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Background: To conduct a systematic review looking into the use of sevoflurane in the management of status asthmaticus (SA) in adults. Methods: We performed a systematic search on PubMed, EMBASE, and The Cochrane Library – CENTRAL through 23rd August 2023, restricting to studies reported in English. We included studies reporting use of sevoflurane in asthmatics beyond its use as an anaesthetic agent in surgeries i.e. in the emergency department (ED) and critical care setting, and focused on patient's clinical parameters, ventilation pressures and weaning of invasive ventilation. Results: A total of 13 publications fulfilled the inclusion criteria, comprising of 18 cases. All publications were of case reports/ series and conference abstracts, and no randomised trials were available. Most patients required intubation despite best medical management before sevoflurane administration, and high airway pressures and respiratory acidosis were apparent. There was significant heterogeneity regarding severity of asthma, treatment instituted, and the delivery, duration and concentration of sevoflurane administered. Many of the studies also did not quantify the changes in parameters pre- and post-sevoflurane. Sixteen patients experienced improvements in clinical status with sevoflurane administration—one required escalation to extracorporeal membrane oxygenation (ECMO), and another did not survive. Conclusion: The systematic review suggests sevoflurane can be a valuable treatment option in SA. As these cases are rare and heterogenous, further prospective case series are needed to support this. [ABSTRACT FROM AUTHOR]

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]

Abstract Background Remimazolam is a recently developed, ultrashort-acting benzodiazepine that is used as a general anesthetic. Some cases of remimazolam anaphylaxis have been reported, but its characteristics are not fully understood. We present an interesting case report and review of the literature to better understand remimazolam anaphylaxis. Case presentation A 75-year-old man scheduled for robot-assisted gastrectomy was administered remimazolam for the induction of general anesthesia. After intubation, low end-expiratory CO2, high airway pressure and concurrent circulatory collapse were observed. Bronchoscopy revealed marked tracheal and bronchial edema, which we diagnosed as anaphylaxis. The patient suffered cardiac arrest after bronchoscopy but recovered immediately with intravenous adrenaline administration and chest compressions. We performed skin prick tests for the drugs used during induction except for remimazolam, considering the high risk of systemic adverse reactions to remimazolam. We diagnosed remimazolam anaphylaxis because the skin prick test results for the other drugs used during anesthesia were negative, and these drugs could have been used without allergic reactions during the subsequent surgery. Furthermore, this patient had experienced severe anaphylactic-like reactions when he underwent cardiac surgery a year earlier, in which midazolam had been used, but it was not thought to be the allergen at that time. Based on these findings, cross-reactivity to remimazolam and midazolam was suspected. However, the patient had previously received another benzodiazepine, brotizolam, to which he was not allergic, suggesting that cross-reactivity of remimazolam may vary among benzodiazepines. In this article, we reviewed the 11 cases of remimazolam anaphylaxis that have been described in the literature. Conclusions Remimazolam is an ultrashort-acting sedative; however, it can cause life-threatening anaphylaxis. In addition, its cross-reactivity with other benzodiazepines is not fully understood. To increase the safety of this drug, further research and more experience in its use are needed.

Background: Ibuprofen is one of the most commonly used analgesic and antipyretic drugs in children. However, its potential causal role in childhood asthma pathogenesis remains uncertain. In this systematic review, we assessed the association between ibuprofen administration in children and the risk of developing or exacerbating asthma. Methods: We searched MEDLINE, Embase, Cochrane Library, CINAHL, Web of Science, and Scopus from inception to May 2022, with no language limits; searched relevant reviews; and performed citation searching. We included studies of any design that were primary empirical peer-reviewed publications, where ibuprofen use in children 0–18 years was reported. Screening was performed in duplicate by blinded review. In total, 24 studies met our criteria. Data were extracted according to PRISMA guidelines, and the risk of bias was assessed using RoB2 and NOS tools. Quantitative data were pooled using fixed effect models, and qualitative data were pooled using narrative synthesis. Primary outcomes were asthma or asthma-like symptoms. The results were grouped according to population (general, asthmatic, and ibuprofen-hypersensitive), comparator type (active and non-active) and follow-up duration (short- and long-term). Results: Comparing ibuprofen with active comparators, there was no evidence of a higher risk associated with ibuprofen over both the short and long term in either the general or asthmatic population. Comparing ibuprofen use with no active alternative over a short-term follow-up, ibuprofen may provide protection against asthma-like symptoms in the general population when used to ease symptoms of fever or bronchiolitis. In contrast, it may cause asthma exacerbation for those with pre-existing asthma. However, in both populations, there were no clear long-term follow-up effects. Conclusions: Ibuprofen use in children had no elevated risk relative to active comparators. However, use in children with asthma may lead to asthma exacerbation. The results are driven by a very small number of influential studies, and research in several key clinical contexts is limited to single studies. Both clinical trials and observational studies are needed to understand the potential role of ibuprofen in childhood asthma pathogenesis. [ABSTRACT FROM AUTHOR]

