PERIOPERATIVE

MANAGEMENT OF
ASTHMA IN
CESAREAN
SECTION
Houman Teymourian, M.D.
Assistant professor, Department of
Anesthesiology and Critical Care,
Shahid Beheshti Medical
University
 ASTHMA
 Asthma is a very common chronic disease
 150 million people worldwide are affected
 The most common respiratory disease in
women of childbearing age
 4% of all pregnancies are complicated by
asthma
 DEFINITION &
PATHOPHYSIOLOGY
 It is a chronic inflammatory disease
of the airways involving multiple
components of immune system (mast
cells, eosinophils, neutrophils, T cell lymphocytes
& cysteinyl leukotrienes)
 Is associated with : acute
bronchoconstriction , airway edema , mucus plug
formation ,& airway wall remodeling
 Hyper reactivity ,Hypertrophy,
Autonomic dysfunction, Inflammation
secretion & edema
 CLASSIFICATION
1. Childhood-onset asthma (extrinsic)
2. Adult-onset asthma (intrinsic)
or traditionally:
 Mild , Moderate , Severe
 Women with severe asthma tends to
have more pronounced exacerbations of
disease during pregnancy
 CLASSIFICATION OF
ASTHMA SEVERITY
 STEP 1 (mild intermittent)
Symptoms: <2 times a week , brief exacerbations
Nighttime symptoms: < 2 times a month
Lung function: FEV1 >80% predicted
 STEP 2 (mild persistent)
Symptoms: >2 times a weak but<1 time a day,
exacerbations affect activity
Nighttime symptoms:> 2 times a month
Lung function: FEV1 >80% predicted
 STEP 3 (moderate persistent)
Symptoms: daily , daily use of inhaled short acting
β2 agonists, exacerbations affect activity and
are >2 time a weak , may last days
Nighttime symptoms: > 1 time a weak
Lung function: FEV1 >60 -<80% predicted
 STEP 4 (severe persistent)
Symptoms: continuous , limited activity , frequent
exacerbations
Nighttime symptoms: frequent
Lung function: FEV1 <60%
PHYSIOLOGIC CHANGES OF
PREGNANCY
 Cardiovascular: HR, SV , CO ,BP ,SVR , PVR
 Respiratory: MV , VT ,FRC , & RR remains
unchanged, CO2 production but PaCO2
 capillary engorgement of mucosa and edema of
the oropharynx ,larynx ,and trachea
 Hematologic: Blood volume 45%, red cell
30%
 EFFECTS OF ASTHMA ON
PREGNANCY
 The rate of prematurity ,pregnancy
induced hypertension , perinatal mortality
, low birth weight are increased (particularly in
steroid dependents)
 Pre & post partum hemorrhage, preterm
labor , premature rupture of membranes
 Neonatal tachycardia & transient
tachypnea
 Increase in need to induce labor & the
rate of cesarean section
 MECHANISM
1.Disease process itself
Interfering with increase of MV results in
maternal co2 retention & hypoxemia.
 CO2 retention shifts PH & decreases neonatal
oxygenation
 Maternal SPO2 less than 95% decreases
neonatal oxygenation
 Hyperventilation (alkalosis) decreases
neonatal oxygenation
Asthmatics are dehydrated and have increased
intrathoracic pressure
 Cardiac output decrease results in decrease
in uterine blood flow
2.Treatment (steroids)
3.Other undefined causes (tobacco
TREATMENT OF ASTHMA
Removal of triggers , monitoring ,patient
education
 STEP 1 (mild intermittent):
Inhaled short acting β2-agonist ( e.g. albuterol )
 STEP 2 (mild persistent):
step 1 +anti inflammatory (Inhaled steroid or cromolyn sodium) +
possible use of sustained-release theophylline
 STEP 3 ( moderate persistent):
long acting β2-agonist (e.g. salmeterol) + Inhaled steroid
 STEP 4 (severe persistent):
all above + systemic steroid
 TREATMENT OF ASTHMA
DURING PREGNANCY
 Poor treatment of asthma during
pregnancy contribute significantly to
adverse outcome
 The risk of untreated asthma far
exceeds the risk of the medications
 Use of β2-agonists is safe.
 Use of oral corticosteroids is
associated with pregnancy-induced
hypertension & weakly with low-birth
weight & cleft palate
 Anti cholinergics (Ipratropium) may
be useful.
 During delivery , Inhaled β2-agonists +
steroid + supplemental O2 should be
used for any level of asthma
 Leukotriene modifiers are safe during
pregnancy (zafirlukast ,montelukast)
 Zileuton is associated with IUGR,
cleft palate, & long bone
abnormalities
 Status Asmathicus
 Severe bronchospasm unresponsive
to systemic steroids & β2-agonists that
requires mechanical ventilation & sedation
& may be muscle relaxants & volatile
anesthetics
 Use permissive hypercarbia ,
anticholinergics , heliox , methyl xantines
 STATUS ASTHMATICUS IN
PREGNANTS
 In pregnants permissive hypercarbia
cannot be achieved
 PPV may make the decrease in cardiac out
put even more pronounced
 Position is important( aortocaval
compression )
 β2-agonists & theophylline can cause
excessive tachycardia in mother & atrial
arrhythmia in fetus
 Heliox : only if adequate oxygenation can
be achieved with an FIO2 less than 0.4
 Magnesium sulfate particularly in
pregnancy-induced hypertension and
asthma
 There is some evidence that epidural
anesthesia alone can be efficacious in
termination of status asthmaticus in the
parturient
 Early termination of pregnancy may be
necessary to insure the survival of the
mother and may result in immediate
improvement in the respiratory status
 Induction of labor
 Prostaglandin F α provokes
2

