Case report
Bronchospasm triggered by spinal anaesthesia. Case report and review of the literature
Broncoespasmo desencadenado por anestesia espinal. Informe de caso y revisión de la literatura
Ana María Rodilla-Fiz
, Marta Gómez-Garrido, Fernando Martínez-López, Jose Ángel Monsalve-Naharro, María Girón-La Casa, Alfonso López-Pérez
Corresponding author
ana.rodilla.fiz@gmail.com
Corresponding author at: Hospital General Universitario de Albacete. Calle Hermanos Falcó, n° 37, 02006. Albacete, Spain.
Corresponding author at: Hospital General Universitario de Albacete. Calle Hermanos Falcó, n° 37, 02006. Albacete, Spain.
Anaesthesia, Resuscitation and Pain Treatment Service, Complejo Hospitalario Universitario de Albacete, Albacete, Spain
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Calle Hermanos Falcó, n° 37, 02006. Albacete, Spain." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Broncoespasmo desencadenado por anestesia espinal. Informe de caso y revisión de la literatura" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Bronchospasm following spinal anaesthesia is very rare and little known to practitioners. However, it is a potential occurrence considering a few published cases, and it has been reproduced and demonstrated experimentally in animals.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">1</span></a> In humans, the majority of cases have occurred in asthmatics, which points to the fact that regional anaesthesia does not totally reduce the risk of bronchospasm in certain patients. Although the pathophysiological mechanism is not clear, it appears that the neuroaxial block might have a direct or indirect effect on the smooth muscles of the bronchial tree. In the clinical case presented here, the patient had emphysema-type COPD and the respiratory complication was finally attributed to spinal anaesthesia after ruling out all potential reasonable causes of bronchospasm.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case description</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Patient information</span><p id="par0010" class="elsevierStylePara elsevierViewall">Retired 69-year old male Caucasian patient, scheduled for transurethral resection due to benign prostatic hypertrophy. Relevant personal history included no drug allergies, cigarette smoking and a diagnosis of emphysema-type COPD for which he was receiving treatment with inhaled bronchodilators. He had been operated several years before for a fracture dislocation at the level C6-C7, with no reported incidents during anaesthesia or surgery.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Clinical findings, diagnostic assessment and interventions</span><p id="par0015" class="elsevierStylePara elsevierViewall">As part of the preoperative workup, a recent CT scan showed a pattern of panacinar emphysema and findings of multiple bronchiectasis and bullae. All other tests (laboratory, EKG) were within normal ranges.</p><p id="par0020" class="elsevierStylePara elsevierViewall">On the day of surgery, the patient received his usual bronchodilator treatment and reported no recent respiratory infection or current symptoms of exacerbation. Antibiotic prophylaxis with amoxicillin 1<span class="elsevierStyleHsp" style=""></span>g iv was given 20<span class="elsevierStyleHsp" style=""></span>min before the intervention. After standard monitoring, premedication with midazolam 0.5<span class="elsevierStyleHsp" style=""></span>mg iv was given, followed by the initiation of a slow infusion of 500<span class="elsevierStyleHsp" style=""></span>ml of Ringer's lactate. Spinal anaesthesia was then administered with a 27 G needle at the level of L3-L4 using 0.5% hyperbaric bupivacaine 10<span class="elsevierStyleHsp" style=""></span>mg, uneventfully. Anaesthesia was demonstrated at the level of T6-T7 before the start of the surgery. Thirty-five minutes into the procedure the patient reported dyspnoea with no abnormal changes in vital signs initially: blood pressure (BP) 120/70<span class="elsevierStyleHsp" style=""></span>mmHg, heart rate (HR) 85<span class="elsevierStyleHsp" style=""></span>bpm and oxygen saturation (Sp02) of 98% with nasal cannula at 3<span class="elsevierStyleHsp" style=""></span>l/m. No changes were identified in the depth of anaesthesia and there were no adventitious breath sounds on lung auscultation. However, 4<span class="elsevierStyleHsp" style=""></span>min later, dyspnoea worsened and the patient exhibited tachypnea, slight HR increase to 90<span class="elsevierStyleHsp" style=""></span>bpm, lowering of Sp02 down to 92%, and onset of disseminated wheezing on lung auscultation, with no additional associated symptoms. Bronchospasm was treated immediately with methylprednisolone 100<span class="elsevierStyleHsp" style=""></span>mg iv and salbutamol spray 2.5<span class="elsevierStyleHsp" style=""></span>mg, with progressive improvement of the clinical findings. The intervention was completed 10<span class="elsevierStyleHsp" style=""></span>min after the episode and the patient was transferred to the post-anaesthetic care unit (PACU).