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This review summarises the current evidence for the perioperative preparation in children with upper respiratory tract infections (URTI), including COVID-19 infection. URTI, including COVID-19 infection, are common and frequent in children who present for elective surgery. Children with URTI are at increased risk of perioperative respiratory adverse events. Perioperative respiratory adverse events are among the most serious and impactful consequences of paediatric anaesthesia, including cardiorespiratory arrest, and therefore present a significant challenge for the paediatric anaesthetist. This review addresses the pathophysiology and time course of URTI, including COVID-19. The evidence-based patient, anaesthetic, and surgical risk factors for perioperative respiratory adverse events are summarised. These risk factors work synergistically to determine individual patient risk and allow for risk stratification both clinically and with validated scoring systems. Evidence-based optimisation of modifiable respiratory risk factors can reduce the risk of perioperative bronchospasm. The evidence for the anaesthesia management options, including the timing and setting of surgery, experience of the paediatric anaesthetist, premedication, choice of airway device, choice of agent for induction and maintenance of anaesthesia, and deep vs awake tracheal extubation techniques along with a risk stratification framework are discussed. [ABSTRACT FROM AUTHOR]

• IA use in stable NCFB had microbiologic benefit with 10% reduction of exacerbations. • IA therapy in NCFB increased antimicrobial resistance, with NNT of 6. • Minimal benefit in terms of patient-centered outcomes was documented. • Further research is required in high inflammatory phenotypes and alternative strategies. Inhaled antibiotics (IA) in non-cystic fibrosis bronchiectasis (NCFB) are recommended by some clinical practice guidelines for prevention or treatment of NCFB exacerbations. We performed a systematic review and meta-analysis to evaluate the efficacy and safety of IA use for treatment of adults with NCFB and Pseudomonas aeruginosa chronic bronchial infection. The search was performed in the Cochrane Library, PubMed, and Web of Science databases from 2000 to 2019. Studies of IA for treatment of stable or exacerbated NCFB adults (≥18 years) with P. aeruginosa infection were considered eligible. PROSPERO Registration number: CRD42019136154. Twelve trials (2476 participants) were included. IA therapy increased P. aeruginosa eradication from sputum in patients with exacerbations (OR: 3.19, 95%CI: 1.70–5.99) with similar effects on stable patients (OR: 7.22, 95%CI: 2.81–18.59), and a trend to reduced emergence of new respiratory pathogens (OR: 0.58, 95%CI: 0.28–1.18). IA achieved significant reduced exacerbation rates (RR: 0.90; 95%CI: 0.82–0.98) in stable patients, with a number needed to treat (NNT) of 59, but no significant changes in FEV 1 , mortality, hospitalizations or quality of life were identified. In stable patients, IA use increased antimicrobial resistance (RR: 2.10, 95%CI: 1.35–3.27) at the end of therapy, with a number needed to treat of 6. IA therapy achieved a statistically significant eradication of P. aeruginosa from sputum, with a 10% reduction of exacerbations in stable patients. This effect has to be balanced with significant increases in antimicrobial resistance. Our meta-analysis failed to show a significant benefit in terms of patient-centered outcomes. [ABSTRACT FROM AUTHOR]

Adverse events associated with salvaged blood reinfusion are common, but bronchospasm has been rarely reported, especially in pediatrics. We report the case of a child undergoing epileptogenic focus resection, who experienced bronchospasm and kidney injury associated with reinfusion of salvaged blood, presumably related to excessive free hemoglobin. [ABSTRACT FROM AUTHOR]