Background: Remimazolam is a recently developed, ultrashort-acting benzodiazepine that is used as a general anesthetic. Some cases of remimazolam anaphylaxis have been reported, but its characteristics are not fully understood. We present an interesting case report and review of the literature to better understand remimazolam anaphylaxis. Case presentation: A 75-year-old man scheduled for robot-assisted gastrectomy was administered remimazolam for the induction of general anesthesia. After intubation, low end-expiratory CO2, high airway pressure and concurrent circulatory collapse were observed. Bronchoscopy revealed marked tracheal and bronchial edema, which we diagnosed as anaphylaxis. The patient suffered cardiac arrest after bronchoscopy but recovered immediately with intravenous adrenaline administration and chest compressions. We performed skin prick tests for the drugs used during induction except for remimazolam, considering the high risk of systemic adverse reactions to remimazolam. We diagnosed remimazolam anaphylaxis because the skin prick test results for the other drugs used during anesthesia were negative, and these drugs could have been used without allergic reactions during the subsequent surgery. Furthermore, this patient had experienced severe anaphylactic-like reactions when he underwent cardiac surgery a year earlier, in which midazolam had been used, but it was not thought to be the allergen at that time. Based on these findings, cross-reactivity to remimazolam and midazolam was suspected. However, the patient had previously received another benzodiazepine, brotizolam, to which he was not allergic, suggesting that cross-reactivity of remimazolam may vary among benzodiazepines. In this article, we reviewed the 11 cases of remimazolam anaphylaxis that have been described in the literature. Conclusions: Remimazolam is an ultrashort-acting sedative; however, it can cause life-threatening anaphylaxis. In addition, its cross-reactivity with other benzodiazepines is not fully understood. To increase the safety of this drug, further research and more experience in its use are needed. [ABSTRACT FROM AUTHOR]

Summary: The 7th National Audit Project (NAP7) of the Royal College of Anaesthetists studied peri‐operative cardiac arrest. Among 59 cases reported as possible anaphylaxis, 33 (56%) were judged to be so by the review panel with high or moderate confidence. Causes in excluded cases included: isolated severe hypotension; bronchospasm; and oesophageal intubation. Severe bronchospasm leading to cardiac arrest was uncommon, but notably in one case led to a reported flat capnograph. In the baseline survey, anaesthetists estimated anaphylaxis as the cause of 10% of cases of peri‐operative cardiac arrests and to be among the four most common causes. In a year‐long registry of peri‐operative cardiac arrest, suspected anaphylaxis was the seventh most common cause accounting for 4% of reports. Initial management was most often with low‐dose intravenous adrenaline, and this was without complications. Both the NAP7 baseline survey and case registry provided evidence of reluctance to starting chest compressions when systolic blood pressure had fallen to below 50 mmHg and occasionally even when it was unrecordable. All 33 patients were resuscitated successfully but one patient later died. The one death occurred in a relatively young patient in whom chest compressions were delayed. Overall, peri‐operative anaphylaxis leading to cardiac arrest occurred with a similar frequency and patterns of presentation, location, initial rhythm and suspected triggers in NAP7 as in the 6th National Audit Project (NAP6). Outcomes in NAP7 were generally better than for equivalent cases in NAP6. [ABSTRACT FROM AUTHOR]

