Is this a B-cell or T-cell deficiency, or both? Of what significance is the comparison? What is the immune globulin that is deficient?

What is bronchiectasis? Of what importance is it to anesthetic management? Of what significance is the recent visit to the E.D? Do you desire additional information regarding his chronic lung disease? Specifically? Why? Is a chest x-ray necessary? Why/why not? Do you need to identify which inhaler he is using? Why? Relevance?

What effect does his lung disease have on his cardiovascular system? How will you evaluate this preoperatively? Why? What are the anesthetic implications? Are there tertiary effects of such cardiac disease on other organ systems?

The child is quite anxious and the mother tells you the anxiety can initiate asthma symptoms. Would you order premedication? If not, why not? If so, what? Rationale. Should this patient receive preoperative antibiotics? Why/why not?

B cells are functionally deficient rather than decreased in number. Progression through the normal stages of B-cell development into memory B cells appears to be delayed or blocked. In addition, non-B cells may have abnormalities as well, for example, low numbers of CD4+ cells and high numbers of CD8+ T cells. Natural killer (NK) cells are typically lower than normal. CVID is a pan-hypoglobulinemia; there are decreased levels of IgG and IgA. IgM antibodies are decreased in about 50 % of affected patients as well. Recurrent infections are the typical presentation, with H. influenza, S. pneumoniae, and S. aureus the frequent causes. Respiratory tract infections are most common, along with sinuses, eyes, skin, and gastrointestinal manifestations. Bronchiectases are the anatomic result of severe recurrent pulmonary infections.

Bronchiectasis is characterized by weakness and loss of cartilaginous integrity of the bronchial wall as a result of chronic inflammation, infection, and abscess. It is usually the result of chronic focal or diffuse lung infections. Anesthetic management is influenced by the presence of chronic secretions, mucous plugging of the airways, impaired gas exchange, and air trapping affecting shunt as well as dead space. Patients often have chronic pulmonary disease such as cystic fibrosis or impaired immune defense mechanisms such as hypogammaglobulinemia. The recent visit to the ED suggests that the patient’s compensation may be marginal. It would be helpful to know whether he is on bronchodilators and what those are, whether supplemental oxygen is required at home, whether he has been treated with steroids recently, and whether his respiratory difficulties are associated with any other medical abnormalities. A chest x-ray is helpful if the history points to an acute exacerbation above his usual baseline. It is important to identify the inhaler he uses because you might wish to employ additional inhalers or intravenous medications that may work additively or synergistically with his home medication.

Chronic pulmonary disease with hypoxemia may result in gradual elevation of pulmonary artery pressure and pulmonary vascular resistance, with eventual right heart strain. Ultimately, right heart failure will affect not only pulmonary circuit volume but also systemic cardiac output and contribute to left ventricular failure and impaired perfusion. Because general anesthesia typically involves the use of positive pressure ventilation, which can adversely affect cardiac filling as well as cardiac performance and also involves the use of volatile anesthetics, myocardial performance can be severely affected. Tertiary effects of impaired cardiac disease include hypoperfusion to the splanchnic circulation and protein-losing enteropathies, hepatic and splenic congestion, and renal failure.