</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Follow-up and outcome</span><p id="par0030" class="elsevierStylePara elsevierViewall">The clinical manifestations resolved within 20<span class="elsevierStyleHsp" style=""></span>min of arrival at the PACU. Laboratory testing and portable chest X-rays were performed and no significant abnormalities were found, except for hyponatremia at 119<span class="elsevierStyleHsp" style=""></span>mEq/L. In view of the possibility of post-TUR reabsorption syndrome, furosemide 10<span class="elsevierStyleHsp" style=""></span>mg iv was administered, although at the time the patient was already completely asymptomatic.</p><p id="par0035" class="elsevierStylePara elsevierViewall">After 6<span class="elsevierStyleHsp" style=""></span>h under observation and no additional findings, the patient was transferred to the floor and later discharged after four days from the date of admission.</p></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Discussion</span><p id="par0040" class="elsevierStylePara elsevierViewall">For the review of the literature, a search was conducted in <span class="elsevierStyleItalic">Pubmed</span> of all articles published in any language, with no time limitation, using the terms “spinal anaesthesia and bronchospasm” and “spinal anaesthesia and complications”.</p><p id="par0045" class="elsevierStylePara elsevierViewall">Described complications following spinal anaesthesia include haematomas, infection, back pain, headache, pneumoencephalus, neurological lesions, needle or catheter rupture, total spinal anaesthesia, thermoregulatory dysfunction, hypotension, and bradycardia, and other more rare complications such as hearing loss, or VIth cranial nerve palsy.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">2</span></a> In contrast, lung physiology abnormalities are minimal, despite the fact that the blockade obtained reaches thoracic levels. Those changes, such as loss of abdominal contribution to forced expiration – leading to diminished vital capacity – may be more evident in patients with chronic pulmonary disease. However, bronchospasm following spinal anaesthesia is extremely rare in healthy patients as well as in patients with bronchial disease. Airway manipulation is considered the main triggering factor of bronchospasm during anaesthesia.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">3</span></a> Although a clear consensus is lacking in this regard, subarachnoid or epidural anaesthesia are considered attractive options when wanting to avoid intubation.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">4</span></a> Specifically in asthmatic patients, there appears to be a lower risk of bronchospasm under regional anaesthesia compared to general anaesthesia, the main goal being the elimination of neural reflexes caused by intubation which have been found to give rise to the contraction of the smooth muscles of the tracheobronquial tree. However, regional anaesthesia is no guarantee of protection against bronchospasm. In 1982, Mallampati<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">5</span></a> published the first case in a pregnant woman given spinal anaesthesia due to abortion, with an additional two cases reported years later.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">6</span></a> All three cases happened in patients with a diagnosis of asthma. On the other hand, the case published by Prabhakar<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">7</span></a> is probably the only one published so far in the English language in an otherwise healthy patient. Our case happened in a male patient with bronchial disease and severe non-asthmatic emphysematous pattern.</p><p id="par0050" class="elsevierStylePara elsevierViewall">Possible causes of bronchospasm following spinal anaesthesia are unclear. It has been speculated that parasympathetic stimulation from surgery may be responsible, considering that the smooth muscle of the bronchial tree has muscarinic receptors, which produce bronchial constriction when activated by cholinergic stimulation. On the other hand, it has been proposed that blockade of sympathetic fibres in the thoracic segments may precipitate bronchospasm, considering that they are responsible for the conduction of bronchodilator nerve impulses. This has been replicated in animals, confirming that spinal anaesthesia in animals increase bronchial constriction response to metacholine.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">1</span></a> Moreover, a sympathetic block above T10-L1 could reduce adrenal production of adrenalin and, considering that clearance of plasma adrenalin is fast, a lower level of this substance during anaesthesia could lead to bronchospasm. Also, anxiety has been considered a favourable factor because the use of anxiolytics could prevent bronchospasm in selected patients.