Exercise-induced bronchoconstriction (EIB) is a dysfunction of the respiratory tract consisting of transient airflow obstruction that occurs during or immediately after physical exercise, being the preferred term to define what was known for years as exercise-induced asthma. Symptoms develop when airways narrow as a result of physical activity. As many as 90 percent of people with asthma also have EIB, but not everyone with EIB has asthma. EIB is defined as the coexistence of at least two of the following symptoms: dyspnea, cough, wheezing, shortness of breath and chest pain, combined with the decrease of forced expiratory volume in one second (FEV1). Perception of these symptoms may restrain children’s ability and willingness to exercise. The pathophysiology of the process and the severity of bronchospasm depend on the level of ventilation, temperature and humidity of the inspired air. The mechanism is related to thermal hyperemia and congestion of small vessels in the bronchial wall. Most of the symptoms are non-specific, the differential diagnosis including chronic lung diseases and certain cardiovascular diseases or gastroesophageal reflux. For the diagnosis of this entity, a series of challenge tests can be used: at graded exercise, voluntary hyperpnea, methacholine, mannitol, hypertonic saline or histamine, FEV1 decreasing by 10-20% depending on the chosen test. Effective treatment includes preventive therapy – prior administration of a beta 2 agonist and/or antileukotriens, or regular CSI treatment in children with asthma that reduce the number of mast cells required for this type of response.

Peroral endoscopic myotomies (POEM) done primarily for treating achalasia cardia patients not responding to medical therapy involve creating a submucosal tunnel, followed by a myotomy and a mucosal incision. Common intraoperative complications of such procedures include subcutaneous emphysema, pneumothorax, pneumomediastinum, pneumoperitoneum, and hemodynamic instability. This is a case of a 56-year-old 62 kg nil-comorbid female patient diagnosed with achalasia cardia who was taken up for a POEM under general anesthesia. She developed an episode of bronchospasm postinsufflation of the abdomen with carbon dioxide.

Severe asthma exacerbations, including near-fatal asthma (NFA), have high morbidity and mortality. Mechanical ventilation of patients with severe asthma is difficult due to the complex pathophysiology resulting from severe bronchospasm and dynamic hyperinflation. Life-threatening complications of traditional ventilation strategies in asthma exacerbations include the development of systemic hypotension from hyperinflation, air trapping, and pneumothoraces. Optimizing pharmacologic techniques and ventilation strategies is crucial to treat the underlying bronchospasm. Despite optimal pharmacologic management and mechanical ventilation, the mortality rate of patients with severe asthma in intensive care units is 8%, suggesting a need for advanced non-pharmacologic therapies, including extracorporeal life support (ECLS). This review focuses on the pathophysiology of acute asthma exacerbations, ventilation management including non-invasive ventilation (NIV) and invasive mechanical ventilation (IMV), the pharmacologic management of acute asthma, and ECLS. This review also explores additional advanced non-pharmacologic techniques and monitoring tools for the safe and effective management of critically ill adult asthmatic patients. [ABSTRACT FROM AUTHOR]

Background: Achyranthes aspera L. (family Amaranthaceae) is a plant species valued in Ayurveda for the treatment of respiratory ailments. Scientific validation of its antiallergic potential was aimed. Methods and Results: Three extracts of A. aspera [aqueous (AaAq), hydroalcoholic (AaHA), ethanolic (AaEt)] were evaluated for their potency against C48/80-induced anaphylaxis in mice at 200 mg/kg BW oral dose. The effective dose of the most potent extract was determined through its effect on C48/80-induced anaphylaxis, and was further analyzed through its effect on mast cell degranulation, histamine-induced bronchospasm and ovalbumin (OVA)-induced asthma in a murine model. Among the three extracts, AaAq was found to be most potent at 200 mg/kg BW. AaAq 400 (400 mg/kg BW) was found to be the most effective dose in terms of inhibition of mortality and histamine level. AaAq 400 prevented the peritoneal and mesenteric mast cells from undergoing morphological changes due to degranulation induced by C48/80. Further, AaAq 400 delayed pre-convulsive time in histamine-induced bronchospasm. In the OVA-induced asthma model, AaAq 400 inhibited the level of inflammatory cell count in blood, bronchoalveolar lavage fluid and peritoneal fluid of mice. The Th2 cytokines (IL-4, IL-5, IL-13), TGF-β and OVA-specific IgE were also reduced as evaluated by ELISA. Also, significant reduction in IL-5 (an eosinophilia indicator) transcript abundance and lung inflammatory score was observed. AaAq was safe up to 4000 mg/kg BW. Conclusions: Thus AaAq 400 possesses significant antiallergic potential and acts via attenuation of C48/80-induced anaphylaxis and inhibition of mast cell degranulation. It reduces pre-convulsive dyspnea in histamine-induced bronchospasm and Th2 cytokines in asthmatic mice. [ABSTRACT FROM AUTHOR]

