James L Rothschiller MD PA

Pediatric Anesthesiologist

Bronchospasm Intraoperative

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Intraoperative Bronchospasm Management

Source: Adapted from RothschillerMD.com (rev 2024-02-02, 2024-02-03)

Overview

Intraoperative bronchospasm may result from mechanical hyperreactivity, irritant hyperreactivity (e.g., gastric acid aspiration), or immune-mediated hypersensitivity. Identifying the cause guides treatment. Epinephrine is effective for immune-mediated bronchospasm but may be less effective for chemical irritants like gastric acid, where neutralization and irritant removal are critical.

Pulmonary Aspiration Context

Reference: Pulmonary Aspiration – Perioperative
Gastric fluid aspiration damages airway epithelium due to acidity and digestive enzymes (e.g., pepsin, bile salts), causing inflammation. This can exacerbate bronchospasm, particularly in irritant hyperreactivity cases, and may delay SpO2 improvement as neutralization occurs.

Pediatric Epinephrine Dosing

  • Bronchospasm (Immune-Mediated): 1–2 mcg/kg IV
  • Hypoxic Bradycardia: 1–10 mcg/kg IV
  • Resuscitation (Cardiac Arrest): 10–20 mcg/kg IV, with 5–10 mL flush per dose
  • Endotracheal (ETT) Administration: Viable for epinephrine, lidocaine, atropine, or naloxone if IV access is unavailable. May dilute gastric acid in aspiration cases.

Note: Epinephrine is incompatible with sodium bicarbonate; use separate IV lines.

Management of Intraoperative Bronchospasm

1. Mechanical Hyperreactivity

  • Cause: Endotracheal tube (ETT) stimulating carina or mainstem bronchus, often pronounced in reactive airway disease (RAD).
  • Actions:
    • Reposition ETT (pull back) and confirm placement via auscultation.
    • Administer 20 mg (1 mL of 2%) lidocaine via ETT for mucosal/recurrent laryngeal nerve block.

2. Immune-Mediated Hypersensitivity

  • Cause: Mast cell release of histamine or other mediators.
  • Actions:
    • Switch to less pungent gas (e.g., sevoflurane) and deepen anesthesia.
    • If SpO2 ≥ 80%: Administer albuterol via in-line nebulizer or MDI/elbow.
    • If SpO2 < 80% (severe bronchospasm): Administer epinephrine 1–2 mcg/kg IV.

3. Irritant Hyperreactivity (e.g., Gastric Acid Aspiration)

  • Cause: Chemical irritants like gastric acid from reflux.
  • Actions:
    • Epinephrine may be less effective; focus on neutralizing acid and removing irritants.
    • Consider ETT-administered drugs (e.g., lidocaine) to dilute acid.
    • Monitor for delayed SpO2 improvement due to acid neutralization time.

Pediatric Hypoxic Bradycardia and Resuscitation

  • Hypoxic Bradycardia:
    • Use epinephrine (1–10 mcg/kg IV), not atropine, as bradycardia results from hypoxia affecting the sinoatrial (SA) node.
    • If heart rate drops during prolonged hypoxia, initiate chest compressions with a backboard.
  • Resuscitation:
    • Administer epinephrine 10–20 mcg/kg IV with 5–10 mL flush to ensure central compartment delivery.
    • Repeat doses until heart rate, blood pressure, and SpO2 improve.
    • Higher doses may be needed as cardiac arrest duration increases to achieve return of spontaneous circulation (ROSC).
    • In low-flow states (low SpO2, weak pulse, mottled skin), prioritize second IV placement if feasible.

Pediatric CPR Guidelines

  • Compression Rate: 100–120 per minute.
  • Depth: ~1/3 anterior-posterior chest diameter (~4 cm in infants, ~5 cm in children).
  • Technique: Use a backboard, allow complete chest recoil, and monitor ETCO2 waveform via capnography to assess compression quality.
  • Capnography Role: ETCO2 confirms adequate CPR, coronary artery perfusion, and blood flow to vital organs (brain, lungs, airway). Document ETCO2 values.
  • Caution: Avoid afterload-reducing agents (e.g., propofol), especially in aortic stenosis, to maintain coronary perfusion.

Additional Notes

  • Route and Bioavailability: Most drugs (e.g., ondansetron, hydrocodone, midazolam) can be given via multiple routes (e.g., oral, sublingual) with high bioavailability, especially sublingual administration. Re-dosing is rarely needed if a child spits out or vomits oral medication held sublingually.
  • ETT Drug Delivery: Effective for epinephrine, lidocaine, atropine, or naloxone in emergencies without IV access. May aid in diluting gastric acid in aspiration cases.