INTRODUCTION

Asthma is a chronic inflammatory lung disease characterized by symptoms of cough,

wheezing, dyspnea and chest tightness, partially or completely reversible airway narrowing,
and increased airway responsiveness to a variety of stimuli. Increased airway responsiveness
is also seen in children with recurrent acute wheezing due to causes other than asthma (eg,
allergies, viral infections). Asthma and recurrent wheezing are common childhood illnesses;
pediatric patients with these conditions commonly present for anesthesia and surgery and can
pose challenges for the anesthesiologist. Children with these conditions are at increased risk
for perioperative respiratory adverse events, including laryngospasm and bronchospasm.

Wheezing can occur at any time during anesthesia, most commonly during induction of
general anesthesia after endotracheal intubation. If it occurs, it is usually transient and
without sequelae if treated. However, bronchospasm can be severe and can result in
significant morbidity and mortality.

This topic will discuss preoperative assessment and preparation of pediatric patients with
asthma and recurrent wheezing, as well as intraoperative management. Evaluation and
management of asthma in children is discussed in more depth separately. (See "Asthma in
children younger than 12 years: Initiating therapy and monitoring control" and "Asthma in
children younger than 12 years: Initial evaluation and diagnosis" and "Virus-induced
wheezing and asthma: An overview" and "Evaluation of wheezing in infants and children".)

PREOPERATIVE EVALUATION

When possible, we prefer to assess patients with asthma one to two weeks prior to elective
surgery to allow time for modification of treatment, if necessary. The goal of preoperative
preparation is optimization of therapy to reduce the risk of perioperative respiratory adverse
events (PRAE).

Asthma severity and control The history given by the patient or caregiver at the time of
preoperative evaluation can help determine the severity and level of medical control of
asthma and predict the likelihood of perioperative bronchospasm. Important historical points
to emphasize during preoperative evaluation, in addition to a complete preoperative history,
include:

Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group
practice subscription. For more information or to purchase a personal subscription, click
below on the option that best describes you:

Medical Professional or Student

Hospital or Institution
Group Practices
Patient or Caregiver

Literature review current through: Sep 2017. | This topic last updated: Jan 03, 2017.
The content on the UpToDate website is not intended nor recommended as a substitute for
medical advice, diagnosis, or treatment. Always seek the advice of your own physician or
other qualified health care professional regarding any medical questions or conditions. The
use of this website is governed by the UpToDate Terms of Use 2017 UpToDate, Inc.
References
Top