</p><p id="par0055" class="elsevierStylePara elsevierViewall">The diagnosis of bronchospasm attributable to spinal anaesthesia must be made after ruling out all other potential causes. In our case, post-TUR reabsorption syndrome and fluid overload or cardiac asthma were causes that had to be considered as part of the differential diagnosis, but no clinical signs were observed of cardiac overload or ventricular failure, or crepitus or jugular engorgement, and the X-ray taken in the immediate postoperative period was similar to the preoperative radiograph, with no findings of heart failure or acute pulmonary oedema; also important is the fact that the clinical manifestations resolved before the administration of furosemide. Another possible diagnosis that had to be considered was an allergic reaction to local anaesthetics, which occurs typically within 10<span class="elsevierStyleHsp" style=""></span>min of the injection and is associated, besides bronchospasm, with skin rash or facial blush and hypotension. In our patient, symptoms appeared after 35<span class="elsevierStyleHsp" style=""></span>min and they were not associated with any other finding attributable to an allergic reaction. No oral or parenteral medications had been administered previously, except for amoxicillin as prophylactic antibiotic, which could not explain the complication on the grounds of either time or symptomatology. Pain or inadequate anaesthesia could have also triggered the symptoms as a result of a vagal reflex, but in our patient the anaesthetic level was the right one and the patient was comfortable. Finally, motor block of abdominal and thoracic muscles may compromise ventilation, and although it is possible that such compromise may have influenced the onset of dyspnoea, the clinical manifestations were indicative of bronchospasm and not of muscle fatigue.</p><p id="par0060" class="elsevierStylePara elsevierViewall">We are aware that, given the multiple causes that may trigger bronchospasm, this may be a limitation of the clinical case presented here. However, we think that this limitation is also a strong point because, having ruled out all potential causes of bronchospasm, and given the precedent in humans and in an animal model of higher bronchial reactivity after spinal anaesthesia, our diagnostic approach was correct.</p><p id="par0065" class="elsevierStylePara elsevierViewall">In summary, bronchospasm is a condition that may occur unexpectedly during anaesthesia, although it is very rare following spinal anaesthesia. In this case, our patient developed bronchospasm following subarachnoid anaesthesia, which could not be attributed to any other cause, adding one more case to the scant literature on this topic. In our opinion, further studies are required to elucidate how neuroaxial blockade affects the smooth muscle of the tracheobronchial tree. Additionally, it is important to recognize that although spinal anaesthesia is considered the safest modality in patients with respiratory disease, specifically in asthmatics there is a possibility that it may induce bronchospasm in susceptible patients.</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Funding</span><p id="par0070" class="elsevierStylePara elsevierViewall">The authors have not received any form of aid or grant during the development of this work.</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Conflicts of interest</span><p id="par0075" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:3 [ "identificador" => "xres631157" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec644011" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres631158" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec644010" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Case description" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Patient information" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Clinical findings, diagnostic assessment and interventions" ] 2 => array:2 [ "identificador" => "sec0030" "titulo" => "Follow-up and outcome" ] ] ] 6 => array:2 [ "identificador" => "sec0035" "titulo" => "Discussion" ] 7 => array:2 [ "identificador" => "sec0040" "titulo" => "Funding" ] 8 => array:2 [ "identificador" => "sec0045" "titulo" => "Conflicts of interest" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2015-04-29" "fechaAceptado" => "2016-02-02" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec644011" "palabras" => array:4 [ 0 => "Bronchial spasm" 1 => "Anesthesia, general" 2 => "Anesthesia, spinal, anesthesia" 3 => "Peer review" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec644010" "palabras" => array:5 [ 0 => "Espasmo bronquial" 1 => "Anestesia, general" 2 => "Anestesia raquídea" 3 => "Anestesia" 4 => "Revisión por expertos" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Bronchospasm is a clinical condition that can occur unexpectedly during general anaesthesia, but is extremely rare after spinal anaesthesia. The following is a case presentation of a patient who developed bronchospasm after undergoing spinal anaesthesia not attributable to other causes, and that adds another case to the limited literature. Most publications allude to asthmatic patients, and this is probably the first description about a patient with emphysema-type COPD. Our case shows that although spinal anaesthesia is considered safe for patients with respiratory disease, specifically in asthmatic patients there is a possibility of bronchospasm in susceptible patients.