[page 70] [Pediatric Reports 2012; 4:e19]

Update on perioperative management of the child with asthmaFrancesco Dones, Grazia Foresta,Vincenzo Russotto Department of Anesthesia and IntensiveCare AOUP, University of Palermo, ItalyAbstract

Asthma represents the leading cause ofmorbidity from a chronic disease among chil-dren. Dealing with this disease during theperioperative period of pediatric surgical pro-cedures is, therefore, quite common for theanesthesiologist and other professionalitiesinvolved. Preoperative assessment has a keyrole in detecting children at increased risk ofperioperative respiratory complications. Forchildren without an optimal control of symp-toms or with a recent respiratory tract infec-tion elective surgery should be postponed, ifpossible, after the optimization of therapy.According to clinical setting, loco-regionalanesthesia represents the desirable optionsince it allows to avoid airway instrumenta-tion. Airway management goals are preventingthe increase of airflow resistance during gen-eral anesthesia along with avoiding triggers ofbronchospasm. When their use is possible,face mask ventilation and laringeal mask areconsidered more reliable than tracheal intuba-tion for children with asthma. Sevoflurane isthe most commonly used anesthetic for induc-tion and manteinance. Salbutamol seems to beuseful in preventing airflow resistance riseafter endotracheal intubation. Mechanical ven-tilation should be tailored according to patho-physiology of asthma: an adequate expiratorytime should be setted in order to avoid a posi-tive end-expiratory pressure due to expiratoryairflow obstruction. Pain should be preventedand promptly controlled with a loco-regionalanesthesia technique when it is possible.Potential allergic reactions to drugs or latexshould always be considered during the wholeperioperative period. Creating a serene atmos-phere should be adopted as an important com-ponent of interventions in order to guaranteethe best care to the asthmatic child.

IntroductionAsthma is one of the most common chronic

disease, affecting 300 million people world-wide, with an increasing prevalence especiallyamong children.1 In childhood it represents

the leading cause of morbidity from a chronicdisease.

Several host and environmental factorsinfluencing the development of asthma havebeen identified. Sensitization to aeroallergens,maternal diet during pregnancy and/or lacta-tion, tobacco smoke, infections and psychoso-cial elements are the main environmental fac-tors identified. However no intervention hasyet been proven to prevent the onset of asthmaor to modify its long-term natural course.2

Asthma is a chronic inflammatory disorderof the airway characterized by airway hyperre-sponsiveness associated with recurrentepisodes of wheezing, breathlessness, chesttightness and coughing. The widespread butvariable airflow obstruction is often reversibleeither spontaneously or with treatment.1 Inyounger children, however, symptoms could beless specific.2

The improvements of medical care havedecreased morbidity and mortality and theincidence of perioperative severe complica-tions in asthmatic children undergoing anes-thesia and surgery. Nevertheless bron-chospasm can still represent a lifethreateningcomplication3 and an accurate attention fordetails is necessary during the whole perioper-ative care to prevent the most severe adverseevents. The goals of the anaesthesiologicmanagement of the patient with asthma are toprevent the potentially catastrophic event ofintraoperative bronchospasm4 and to tailor ananaesthetic plan to the child in order to ensurean adequate airflow, avoiding drugs and tech-niques associated with a potential risk ofincreasing pulmonary resistance.

The aim of this review is to focus on themost debated topics of the anesthesiologicmanagement of the child with asthma trying toclarify the latest observations.

Pathophysiology and clinicalconsiderationsAirway inflammation is the key feature of

asthma. It characterizes patients of all agesand it is permanent even if symptoms areepisodic.1 The correlation between inflamma-tion and airway hyperresponsiveness has beenestablished, but the mechanisms involved arenot completely clear. Airway hyperresponsive-ness contributes to airway narrowing and air-flow obstruction through several (incompletelyunderstood) mechanisms like changes insmooth muscle contractility or sensory nerveand autonomic activity.5,6

Several triggers of airway obstruction andsymptoms have been identified in childhood:infections, cold air, outdoor air pollution,laughing, crying, activity.2

Inflammatory edema and mucous plugging

contribute to airway narrowing by luminalobstruction.3

Chronic inflammation is associated withcomplex structural changes of the airway col-lectively named airway remodeling. These fac-tors progressively impair response to bron-chodilator therapy.7,8