1. von Ungern-Sternberg BS, Boda K, Chambers NA, et al. Risk assessment for
respiratory complications in paediatric anaesthesia: a prospective cohort study. Lancet
2010; 376:773.
2. Hollevoet I, Herregods S, Vereecke H, et al. Medication in the perioperative period:
stop or continue? A review. Acta Anaesthesiol Belg 2011; 62:193.
3. Mercado DL, Petty BG. Perioperative medication management. Med Clin North Am
2003; 87:41.
4. Kabalin CS, Yarnold PR, Grammer LC. Low complication rate of corticosteroid-
treated asthmatics undergoing surgical procedures. Arch Intern Med 1995; 155:1379.
5. Su FW, Beckman DB, Yarnold PA, Grammer LC. Low incidence of complications in
asthmatic patients treated with preoperative corticosteroids. Allergy Asthma Proc
2004; 25:327.
6. Pien LC, Grammer LC, Patterson R. Minimal complications in a surgical population
with severe asthma receiving prophylactic corticosteroids. J Allergy Clin Immunol
1988; 82:696.
7. von Ungern-Sternberg BS, Habre W, Erb TO, Heaney M. Salbutamol premedication
in children with a recent respiratory tract infection. Paediatr Anaesth 2009; 19:1064.
8. Scalfaro P, Sly PD, Sims C, Habre W. Salbutamol prevents the increase of respiratory
resistance caused by tracheal intubation during sevoflurane anesthesia in asthmatic
children. Anesth Analg 2001; 93:898.
9. Habre W, Petak F. Anaesthesia management of patients with airway susceptibilities:
what have we learnt from animal models? Eur J Anaesthesiol 2013; 30:519.
10. Yamakage M, Iwasaki S, Satoh JI, Namiki A. Inhibitory effects of the alpha-2
adrenergic agonists clonidine and dexmedetomidine on enhanced airway tone in
ovalbumin-sensitized guinea pigs. Eur J Anaesthesiol 2008; 25:67.
11. Groeben H, Mitzner W, Brown RH. Effects of the alpha2-adrenoceptor agonist
dexmedetomidine on bronchoconstriction in dogs. Anesthesiology 2004; 100:359.
12. Dinh Xuan AT, Matran R, Regnard J, et al. Comparative effects of rilmenidine and
clonidine on bronchial responses to histamine in asthmatic subjects. Br J Clin
Pharmacol 1988; 26:703.
13. Dinh Xuan AT, Regnard J, Matran R, et al. Effects of clonidine on bronchial
responses to histamine in normal and asthmatic subjects. Eur Respir J 1988; 1:345.
14. Mamie C, Habre W, Delhumeau C, et al. Incidence and risk factors of perioperative
respiratory adverse events in children undergoing elective surgery. Paediatr Anaesth
2004; 14:218.
15. Bordet F, Allaouchiche B, Lansiaux S, et al. Risk factors for airway complications
during general anaesthesia in paediatric patients. Paediatr Anaesth 2002; 12:762.
16. Tait AR, Pandit UA, Voepel-Lewis T, et al. Use of the laryngeal mask airway in
children with upper respiratory tract infections: a comparison with endotracheal
intubation. Anesth Analg 1998; 86:706.
17. Cox RG, Barker GA, Bohn DJ. Efficacy, results, and complications of mechanical
ventilation in children with status asthmaticus. Pediatr Pulmonol 1991; 11:120.
18. Calder A, Hegarty M, Erb TO, von Ungern-Sternberg BS. Predictors of postoperative
sore throat in intubated children. Paediatr Anaesth 2012; 22:239.
19. Nonaka M, Sakanashi Y, Sugahara K, Terasaki H. [Incidence of asthmatic attack
during anesthesia in patients with a history of bronchial asthma]. Masui 1999; 48:759.
20. von Ungern-Sternberg BS, Ramgolam A, Zhang B, Hegarty M. Is intravenous
induction of anaesthesia superior to inhalational induction in children with increased
airway susceptibility? Australian and New Zealand College of Anaesthetists
Congress, Singapore 2014.
21. Groeben H, Silvanus MT, Beste M, Peters J. Both intravenous and inhaled lidocaine
attenuate reflex bronchoconstriction but at different plasma concentrations. Am J