Perioperative hypersensitivity reactions (POH) constitute a clinical and diagnostic challenge, a consequence of heterogeneous clinical presentations, and multiple underlying pathomechanisms. POH do not necessarily involve an allergen-specific immune response with cross-linking of specific immunoglobulin E (sIgE) antibodies on mast cells and basophils. POH can also result from alternative specific and non-specific effector cell activation/degranulation such as complement-derived anaphylatoxins and off-target occupancy of mast cell, basophil, or both surface receptors. Moreover, POH and anaphylaxis can occur independent from mast cell and basophil degranulation. The manifestations of POH primarily affect the cardiovascular, respiratory, and integumentary systems. POH present within the context of surgical or procedural pathology and the effects of surgical and anaesthetic techniques on pre-existing physiological reserve. The majority of cases of appropriately-treated intraoperative anaphylaxis can be considered a compensated cardiovascular anaphylaxis. With increasing severity of anaphylaxis, maldistribution and hypovolaemia lead to reduced venous return and circulatory failure. Treatment with a combination of epinephrine and i.v. fluid is critical for successful resuscitation, although the excessive use of epinephrine without adequate volume expansion may be deleterious. Neural control of the airways is important in the pathophysiology of bronchospasm. Anticholinergic drug premedication is beneficial in patients with hyperreactive airways. Pulmonary oedema can result from a combination of pulmonary capillary hypertension, incompetence of the alveolocapillary membrane, or both. Angioedema can be distinguished mechanistically into histaminergic and non-histaminergic (e.g. bradykinin-mediated). An understanding of the molecular mechanisms and pathophysiology of POH are essential for the immediate management and subsequent investigation of these cases. [ABSTRACT FROM AUTHOR]

Endobronchial Tuberculosis is hazardous in causing circumferential narrowing of tracheobronchial tree despite the eradication of tubercle bacilli in the initial insult from Pulmonary Tuberculosis. They may present as treatment resistant bronchial asthma and pose challenge to airway management in the acute setting. We present a 25 year-old lady who was newly diagnosed bronchial asthma with a past history of Pulmonary Tuberculosis that had completed treatment. She presented with sudden onset of difficulty breathing associated with noisy breathing for 3 days and hoarseness of voice for 6 months. Due to resistant bronchospasm, attempts were made to secure the airway which led to unanticipated difficult intubation and ventilation. Subsequent investigations confirmed the diagnosis of Endobronchial Tuberculosis and patient was managed successfully with anti TB medication, corticosteroids and multiple sessions of tracheal dilatation for tracheal stenosis. This case highlights the unusual cause of difficulty in intubation and ventilation due to Endobronchial Tuberculosis, which required medical and surgical intervention to improve the condition. [ABSTRACT FROM AUTHOR]

Résumé Les bronchospasmes sont des effets indésirables pouvant mettre en jeu le pronostic vital. Les symptômes ressemblent à ceux de la crise d’asthme aiguë grave. Le pharmacien doit savoir reconnaître ces signes, mais aussi envisager la cause iatrogène afin d’identifier le plus vite possible le traitement suspect et conseiller au mieux le patient sur la conduite à tenir. Summary Drug-induced bronchospasm is a side effect that can be life threatening. Symptoms look like an asthma attack. The pharmacist must be able to recognize those signs, but also consider a potential iatrogenic cause in order to identify, as soon as possible, the suspected drug. He must advise the patient on the best actions to be taken. [ABSTRACT FROM AUTHOR]

Persons with allergies present with symptoms that often are the result of alterations in the nervous system. Neuronally based symptoms depend on the organ in which the allergic reaction occurs but can include red itchy eyes, sneezing, nasal congestion, rhinorrhea, coughing, bronchoconstriction, airway mucus secretion, dysphagia, altered gastrointestinal motility, and itchy swollen skin. These symptoms occur because mediators released during an allergic reaction can interact with sensory nerves, change processing in the central nervous system, and alter transmission in sympathetic, parasympathetic, and enteric autonomic nerves. In addition, evidence supports the idea that in some subjects this neuromodulation is, for reasons poorly understood, upregulated such that the same degree of nerve stimulus causes a larger effect than seen in healthy subjects. There are distinctions in the mechanisms and nerve types involved in allergen-induced neuromodulation among different organ systems, but general principles have emerged. The products of activated mast cells, other inflammatory cells, and resident cells can overtly stimulate nerve endings, cause long-lasting changes in neuronal excitability, increase synaptic efficacy, and also change gene expression in nerves, resulting in phenotypically altered neurons. A better understanding of these processes might lead to novel therapeutic strategies aimed at limiting the suffering of those with allergies. [Copyright &y& Elsevier]