The following diagram3,5-10 (Figure 1)underlines the pathophysiology sequence thatoccurs in the patient with airway obstruction.Some of the events described are the conse-quence of a chronic disease (e.g. airwayremodeling)7,8 but a severe airway obstructionand the related cardiac response may repre-sent the expression of an acute perioperativerespiratory complication (bronchospasm)3 in apatient with asthma (previous known or not).Air trapping due to decreased airflow (espe-cially during expiration) leads to dynamichyperinflation (with increasing positive end-expiratory pressure, PEEP) and dynamic com-pliance reduction of the lungs.3,9 Accessorymuscles recruitment is necessary to ensure anormal tidal volume and to perform an activeexhalation in the presence of a severe airflowobstruction:3 an increased work of breathingand oxygen consumption is the consequence.9With air trapping and muscle fatigue develop-ment, CO2 retention increases and it repre-sents the sign of decompensation and of aneed of immediate ventilatory support. Theincreasing lung volume and PEEP may lead toa decreased venous return to the heart andhence to systemic hypotension and low perfu-sion.3,9 Hypoxic pulmonary vasoconstrictioninvolves hypoinflated areas of the lung andventilation/perfusion ratio (V'/Q') mismatchcould be balanced at the beginning. Howeverthe increased pulmonary vasculature resist-

Pediatric Reports 2012; volume 4:e19Correspondence: Francesco Dones, Departmentof Anesthesia and Intensive Care AOUP,University of Palermo, via Trinacria 32, 90144Palermo, Italy.Tel. +39.091.513550. E-mail: donesfra@alice.it

Key words: pediatric, asthma, perioperative man-agement.

Conflicts of interest: all authors declare thatthere are no conflicts of interest.

Received for publication: 7 December 2011.Revision received: 29 February 2012.Accepted for publication: 29 February 2012.

This work is licensed under a Creative CommonsAttribution NonCommercial 3.0 License (CC BY-NC 3.0).

Copyright F. Dones et al., 2012Licensee PAGEPress, ItalyPediatric Reports 2012; 4:e19doi:10.4081/pr.2012.e19

[Pediatric Reports 2012; 4:e19] [page 71]

ance is responsible of the right ventricularoverload and further oxygen consumption.Hypoxaemia represents the end stage of thissequence and it is the result of the increasingV'/Q' mismatch (due, among other factors, tovasodilation run by inflammation).10

Preoperative assessment andrisk factors evaluationHistoryUncontrolled baseline bronchial hyperreac-

tivity represents the most important risk factorfor perioperative adverse respiratory events inasthmatic patients.11 A correct preoperativehistory can intercept patients with inadequatecontrol of asthma.12 Information can beobtained from child or parents, preferably both.

A history of a recent flare of the diseaserequiring oral corticosteroids, an increaseduse of inhaled short-acting 2-agonists, arecent exacerbation of asthma symptoms, theoccurrence of emergency room or hospital visitduring the last months suggest a poorly con-trolled disease.4,11 According to clinical condi-tions of the child, elective surgery should becancelled and rescheduled after the optimiza-tion of therapy. However anesthesia may berequired in children not responding to treat-ment of severe symptoms of asthma exacerba-tion or during urgent diagnostic/therapeuticprocedures such as bronchoscopy.

The use of systemic corticosteroids for morethan 2 weeks within the prior 6 months shouldalso be sought in order to plan a perioperativesteroid therapy for the patients at risk for anadrenal crisis.1,3,13,14 A history of at least twofamily members having asthma, atopy, orsmoking increases the risk for perioperativerespiratory adverse events.15 A personal histo-ry of eczema has been also considered signifi-cant in this sense.15

Information about other possible risks orcomplicating factors, like recent infections inupper or lower respiratory tract, history of peri-operative bronchospasm or previous pul-monary complications during general anesthe-sia,12 obesity, or environmental tobacco expo-sure should be taken in consideration.

