using a facemask or laryn-
geal mask airway (LMA) for appropriate cases, may
be useful as its use avoids the laryngeal and tracheal
stimulation of intubation
37-39
. However, this has not been
investigated in children. It is known that children with
upper respiratory tract infections who also have reac-
tive airways, the incidence of complications with LMA
was significantly less than that with tracheal intubation
40-
42
.For very short procedures in children with reactive
airways it would seem reasonable to avoid instrumen-
A Rudra. Paediatric asthma
720
Indian Journal of Anaesthesia, October 2008(P.G.Issue)
tation of the oropharynx altogether by use of a face
mask only
43
.
Endotracheal intubation is the most important risk
factor for bronchospasm because the endotracheal tube
stimulates large airway irritant receptors
44
and can trig-
ger bronchospasm. Having the patient use a beta-2-
adrenergic agonist inhaler prior to the induction of ana-
esthesia as well entering a deep plane with inhalational
anaesthesia prior to intubation may decrease the risk
of increased airway resistance and bronchospasm that
can occur with intubation. Intravenous administration
of glycopyrrolate or atropine after induction may de-
crease secretions and provide additional
bronchodilatation prior to intubation. An anaesthetic
technique using a volatile anaesthetic may be prefer-
able to a balanced technique (i.e. nitrous oxide, opioid,
and a muscle relaxant) for child with asthma because
of the advantage of bronchodilating properties of vola-
tile agents.
Recognizing and treating complications
Intraoperative wheezing
Asthmatics may develop bronchospasm because
of their increased airway reactivity, or secondary to an
anaphylactic reaction. If wheezing develops during the
course of anaesthesia, bronchospasm is the mostly likely
cause, although other cause of wheezing includes light
anaesthesia, kinked endotracheal tube, mainstem bron-
chial intubation, increased airway secretions, pulmo-
nary oedema, and aspiration. Bronchospasm is recog-
nized by bilateral expiratory wheeze, prolonged expi-
ration, with increased respiratory effort, increased air-
way pressure, rising end tidal carbondioxide and
hypoxaemia. Hypoxaemia may become manifest more
quickly in the child where the respiratory drive has been
blunted by anaesthesia.
Bronchospasm can be treated by the administra-
tion of 100 percent oxygen and an increased concen-
tration of inhalation anaesthetic. If increasing anaesthetic
depth does not resolve the bronchospasm, the beta-
agonists (e.g., terbutaline, albuterol) are the drug of
choice, usually given in nebulized form. Terbutaline can
also be given subcutaneously 5 to 10 mcg/kg. Steroids
are also appropriate, although their slow onset of ac-
tion limits their utility in an episode of acute broncho-
spasm. An intravenous dose of ketamine (0.5 to 2 mg/
kg) is a quick way of maintaining blood pressure, rap-
idly deepening the anaesthesia and supplementing in-
halation anaesthetics. Intravenous or subcutaneous ad-
ministration of adrenaline in racemic form, or intrave-
nous administration of isoproterenol may be used if
previous therapy is unsuccessful in terminating the bron-
chospasm. Other options include intravenous
magnesium 40 mg / kg over 20 minutes
2
. The anticho-
linergics should be viewed as useful adjuncts.
Anaphylaxis
Anaphylaxis is a rare but potentially catastrophic
complication of anaesthesia. Neuromuscular blocking
agents, antibiotics, or latex are the most common pre-
cipitants
45
. Latex allergy is most common in children
who have encountered this antigen before. For example,
children who require intermittent bladder catheteriza-
tion may be sensitized
46,47
. In addition, cross reactiv-
ity between latex and various fruit antigens( such as
avocado, kiwi, and banana) also exists
48
. Patients with
proven or suspected allergy to latex or rubber should
be managed in a latex-free environment and premedi-
cation with intravenous steroids and H
1
and H
2
re-
ceptor antagonists. (Table 2)
Table 2 Pretreatment of children with latex allergy
Drug Dose Schedule
Methylprednisolone 1 mg.kg
-1
6 h iv
Ranitidine 1 mg.kg
-1
6 h iv, over 20
minutes
Chlorpheniramine 0.25 mg. kg
-1
(1-12 mon)
5 mg (1-5 years) 6 h iv
10 mg ( 5-12 years) 6 h iv
Doses to be given for 12 h (i.e. 2 doses) preoperatively
and 24 h postoperatively.
721
Signs of anaphylaxis include angioedema, flush-
ing or urticaria, and tachycardia, reduced perfusion and
hypotension secondary to hypovolemia. Unfortunately,
in anaesthetized patient, prodromal symptoms such as
perioral tingling, urticaria or angioedema may be ab-
sent. The most common presentation is cardiovascular
collapse (with absent pulse noted) or bronchospasm
(with difficulty in ventilating the patient).
Anaphylaxis should be treated quickly and ag-
gressively according to established protocol with the
administration of intramuscular adrenaline, nebulized
salbutamol and fluid resuscitation
49
. Corticosteroids and
antihistamines should also be considered. Intramuscu-
lar adrenaline is first-line therapy although in patients
with intravenous access, careful administration of in-
travenous adrenaline may be considered (1: 10 000
solution of epinephrine titrated to effect). Any suspected
anaphylactic reaction should be investigated and re-
ferred for follow up.
Adrenal Crisis