Abstract: A critical incident is an event that causes harm, or could cause harm if allowed to continue without intervention and it is events in the respiratory and circulatory systems that can lead most rapidly to the greatest harm. Minor critical incidents are common but troublesome; major ones can lead rapidly to hypoxaemia, brain injury and death. The introduction of pulse oximetry and capnography led to a marked fall in the frequency of such incidents in the late 1980s; better training and availability of special equipment have helped to maintain this fall. The sharing of information by reporting systems such as the Safe Anaesthesia Liaison Group (SALG) has disseminated information about potential problems more widely, and the improved designs of anaesthetic machines and equipment have contributed to a reduction in hazards. Despite these improvements, risks still remain; only intelligent assessment, preparation, and planning as well as continued training for such events can minimize the severity and frequency of their occurrence. High standards of monitoring in the perioperative period, and a willingness to seek help reduce the chance of an adverse event. This article deals with events related to the respiratory system including airway injury, airway obstruction, inadequate ventilation, aspiration, laryngospasm, bronchospasm, pulmonary oedema, and pneumothorax. Difficult intubation is dealt with elsewhere in this journal. [Copyright &y& Elsevier]

Management of life-threatening acute severe asthma in children and adults may require anaesthetic and intensive care. The inhaled route for drug delivery is not appropriate when only small respiratory gas volumes are shifted; the i.v. route may be associated with greater side-effects. Magnesium sulphate i.v. has a place in acute asthma management because it is a mild bronchodilator, and has a stabilizing effect on the atria which may attenuate tachycardia occurring after inhaled and i.v. salbutamol. If intubation and ventilation are required, a reduction in bronchoconstriction by any means before and during these procedures should reduce morbidity. This narrative review aims to show strengths and weakness of the evidence, present controversies, and forward opinions of the author. The review contains a practical guide to the setting up, use and efficiency of nebulizers, metered dose inhalers, and spacers (chambers). It also presents a commonsense approach to the management of severe asthmatics in whom delay in bronchodilatation would cause clinical deterioration. When self-inhaled agents have had no effect, i.v. drugs may help avoid intubation and ventilation. The review includes suggestions for the use of inhaled anaesthetics, anaesthetic induction, and brief notes on subsequent ventilation of the lungs. [ABSTRACT FROM AUTHOR]

Abstract: Study Objective: To evaluate the safety and efficacy of sugammadex for reversal of rocuronium-induced neuromuscular blockade in patients with pulmonary disease. Design: Phase III, randomized, multicenter, parallel-group, comparative, safety-assessor blinded study. Setting: Nine hospital sites. Patients: 77 ASA physical status 2 and 3 patients, aged ≥ 18 years, with a history of pulmonary disease, and scheduled for surgery with general anesthesia requiring neuromuscular blockade. Interventions: Following anesthesia induction, patients received rocuronium 0.6 mg/kg with 0.15 mg/kg maintenance doses as needed. Patients were randomized to receive sugammadex 2 mg/kg or 4 mg/kg after the last rocuronium dose at reappearance of the second twitch. Measurements: Safety evaluations included adverse events, laboratory parameters, vital signs, and evidence of recurrent or residual neuromuscular blockade. Efficacy was evaluated as the time from sugammadex administration to recovery of the train-of-four (TOF) ratio to ≥ 0.9. Main Results: Safety was comparable between doses, with no evidence of residual or recurrent neuromuscular blockade. Two bronchospasm cases were reported (4 mg/kg group), both in patients with asthma who received desflurane for anesthesia maintenance. Geometric mean (95% confidence interval) times to a TOF ratio of ≥ 0.9 were 2.1 (1.7 - 3.1) min (2 mg/kg) and 1.8 (1.5 - 2.7) min (4 mg/kg). Conclusion: Sugammadex 2 mg/kg and 4 mg/kg were well tolerated and effective in patients with a history of pulmonary disease. Bronchospasm is a possibility when administering sugammadex to patients with underlying pulmonary disease. [Copyright &y& Elsevier]