Previous allergic reactions should be inves-tigated.16 In a prospective survey, latex was themain cause of perioperative anaphylactic reac-tions in children (76%).17-19 History is themain tool to investigate a latex sensitivity.Children submitted to multiple surgical proce-dures, such as for spina bifida, especially at avery young age, are at an increased risk oflatex sensitization. It could be useful to askspecifically to parents and children whethercontact with rubber toys (e.g. ballons) or rub-ber dam are responsible of lips and tongue

swelling, itching, rash or angioedema.19,20Asking for allergy to some fruits (e.g. avocado,banana, kiwi, chestnut) and vegetables (e.g.tomato, bell pepper, carrot) has been suggest-ed to be helpful to detect an increased risk oflatex sensitivity since there is evidence ofcross-sensitivity between several shared anti-gens.19

Concerning upper respiratory tract infec-tions, fever, moist cough and green runny noseare important elements to consider during thepreoperative evaluation.15 The higher inci-dence of respiratory adverse events in childrenwith a present or recent respiratory tract infec-tion21 might be explained by an increased air-way sensitivity provoked by the underlyinginflammation and its influence on the auto-nomic nervous system.6,22 This condition per-sists after resolution of signs and symptomsfor a variable period and rescheduling an elec-tive procedure 2-3 weeks after the upper respi-ratory tract infection, when possible, is consid-ered a safe approach.15 However this last deci-sion should be made on a case by case basis,after a risk-benefit ratio assessment includingthe child's presenting symptoms and theurgency and type of surgery. Frequency of res-piratory infections should also be considered,since a child could experience six to eightepisodes per year and it may be difficult to pre-dict a symtoms free period for elective surgery.Nevertheless, even before a non elective sur-gery, the knowledge of a recent or active respi-

ratory infection could alert the anesthesiolo-gist to the potential of complication and theanesthetic management could be modified inorder to reduce any risk (e.g. avoiding airwayinstrumentation if possible).22

Obese children have a significantly higherprevalence of coexisting conditions, includingasthma.23

Tait et al.24 have identified obesity as anindependent predictor of perioperative criticaladverse events in children. El-Metainy et al.25have observed a significant associationbetween obesity and asthma and a higheroccurrence of perioperative bronchospasm inobese children, especially with coexistingasthma. An association between obesity andquality of control was also identified for allages.1 Lung mechanics alterations, pro-inflam-matory state and genetic, hormonal or neuro-genic factors are some of the proposed mecha-nisms that could influence the development ofasthma and its clinical course in the obesepatient.26,27 Environmental tobacco smokeexposure increases the incidence and severityof asthma and respiratory illness. Several stud-ies have demonstrated that environmentaltobacco smoke exposure is an independentpredictor of adverse respiratory events in chil-dren receiving general anesthesia28 and oflaryngospasm at the emergence from anesthe-sia,29 especially in girls and in children whosemothers had a lower educational level andwere exposed to maternal smoke.30

Review

Figure 1. Pathophysiology of airway obstruction.

[page 72] [Pediatric Reports 2012; 4:e19]

Physical examinationPhysical examination is usually negative

between exacerbations.3 Wheezing should bedetected on auscultation and accessory mus-cles recruitment should be sought. Signs orsymtoms of respiratory infections should bedetected and decision about suitability for sur-gery should be made after a complete evalua-tion of the current clinical condition.15,22Functional tests

Spirometric evaluation could be importantin individuals suffering from severe bron-chospasm or with uncertain anamnesticdata.11 However patient compliance in thepediatric population should be considered andcould represent the main limit to the applica-tion of functional tests.

Functional tests could be particularly usefulto assess bronchodilation response to therapyin children as they could be unaware of signif-icant changes of lung function and symptomscould not be easily adopted to assess potentialoptimization of respiratory function.31

Forced Expiratory Volume in the 1st second(FEV1) has been included as one of the param-eters estimating the level of asthma control. Anormal FEV1 is associated with a well con-trolled disease whereas a FEV1

[Pediatric Reports 2012; 4:e19] [page 73]

necessary for some surgical interventions (e.g.craniofacial surgery), when intubation wasdifficult, when there is concern for aspirationof gastric content or according to hospitalorganization.54

Concerning the use of laryngeal masks, clas-sic pediatric size models are not provided of adrainage tube55 and considering also the big-ger size of the tongue in proportions to theother anatomical structures, suction of airwayand gastric secretions before emergence couldnot be feasible and bronchospasm triggeringby secretions should, therefore, be considered.