</p></span>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">El broncoespasmo es una condición clínica que puede aparecer inesperadamente durante la anestesia general, pero es extremadamente rara tras la anestesia espinal. Presentamos un paciente que desarrolló broncoespasmo tras ser sometido a anestesia espinal, no atribuible a otras causas y que añade un caso más a la escasa literatura al respecto. La mayoría de las publicaciones se refieren a pacientes asmáticos, y esta sea probablemente la primera descripción en un paciente con EPOC tipo enfisematoso. Nuestro caso muestra que aunque la anestesia espinal se considere más segura para pacientes con patología respiratoria, en concreto en pacientes asmáticos, existe la posibilidad de que ésta produzca broncoespasmo en pacientes susceptibles.</p></span>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Rodilla-Fiz AM, Gómez-Garrido M, Martínez-López F, Monsalve-Naharro JÁ, Girón-La Casa M, López-Pérez A. Broncoespasmo desencadenado por anestesia espinal. Informe de caso y revisión de la literatura. Rev Colomb Anestesiol. 2016;44:179–181.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:7 [ 0 => array:3 [ "identificador" => "bib0040" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Spinal anesthesia increases pulmonary responsiveness to methacholine in guinea pigs" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "M. Capelozzi" 1 => "F.M. Arantes" 2 => "P.S. Paiva" 3 => "V.L. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 5 | 0 | 5 |
| 2024 October | 41 | 6 | 47 |
| 2024 September | 78 | 7 | 85 |
| 2024 August | 43 | 3 | 46 |
| 2024 July | 59 | 8 | 67 |
| 2024 June | 43 | 6 | 49 |
| 2024 May | 42 | 4 | 46 |
| 2024 April | 67 | 10 | 77 |
| 2024 March | 62 | 12 | 74 |
| 2024 February | 66 | 10 | 76 |
| 2024 January | 81 | 10 | 91 |
| 2023 December | 81 | 21 | 102 |
| 2023 November | 72 | 21 | 93 |
| 2023 October | 86 | 16 | 102 |
| 2023 September | 70 | 0 | 70 |
| 2023 August | 56 | 8 | 64 |
| 2023 July | 34 | 4 | 38 |
| 2023 June | 44 | 4 | 48 |
| 2023 May | 40 | 6 | 46 |
| 2023 April | 28 | 1 | 29 |
| 2023 March | 12 | 0 | 12 |
| 2023 February | 15 | 3 | 18 |
| 2023 January | 14 | 3 | 17 |
| 2022 December | 33 | 4 | 37 |
| 2022 November | 28 | 11 | 39 |
| 2022 October | 19 | 9 | 28 |
| 2022 September | 21 | 7 | 28 |
| 2022 August | 25 | 5 | 30 |
| 2022 July | 16 | 6 | 22 |
| 2022 June | 12 | 10 | 22 |
| 2022 May | 17 | 4 | 21 |
| 2022 April | 20 | 5 | 25 |
| 2022 March | 22 | 6 | 28 |
| 2022 February | 7 | 6 | 13 |
| 2022 January | 19 | 6 | 25 |
| 2021 December | 19 | 9 | 28 |
| 2021 November | 23 | 8 | 31 |
| 2021 October | 30 | 16 | 46 |
| 2021 September | 23 | 9 | 32 |
| 2021 August | 21 | 8 | 29 |
| 2021 July | 6 | 3 | 9 |
| 2021 June | 8 | 10 | 18 |
| 2021 May | 12 | 6 | 18 |
| 2021 April | 52 | 8 | 60 |
| 2021 March | 4 | 3 | 7 |
| 2021 February | 5 | 10 | 15 |
| 2021 January | 9 | 6 | 15 |
| 2020 December | 4 | 7 | 11 |
| 2020 November | 6 | 6 | 12 |
| 2020 October | 3 | 2 | 5 |
| 2020 September | 3 | 6 | 9 |
| 2020 August | 5 | 12 | 17 |
| 2020 July | 7 | 9 | 16 |
| 2020 June | 6 | 5 | 11 |
| 2020 May | 4 | 5 | 9 |
| 2020 April | 4 | 2 | 6 |
| 2020 March | 2 | 4 | 6 |
| 2020 February | 5 | 2 | 7 |
| 2020 January | 3 | 5 | 8 |
| 2019 December | 5 | 8 | 13 |
| 2019 November | 3 | 1 | 4 |
| 2019 October | 2 | 1 | 3 |
| 2019 September | 2 | 6 | 8 |
| 2019 August | 0 | 2 | 2 |
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| 2019 June | 0 | 3 | 3 |
| 2019 May | 1 | 15 | 16 |
| 2019 April | 1 | 0 | 1 |
| 2018 September | 2 | 0 | 2 |
| 2018 June | 6 | 5 | 11 |
| 2018 May | 34 | 8 | 42 |
| 2018 April | 46 | 11 | 57 |
| 2018 March | 26 | 7 | 33 |
| 2018 February | 22 | 7 | 29 |
| 2018 January | 27 | 8 | 35 |
| 2017 December | 22 | 7 | 29 |
| 2017 November | 13 | 10 | 23 |
| 2017 October | 27 | 12 | 39 |
| 2017 September | 24 | 10 | 34 |
| 2017 August | 20 | 7 | 27 |
| 2017 July | 24 | 4 | 28 |
| 2017 June | 28 | 8 | 36 |
| 2017 May | 40 | 7 | 47 |
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| 2017 March | 21 | 6 | 27 |
| 2017 February | 8 | 4 | 12 |
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| 2016 December | 35 | 11 | 46 |
| 2016 November | 22 | 11 | 33 |
| 2016 October | 50 | 10 | 60 |
| 2016 September | 31 | 8 | 39 |
| 2016 August | 36 | 9 | 45 |
| 2016 July | 26 | 19 | 45 |
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