Introduction: asthma prevalence is 262 million globally, with more than 1,000 deaths each day, most of them preventable. We were performing a longitudinal study, in Brazil, with the objective to following up patients who had a severe asthma attack and attended an emergency room (attaCK study). Here we present a case of a 28-year-old woman presenting what was considered moderate asthma, enrolled in attaCK, who subsequently died of asthma. Case Study: the patient was initially evaluated at an emergency room (eR) with uncontrolled asthma and no regular treatment. she had an asthma diagnosis just before this visit to the eR, despite presenting symptoms of asthma since childhood. she was subsequently evaluated by a specialist, who prescribed a treatment with regular inhaled corticosteroid and an inhaled bronchodilator, if necessary. the patient was systematically monitored by telephone for six months. Results: the patient did not adhere to the treatment, in spite of repeated warnings, and 6 months later had an asthma attack resulting in her death. Conclusion: It is important to prioritize asthma in primary health care, including building capacity health care professionals for early diagnosis, asthma management, and to educate patients with asthma patients for the identification of worsening and signs of severity, to manage the exacerbations according to a written asthma plan. this may reduce the number of premature and preventable asthma deaths. [ABSTRACT FROM AUTHOR]

Birva Khara,1 Joseph D Tobias2,3 1Department of Anesthesiology, Shree Krishna Hospital, Pramukhswami Medical College and Bhaikaka University, Karamsad, Gujarat, India; 2Department of Anesthesiology & Pain Medicine, Nationwide Children’s Hospital, Columbus, OH, USA; 3The Ohio State University College of Medicine, Columbus, OH, USACorrespondence: Joseph D Tobias, Department of Anesthesiology & Pain Medicine, Nationwide Children’s Hospital, 700 Children’s Drive, Columbus, OH, 43205, USA, Tel +1 614 722-4200, Fax +1 614 722-4203, Email Joseph.Tobias@Nationwidechildrens.orgAbstract: Asthma remains a common comorbid condition in patients presenting for anesthetic care. As a chronic inflammatory disease of the airway, asthma is known to increase the risk of intraoperative bronchospasm. As the incidence and severity of asthma and other chronic respiratory conditions that alter airway reactivity is increasing, a greater number of patients at risk for perioperative bronchospasm are presenting for anesthetic care. As bronchospasm remains one of the more common intraoperative adverse events, recognizing and mitigating preoperative risk factors and having a pre-determined treatment algorithm for acute events are essential to ensuring effective resolution of this intraoperative emergency. The following article reviews the perioperative care of pediatric patients with asthma, discusses modifiable risk factors for intraoperative bronchospasm, and outlines the differential diagnosis of intraoperative wheezing. Additionally, a treatment algorithm for intraoperative bronchospasm is suggested.Keywords: asthma, bronchospasm, pediatric anesthesia, wheezing, wheezing-associated respiratory illness

Cough‐ and asthma‐like symptoms are common adverse reactions to angiotensin‐converting enzyme inhibitors (ACEi). However, attributing these symptoms to the use of ACEi might be masked by clinical confounders. We report a 68‐year‐old female residing in a long‐term acute‐care facility for patients requiring prolonged invasive mechanical ventilation treated for years with ACEi. Daily reversible bouts of life‐threatening severe bronchospasm gradually developed over 6 weeks and abruptly resolved following the cessation of ACEi treatment. The late appearance of bronchospasm and the unique clinical setup of chronic invasive ventilation in a patient with smoking‐related chronic obstructive lung disease are among the principal confounders that delay the identification of the causative association between ACEi and respiratory compromise. Chronic positive pressure ventilation may also conceal small airway reactivity and obstruction, similar to auto‐positive end‐expiratory pressure (auto‐PEEP). Conceivably, angiotensin receptor blockers should be preferred over ACEi in such patients. [ABSTRACT FROM AUTHOR]