Ventilation with face mask should be avoid-ed when it is not possible to establish the com-plete gastric emptying.Muscle relaxation

Among pediatric anesthesiologists, the prac-tice of induction without muscle relaxant useis common.46,56,57 According to our experience,intubation is usually performed under deepinhalation anesthesia and muscle relaxationdrugs are not necessary during the majority ofambulatory and minor surgical procedures,especially for younger children. Avoidance ofthese drugs when not necessary reduces theside effects related to their mechanism ofaction (muscarinic agonism and histaminerelease), the incidence of allergic reactionsand the adverse effects due to reversal drugsusing.58 However muscle relaxation may beuseful for certain surgical procedures toimprove operative conditions (e.g. majorabdominal operations). For this purpose, theuse of vecuronium and cisatracurium is con-sidered safe in the asthmatic patient accordingto their lower affinity to M2 muscarinic recep-tors and power of histamine release.4,59

Mivacurium has been identified as a triggerof bronchospasm in asthmatic children accord-ing to its histamine (and maybe other media-tors) release capacity in a dose-dependentmanner.60

Atracurium in asthmatic patients should beused with caution in dose and rate of adminis-tration.4,61 The use of muscle relaxation rever-sal drugs should be avoided since theyincrease airway secretions and bronchialhyperactivity.58 However complete reversal ofneuromuscular blockade should be carefullyverified in order to ensure an adequate postop-erative ventilation. Sugammadex, a selectiveneuro-muscle blockers binding agent, could beused for a rapid muscle relaxation reversal,avoiding the side effects of anticholinesterasedrugs,62,63 but further investigations are nec-essary before its routinary use in the pediatricand asthmatic population.Inhalational agents

Inhalational agents have been the anesthet-ics of choice for patients with airway hyperre-sponsiveness. Volatile agents have shown a

bronchodilatory effect, and a decrease in hista-mine release from leukocytes has beenobserved with their use.4

Desflurane is the only inhalational anes-thetic not recommended in patients with air-way hyperresponsiveness; it has been associ-ated with coughing, laryngospasm, bron-chospasm and an increase of secretions. Theincrease in resistance and inertance in chil-dren with airway hyperresponsiveness, moresusceptible to the irritative nature of desflu-rane, appears to involve the peripheral airwaystoo.64

Sevoflurane is the most used volatile agentfor anesthesia in children. Habre et al.65 haveobserved a small but significative increase ofRrs after endotracheal intubation undersevoflurane (1.2 MAC) in asthmatic children;however a decrease in Rrs both in asthmaticand in non asthmatic children has beenobserved after an increase of sevoflurane con-centration (1.7 MAC). Although the increase ofRrs has been not associated with clinically sig-nificant respiratory adverse events, cautionhas been recommended for children with moresevere and unstable asthma.

The administration of inhaled 2-adrenergicagonists before tracheal intubation undersevoflurane appears to prevent the Rrsincrease. The same authors33 have investigat-ed the use of salbutamol in mild to moderateasthmatic children under sevoflurane, observ-ing a protective effect in this group of patients.However the prophylactic effect seems to beincomplete, showing a decrease in the airwayresistance component but not in the parenchy-mal one.

Recently fentanyl has been studied in orderto detect a protective effect against respiratoryreflexes in children under sevoflurane:Thomas et al.66 have found the same incidenceof laryngospasm in children anesthetized withsevoflurane despite the administration of twosuccessive doses of 1.5 mcg/kg of fentanyl,probably for the lower depressant action of opi-oids on upper airway originating stimuli com-pared to lower airway originating ones.