Respir Crit Care Med 1999; 159:530.
22. Adamzik M, Groeben H, Farahani R, et al. Intravenous lidocaine after tracheal
intubation mitigates bronchoconstriction in patients with asthma. Anesth Analg 2007;
104:168.
23. Groeben H, Foster WM, Brown RH. Intravenous lidocaine and oral mexiletine block
reflex bronchoconstriction in asthmatic subjects. Am J Respir Crit Care Med 1996;
154:885.
24. Erb TO, von Ungern-Sternberg BS, Keller K, Frei FJ. The effect of intravenous
lidocaine on laryngeal and respiratory reflex responses in anaesthetised children*.
Anaesthesia 2013; 68:13.
25. Miller WC, Awe R. Effect of nebulized lidocaine on reactive airways. Am Rev Respir
Dis 1975; 111:739.
26. Weiss EB, Patwardhan AV. The response to lidocaine in bronchial asthma. Chest
1977; 72:429.
27. Fish JE, Peterman VI. Effects of inhaled lidocaine on airway function in asthmatic
subjects. Respiration 1979; 37:201.
28. Hamilton ND, Hegarty M, Calder A, et al. Does topical lidocaine before tracheal
intubation attenuate airway responses in children? An observational audit. Paediatr
Anaesth 2012; 22:345.
29. Eames WO, Rooke GA, Wu RS, Bishop MJ. Comparison of the effects of etomidate,
propofol, and thiopental on respiratory resistance after tracheal intubation.
Anesthesiology 1996; 84:1307.
30. Wu RS, Wu KC, Sum DC, Bishop MJ. Comparative effects of thiopentone and
propofol on respiratory resistance after tracheal intubation. Br J Anaesth 1996;
77:735.
31. Forget P, Pirson E, Scholts JL. Anaphylactic bronchospasm due to propofol. Anaesth
Intensive Care 2009; 37:865.
32. You BC, Jang AS, Han JS, et al. A case of propofol-induced oropharyngeal
angioedema and bronchospasm. Allergy Asthma Immunol Res 2012; 4:46.
33. Murphy A, Campbell DE, Baines D, Mehr S. Allergic reactions to propofol in egg-
allergic children. Anesth Analg 2011; 113:140.
34. Hirshman CA, Bergman NA. Factors influencing intrapulmonary airway calibre
during anaesthesia. Br J Anaesth 1990; 65:30.
35. Pedersen CM, Thirstrup S, Nielsen-Kudsk JE. Smooth muscle relaxant effects of
propofol and ketamine in isolated guinea-pig trachea. Eur J Pharmacol 1993; 238:75.
36. Pizov R, Brown RH, Weiss YS, et al. Wheezing during induction of general
anesthesia in patients with and without asthma. A randomized, blinded trial.
Anesthesiology 1995; 82:1111.
37. Allen JY, Macias CG. The efficacy of ketamine in pediatric emergency department
patients who present with acute severe asthma. Ann Emerg Med 2005; 46:43.
38. Jat KR, Chawla D. Ketamine for management of acute exacerbations of asthma in
children. Cochrane Database Syst Rev 2012; 11:CD009293.
39. Lundy JB, Slane ML, Frizzi JD. Acute adrenal insufficiency after a single dose of
etomidate. J Intensive Care Med 2007; 22:111.
40. Rooke GA, Choi JH, Bishop MJ. The effect of isoflurane, halothane, sevoflurane, and
thiopental/nitrous oxide on respiratory system resistance after tracheal intubation.
Anesthesiology 1997; 86:1294.
41. Habre W, Scalfaro P, Sims C, et al. Respiratory mechanics during sevoflurane
anesthesia in children with and without asthma. Anesth Analg 1999; 89:1177.
42. Lele E, Petak F, Carnesecchi S, et al. The protective effects of volatile anesthestics
against the bronchoconstriction induced by an allergic reaction in sensitized rabbit
pups. Anesth Analg 2013; 116:1257.
43. Schwartz SH. Treatment of status asthmaticus with halothane. JAMA 1984;
251:2688.
44. Dikmen Y, Eminoglu E, Salihoglu Z, Demiroluk S. Pulmonary mechanics during
isoflurane, sevoflurane and desflurane anaesthesia. Anaesthesia 2003; 58:745.
45. von Ungern-Sternberg BS, Saudan S, Petak F, et al. Desflurane but not sevoflurane