Exercise-induced bronchospasm (EIB) is a respiratory condition that causes temporary airflow obstruction during or after physical exercise. It is important to note that not everyone with EIB has asthma. Symptoms of EIB include difficulty breathing, coughing, wheezing, shortness of breath, and chest pain. The severity of bronchospasm depends on factors such as the air's ventilation, temperature, and humidity. Diagnosis of EIB can be done through challenge tests, and treatment options include preventive therapy and regular asthma treatment. It is crucial to differentiate EIB from other conditions like vocal cord dysfunction and gastroesophageal reflux disease (GERD). The article also discusses digestive symptoms associated with GERD, such as postprandial regurgitation and rumination syndrome. GERD can also cause respiratory disorders like otitis media, asthma, and chronic cough. The article provides information on non-pharmacological and pharmacological treatments for these conditions, including the use of short-acting ß2 agonists and leukotriene inhibitors. It emphasizes the importance of proper diagnosis and management, especially in athletes and teenagers who may be hesitant to use medication. [Extracted from the article]

Abstract Cough‐ and asthma‐like symptoms are common adverse reactions to angiotensin‐converting enzyme inhibitors (ACEi). However, attributing these symptoms to the use of ACEi might be masked by clinical confounders. We report a 68‐year‐old female residing in a long‐term acute‐care facility for patients requiring prolonged invasive mechanical ventilation treated for years with ACEi. Daily reversible bouts of life‐threatening severe bronchospasm gradually developed over 6 weeks and abruptly resolved following the cessation of ACEi treatment. The late appearance of bronchospasm and the unique clinical setup of chronic invasive ventilation in a patient with smoking‐related chronic obstructive lung disease are among the principal confounders that delay the identification of the causative association between ACEi and respiratory compromise. Chronic positive pressure ventilation may also conceal small airway reactivity and obstruction, similar to auto‐positive end‐expiratory pressure (auto‐PEEP). Conceivably, angiotensin receptor blockers should be preferred over ACEi in such patients.

Background: When children have a preoperative fever, anesthesiologists must help determine whether to postpone or proceed with surgery, as fever may be a sign of upper respiratory tract infection (URTI). Such infections are a known risk factor for perioperative respiratory adverse events (PRAEs), which are still one of the prime causes of anesthetic mortality and morbidity in pediatric patients. Since the COVID‐19 pandemic, preoperative assessments have become drastically more complex as hospitals strive to balance practicality and safety. In our facility, if pediatric patients presented with preoperative fever, we used the FilmArray® Respiratory Panel 2.1 to determine whether to postpone or proceed with surgery. Methods: This is a single‐center retrospective observational study evaluating the efficacy of the FilmArray® Respiratory Panel 2.1 as a preoperative screening test. This study included pediatric patients scheduled for elective surgeries between March 2021 and February 2022. FilmArray was used if a patient had a preoperative fever (determined by axillary temperature, ≥38°C for <1‐year‐old, ≥37.5°C for ≥1‐year‐old) between hospital admission and before surgery. We excluded patients if they had apparent symptoms of URTI. Results: In the FilmArray positive group, 11 of 25 (44%) cases developed subsequent symptoms after surgery was canceled. No patients in the negative group developed symptoms. The proportion of the development of subsequent symptoms between the FilmArray positive and negative groups was statistically significant (p <.001, odds ratio: 29.6, 95% confidence interval: [3.80–1356.01]). Conclusions: Our retrospective observational study revealed that 44% of the FilmArray positive group subsequently developed symptoms, and no PRAEs were observed in the FilmArray negative group. We suggest that FilmArray could be useful as a screening test for pediatric patients with preoperative fever. [ABSTRACT FROM AUTHOR]

Inhaled selective short-acting β-2 agonists (SABA), such as salbutamol, are the rescue treatment of choice for the relief of symptoms of acute asthma exacerbations: one of the leading causes of pediatric emergency department admission and hospitalization. Cardiovascular events, including supraventricular arrhythmias, are the most frequent side effects reported with inhaled SABA in children with asthma and are the main reason for a continuing debate about their safety, despite their widespread use. Although supraventricular tachycardia (SVT) is the most common potentially serious dysrhythmia in children, the incidence and risk factor of SVT after SABA administration is currently unknown. We here reported three cases and conducted a review of the literature in an attempt to gain insight into this issue. [ABSTRACT FROM AUTHOR]

