Simulation Scenario: bronchospasm under general anesthesia
(Tobias Everett)
Objectives:
 Recognition of onset of bronchospasm
 Recognition of deterioration to life-threatening bronchospasm
 Effective treatment of bronchospasm
 Effective use of available resources
 Review management options
Background (to be given to participant)
3 y.o. male. 14kg. Suprachondylar fracture, right arm, yesterday (accident at playground, no other
injuries). Ate dinner last night, NPO from midnight. Normal, well, active child.
Extra information
No meds, no allergies. Had a persistent nocturnal cough over winter for which family doctor prescribed
inhalers with some improvement of symptoms. No sequelae. One week ago had a day of coughing and
some clear nasal discharge. Resolved quickly.
Scenario progression
Simbaby. Intravenous cannula in situ. Monitored. Ready to go in the OR.
Participant to induce anesthesia as per their preference (discussion point for debrief).
Participant may choose ETT or LMA (discussion point for debrief).
NDMR vs. remi (discussion point)
1 minute after airway manipulation, insidious onset of bronchospasm requiring recognition and
treatment.
Over 5 minutes: Gradual progression to severe bronchospasm (unless all management points completed
early on)
Gradual resolution if majority of actions points met.
Baseline:
HR: 86 bpm
NIBP: 89/52 mmHg
Paw: 16/4 cmH2O
VT: 92 mL
FIO2: 0.48
SpO2: 98%
Breath sounds: vesicular
ETCO2: 42 mmHg
Trend over 1 minute to:
HR: 92 bpm
NIBP: 98/56 mmHg
Paw: 21/4 cmH2O
VT: 76 mL
FIO2: 0.48
SpO2: 96%
Breath sounds: wheeze
ETCO2: 46 mmHg
Trend smoothly over 5 minutes to:
HR: 110 bpm NIBP: 102/62 mmHg
Paw: 29/4 cmH2O
VT: 56 mL
FIO2: var
SpO2: 84%
Breath sounds: wheeze
ETCO2: 58 mmHg
If management inadequate after those first five minutes (at discretion of facilitator), trend over next
five minutes to:
HR: 46 bpm
NIBP: 49/25 mmHg
FIO2: var
SpO2: 62%
ETCO2: 22 mmHg
Paw: 34/4 cmH2O
VT: 32 mL
Breath sounds: silent
At this stage help will arrive (whether summoned or not) and use intravenous epinephrine so prevent
the death of the child.
Expected management:
Systematic step-wise combination of the following (in decreasing order of importance):
Team-management
 Alert team to development
 Communicate diagnosis
 Explicit delegation
 Not permit surgery to start
 ?enlist help
Treatments
 Oxygen (increase FIO2)
 Slow ventilation (long E-time)(± disconnect circuit for hyperexpansion)
 Exclude equipment issues (kink, obstruction etc.)
 Salbutamol
o MDI
o Nebulised
o Intravenous
 Steroid
o Prednisolone (not under GA)
o Methylprednisolone
o Hydrocortisone
 Ipratropium bromide
 Magnesium
 Epinephrine
 Ketamine
 Volatile anesthetic agents
 Aminophylline
Investigations
 ABG
 CXR - ?pneumothorax
Setup
Simbaby
Induction nurse
Anesthesia record
OR table
Anesthesia machine
I.v. fluids run-through
Induction drugs
Face-mask
Laryngoscope
Range of airway management devices
Bronchospasm meds (as above – immediate availability may be limited consistent with context of sim)
In-line nebuliser
MDI adapter for ET administration
60 mL syringes and minibore tubing
Syringe pump
Usual contents of anesthesia cart
Maybe crash cart, defibrillator
Discussion points
Systematic stepwise approach
Canadian Thoracic Society Guidelines1
Canadian Pediatric Society Position statement2
Leukotriene receptors antagonists
Threshold for ECM
Long-acting beta-2 agonist
Heliox
FENO monitoring
DNAase / mucolytic meds
Refs1-14
Doses
In awake kids, MDI plus spacer preferable to nebs. More efficient. Less tachycardia. Nasal prongs for O2
if necessary.
Through ETT: 5-10 puffs (500 – 1000 mcg) co-ordinated with ventilation (inspiration). Inefficient.
Salbutamol nebulised: 2.5 – 5 mg intermittent (or 300mcg/kg/hr continuous)