bronchospasm in induction of the

labor
 Oxytocin has no adverse effect on
asthma and is the agent of choice
 ANESTHESIA FOR LABOR
AND CESAREAN SECTION IN
THE ASMATHIC PATIENT
 Basic principles:
1. Optimization of pulmonary status
before anesthesia
2. Avoidance of bronchospasm inducing
agents (histamine releasers)
3. Avoidance of airway irritation by an
endotracheal tube whenever possible
 Neuraxial Anesthesia For
Cesarean Section
 Epidural , Spinal , Combined spinal-
epidural
 Epidural anesthesia decreases
catecholamine levels & O2
consumption , and may result in
termination of the status asthmaticus
 Few cases of bronchospasm has
been reported after spinal anesthesia
 Patients on steroid therapy may be
at risk for infections
 No special considerations regarding
choice of local anesthetics for this
population
 Careful attention must be paid to
avoidance of high block & respiratory
failure
 Maintenance of Adequate
intravascular volume is important
 If opioids are used either epidural or
intrathecally the patient must be
monitored carefully for respiratory
 GENERAL ANESTHESIA
 General anesthesia only if neuraxial
anesthesia is contraindicated
 Risk of bronchospasm is high:
1. Tracheal intubation
2. Rapid sequence induction
3. Anesthetic level Insufficiency
 Agents for induction: most
commonly thiopental, ketamin ,
propofol
 Ketamin : has mild bronchodilatory
action due to release of endogenous
catecholamines
 Propofol: efficacious in blunting
airway responces & has weak
bronchodilatory action but
hemodynamic changes must be
managed appropriately and
aggressively in parturient
 Thiopental: can cause histamine
release, doses which is safe for fetus
 Lidocaine: is useful as an adjuvant to
thiopental induction (1 mg/kg is
enough to attenuate both airway and
hemodynamic responses) ,
Aerosolized lidocaine is airway
irritant and should not be used
 MUSCLE RELAXANTS
 Succinylcholine can be used for
initial relaxation
 Rocuronium is a safe alternative
in asthmatics
 Atracurium & Rapacuronium can
worsen bronchospasm &
histamine release
 Cisatracurium also is a choice
 REVERSAL OF
NEUROMUSCULAR
BLOCKADE
 Neostigmine can exacerbate airflow
obstruction by increasing secretions
and bronchospasm
 Edrophonium is a better choice in
asthmatic patients
 Use of atropine or glycopyrrolate can
attenuate these effects
 Succinylcholine infusion may be
used to avoid using reversal agents
 Maintenance of
anesthesia
 Halogenated agents have
bronchodialating properties :
halothane, isoflurane , sevoflurane
 Disadvantage: using high alveolar
concentration (>1 – 1.5 MAC) for
control of bronchospasm increase
bleeding from uterine relaxation
 Halothane disadvantage : cardiac
irritability particularly in high
catecholamine state and
 Extubation take place when the
patient is fully awake & airway
obstruction controlled
 Patient should be treated during
surgery with Steroids & β2-agonist
 Lidocaine infusion decreases airway
reactivity during emergence
 Post operative Mechanical ventilation
may be necessary to control
obstruction
Postpartum Hemorrhage
 Is Increased in asthmatics due to:
 Abnormalities in smooth muscles and
neural regulation of contraction
 Peripartum use of β2-agonists
 Use of Oxytocin is valid in
asthmatics
 Use of Ergot alkaloid e.g.
methylegonovine
( methergine) & ergonovine
(ergotrate) is relatively
Postpartum Hemorrhage
 Prostaglandins used for uterine
atony :
 E causes bronchodilatation
(only vaginal gel is available)
 F2α causes bronchoconstriction

 Severe bronchospasm might be

preferable to cardiovascular
collapse
 HYPERTENSION
PREECLAMPSIA AND
ASTHMA
 Aspirin, NSAIDS & all beta blockers(
specially non β1 selective) can cause
bronchospasm
 Hydralazine, TNG , Sodium nitroprusside
,and calcium channel blockers can be
used, but they may cause hypoxemia by
interfering with HPV
 Volume expansion is critical in both
asthma & hypertension
 Magnesium sulfate has benefit in seizure
prophylaxis and treatment of
bronchospasm
 Neuraxial anesthesia is the preferred
option unless there are clear