impairs airway and respiratory tissue mechanics in children with susceptible airways.
Anesthesiology 2008; 108:216.
46. Nyktari V, Papaioannou A, Volakakis N, et al. Respiratory resistance during
anaesthesia with isoflurane, sevoflurane, and desflurane: a randomized clinical trial.
Br J Anaesth 2011; 107:454.
47. Naguib M, Samarkandi AH, Bakhamees HS, et al. Histamine-release haemodynamic
changes produced by rocuronium, vecuronium, mivacurium, atracurium and
tubocurarine. Br J Anaesth 1995; 75:588.
48. Laxenaire MC, Mertes PM, Groupe d'Etudes des Ractions Anaphylactodes
Peranesthsiques. Anaphylaxis during anaesthesia. Results of a two-year survey in
France. Br J Anaesth 2001; 87:549.
49. Basta SJ. Modulation of histamine release by neuromuscular-blocking drugs. Curr
Opin Anesthesiol 1992; 5:572.
50. Hazizaj A, Hatija A. Bronchospasm caused by neostigmine. Eur J Anaesthesiol 2006;
23:85.
51. Yoshioka N, Hanazaki M, Fujita Y, et al. Effect of sugammadex on bronchial smooth
muscle function in rats. J Smooth Muscle Res 2012; 48:59.
52. Amao R, Zornow MH, Cowan RM, et al. Use of sugammadex in patients with a
history of pulmonary disease. J Clin Anesth 2012; 24:289.
53. Tsur A, Kalansky A. Hypersensitivity associated with sugammadex administration: a
systematic review. Anaesthesia 2014; 69:1251.
54. Philbin DM, Moss J, Akins CW, et al. The use of H1 and H2 histamine antagonists
with morphine anesthesia: a double-blind study. Anesthesiology 1981; 55:292.
55. Prieto-Lastra L, Iglesias-Cadarso A, Reao-Martos MM, et al. Pharmacological
stimuli in asthma/urticaria. Allergol Immunopathol (Madr) 2006; 34:224.
56. Flacke JW, Flacke WE, Bloor BC, et al. Histamine release by four narcotics: a
double-blind study in humans. Anesth Analg 1987; 66:723.
57. Rosow CE, Moss J, Philbin DM, Savarese JJ. Histamine release during morphine and
fentanyl anesthesia. Anesthesiology 1982; 56:93.
58. Guedes AG, Papich MG, Rude EP, Rider MA. Comparison of plasma histamine
levels after intravenous administration of hydromorphone and morphine in dogs. J Vet
Pharmacol Ther 2007; 30:516.
59. Eschenbacher WL, Bethel RA, Boushey HA, Sheppard D. Morphine sulfate inhibits
bronchoconstriction in subjects with mild asthma whose responses are inhibited by
atropine. Am Rev Respir Dis 1984; 130:363.
60. Khosla S, Kunjummen B, Khaleel R, et al. Safety of therapeutic beta-blockade in
patients with coexisting bronchospastic airway disease and coronary artery disease.
Am J Ther 2003; 10:48.
61. Morales DR, Jackson C, Lipworth BJ, et al. Adverse respiratory effect of acute -
blocker exposure in asthma: a systematic review and meta-analysis of randomized
controlled trials. Chest 2014; 145:779.
62. Stather DR, Stewart TE. Clinical review: Mechanical ventilation in severe asthma.
Crit Care 2005; 9:581.
63. Qaseem A, Snow V, Fitterman N, et al. Risk assessment for and strategies to reduce
perioperative pulmonary complications for patients undergoing noncardiothoracic
surgery: a guideline from the American College of Physicians. Ann Intern Med 2006;
144:575.
64. Sabato K, Hanson JH. Mechanical ventilation for children with status asthmaticus.
Respir Care Clin N Am 2000; 6:171.
65. Sarnaik AP, Daphtary KM, Meert KL, et al. Pressure-controlled ventilation in
children with severe status asthmaticus. Pediatr Crit Care Med 2004; 5:133.
66. Dhand R, Tobin MJ. Bronchodilator delivery with metered-dose inhalers in
mechanically-ventilated patients. Eur Respir J 1996; 9:585.
67. Mazela J, Polin RA. Aerosol delivery to ventilated newborn infants: historical
challenges and new directions. Eur J Pediatr 2011; 170:433.
