START

❶ Call for help and inform theatre team of problem.

❷ Give 100% oxygen.

❸ Stop surgery / other stimulation.

❹ Fully expose the chest and perform a rapid systematic examination:

• Inspect, percuss, palpate, auscultate.
• Absence of wheeze may indicate severe bronchospasm with no air movement.

❺ Deepen anaesthesia:

• Bronchospasm may be a consequence of light anaesthesia.
• Inhalational anaesthetic agents are bronchodilators.
• Avoid isoflurane or desflurane if possible – airway irritant if increased rapidly.

❻ Exclude malpositioned or obstructed tracheal tube or supraglottic airway

• Consider whether there could be endobronchial or oesophageal intubation.

❼ If anaphylaxis suspected → 3-1

❽ If airway soiling/aspiration suspected airway see Box A.

❾ Treat bronchospasm (Box B). First line is salbutamol by metered dose inhaler or by nebuliser; i.v. route is second line. Other drugs at clinician discretion.

❿ Consider alternate diagnoses causing or mimicking bronchospasm (Box C).

⓫ Use appropriate ventilation strategy (Box D).

⓬ If raised airway pressure and/or desaturation persists, consider → 2-2 Hypoxia/ desaturation/cyanosis.

⓭ Obtain a chest X-ray as soon as clinically safe to do so.

⓮ Plan appropriate placement for post-procedure care.

Box A: ACTIONS IF AIRWAY SOILING/ASPIRATION

Consider tracheal intubation and tracheal toilet 

Use nasogastric tube to aspirate gastric contents 

Chest X-ray 

Consider post op level of care and follow-up 

Box B: DRUG DOSES

Salbutamol

Nebuliser: Child <5 yr, 2.5 mg; Adult and >5 yr 5 mg  

i.v. bolus: Adult 250 µg diluted, slowly; Child 1-23 months 5 µg.kg^-1 once over 5 mins; Child 2-17 years 15 µg.kg^-1 once over 5 mins (max. 250 µg) 

Adult i.v. infusion: 5-20 µg.min^-1  

Child i.v. infusion: 0.5-1 µg.kg^-1.min^-1  (max. 20 µg.min^-1) 

Ipratropium

Neb: 2-12 yr 0.25 mg; Adult 0.5 mg

Adrenaline

Neb: Child 0.5 ml of 1:1000  

Neb: Adult 5 ml of 1:1000  

i.m.: <6 mo 50 µg; <6 yr 120 µg; <12 yr 250 µg; Adult 500 µg 

Slow i.v. bolus: 0.1 - 1 µg.kg^-1 (Adult 10-100 µg)  

Magnesium

I.v. over 20 min: 50 mg.kg^-1 (Adult 2g)

Ketamine

Bolus: Adult 20 mg 

i.v. Infusion: 1-3 mg.kg^-1.hr^-1 

Aminophylline

i.v. over 20 min: 5 mg.kg^-1 (omit if already on theophylline) 

i.v. infusion: 

<9 yr 1 mg.kg^-1.hr^-1; <16 yr 0.8 mg.kg^-1.h^-1; Adult 0.5 mg.kg^-1.h^-1 

Hydrocortisone

4 mg.kg^-1 (Adult 200 mg) 

Box C: ALTERNATES AND MIMICS

Wheeze: pulmonary oedema; misplaced airway device; ARDS; laryngospasm 

Raised airway pressure: obstruction of larynx, trachea or bronchi; obstruction of breathing system (any part); decreased lung compliance; pneumothorax 

Box D: VENTILATION STRATEGIES

Increase expiratory time to allow complete expiration 

Pressure control ventilation may be better 

Be alert to ‘breath stacking’ 

Permissive hypercapnia may be appropriate