What is the pharmacology of medications available to treat asthma; which medications are used for long-term control, and which medications are used for acute attacks; and what would be a treatment plan based on the degree of severity?
What preoperative evaluation and preparation would you order for this patient; would you cancel the case if the patient said that she was just recovering from a “bad cold” and had a few scattered wheezes on auscultation?
After uneventful induction of general anesthesia and intubation, the patient’s peak airway pressures suddenly increased during the procedure, and wheezing was heard on auscultation; what would you do?
A 30-year-old woman presented for elective uterine myomectomy. She had a long history of asthma, treated with an unknown inhaler, as needed. Preoperatively, her chest was clear to auscultation.
What is asthma, and how is it diagnosed?
Asthma is a common disease characterized by reversible airway obstruction with components of hyperresponsiveness and inflammation. Asthma “attacks” are characterized by episodes of shortness of breath, wheezing, and often cough. These episodes usually follow exposure to known triggers (e.g., pollen, dust, animal dander, smoke, change in weather, viral illness). The diagnosis is most commonly made by history and examination alone. Measurements of peak expiratory flow (PEF) rate and forced expiratory volumes and their response to bronchodilator administration may sometimes be necessary.
What are the characteristic pulmonary function test findings seen in obstructive and restrictive lung disease, asthma, and chronic obstructive pulmonary disease?
Pulmonary function tests (PFTs) comprise spirometry and flow-volume loops. An arterial blood gas and diffusion of carbon monoxide can also be included. Typical values in obstructive and restrictive lung disease are shown in Table 78-1 .
|FVC||Normal or decreased||Decreased|
|FEV 1 /FVC||Decreased||Normal or increased|
|MMEFR (FEF 25%-75% )||Decreased||Normal|
|TLC||Normal or increased||Decreased|
|DLCO||Decreased in COPD||Decreased|
|Normal in asthma|
Asthmatics usually have normal PFTs between exacerbations. Narrowing limited to small airways may yield a normal ratio of forced expired volume in the first second (FEV 1 ) to forced vital capacity (FVC), but the more sensitive forced expiratory flow between 25% and 75% of FVC (FEF 25%-75% ) would be decreased. Also, the FEV 1 /FVC ratio is effort dependent and requires patient cooperation for accurate measurement, whereas FEF 25%-75% does not depend on patient effort. FEF 25%-75% is obtained by dividing the volume expired between 25% and 75% of the FVC by the time elapsed between these two points. Occasionally, bronchospasm may be intentionally triggered during PFT evaluation with methacholine or histamine to assess airway reactivity in patients with normal baseline PFTs who are suspected to have asthma.
For patients with chronic obstructive pulmonary disease (COPD), measurements are repeated after inhaled bronchodilators to evaluate the degree of reversibility. The fixed component of COPD is due to inflammation and airway destruction.
Flow-volume curves may also be helpful. A normal curve and typical curves from patients with obstructive and restrictive disease are shown in Figure 78-1 . By convention, inspiration is below the x axis, and expiration is above the x axis. In restrictive disease, airway resistance is normal with no flow limitation, whereas lung volumes are reduced. In obstructive disease, the expiratory flow curve shows a characteristic flattening secondary to increased airway resistance.
Curves from patients with fixed airway obstruction and variable extrathoracic and intrathoracic obstructions are shown in Figure 78-2 . Fixed obstruction, exemplified by tracheal stricture or compression by a tumor or goiter, causes decreases in inspiratory and expiratory flows. Variable extrathoracic obstruction, such as vocal cord paralysis or marked pharyngeal muscle weakness, causes airway collapse during inspiration because negative inspiratory pressure is transmitted to the extrathoracic airway. Mobile surrounding tissues are drawn into the airway, obstructing the flow of gas. With variable intrathoracic obstruction (e.g., caused by tracheal or endobronchial tumor), airway narrowing increases during forced expiration.