Salbutamol is a bronchodilatator commonly used for the treatment of feline inflammatory lower airway disease, including asthma or acute bronchospasm. As in humans, a pressurized metered dose inhaler (pMDI) is used in conjunction with a spacer and a spherical mask to facilitate salbutamol administration. However, efficacy of inhalation therapy is influenced by different factors including the non-cooperative character of cats. In this study, the goal was to use computational fluid dynamics (CFD) to analyze the impact of breathing patterns and salbutamol particle size on overall drug transport and deposition using a specific spherical mask and spacer designed for cats. A model incorporating three-dimensional cat airway geometry, a commercially available spherical mask, and a 10 cm spacer, was used for CFD analysis. Two peak inspiratory flows were tested: 30 mL/s and 126 mL/s. Simulations were performed with 30s breathing different inspiratory and expiratory times, respiratory frequencies and peaks. Droplet spray transport and deposition were simulated with different particle sizes typical of the drug delivery therapies (1, 5, 10, and 15 μm). The percentage of particle deposition into the device and upper airways decreased with increasing particle diameter during both flows imposed in this cat model. During increased mean ventilatory rate (MVR) conditions, most of the salbutamol was lost in the upper airways. And during decreased MVR conditions, most of the particles remained in suspension (still in hold-up) between the mask and the carina, indicating the need for more than 30 s to be transported. In both flows the percentage of particles traveling to the lung was low at 1.5%–2.3%. In conclusion, in contrast to what has been described in the human literature, the results from this feline model suggest that the percentage of particles deposited on the upper airway decreases with increasing particle diameter.

The BNT162b2 COVID-19 vaccine is composed of lipid-nanoparticles (LNP) containing the mRNA that encodes for SARS-CoV-2 spike glycoprotein. Bronchospasm has been reported as an early reaction after COVID-19 mRNA vaccines in asthmatic patients. The aim of this study was to investigate the acute impact of BNT162b2 in a human ex vivo model of severe eosinophilic asthma. Passively sensitized human isolated bronchi were challenged with the platelet-activating factor to reproduce ex vivo the hyperresponsiveness of airways of patients suffering from severe eosinophilic asthma. BNT162b2 was tested on the contractile sensitivity to histamine and parasympathetic activation via electrical field stimulation (EFS); some experiments were performed after mRNA denaturation. BNT162b2 increased the resting tone (+11.82 ± 2.27%) and response to histamine in partially contracted tissue (+42.97 ± 9.64%) vs. the control (p < 0.001); it also shifted the concentration-response curve to histamine leftward (0.76 ± 0.09 logarithm) and enhanced the response to EFS (+28.46 ± 4.40%) vs. the control. Denaturation did not significantly modify (p > 0.05) the effect of BNT162b2. BNT162b2 increases the contractile sensitivity to histamine and parasympathetic activation in hyperresponsive airways, a detrimental effect not related to the active component but to some excipient. A possible candidate for the bronchospasm elicited by BNT162b2 could be the polyethylene glycol/macrogol used to produce LNP. [ABSTRACT FROM AUTHOR]

Background: Considering the incidence of respiratory complications after cleft lip and palate surgery and its significance in the survival of children undergoing the mentioned surgery, the present study was performed to evaluate the association between the nasopharyngeal depth and the incidence of respiratory complications after cleft palate surgery. Materials and Methods: The present cross-sectional study was performed on 222 children who aged 9–18 months and were the candidates for cleft palate surgery. After performing general anesthesia and implanting mouth gag and before surgery, the nasopharyngeal depth and the cleft palate width were measured with a calibrated ruler and an ophthalmic caliper, respectively. At the end of the surgery and after extubation, the incidence of respiratory complications such as respiratory distress, laryngospasm, bronchospasm, and need for intubation was recorded. Results: The nasopharyngeal depth in children with respiratory complications with a mean of 7.57 ± 3.12 mm was significantly less than that of children without respiratory complications with a mean of 10.82 ± 2.14 mm (P < 0.001). The nasopharyngeal depth of ≤8 mm with a sensitivity of 80% and a specificity of 89.60% had a significant predictive value in the incidence of respiratory complications (P < 0.001). Conclusion: According to the results of the present study, it seems that the nasopharyngeal depth of ≤8 mm can make the incidence of respiratory complications more likely. Therefore, considering the simplicity and convenience of measuring the nasopharyngeal depth and the cleft palate width, it is suggested to perform further studies to evaluate the anatomy of palate before this surgery using the employed method and address its association with respiratory complications.