The incidence of laryngospasm seems to behigher using sevoflurane than propofol unlesscough and expiratory reflexes have beenobserved to be lower under sevoflurane anes-thesia, regardless of level of hypnosis.67Intravenous agents

Several studies have been conducted to eval-uate the effects of intravenous agents on res-piratory resistances. Using an animal model,Brown et al.68 have observed a dose dependentattenuation of vagal nerve stimulation-inducedbronchoconstrinction after the infusion ofpropofol or ketamine. They supposed a local,neurally mediated, mechanism. The sameauthors have underlined the importance of thepreservative agents contained in some propo-

fol formulations (e.g. metabisulfite) in influ-encing these observations.69

In a population of non asthmatic patients,etomidate, propofol and thiopental have beencompared for their effect on respiratory resist-ance after tracheal intubation, observing thelowest Rrs increase after propofol induction.70Recently a neurokinin A involving mechanismhas been observed in an animal model investi-gating the tracheal smooth muscle contrationattenuation by propofol.71

There is concern about a higher risk ofadverse reactions to propofol in patients with asensitivity to some food (e.g. eggs, peanuts andsoybean oil).72 A possible anaphylaxis afterpropofol administration in a child with severalfood allergies (eggs and peanut oil), atopy andreactive airway disease has been reported; theauthors suggest to avoid propofol in patientswith a documented allergy to these foodswhether it is possible.73 It is likely that themanufacturing process of propofol removes ordenatures the proteins which are responsiblefor egg and soya allergies. However a cautiousapproach for these groups of patients has beenrecently suggested.20 Use of propofol, there-fore, should be evaluated after a risk-benefitbalance in the single child.20,74-76

Ketamine has been promoted in the past asthe intravenous anesthetic of choice for thepatient with asthma.14 Its bronchodilator effectis related to the systemic catecholamineincreased level following its infusion and to adirect interference with the parasympatheticand endothelin pathways.3,77 The increase ofairway secretion represents a disadvantage ofits use in the asthmatic child when not associ-ated with an anticholinergic drug.3,4 A big ran-domized controlled trial involving asthmaticchildren is necessary in order to justify its useas a first choice intravenous agent.

Concerning the use of opioid analgesics,histamine-release potential of morphine iswell known78 and its use in asthmatic patientshas been discouraged. Conversely, syntheticopioids like fentanyl and remifentanyl have notbeen associated with a significant histaminerelease78 and therefore they have been used inasthmatic patients. Despite their off-label con-dition in pediatrics, their use is widespreadand experience with these drugs is growing.

Coughing after fantanyl and remifentanylintravenous administration has been reportedin adults and children79-82 and risk seems to behigher in this last group;83 since coughingcould represent a trigger of bronchospasm inasthmatic children, particular attention shouldbe paid during and after their use.Mechanical ventilation

Mechanical ventilation should be tailored tothe pathophysiologic changes observed in thechild with asthma. In order to prevent air trap-ping due to increased expiratory resistances, a

Review

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longer expiratory time should be assured andthus an adeguate respiratory frequency rateadopted. The aim of this strategy is to avoidintrinsic positive end-expiratory pressure(PEEP) and the subsequent events describedabove.3,9,84

Plateau pressure (Pplat), which is theexpression of post-inspiratory alveolar pres-sure, should be assessed and monitored inorder to prevent barotrauma.9,85-87

Inhaled gases should be properly warmedand humidified,3 especially when a low flowcircuit is not used, since cold and dry air couldrepresent a trigger of bronchospasm.1Perioperative complications

Complications could be divided (Table 1)into two big groups: complications due to air-way management (bronchospasm, laryn-gospasm, cough, oxygen desaturation, stri-dor)15 and complications due to air trapping(hypotension, pneumothorax, subcutaneousemphysema, cardiac arrest).3,84,85 Even if notspecifically related to the pathophysiology ofasthma, anaphylaxis could be consideredamong the possible complications of the childwith atopy and allergic asthma.14,19

The incidence of complications in asthmat-ic patients appears to be low, according toreported data. Warner et al.88 have found a fur-ther low incidence of complications in chil-dren (0,6% of perioperative respiratory com-plications in patients aged 9; laryingospasm was the onlycomplication observed in patients aged 0-9).

Tube malposition and tube occlusionbecause of secretions are the first causes ofcomplications and they must be rapidly veri-fied at the occurrence of signs suggesting apossible adverse event.27 Intraoperative bron-chospam is recognized by polyphonic, bilater-al, expiratory wheeze, increased airway pres-sure, endtidal CO2 rise and possibly hypox-emia.

