Asthma and chronic obstructive pulmonary disease in the intensive care unit

Tuxen, D & Hew, M. Anaesthesia and Intensive Care Medicine. Published online: September 8, 2016

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There are many pitfalls in the management of patients with asthma or COPD especially when their condition becomes severe enough to warrant intensive care. Mortality in both groups remains significant.

Standard principles of oxygen and drug administration and mechanical ventilation technique used for typical critically ill patients can all cause problems in this patient group. Recognition of the presence of airflow obstruction, the potential for dynamic hyperinflation and careful adherence to the principles of therapy specific to this group are required to avoid complications.

This article addresses the physiological derangements in airflow obstruction, their treatment consequences and how to avoid the management pitfalls that are important contributors to the morbidity and mortality of both conditions.

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Variability in anesthesiologists’ approach to the preoperative management of asthmatic children

Domany, K.A. et al. Journal of Clinical Anesthesia. December 2016. Volume 35. pp. 62–69

Highlights

  • No preoperative guidelines exist for asthmatic child referred to elective surgery.
  • A national survey showed substantial variability among pediatric anesthesiologists.
  • A relative homogeneity exists for the stable, school-aged asthmatic child.
  • Further studies and implementation of consensus guidelines are needed.

Abstract

Objective: No consensus guidelines exist for the preoperative treatment of asthmatic children referred for elective surgery. We investigated the attitude of pediatric anesthesiologists to this issue.

Measurement: Twenty-one questions regarding the approach to preoperative management of asthmatic children including 6 case scenarios with a variety of clinical situations and treatments of asthmatic children. The results were compared with the attitude of pediatric pulmonologists recently published using a similar methodology.

Main results: Forty-four pediatric anesthesiologists from all 24 general hospitals in Israel responded. Twenty-five percent of pediatric anesthesiologists answered that, in addition to pediatric anesthesiologists, the primary pediatrician should be consulted, and 70% believed that a pediatric pulmonologists should also be consulted. Overall, results showed a wide variability between responders especially for preschool children and unstable school-aged asthmatic children for both disciplines. The variability referred to the use of any treatment, bronchodilators, inhaled corticosteroids and their combination, addition of systemic corticosteroids, and the length of preoperative treatment. Compared with pediatric pulmonologists, a better within-discipline agreement was observed by the pediatric anesthesiologists for stable school-aged asthmatic children with a lower inclination to augment preoperative treatment (P< .001). No difference was observed for the preschool children with asthma and for the unstable school-aged asthmatic child.

Conclusions: A wide variability exists in pediatric anesthesiologists’ approach to the preoperative management of asthmatic children for most common case scenarios. This is probably explained by the heterogeneity of asthma, the type of surgery, the lack of guidelines, and the paucity of data. Similarities as well as differences exist between pediatric anesthesiologists and pulmonologists. Further studies and implementation of consensus guidelines are needed.

Read the abstract here