Perioperative pneumothorax is a potentially dangerous and rare complication during general anaesthesia. Hereby the authors report a case of 25-year-old female, who was posted for a dental procedure, and developed spontaneous pneumothorax under general anaesthesia. The patient had no co-morbidities or risk factors during the perioperative period and classified as American Society of Anaesthesiologist’s (ASA) class I. She was planned under general anaesthesia with an orotracheal intubation with controlled positive pressure ventilation. At the end of the surgery, she developed significant respiratory changes which rose the suspicion of pneumothorax and later, it was confirmed radiologically. This early suspicion and early intervention by tube thoracostomy in Postanaesthesia Care Unit (PACU) stabilised the patient and resolved eventually. Early recognition and appropriate intervention can mitigate the perioperative outcome and reduce morbidity. Positive pressure ventilation, Positive End Expiratory Pressure (PEEP) and airway handling being the major predisposing factors for the development of pneumothorax. This further reiterates the need for keen perioperative vigilance for early recognition and appropriate management. Although rare, pneumothorax should be considered as differential diagnosis in crisis scenarios like tight bag.

Purpose: Asthma is a heterogeneous disease with a wide range of symptoms. Severe asthma exacerbations (SAEs) are characterized by worsening symptoms and bronchospasm requiring emergency department visits. In addition to conventional strategies for SAEs (inhaled β-agonists, anticholinergics, and systemic corticosteroids), another pharmacological option is represented by ketamine. We performed a systematic review to explore the role of ketamine in refractory SAEs. Methods: We performed a systematic search on PubMed and EMBASE up to August 12th, 2021. We selected prospective studies only, and outcomes of interest were oxygenation/respiratory parameters, clinical status, need for invasive ventilation and effects on weaning. Results: We included a total of seven studies, five being randomized controlled trials (RCTs, population range 44–92 patients). The two small prospective studies (n = 10 and n = 11) did not have a control group. Four studies focused on adults, and three enrolled a pediatric population. We found a large heterogeneity regarding sample size, age and gender distribution, inclusion criteria (different severity scores, if any) and ketamine dosing (bolus and/or continuous infusion). Of the five RCTs, three compared ketamine to placebo, while one used fentanyl and the other aminophylline. The outcomes evaluated by the included studies were highly variable. Despite paucity of data and large heterogeneity, an overview of the included studies suggests absence of clear benefit produced by ketamine in patients with refractory SAE, and some signals towards side effects. Conclusion: Our systematic review does not support the use of ketamine in refractory SAE. A limited number of prospective studies with large heterogeneity was found. Well-designed multicenter RCTs are desirable. [ABSTRACT FROM AUTHOR]

Background: Considering the incidence of respiratory complications after cleft lip and palate surgery and its significance in the survival of children undergoing the mentioned surgery, the present study was performed to evaluate the association between the nasopharyngeal depth and the incidence of respiratory complications after cleft palate surgery. Materials and Methods: The present cross-sectional study was performed on 222 children who aged 9–18 months and were the candidates for cleft palate surgery. After performing general anesthesia and implanting mouth gag and before surgery, the nasopharyngeal depth and the cleft palate width were measured with a calibrated ruler and an ophthalmic caliper, respectively. At the end of the surgery and after extubation, the incidence of respiratory complications such as respiratory distress, laryngospasm, bronchospasm, and need for intubation was recorded. Results: The nasopharyngeal depth in children with respiratory complications with a mean of 7.57 ± 3.12 mm was significantly less than that of children without respiratory complications with a mean of 10.82 ± 2.14 mm (P < 0.001). The nasopharyngeal depth of ≤8 mm with a sensitivity of 80% and a specificity of 89.60% had a significant predictive value in the incidence of respiratory complications (P < 0.001). Conclusion: According to the results of the present study, it seems that the nasopharyngeal depth of ≤8 mm can make the incidence of respiratory complications more likely. Therefore, considering the simplicity and convenience of measuring the nasopharyngeal depth and the cleft palate width, it is suggested to perform further studies to evaluate the anatomy of palate before this surgery using the employed method and address its association with respiratory complications. [ABSTRACT FROM AUTHOR]

The incidence of asthma, a chronic inflammatory disease of the airway that increases the risk of intraoperative bronchospasm, is increasing and thus a higher number of asthmatic patients are presenting for anesthetic care. As intraoperative bronchospasm can be an acute life-threat- ening event, recognizing and mitigating risk factors as well as having a specific treatment algorithm in place may be helpful to facilitate safe care. We present a 3- year-old child who developed intraoperative bron- chospasm. The differential diagnosis of intraoperative wheezing is presented, risk factors for intraoperative bronchospasm reviewed, and a treatment algorithm pro- posed.

