Despite millions of dollars spent to help control asthma, the rates of emergency department

(ED) visits due to asthma symptoms increased by about 18% for children aged 5 to 17 years
and by 6% for children younger than age 5 years in California between 2005 and 2012,
according to a Kaiser Health News analysis. In certain areas of the state, asthma is even more
pervasive. In the San Joaquin Valley, for example, an estimated 157,000 (15.8%) children
and adolescents have been diagnosed with asthma, far exceeding the national rate of 4% to
9%.

Although we have made great strides in the care and control of pediatric asthma, children are
clearly at higher risk of asthma symptoms and complications. This is particularly important in
the care of pediatric surgery patients with asthma. Asthmatic children are 5.5 times more
likely to experience wheezing perioperatively than are nonasthmatics, and they are more
likely to have perioperative respiratory complications.

Special attention must be paid to minimize the chance that pediatric surgery will not result in
bronchospasms in asthma patients, as the severity of the disease correlates with the risk of
respiratory complications. Several factors should be taken into account in the perisurgical
care of pediatric asthmatic patients.

Preoperative anesthesiology assessment is critical. An uncontrolled baseline asthma condition

represents the most important risk factor for perioperative events in asthmatic patients,
especially in very young children. For children without optimal control of symptoms or with
a recent respiratory tract infection, elective surgery should be postponed, if possible, after the
optimization of therapy. Treating clinicians should also be diligent about scheduling a
preoperative anesthesiology assessment, including clinician examination, complete
medication history, functional tests such as spirometric evaluation, and even preoperative
laboratory tests if necessary for very high-risk children with asthma.

Provide a low-stress, peaceful preoperative environment. There is a significant psychological

element with asthma, exacerbated by the anxiety associated with even the most routine
surgery. Allow a parent to stay with the child as long as possible until the induction of
anesthesia, and consider administering an oral sedative to relax the child.

Use of regional anesthesia can minimize complications. Although each case is unique, there
is a general consensus that for the pediatric asthmatic patient, the use of regional analgesia to
control pain is the best course, while narcotics should be avoided due to the risk of
respiratory depression and the potential for the release of histamine, a frequent cause of
bronchospasm.

Incorporating a cautious and compassionate perioperative approach with the pediatric asthma
patient can help to facilitate an uneventful surgery with the best possible health outcomes.
LINDA MASON, MD, is a professor of anesthesiology and pediatrics at Loma Linda
University and director of pediatric anesthesiology at Loma Linda University Medical
Center, Calif. (203-4)