69-year-old lady, consult request for consideration of bronchial thermoplasty
- Severe refractory asthma
- Intermittent vocal cord dysfunction
- IHD – cardiac arrest in 2010, emergency PCI to RCA. Well since. Recent normal stress and resting echocardiogram.
- NIDDM – reasonable control
- Good exercise tolerance. 5.6 METS
- Severe refractory asthma – frequent exacerbations despite optimal therapy. Wakes at night to use salbutamol
- Postoperative bronchospasm – after recent shoulder surgery. Required reintubation in PARU and had a 3-day ICU admission on BiPAP and steroids
- Patient apprehensive given recent experience but understands risks and is keen to proceed given current QoL.
- Targeted application of radiofrequency to the airways. No current RCT evidence but is approved for use in severe refractory asthma. Case study evidence supports post-procedure reduction in asthma severity and frequency of exacerbations
- Ablation is carried out in 10-second bursts
- Cough suppression is imperative during radiofrequency ablation and patient is required to remain still
- Frequently performed in 2-3 staged procedures
Conduct of anaesthesia
- Little collective experience at JHH but one anaesthetist has significant experience from overseas hospitals
- Anaesthetic options:
- GA – ETT and muscle relaxant provide perfect conditions for procedure but will increase risk of perioperative bronchospasm and asthma exacerbation
- Sedation – with minimal airway instrumentation. Previous experienced anaesthetist suggests use of dexmedetomidine and/or remifentanil with propofol.
- Airway topicalisation – necessary to topicalise airway effectively, increased risk of layngo-and bronchospasm. Recommendations are as for AFOI. Consider nebulised local anaesthetic and proceduralist will employ “spray as you go technique.”
- Minimise secretions – consider use of glycopyrrolate
- Postoperative disposition – critical care monitoring required due to risk of postoperative bronchospasm.
- See article for further discussion of anaesthetic considerations (Anesth Analg 2018;126:1575–9)
- Regular respiratory physician review but consider perioperative course of steroids in consultation with team.
- Proceed as planned
- ICU 2 bed postoperatively
- Liaise with proceduralist regarding anaesthetic requirements, management of medications perioperatively, consideration of steroid therapy, and appropriateness of planned disposition