Epinephrine (EPI), an endogenous catecholamine involved in the body's fight-or-flight responses to stress, activates a1-adrenergic receptors (a1ARs) expressed on various organs to evoke a wide range of physiological functions, including vasoconstriction. In the smooth muscle of human bronchi, however, the functional role of EPI on a1ARs remains controversial. Classically, evidence suggests that EPI promotes bronchodilation by stimulating b2-adrenergic receptors (b2ARs). Conventionally, the selective b2AR agonism of EPI was thought to be, in part, due to a predominance of b2ARs and/or a sparse, or lack of a1AR activity in human airway smooth muscle (HASM) cells. Surprisingly, we find that HASM cells express a high abundance of ADRA1B (the a1AR subtype B) and identify a spontaneous "switchlike" activation of a1ARs that evokes intracellular calcium, myosin light chain phosphorylation, and HASM cell shortening. The switch-like responses, and related EPI-induced biochemical and mechanical signals, emerged upon pharmacological inhibition of b2ARs and/or under experimental conditions that induce b2AR tachyphylaxis. EPI-induced procontractile effects were abrogated by an a1AR antagonist, doxazosin mesylate (DM). These data collectively uncover a previously unrecognized feed-forward mechanism driving bronchospasm via two distinct classes of G protein-coupled receptors (GPCRs) and provide a basis for reexamining a1AR inhibition for the management of stress/exercise-induced asthma and/or b2-agonist insensitivity in patients with difficult-to-control, disease subtypes. [ABSTRACT FROM AUTHOR]

We present a case of a 52-year-old patient suffering from multi-phasic life-threatening anaphylaxis refractory to epinephrine treatment. Extracorporeal membrane oxygenation (ECMO) therapy was initiated as the ultima ratio to stabilize the patient hemodynamically during episodic severe bronchospasm. ECMO treatment was successfully weaned after 4 days. Mastocytosis was diagnosed as the underlying condition. Although epinephrine is recommended as a first-line treatment for anaphylaxis, this impressive case provides clear evidence of its limited therapeutic success and emphasizes the need for causal therapies.

Inhaled selective short-acting β-2 agonists (SABA), such as salbutamol, are the rescue treatment of choice for the relief of symptoms of acute asthma exacerbations: one of the leading causes of pediatric emergency department admission and hospitalization. Cardiovascular events, including supraventricular arrhythmias, are the most frequent side effects reported with inhaled SABA in children with asthma and are the main reason for a continuing debate about their safety, despite their widespread use. Although supraventricular tachycardia (SVT) is the most common potentially serious dysrhythmia in children, the incidence and risk factor of SVT after SABA administration is currently unknown. We here reported three cases and conducted a review of the literature in an attempt to gain insight into this issue.

Asthma is a chronic obstructive pulmonary disease which affects the bronchi airways and results in the inflammation of bronchioles along with the hyper‐responsiveness to some direct or indirect stimuli which leads to bronchoconstriction. Substituted xanthines have provided several lead compounds for the development of antiasthmatic agents over the decades. In this present paper, a series of 42 xanthine based derivatives (17 a–g; 18 a–g; 19 a–g; 20 a–g; 28 a–g and 29 a–g) were designed and synthesized. Chemical structures were elucidated by spectroscopic methods. All target compounds were evaluated for their in silico anti‐bronchospasmodic potential using PASS software. Compounds with >95 % potential (18 c–f; 28 a and 29 a–g) in comparison to the standard drug were selected for in vivo bronchospasmodic activity using histamine chamber model. In silico and in vivo activity revealed that the compounds substituted with furan spacer were more active than the cinnamic acid. Substitution with propyl functionality at 1‐and 3‐position of xanthine moiety is also accounted for the enhanced activity of furan derivatives (29 a–g). In conclusion, the synthesized new xanthine derivatives stands out as promising anti‐bronchospasmodic agents for future development. [ABSTRACT FROM AUTHOR]