Suppresion of hypothalamic-pituitary-adrenal
(HPA) axis may occur with steroid therapy. Adrenal
crisis is then precipitated by a stress such as surgery.
The presentation may be dramatic with hypotension,
hypoglycaemia or seizures. The patient will usually re-
spond to intravenous hydrocortisone and fluid resusci-
tation to increase intravascular volume, and dextrose
as required to correct hypoglycaemia.
HPA suppression may be assumed in any child
who has received significant doses of steroids for a
prolonged period. Short courses of prednisolone used
to treat asthma exacerbations can affect HPA function
for up to 10 days but dysfunction is unlikely to be pro-
longed
50,51
.
High-doses inhaled steroid therapy has also been
associated with HPA suppression with several case of
adrenal crisis reported including one postoperatively
52
.
HPA suppression may occur without obvious growth
retardation
53
.The Committee on the Safety of Medi-
cines advices that inhaled steroids may be associated
with adrenal insufficiency
54
.Perioperative steroid cover
is indicated for those recently requiring systemic ste-
roids and should be considered for those on high-doses
inhaled steroid
48,55
.
Intraoperative management
Tracheal suction of any secretions should be per-
formed before emergence to decrease coughing due to
migration of mucous plugs. If a mechanical ventilator is
used it should be set with low inflating pressures to pro-
vide optimal distribution of ventilation relative to perfu-
sion and prolonged expiratory time to prevent air trap-
ping in the presence of expiratory airflow obstruction
characteristic of asthma. Therefore, positive end-expi-
ratory pressure may not be ideal because of the likeli-
hood that it impairs adequate exhalation in the pres-
ence of narrowed airways. Liberal intravenous admin-
istration of crystalloid solutions during the perioperative
period is important for maintaining adequate hydration
and ensuring the presence of less viscous secretions,
which can be expelled more easily from the airways.
Techniques of extubation
56,57
At the conclusion of surgery, a slow, smooth
emergence from anaesthesia minimizes the risk of bron-
chospasm. Therefore, unless contraindicated by other
contraindications, tracheal extubation at deeper plane
of anaesthesia avoids the risk of bronchospasm from
bucking on the endotracheal tube. Successful deep
extubation is facilitated by the achievement of sponta-
neous breathing before attempted extubation. After
deep extubation, the patient should be taken to the
recovery room for postoperative observation and care.
If a deep extubation is contraindicated, awake
extubation should be considered. Prophylactic treat-
ment with the inhalation of a beta-2-agonist should be
considered prior to the awake extubation even if a
dose was previously given, during or after the induc-
tion of anesthesia. Alternatively, adding opioid agent
(e.g., fentanyl, 1-2 mcg/kg) or intravenous lidocaine (1
A Rudra. Paediatric asthma
722
Indian Journal of Anaesthesia, October 2008(P.G.Issue)
mg/kg) or both as the child emerges will help to smooth
the awake extubation.
Emergency surgery
58,59
The combination of emergency surgery and asthma
introduces a conflict between protection of the airway
in patients at risk for aspiration and the risk of trigger-
ing bronchospasm in the presence of light anaesthesia.
Furthermore, due to lack of time it would not be pos-
sible to start bronchodilator therapy. In extremities or
superficial surgery, choice of technique would be re-
gional anaesthesia.
Postoperative pain relief
Non-steroidal analgesics are commonly used in
paediatric surgery. Their association with sudden dete-
rioration of children with asthma is a cause for con-
cern. Provocation of bronchospasm by NSAIDs is
thought to be a result of a relative excess of leukotriene
production. Aspirin sensitivity is present in about 2%
of children with asthma and around 5% of these pa-
tients are cross-sensitive to other NSAIDs. However,
a recent study found no change in lung functions in a
group of known asthmatic children given a single dose
of diclofenac under controlled conditions
60
. A local/re-
gional analgesic technique should be used in all cases
of pediatric anaesthesia unless there is a specific rea-
son not to
61
(Table 3). In paediatric hospitals or other
centres with significant numbers

of paediatric surgical
interventions, the establishment of a

dedicated paediat-
ric pain service is the standard of care. Where

this is
not possible, adult pain services often manage children
with specific paediatric medical and nursing advice and
expertise.
The studies on drug safety are, however, severely
limited by the small numbers of children involved, as
shown by secondary surveillance.
Asthma is a chronic inflammatory disease and the
physiological consequence is bronchial
hyperresponsiveness to different stimuli. With the
worldwide increase in the prevalence of asthma, an in-
creased number of asthmatics are likely to require ana-
esthesia for surgical procedures. The evidence-base for
the safety of many medications used in anaesthetizing
the child with asthma remains poor. However, an aware-
ness of the potential problems together with careful
preoperative assessment and preparation would hope-
fully make common complications less common.
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