Abstract: A critical incident is an event that causes harm, or could cause harm if allowed to continue without intervention. The respiratory system and the circulatory system are areas of anatomy and physiology that can lead most rapidly to the greatest harm. Minor critical incidents are common but troublesome, major ones can lead rapidly to hypoxaemia, brain injury and death. The introduction of pulse oximetry and capnography led to a marked fall in the frequency of such incidents in the late 1980s; better training and availability of special equipment have helped to maintain this fall. The sharing of information by reporting systems such as the Australian Incident Monitoring Study (AIMS) has disseminated information about potential problems more widely, and the improved designs of anaesthetic machines and equipment have contributed to a reduction in hazards. Despite these improvements, risks still remain; only intelligent assessment, preparation, and planning as well as continued training for such events can minimize the severity and frequency of their occurrence. High standards of monitoring in the perioperative period, and a willingness to seek help reduce the chance of an adverse event. This article deals with events related to the respiratory system including airway injury, airway obstruction, inadequate ventilation, aspiration, laryngospasm, bronchospasm, pulmonary oedema, and pneumothorax. Difficult intubation is dealt with elsewhere. [ABSTRACT FROM AUTHOR]

Summary: Helium-oxygen (heliox) gas mixtures have been studied for over 70 years as an adjunctive therapy for airway obstruction in a variety of respiratory diseases. The medical use of heliox is based on the physical properties of helium as its low density makes it advantageous in promoting more efficient flow through narrowed passages. Clinical evidence of the efficacy of heliox in treating paediatric respiratory diseases is increasing in the medical literature. This article consists of a comprehensive review of the literature investigating the utility of heliox in the treatment of paediatric respiratory disorders, including upper and lower airway obstruction, mechanical ventilation, and aerosol delivery. [Copyright &y& Elsevier]

Abstract: We report the case of a severe acute asthma, which required, after optimal medical therapy, helium and sevoflurane CO-administration after tracheal intubation. The Anesthetic Conserving Device® allowed sevoflurane use with intensive care unit''s ventilator. The helium-sevoflurane association was maintained during 9days to decrease the bronchospasm, waiting for the efficiency of an aetiologic treatment. We discuss the suitability of this association to treat severe acute asthma, and its administration modalities. [Copyright &y& Elsevier]

Abstract: We review here four recent findings that have altered in a fundamental way our understanding of airways smooth muscle (ASM), its dynamic responses to physiological loading, and their dominant mechanical role in bronchospasm. These findings highlight ASM remodeling processes that are innately out-of-equilibrium and dynamic, and bring to the forefront a striking intersection between topics in condensed matter physics and ASM cytoskeletal biology. By doing so, they place in a new light the role of enhanced ASM mass in airway hyper-responsiveness as well as in the failure of a deep inspiration to relax the asthmatic airway. These findings have established that (i) ASM length is equilibrated dynamically, not statically; (ii) ASM dynamics closely resemble physical features exhibited by so-called soft glassy materials; (iii) static force–length relationships fail to describe dynamically contracted ASM states; (iv) stretch fluidizes the ASM cytoskeleton. Taken together, these observations suggest that at the origin of the bronchodilatory effect of a deep inspiration, and its failure in asthma, may lie glassy dynamics of the ASM cell. [Copyright &y& Elsevier]

Abstract: Respiratory failure in the perioperative period is associated with significant morbidity and mortality. Underlying respiratory disease, as well as factors related to the patient, anaesthesia and surgery contribute to perioperative pulmonary complications and respiratory failure. The proven strategies to reduce the risk of postoperative pulmonary complications include optimizing management of chronic lung disease before surgery, lung expansion manoeuvres, and pain control. Postoperative respiratory failure usually results from dysfunction of alveolar gas exchange, but may also arise from problems with the respiratory pump (respiratory muscles, thoracic cage, abdomen), central respiratory drive or neuromuscular conduction. Treatment depends on the cause and includes measures to reverse atelectasis, mobilization and removal of secretions, bronchodilation, treatment of infections and, ultimately, mechanical ventilation. Heterogeneous causes and protean manifestations make diagnosis and management challenging. [Copyright &y& Elsevier]

