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LETTER TO EDITOR
Year : 2012 | Volume
: 6
| Issue : 2 | Page : 186-188
Severe unilateral bronchospasm due to inadequate anesthetic depth: A case report and review of literature
Rohini Bhat Pai, Harihar V Hegde, V Srikanth, P Raghavendra Rao
Department of Anaesthesiology, SDM College of Medical Sciences and Hospital, Dharwad, Karnataka, India
Correspondence Address:
Rohini Bhat Pai
Associate Professor, Department of Anaesthesiology, SDM College of Medical Sciences and Hospital, Dharwad, Karnataka - 580 009
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/1658-354X.97039
| Date of Web Publication | 8-Jun-2012 |
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How to cite this article:
Bhat Pai R, Hegde HV, Srikanth V, Rao P R. Severe unilateral bronchospasm due to inadequate anesthetic depth: A case report and review of literature. Saudi J Anaesth 2012;6:186-8 |
How to cite this URL:
Bhat Pai R, Hegde HV, Srikanth V, Rao P R. Severe unilateral bronchospasm due to inadequate anesthetic depth: A case report and review of literature. Saudi J Anaesth [serial online] 2012 [cited 2023 Feb 5];6:186-8. Available from: https://www.saudija.org/text.asp?2012/6/2/186/97039 |
Sir,
A 28-year-old man, weighing 58 kg was scheduled for elective open reduction and internal fixation of fracture mandible. He gave history of blunt chest trauma with fractured ribs. On examination, mouth opening was one finger breadth and painful, and Mallampati class was 4. In the operation theater, after preoxygenation with 100% oxygen for 3 min, anesthesia was induced with intravenous fentanyl 150 μg and propofol 120 mg till loss of verbal response, with an additional dose of propofol (40 mg + 40 mg). After confirming adequate mask ventilation, neuromuscular blockade was achieved with intravenous vecuronium 7 mg. The lungs were ventilated with 100% O 2 and isoflurane 2%.
Three minutes later, direct laryngoscopy was performed. A 1 × 2 cm hematoma was noted just above the laryngeal inlet obscuring the view of the right vocal cord. The trachea was intubated with the hematoma undisturbed and the tube was fixed at 26 cm at the nostril. Upon auscultation, there was absolutely no air entry on the right side of the chest and good air entry on the left side. No added sounds were heard on either side. Peak airway pressures were 35-40 cmH 2 O. Oxyhemoglobin saturation (SpO 2) decreased to 90% in spite of ventilation with 100% oxygen and isoflurane 3%. The alveolar slope of the capnograph became markedly upsloping. Endobronchial intubation was suspected and the endotracheal tube (ETT) was withdrawn by 1 cm. There was no improvement in the air entry or other parameters. Direct laryngoscopic examination confirmed the "black mark" of the ETT at the level of vocal cords and the hematoma undisturbed. A suction catheter was passed smoothly down the ETT and no secretions or blood was aspirated. Isoflurane was stopped and halothane was started at 2%. Repeat auscultation few minutes later revealed slightly better air entry with expiratory wheeze and peak airway pressure of 27-29 cmH 2 O. SpO2 was 97% and the capnograph was better. This was when the possibility of unilateral bronchospasm was strongly suspected. Four puffs of salbutamol from a metered dose inhaler were discharged down the ETT and intravenous hydrocortisone 100 mg was administered. After 3-4 min the air entry improved and was equal bilaterally. SpO 2 improved to 99% and the peak airway pressure decreased to 18-20 cmH 2 O. Dynamic X-ray screening (C-arm) was subsequently performed. There was no pneumothorax or inflation of any lobe on the right side. After 5 min halothane was discontinued and the patient was ventilated with O 2 , N 2 O, and isoflurane. Tracheal extubation was done when the patient was awake at the end of surgery. Further course intra- and postoperatively was uneventful.
