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“The Science Behind the Art” 
Volume 10- No. 4 2022 

Anesthesia eJournal - Online
ISSN 2333-2611

Page 1

Preoperative Optimization of the Asthmatic Patient
Ryan Jordan, BSN, RN, CCRN

Affiliation:
Texas Christian University 

Grant/Financial Support: 
None 

Biographical data:  
Ryan Jordan is a Resident Registered Nurse Anesthetist pursuing his DNP in nurse anesthesia at Texas Christian University in 
Fort Worth, Texas. 

KEYWORDS: Bronchodilators, bronchospasm, asthma, optimization

Abstract
Asthma is a common upper respiratory condition among patients across the developmental spectrum estimated to affect 
over 300 million people worldwide with prevalence rate and condition severity continually increasing.1 The purpose 
of pursuing this topic is to share a case study to educate anesthesia providers about the complications resulting from 
intraoperative bronchospasm and to provide guidelines for preventing bronchospasm during the perioperative period. A 
77-year-old, female, ASA 4, inpatient was undergoing general anesthesia for left percutaneous hip pinning. The patient
had significant medical history including asthma and COPD (well-controlled) but still experienced bronchospastic
events intraoperatively. This case report reviews current prevention, treatment, and optimization of bronchospasm in at-
risk adults.

AEJ
Volume 10- No. 4 2022

About the author: Ryan Jordan is a nurse anesthesia graduate student at Texas Christian University. Ryan received a 
BS in Psychology from the University of Georgia in 2012 and a BSN from UT-Arlington in 2017. Since graduating 
nursing school, he has worked as a Registered Nurse in both Cardiac and Trauma ICUs at Harris Methodist Fort 
Worth hospital in downtown Fort Worth, TX.



Texas Christian University 
“The Science Behind the Art” 
Volume 10 - No.4 2022

Anesthesia eJournal - Online
ISSN 2333-2611

Page 2

PowerPoint Template ©2009 Texas Christian University, Center for Instructional Services. For Educational Use Only. Content is the property of the presenter and their resources.

Introduction
• Asthma is a common respiratory condition affecting

millions of people worldwide
• Bronchospasms are a defining feature of asthma in which

the smooth muscle of the airway contracts and narrows 
(figure 1)1

• The high prevalence of asthma means that many patients
undergoing surgery are at risk of an intraoperative 
bronchospasm

• Preventing intraoperative bronchospasm decreases the 
risk of postoperative respiratory complications

• Preoperative pharmacologic interventions are a well-
documented method for reducing intraoperative 
bronchospasm and postoperative respiratory issues.

• However, the preventative strategies are often omitted 
preoperatively for some asthmatic surgical patients 

• Purpose statement: To educate heath care providers
about the risks surrounding intraoperative bronchospasm
and to encourage the optimization of asthmatic patients 
prior to surgery. 

Discussion
• Asthmatic patients undergoing general anesthesia with

tracheal intubation are at risk for intraoperative 
bronchospasm caused by the airway irritation inherent in
placement of an endotracheal tube.

• Intraoperative bronchospasm increases the risk of 
postoperative pulmonary complications such as prolonged
intubation, oxygen desaturation, severe coughing, and 
postoperative stridor.4

• Comprehensive assessment and preoperative 
pharmacologic optimization of the asthmatic patient is the
most effective way of decreasing the incidence of 
intraoperative bronchospasm and the complications 
associated with it.

• Strategies for preventing intraoperative bronchospasm, 
such as preoperative beta-2 agonist administration, are 
well documented in the literature 

• Despite the evidence, some patients diagnosed with 
asthma are not receiving preoperative intervention based
on the self-report that their asthma is well-controlled.

• If all asthmatic patients, regardless of the severity of their 
asthma, are pharmacologically optimized during the 
preoperative period, the overall incidence of intraoperative
bronchospasm may be reduced.