Abstract: Adverse drug reactions are unwanted reactions to drugs that occur under normal conditions of use, and are probably responsible for 3–5% of all hospital admissions. They are usually classified as Type A (augmented) or Type B (bizarre) reactions. Type A reactions are responsible for 80–90% of all adverse responses to drugs. They are relatively common, well known, and predictable, and have a close temporal relation with drug administration. Although patients vary in their susceptibility, most Type A reactions occur in every patient who is given the drug in sufficient dose. Type B reactions are usually unrelated to the main effects of drugs; they are often dose-independent, uncommon and unpredictable. Although their cause may be obscure, they are sometimes related to genetic predisposition or drug hypersensitivity. In anaesthetic practice, at least three important Type B reactions are directly related to genetic predisposition (malignant hyperthermia, suxamethonium apnoea, hepatic porphyria). Hypersensitivity or allergic responses to drugs depend on immunological factors; there are four types, depending on the mechanism involved. Most severe allergic reactions to drugs are a result of Type I hypersensitivity (anaphylaxis). In anaesthesia, the main aetiological factors are muscle relaxants, antibiotics, latex rubber and chlorhexidine; reactions to these agents may cause hypotension, bronchospasm, facial and laryngeal oedema, or urticaria. Similar effects occur when histamine and other factors are directly released from mast cells by non-immunological mechanisms (anaphylactoid reactions). Finally, drugs that are given during pregnancy may cross the placental barrier and adversely affect the fetus. [Copyright &y& Elsevier]

Study Objective: To demonstrate a favorable effect of propofol on respiratory system resistance during anesthetic induction, and to determine if generic propofol causes adverse effects on respiratory resistance.Design: Randomized pilot study.Setting: Anesthetic induction for elective surgery.Patients: 27 consenting ASA physical status II and III patients with reactive airways (positive smoking history or chronic obstructive pulmonary disease), but not receiving bronchodilator therapy.Interventions: Patients were randomized equally to one of three anesthetic induction (and maintenance) drugs: sodium thiopental, 5 mg/kg (25 μg/kg/min), generic or nongeneric propofol, 1.25 mg/kg (50 μg/kg/min). They received preinduction midazolam and fentanyl (2 mg and 150 μg) and intravenous lidocaine (0.5 mg/kg). After anesthetic induction, tracheal intubation was established, and predetermined settings for mechanical ventilation were initiated.Measurements: Immediately after intubation, a sensor was placed on the 8-mm endotracheal tube to detect baseline airway pressure and flow. During maintenance, repeat measurements of pressure and flow were obtained at 2.5-minute intervals for 10 minutes. Respiratory system resistance was derived off-line using the isovolumetric technique.Main Results : Patients were similar across groups. The respiratory resistance measured after anesthetic induction did not differ among groups. During the maintenance infusion of thiopental or propofol, respiratory resistance increased gradually across all groups. There was no difference in the response of respiratory resistance either at induction or during the 10-minute maintenance between the generic and the nongeneric propofol groups.Conclusions: In contrast to earlier reports, this pilot study was unable to document a difference in the respiratory resistance in patients induced with thiopental or propofol. In addition, we were unable to demonstrate any different respiratory responses between generic propofol, containing sodium metabisulfite preservative, and nongeneric propofol. [Copyright &y& Elsevier]

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Abstract: Diprivan® is composed of propofol, refined soybean oil and purified egg phosphatide. One must eliminate any allergy to one of its components before use. We report the story of a child who underwent nevus surgery under general anesthesia which was associated with an hypersensitivity reaction. In fact, this child had asthma and allergy to peanuts, raising the problem of cross allergy between birch, peanut, soy and Diprivan®. [Copyright &y& Elsevier]

Abstract: Vitamin B12 deficiency is an important nutritional disorder causing neurological manifestations of myelopathy, neuropathy and dementia. Sub-acute combined degeneration (SCD) with involvement of the posterior columns in the cervical and thoracic cord is a common presentation of this disorder. In this case report, we describe a 43year old woman with pernicious anemia and myelopathy with atypical clinical features. The patient presented with motor symptoms, a sensory level and bladder dysfunction. She had severe autonomic disturbances including an episode of unexplained bronchospasm, which has not been previously reported as a manifestation of vitamin B12 deficiency. We review the literature regarding these rarely reported features of vitamin B12 deficiency, and discuss aspects of management of this reversible condition. We emphasize the importance of awareness of autonomic disturbances in B12 deficient individuals. [Copyright &y& Elsevier]