Failure to ventilate one side of the chest after intubation of the trachea occurs commonly and can promptly be identified by routine examination of the chest by inspection and auscultation. The most likely causes are endobronchial intubation, foreign body bronchus, pneumothorax, and bronchospasm. [1]
During general anesthesia any sudden/unexplained deterioration in blood pressure, heart rate, oxygen saturation, or pulmonary compliance suggests tension pneumothorax, especially in a patient with fracture ribs. [2] A simple pneumothorax may develop into a tension pneumothorax when positive pressure ventilation is incorporated. [3] The radiographic examination ruled out this differential diagnosis.
Tracheal tube touching the carina/endobronchial intubation or overinflation of the tracheal cuff is known to cause bronchospasm. [4] Intraoperative bronchospasm may be encountered in many patients with asthma or recent upper airway infection. However, it may also be observed in otherwise healthy patients with no known predictors. [5] In cases of severe bronchospasm the chest may be silent on auscultation and the diagnosis may rest on correct assessment of increased inflation pressures. [6] Although isoflurane and halothane equally dilate proximal bronchi, halothane causes better relaxation of the distal bronchi. [7]
Unilateral bronchospasm per se is known but is a rare entity. [8] A majority of the reports describing unilateral bronchospasm are found in anesthesia literature mainly following interpleural analgesia. It also has been rarely reported after subclavian vein puncture, pleurodesis, neuroradiologic intervention and during airway manipulation with inadvertent topical lignocaine injection into the left bronchus with a Laryngojet device. [1],[8]
Unilateral bronchospasm could result from (1) disproportionate sympathetic blockade or (2) stimulation of superficial airway receptors supplied by vagal fibers by any irritant. [9] In our patient, the likely reason could be the attempted mask ventilation in an inadequately anesthetized patient leading to stimulation of airway receptors.
In conclusion, unilateral bronchospasm should be considered a differential diagnosis in a patient developing acute unilateral reduction in air entry. Early diagnosis is the key for successful management.
| References | |  |
| 1. | Farmery AD. Severe unilateral bronchospasm mimicking inadvertent endobronchial intubation: A complication of the use of a topical lidocaine laryngojet injector. Br J Anaesth 2000;85:917-9. 
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| 2. | Yao FS, Stein D, Savarese JJ. Congenital Diaphragmatic Hernia. In: Yao FS, editor. Anesthesiology: Problem-oriented patient management. 6 th ed. Philadelphia: Lippincott Williams and Wilkins; 2008. p. 115-29.
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| 3. | Gambrill VL. Diagnosis and treatment of tension pneumothorax under anesthesia: A case report. AANA J 2002;70:21-4.
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| 4. | Stoelting RK. Dierdorf SF. Asthma. In: Stoelting RK, Editor. Dierdorf SF eds. anesthesia and co-existing disease, 4 th ed. Philadelphia: Churchill Livingstone; 2002. p. 193-204.
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| 5. | Ajjappa AK, Kaul N, Sumant A, Khan RM. Proseal LMA - tracheal tube exchange technique during extubation in refractory bronchospasm: A safe strategy. J Anaesth Clin Pharmacol 2009;25:85-6.
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| 6. | Westhorpe RN, Ludbrook GL, Helps SC. Crisis management during anaesthesia: Bronchospasm. Qual Saf Health Care 2005;14:e7.
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| 7. | Mercier FJ, Naline E, Bardou M, Georges O, Denjean A, Benhamou D, et al. Relaxation of proximal and distal isolated human bronchi by halothane, isoflurane and desflurane. Eur Respir J 2002;20:286-92.
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| 8. | Reddy K, Prabhakar H, Yadav N, Singh GP, Ali Z. Unilateral bronchospasm during microcatheter manipulation in an interventional neuroradiology suite. J Anesth 2010;24:313-4.
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| 9. | Shantha TR. Unilateral bronchospasm after interpleural analgesia. Anesth Analg 1992;74:291-3.
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