Salbutamol i.v.: 15 mcg/kg bolus over 10 mins, then 1 mcg/kg/min
(NB guidelines depend on country, some say 5 mcg/kg/min for 1 hour then 1 mcg/kg/min or smaller
loding bolus to avoid toxicity – tachycardia, hypokalemia, hyperglycemia)
Methylprednisolone: 1-2 mg/kg
Hydrocortisone: 5 mg/kg
Ipratropium: 2.5 mg (if <20 kg) otherwise 5 mg nebs.
Magnesium sulphate: 50 mg/kg over 20 minutes (caution re hypotension)
Aminophylline: 5 mg/kg over 20 minutes followed by 0.9 mg/kg/h (ICU, monitoring. Not superior to
salbutamol acutely but does shorted hospital stay)
Epinephrine: 1mcg/kg iv repeatedly
Ketamine/volatiles – discretionary
1.
Lougheed M, Lemiere C, Ducharme FM, Licskai C, Dell SD, Rowe BH, FitzGerald M, Leigh R,
Watson W, Boulet LP: Canadian Thoracic Society 2012 guideline update: diagnosis and management of
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2.
Ortiz-Alvarez O, Mikrogianakis A, Society CP: Managing the paediatric patient with an acute
asthma exacerbation. Paediatr Child Health 2012; 17: 251-255
3.
Browne GJ, Penna AS, Phung X, Soo M: Randomised trial of intravenous salbutamol in early
management of acute severe asthma in children. The Lancet 1997; 349: 301-305
4.
Camargo Jr CA, Rachelefsky G, Schatz M: Managing Asthma Exacerbations in the Emergency
Department Summary of the National Asthma Education and Prevention Program Expert Panel Report 3
Guidelines for the Management of Asthma Exacerbations. Proceedings of the American Thoracic Society
2009; 6: 357-366
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Carroll CL, Smith SR, Collins MS, Bhandari A, Schramm CM, Zucker AR: Endotracheal intubation
and pediatric status asthmaticus: Site of original care affects treatment*. Pediatric Critical Care Medicine
2007; 8: 91
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2009; 13: 136
7.
Kim IK, Phrampus E, Venkataraman S, Pitetti R, Saville A, Corcoran T, Gracely E, Funt N,
Thompson A: Helium/oxygen-driven albuterol nebulization in the treatment of children with moderate
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8.
Levine DA: Novel therapies for children with severe asthma. Current opinion in pediatrics 2008;
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9.
Mitra A, Bassler D, Goodman K, Lasserson T, Ducharme F: Intravenous aminophylline for acute
severe asthma in children over two years receiving inhaled bronchodilators. Cochrane Database Syst Rev
2005; 2
10.
Mohammed S, Goodacre S: Intravenous and nebulised magnesium sulphate for acute asthma:
systematic review and meta-analysis. Emergency Medicine Journal 2007; 24: 823
11.
Ream RS, Loftis LL, Albers GM, Becker BA, Lynch RE, Mink RB: Efficacy of IV Theophylline in
Children With Severe Status Asthmaticus*. Chest 2001; 119: 1480-1488
12.
Roberts G, Newsom D, Gomez K, Raffles A, Saglani S, Begent J, Lachman P, Sloper K, Buchdahl R,
Habel A: Intravenous salbutamol bolus compared with an aminophylline infusion in children with severe
asthma: a randomised controlled trial. Thorax 2003; 58: 306-310
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among pediatric intensive care units*. Critical care medicine 2002; 30: 581
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Baseline
Stage 1
1 minute
5 minutes
Terminal
Resolution
Name of State
Rhythm
SR
SpO2(%)
98
HR
86
NIBP
89/52
Cap refill
<2

Periph Pulses
Resp Rate
*
Tidal Volume
*
Air Entry
equal
Breath sounds
vesicular
ETCO2 (mmHg)
42
Bronchial
Normal
resistance
Lung compliance
normal
Temp
Pupil Size
AVPU
* Participant controls
SR
<2

*
*
equal
vesicular
42
Normal
SR
96
92
98/56
<2

*
*
equal
wheezes
46
Increased
ST
84
110
102/62
<2

*
*
quiet
wheezes
58
Increased
SB
62
46
49/25
4

*
*
silent
Silent
22
max
SR
92
103
79/46
<2

*
*
equal
wheezes
48
Normal
Normal
decreased
decreased
min
normal