The specific aim of this study was to assess the effect of higher fentanyl doses on reducing perioperative complication rates among infants undergoing rigid bronchoscopy. Sixty children who underwent rigid bronchoscopy for foreign body removal were enlisted in our 2-year prospective cohort study at the Department of ENT and Head & Neck Surgery, Medical University – Sofia. Infants were randomly distributed into two groups according to fentanyl dose (group 1 - 1–2 μg/kg vs group 2 - 6–7 μg/kg). Hemodynamic parameters and perioperative complications were recorded. The mean age of the whole study group was 1.94 years. Five minutes prior to anesthesia both groups presented with similar parameter levels and no statistically significant difference was found. In contrast, at 5th and 10th minutes after intubation the heart rate, systolic and diastolic blood pressure levels were recorded at significantly higher levels in group 1 compared to group 2 (p =.000). Same results were obtained five minutes after extubation. Additionally, after performing the Pearson chi-Square test we found that bronchospasm and laryngospasm were significantly more frequent among patients from group 1 infused with lower dosage of fentanyl in comparison to the infants that were administered with a higher dose of this medication (p =.020). Phi and Cramer's V tests both display moderate strength of this association (V = 0.302). In the current study we propose refinement of current anesthetic protocols by using higher doses of fentanyl during rigid bronchoscopy in infants. This significantly reduces perioperative complication rates and improves intraoperative hemodynamics without presenting any newly formed risks. [ABSTRACT FROM AUTHOR]

Purpose To identify and assess billing, procedural, or diagnosis code, or pharmacy claim-based algorithms used to identify acute bronchospasm in administrative and claims databases. Methods We searched the MEDLINE database from 1991 to September 2012 using controlled vocabulary and key terms related to bronchospasm, wheeze and acute asthma. We also searched the reference lists of included studies. Two investigators independently assessed the full text of studies against pre-determined inclusion criteria. Two reviewers independently extracted data regarding participant and algorithm characteristics. Results Our searches identified 677 citations of which 38 met our inclusion criteria. In these 38 studies, the most commonly used ICD-9 code was 493.x. Only 3 studies reported any validation methods for the identification of bronchospasm, wheeze or acute asthma in administrative and claims databases; all were among pediatric populations and only 2 offered any validation statistics. Some of the outcome definitions utilized were heterogeneous and included other disease based diagnoses, such as bronchiolitis and pneumonia, which are typically of an infectious etiology. One study offered the validation of algorithms utilizing Emergency Department triage chief complaint codes to diagnose acute asthma exacerbations with ICD-9 786.07 (wheezing) revealing the highest sensitivity (56%), specificity (97%), PPV (93.5%) and NPV (76%). Conclusions There is a paucity of studies reporting rigorous methods to validate algorithms for the identification of bronchospasm in administrative data. The scant validated data available are limited in their generalizability to broad-based populations. [ABSTRACT FROM AUTHOR]

Abstract: Cannabis is a common substance of drug abuse among the young adults because of its euphoric and addictive effects. The pathophysiological effects of cannabis smoking and its relation to adverse cardiovascular events are well known. However, the relative contribution of cannabis smoking when combined with tobacco smoking to coronary artery disease is unclear and has not been well emphasized. We describe two cases of acute coronary syndrome occurring in cannabis smokers who were tobacco smoker too. One, a 23 year old young boy who suffered from hypertension and acute coronary syndrome at a very young age and other, a 50 year old male admitted with acute coronary syndrome, developed asymptomatic dynamic electrocardiographic changes and had beta-blocker induced severe bronchospasm. The modifiable nature of cannabis smoking and cigarette smoking, which often go hand in hand, needs no over emphasis. The cessation of twin smoking habits along with correction of other coronary artery disease risk factors is an important part of primary and secondary prevention. [Copyright &y& Elsevier]