Preoperative Optimization of the Asthmatic Patient
Ryan Jordan, RN, BSN, CCRN, Texas Christian University

Clinical assessment Well 
controlled

Not well 
controlled

Poorly 
controlled

Symptoms 
(wheezing, 
shortness of breath, 
chest tightness)

≤2 days/week >2 days/week Daily

Night-time 
awakenings with 
breathing problems

≤2 x/month 3–4 x/month >1 x/week

Short-acting beta 2 
agonist use for 
rescue

≤2 days/week >2 days/week 
but not daily

Daily

Interference with 
normal activity

None Some limitation Extreme 
limitation

Exacerbations 
requiring systemic 
corticosteroids

≤1 x/year 2–3 x/year >3 x/year

Patients above 5 years include additionally

FEV1 predicted >80% 60–80% <60%

FEV1/FVC >0.8 0.75–0.80 <0.75

Table 1. Assessment Of Asthma Severity1
Abbreviations.  FEV1, forced expiratory volume in 1 sec; FVC, forced vital 
capacity.  

Figure 1. Asthmatic Airway During Bronchospasm6

Case Report
• 77-year-old, physical status 4, female presented for closed

reduction of left hip and percutaneous pinning.
• Medical history: COPD, well-controlled asthma per patient
• Due to self-report of well-controlled asthma, no 

bronchodilator medication were administered. Lung
sounds clear bilaterally upon auscultation.

• Preoperative vital signs: BP 154/89 mm Hg, HR 82/min, 
RR 16/min, SpO2 98%, oxygen 2 L/min via nasal cannula,
temperature 36.5 °C

• Anesthesia induction: preoxygenation FiO2 1.0, 10 L/min,
lidocaine 100 mg, fentanyl 100 mcg, propofol 100 mg IV;
succinylcholine 100 mg IV for neuromuscular blockade

• Atraumatic direct laryngoscopy, Macintosh #3 blade, size 
7.0 mm endotracheal tube, grade 1 Cormack-Lehane view
of vocal cords, positive end-tidal CO2 (ETCO2), bilateral 
breath sounds equal.

• Mechanical ventilation, pressure-controlled ventilation 
with volume guarantee (PCV-VG) mode, RR 12/min, tidal 
volume (VT) 562mL, FiO2 0.5, peak inspiratory pressure 
(PIP) 17 cm H2O, positive end expiratory pressure (PEEP)
4 cm H2O.

• Shortly after induction of anesthesia, ETCO2 decreased,
prolonged upstroke on capnogram, SpO2 drop from 98%
to 91%, PIP increase to 38 cm H2O, and breath sounds
were absent.

• The bronchospasm was quickly treated with multiple 90
mcg puffs of endotracheal albuterol. ETCO2 returned to
52, SpO2 increase to 97%, bilateral breath sounds
returned. 

• The surgical procedure commenced and proceeded
without further exacerbation of asthma.

• However, prior to emergence, a second severe
bronchospasm occurred requiring endotracheal albuterol 
and epinephrine 100 mcg IV.  

• The bronchospasm resolved with medications.
Postoperative course
• Patient remained intubated, sedated, and was transferred

to ICU for postsurgical and pulmonary care. The patient 
was extubated the following day once stable. 

References
1. Bayable SD, Melesse DY, Lema GF, Ahmed SA. Perioperative management of patients with 

asthma during elective surgery: a systematic review. Ann Med Surg. 2021; 70. 
doi:10.1016/j.amsu.2021.102874

2. Dewachter P, Mouton-Faivre C, Emala CW, Beloucif S, Riou B. Case scenario: 
bronchospasm during anesthetic induction. Anesthesiology. 2011; 114(5):1200-1210. 
doi:10.1097/ALN.0b013e3182172cd3

3. Maslow AD, Regan MM, Israel E, Darvish A, Mehrez M, Boughton R, Loring SH. Inhaled 
albuterol, but not intravenous lidocaine, protects against intubation-induced 
bronchoconstriction in asthma. Anesthesiology. 2000;93(5):1198–1204.
doi:10.1097/00000542-200011000-00011