68. Holland A, Smith F, Penny K, et al. Metered dose inhalers versus nebulizers for
aerosol bronchodilator delivery for adult patients receiving mechanical ventilation in
critical care units. Cochrane Database Syst Rev 2013; :CD008863.
69. MacIntyre NR, Silver RM, Miller CW, et al. Aerosol delivery in intubated,
mechanically ventilated patients. Crit Care Med 1985; 13:81.
70. von Ungern-Sternberg BS, Ramgolam A, Schultz A, et al. Salbutamol in ventilated
children does it get to where we want it? Society for Paediatric Anaesthesia in New
Zealand and Australia Congress (SPANZA). Sydney, Australia 2013.
71. British Thoracic Society Scottish Intercollegiate Guidelines Network. British
Guideline on the Management of Asthma. Thorax 2008; 63 Suppl 4:iv1.
72. Travers AH, Jones AP, Camargo CA Jr, et al. Intravenous beta(2)-agonists versus
intravenous aminophylline for acute asthma. Cochrane Database Syst Rev 2012;
12:CD010256.
73. Shan Z, Rong Y, Yang W, et al. Intravenous and nebulized magnesium sulfate for
treating acute asthma in adults and children: a systematic review and meta-analysis.
Respir Med 2013; 107:321.
74. Rowe BH, Bretzlaff JA, Bourdon C, et al. Magnesium sulfate for treating
exacerbations of acute asthma in the emergency department. Cochrane Database Syst
Rev 2000; :CD001490.
75. Gal TJ, Suratt PM. Atropine and glycopyrrolate effects on lung mechanics in normal
man. Anesth Analg 1981; 60:85.
76. Tuxen DV, Lane S. The effects of ventilatory pattern on hyperinflation, airway
pressures, and circulation in mechanical ventilation of patients with severe air-flow
obstruction. Am Rev Respir Dis 1987; 136:872.
77. Rodrigo GJ, Rodrigo C, Pollack CV, Rowe B. Use of helium-oxygen mixtures in the
treatment of acute asthma: a systematic review. Chest 2003; 123:891.
78. Shapiro JM. Management of respiratory failure in status asthmaticus. Am J Respir
Med 2002; 1:409.
79. von Ungern-Sternberg BS, Davies K, Hegarty M, et al. The effect of deep vs. awake
extubation on respiratory complications in high-risk children undergoing
adenotonsillectomy: a randomised controlled trial. Eur J Anaesthesiol 2013; 30:529.
80. Manion SC, Brennan TJ. Thoracic epidural analgesia and acute pain management.
Anesthesiology 2011; 115:181.
81. Short JA, Barr CA, Palmer CD, et al. Use of diclofenac in children with asthma.
Anaesthesia 2000; 55:334.
82. McBride JT. The association of acetaminophen and asthma prevalence and severity.
Pediatrics 2011; 128:1181.
83. Debley JS, Carter ER, Gibson RL, et al. The prevalence of ibuprofen-sensitive asthma
in children: a randomized controlled bronchoprovocation challenge study. J Pediatr
2005; 147:233.
84. Micheli L, Cerretani D, Fiaschi AI, et al. Effect of acetaminophen on glutathione
levels in rat testis and lung. Environ Health Perspect 1994; 102 Suppl 9:63.
85. Cheelo M, Lodge CJ, Dharmage SC, et al. Paracetamol exposure in pregnancy and
early childhood and development of childhood asthma: a systematic review and meta-
analysis. Arch Dis Child 2015; 100:81.
86. Mayberg TS, Lam AM, Matta BF, et al. Ketamine does not increase cerebral blood
flow velocity or intracranial pressure during isoflurane/nitrous oxide anesthesia in
patients undergoing craniotomy. Anesth Analg 1995; 81:84.
87. Himmelseher S, Durieux ME. Revising a dogma: ketamine for patients with
neurological injury? Anesth Analg 2005; 101:524.
88. Chang LC, Raty SR, Ortiz J, et al. The emerging use of ketamine for anesthesia and
sedation in traumatic brain injuries. CNS Neurosci Ther 2013; 19:390.
89. Milde LN, Milde JH, Michenfelder JD. Cerebral functional, metabolic, and
hemodynamic effects of etomidate in dogs. Anesthesiology 1985; 63:371.