In awake child wheezing is associated withprolonged expiration and accessory musclesrecruitment with increased respiratory effort.In most severe cases respiratory silence repre-sents the complete airflow arrest. The differ-ential diagnosis, along with mucous pluggingand tube malposition (e.g. kinked, bronchialintubation with unilateral wheezing) includespulmonary edema and tension pneumotorax.The possibility of a foreing body obstruction(e.g. a tooth) should also be considered.3,27Broncho spasm should be promptly treatedsince development of hypoxia is responsiblefor serious and early injuries in children.100% oxigen shoud be administered and anes-thesia deepened (raising the concentration ofinhalational anesthetics). Manual bag ventila-tion could be useful to asses compliance of thethoraco-pulmonary system and to achieve arapid inspiratory flow to facilitate a longerexpiratory time.3,27 A rapid-acting 2 agonistshould be administered via a nebulizer (2.5-5mg every 20-30 min).14 Corticosteroid therapyis usually administered even if it does not rep-resent a first line therapy of bronchospam (4mg/Kg hydrocortisone e.v.).14,27,89 Magnesiumsulfate ev, a drug proposed for status asthmati-cus, has been included as a second line treat-ment for persistent bronchospasm (40 mg/Kgover 20 min).3,9,14 For refractory bron-chospasm or when an anaphylactic reaction issuspected, epinephrine use should be prompt-ly considered (1-10 mcg/Kg, depending on theseverity of bronchospasm and patient'srespon se).19,89,90

The incidence of perioperative anaphylax-is in children is 1:7,700 and latex representsthe main substance involved in this popula-tion (76% of reactions).17,18 It has beenreported that a history of atopy is associatedwith an up to 10-fold increase of latex sensiv-ity.19 As mentioned above (see History), chil-dren at increased risk of latex sensitivity arethose who have undergone multiple surger-ies (especially in early life, e.g for congenitalurologic, gastrointestinal and tracheoe-sophageal defects) as well as children withspina bifida.19

Intraoperative allergic reactions have abroad spectrum of manifestations dependingon trigger agent, its route and rate of adminis-tration, the nature of the patient's hypersensi-tivity, the state of health of the patient and theeffects of concomitant medications (e.g. anti-histaminic drugs, blockers).20 The clinicalfeatures usually develop within few minutesbut may be delayed by up to an hour.20Distinction between the allergic nature of areaction and a non-immunologic adverseevent, such a direct non-specific hystaminerelease, could be impossible on a clinicalbasis. However clinical manifestations seemto be more severe when they occur during anallergic anaphylaxis.18,20 Clinical features of

an anaphylactic reaction include hypotension,tachycardia or bradycardia, bronchospasm andhypoxia, cutaneous manifestations such asflushing, erythema, rash or urticaria,angioedema and cardiac arrest.19,20 In patientswith pre-existing asthma, bronchospam couldbe more common.20 Cutaneous manifestationsmay be more likely observed during non-aller-gic anaphylaxis or may be masked by surgicaldrapes during an allergic anaphylaxis.18,19When a single clinical sign represents thepresentation of anaphylaxis, it could easily bemisdiagnosed since other causes related toanesthesia are commonly sought. Consideringanaphylaxis as the cause of an intraoperativeadverse event such as hypotension or bron-chospam, unless there exists a more likelycause, could represent an advisable approach,especially in high risk patients.19,20,89

When a trigger substance is suspected itshould be promptly removed.19,89 Cardiova -scular instability could be treated with intra-venous boluses of balanced salt solution (20mL/Kg during 10-20 min) and Trendelenburgposition.19 Balanced salt solutions containingsodium metabisulfite as stabilizer should beavoided since thay could provoke bron-chospam in asthmatic patients.91 According tothe severity of bronchospasm and hypoten-sion, intravenous epinephrine should be asso-ciated to fluid resuscitation (from 1-10mcg/Kg).19 After stabilization of clinical condi-tion, the allergic nature of the reaction shouldbe confirmed along with the responsibility ofthe suspected agent in order to provide preciserecommendations for future anesthetic proce-dures. A detailed description of the reaction,its time of onset and its relation with drugsadministration and other events should beprovided by the anesthesiologist to the spe-cialist centre to which the patient should bereferred. Blood samples should be taken assoon as possible after the stabilization of theclinical condition, 1-2 hours after the onset ofthe event and at 24 h or during convalescence:these samples are useful for mast cell tryptaselevel determination, a commonly used markerof mast cell degranulation. Skin tests for thesuspected agent and specific IgE determina-tion, according to local availability, are theother tests which should be performed in theallergology centre.19,20