4. Ungern-Sternberg BS, Sommerfield D, Slevin L, Drake-Brockman TFE, Zhang G, Hall GL. 
Effect of albuterol premedication vs placebo on the occurrence of respiratory adverse events 
in children undergoing tonsillectomies: the REACT randomized clinical trial. JAMA 
Pediatr. 2019;173(6):527–533. doi:10.1001/jamapediatrics.2019.0788

5. Erdoğan T, Göksel Ö, Kırkıl G, et al. Is the perioperative period no longer a problem for adult 
asthmatics under control?-OPERA study. Turk Thorac J. 2020;21(3):140-144.
doi:10.5152/TurkThoracJ.2019.18051

6. Lynn SJ & Kushto-Reese K. Understanding asthma pathophysiology, diagnosis, and 
management. Myamericannurse.com. Published July 7, 2015. Accessed February 15, 2022. 
https://www.myamericannurse.com/understanding-asthma-pathophysiology/

7. Bronchospasm 2-Patient Monitor. Kaiser Permanente School of Anesthesia. Youtube.com. 
Published March 2, 2016. Accessed February 23, 2022.
https://www.youtube.com/watch?v=Ty2qb-6Gdk4 

Conclusions & Recommendations for 
Practice 

• Every asthmatic patient undergoing surgery with general
anesthesia requiring tracheal intubation should be 
pharmacologically optimized during the preoperative 
period, regardless of the perceived severity of their 
asthma.

• Adopting this practice will likely decrease the incidence of
intraoperative bronchospasm and the adverse 
postoperative complications associated with it.

• Providing bronchodilatory medications such as albuterol or 
ipratroprium via inhaler or nebulizer 10 minutes prior to 
surgery can potentially reduce the costs associated with 
lengthier hospital stays and increase patient satisfaction 
scores.1

Synthesis of Literature
• A structured evidence search was conducted to investigate the

topic of perioperative asthma optimization 
• Five articles obtained through the search were used as

evidence
• The design and methods used to investigate the topic varied

from a single case study, to prospective randomized control 
trials, to systematic reviews.

• Sample sizes used in the studies varied from a small, single
participant case study to a large, 484 participant study

• The participants included in each sample consisted of surgical
patients with history of asthma undergoing general anesthesia 
with tracheal intubation

• Measures used in the study focused on the severity of the 
patients’ asthma and the incidence of adverse perioperative
respiratory events (ie, bronchospasm, wheezing, oxygen 
desaturation)

• The results of each study suggest that administration of beta-2 
agonists prior to induction of anesthesia greatly reduce the 
incidence of adverse respiratory events among this patient 
population 

• Based on the results from these studies, prevention of adverse
respiratory events among the asthmatic patient population are 
largely preventable through preoperative pharmacologic 
optimization

• Some of the studies were limited by either sample size or 
inclusion criteria (such as age or asthma severity)

• Level of evidence for each of the reviewed studies was 
assessed using the Joanna Briggs Institute (JBI) levels of
evidence 

• JBI levels included 1a, 1c, 4b, and 4d
• Future directions for research on prevention of intraoperative 

bronchospasm should aim at addressing the existing barriers to
standardizing the practice of preoperative pharmacologic 
optimization of the asthmatic patient

Figure 2. Presentation Of Intraoperative Bronchospasm On 
Patient Monitor7 Classic Clinical Signs of Bronchospasm (eg, 
Tachycardia, Decreased SpO2, and Prolonged Upstroke on 
the Capnogram) Circled in Red

Assessment
• History of asthma should be screened for and assessed 

during the preoperative period to determine the level of
control the patient has over the disease

• Preoperative assessment of asthma should include:

1) Severity of disease (table 1)1

2) Triggers (cold air, dust, medications?)
3) Frequency of exacerbations
4) Effectiveness of treatment (was hospital

admission necessary?)
5) Steroid use

• Asthma severity can also be screened for with blood
eosinophil counts and pulmonary functions tests 