Suppression of hypothalamic-pituitary-adrenal axis may be present after a steroidtherapy and thus an adrenal crisis may be pre-cipitated by the surgical stress.14 Such possi-bility should be considered particularly in chil-dren requiring high doses of systemic corti-costeroids to control asthma, but also in chil-dren using high doses of inhaled corticos-teroids.92,93 Intrave nous hydrocortisone andfluid resuscitation are the key point of therapyfor the adrenal crisis, along with treatment ofhypoglicemia.14

Review

Table 1. Classification of perioperativecomplications of the child with asthma.

Complications related to airway managementBronchospasmLaryngospasmCoughOxygen desaturationStridor

Complications related to air trappingHypotensionPneumothoraxSubcutaneous emphysemaCardiac arrest

OthersAnaphylaxisAdrenal crisis

[Pediatric Reports 2012; 4:e19] [page 75]

Postoperative CareThe control of post-operative pain has a key

role in the post-operative management of thechild;94 furthermore in the asthmatic childuncontrolled pain could induce a stressfulstate and provoke bronchospasm and othercomplications. Pain should be prevented orrapidly controlled;94 the use of non-pharmaco-logical strategies may have positive effects andcontribute to create a relaxing environmentaround the child and his family.38

A local/regional anesthesia techniqueshould be always chosen unless there areimportant contraindications not to.94 When asystemic analgesia is required, acetamino-phen (paracetamol) is the first choice drug totreat mild to moderate post-operative pain inchildren.95 Acetaminophen has been associat-ed to bronchospasm and wheezing, especiallyin patients with aspirin-sensitivity history;1,96glutathione depletion in the respiratory tractor trigger action of some additives have beensuggested as possible mechanisms.96,97 How -ever the association between reported reac-tions to paracetamol and a real hypersensitivi-ty to this drug appears to be weak in mostcases, and thus paracetamol remains a validalternative to non-steroid anti-inflammatorydrugs (NSAIDs) in asthmatic patients.96,98Anyway many asthmatic children can takeNSAIDs without reactions; it could be useful tocheck any past exposure and reactions toNSAIDs.1,94 Because of the associationbetween aspirin and Reye syndrome, aspirin istoday rarely administered to children andaspirin sensitivity could be not recognized inyoung children with asthma. Aspirin-inducedasthma is probably underestimate in chil-dren;97 aspirin hypersensitivity seems to bepresent in about 2% of children,94 but this per-centage increases when children undergo anoral provocation test.

It has been suggested that NSAIDs likeibuprofen could offer a protective effect whenused in acute scenarios (e.g. post-operativepain) because of the antinflammatory activityon the airway inflammation, known as one ofthe main features of pathogenesis of asthma.97

Despite diclofenac has been proven safe inchildren with asthma in some studies, authorsof a recently published Cochrane review haveconcluded that further investigation arerequired to definitely asses its optimal dosingand safety.99

ConclusionsAsthma is a very common disease, with

increasing trends especially in children2 andall professionalities involved in the pediatric

setting have to handle with it.The correct evaluation of the baseline dis-

ease is the key point of preoperative assess-ment;1,4,11 every possible risk factor for respira-tory complications must be taken into consid-eration,15 corrected if possible or suggest toreschedule surgery if elective and whether thisis feasible based on clinical conditions of thechild. According to the clinical setting, locore-gional anesthesia should be always consideredas the fist choice for the child with asthma.14

Airway should be carefully managed andinhalational anesthesia appears to be the bestoption in the asthmatic child under generalanesthesia. Perioperative complicationsshould be promptly recognized and treat-ed.19,88-93 An adequate post-operative pain con-trol may reduce the risk of complications andimprove the outcome of the patient.94 A properperioperative management of the child withasthma has a key role for an uneventful anes-thesia with a sufficiently low risk of seriouscomplications.

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