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Ballók B, Schranc Á, Tóth I, Somogyi P, Tolnai J, Peták F, Fodor GH. Comparison of the respiratory effects of commonly utilized general anaesthesia regimes in male Sprague-Dawley rats. Front Physiol 2023; 14:1249127. [PMID: 37791348 PMCID: PMC10544940 DOI: 10.3389/fphys.2023.1249127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Accepted: 09/05/2023] [Indexed: 10/05/2023] Open
Abstract
Background: Respiratory parameters in experimental animals are often characterised under general anaesthesia. However, anaesthesia regimes may alter the functional and mechanical properties of the respiratory system. While most anaesthesia regimes have been shown to affect the respiratory system, the effects of general anaesthesia protocols commonly used in animal models on lung function have not been systematically compared. Methods: The present study comprised 40 male Sprague-Dawley rats divided into five groups (N = 8 in each) according to anaesthesia regime applied: intravenous (iv) Na-pentobarbital, intraperitoneal (ip) ketamine-xylazine, iv propofol-fentanyl, inhaled sevoflurane, and ip urethane. All drugs were administered at commonly used doses. End-expiratory lung volume (EELV), airway resistance (Raw) and tissue mechanics were measured in addition to arterial blood gas parameters during mechanical ventilation while maintaining positive end-expiratory pressure (PEEP) values of 0, 3, and 6 cm H2O. Respiratory mechanics were also measured during iv methacholine (MCh) challenges to assess bronchial responsiveness. Results: While PEEP influenced baseline respiratory mechanics, EELV and blood gas parameters (p < 0.001), no between-group differences were observed (p > 0.10). Conversely, significantly lower doses of MCh were required to achieve the same elevation in Raw under ketamine-xylazine anaesthesia compared to the other groups. Conclusion: In the most frequent rodent model of respiratory disorders, no differences in baseline respiratory mechanics or function were observed between commonly used anaesthesia regimes. Bronchial hyperresponsiveness in response to ketamine-xylazine anaesthesia should be considered when designing experiments using this regime. The findings of the present study indicate commonly used anaesthetic regimes allow fair comparison of respiratory mechanics in experimental animals undergoing any of the examined anaesthesia protocols.
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Affiliation(s)
- Bence Ballók
- Department of Medical Physics and Informatics, Albert Szent-Györgyi Medical School, University of Szeged, Szeged, Hungary
| | - Álmos Schranc
- Department of Medical Physics and Informatics, Albert Szent-Györgyi Medical School, University of Szeged, Szeged, Hungary
- Unit for Anaesthesiological Investigations, Department of Anaesthesiology, Pharmacology, Intensive Care, and Emergency Medicine, University of Geneva, Geneva, Switzerland
| | - Ibolya Tóth
- Department of Medical Physics and Informatics, Albert Szent-Györgyi Medical School, University of Szeged, Szeged, Hungary
| | - Petra Somogyi
- Department of Medical Physics and Informatics, Albert Szent-Györgyi Medical School, University of Szeged, Szeged, Hungary
- Department of Cell Biology and Molecular Medicine, Albert Szent-Györgyi Medical School, University of Szeged, Szeged, Hungary
| | - József Tolnai
- Department of Medical Physics and Informatics, Albert Szent-Györgyi Medical School, University of Szeged, Szeged, Hungary
| | - Ferenc Peták
- Department of Medical Physics and Informatics, Albert Szent-Györgyi Medical School, University of Szeged, Szeged, Hungary
| | - Gergely H. Fodor
- Department of Medical Physics and Informatics, Albert Szent-Györgyi Medical School, University of Szeged, Szeged, Hungary
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Regli A, Sommerfield A, von Ungern-Sternberg BS. Anesthetic considerations in children with asthma. Paediatr Anaesth 2022; 32:148-155. [PMID: 34890494 DOI: 10.1111/pan.14373] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Revised: 11/24/2021] [Accepted: 11/25/2021] [Indexed: 01/23/2023]
Abstract
Due to the high prevalence of asthma and general airway reactivity, anesthesiologists frequently encounter children with asthma or asthma-like symptoms. This review focuses on the epidemiology, the underlying pathophysiology, and perioperative management of children with airway reactivity, including controlled and uncontrolled asthma. It spans from preoperative optimization to optimized intraoperative management, airway management, and ventilation strategies. There are three leading causes for bronchospasm (1) mechanical (eg, airway manipulation), (2) non-immunological anaphylaxis (anaphylactoid reaction), and (3) immunological anaphylaxis. Children with increased airway reactivity may benefit from a premedication with beta-2 agonists, non-invasive airway management, and deep removal of airway devices. While desflurane should be avoided in pediatric anesthesia due to an increased risk of bronchospasm, other volatile agents are potent bronchodilators. Propofol is superior in blunting airway reflexes and, therefore, well suited for anesthesia induction in children with increased airway reactivity.
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Affiliation(s)
- Adrian Regli
- Intensive Care Unit, Fiona Stanley Hospital, Perth, Western Australia, Australia.,School of Human Sciences, The University of Western Australia, Perth, Western Australia, Australia.,Medical School, The University of Notre Dame Australia, Fremantle, Western Australia, Australia
| | - Aine Sommerfield
- Department of Anaesthesia and Pain Management, Perth Children's Hospital, Perth, Western Australia, Australia.,Perioperative Medicine Team, Telethon Kids Institute, Perth, Western Australia, Australia
| | - Britta S von Ungern-Sternberg
- Department of Anaesthesia and Pain Management, Perth Children's Hospital, Perth, Western Australia, Australia.,Perioperative Medicine Team, Telethon Kids Institute, Perth, Western Australia, Australia.,Division of Emergency Medicine, Anaesthesia and Pain Medicine, Medical School, The University of Western Australia, Perth, Western Australia, Australia
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Luo J, Chen Q, Min S, Yu J. Perioperative Anaphylaxis from a Perspective of Temperature. J INVEST SURG 2021; 35:833-840. [PMID: 33998366 DOI: 10.1080/08941939.2021.1922553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Perioperative anaphylaxis poses a special challenge due to its unique condition with the additive effects of surgery and anesthesia, which tends to be more difficult to recognize, diagnose, and manage, resulting in potentially fatal outcomes. Appropriate prevention and treatment benefits patients and reduces mortality and morbidity. Significant body temperature changes occur during anaphylaxis and/or anesthesia, which correlates with the outcomes. During the perioperative period, body temperature and anaphylaxis bidirectionally interact with each other, and anaphylaxis is generally deteriorated by hypothermia, which is usually required in cardiac surgeries. Perioperative factors, such as surgery and anesthesia, affect body temperature and anaphylaxis. The complicated role of body temperature and its application in the diagnosis of perioperative anaphylaxis and prediction of the outcomes are still unclear. To date, a profile of body temperature change during perioperative anaphylaxis is lacking, which requires further study. This literature review was conducted with updated data on perioperative anaphylaxis from the perspective of temperature as a component aiming to bring attention to and offer some cues for improving perioperative prevention and management for perioperative medical teams.Supplemental data for this article is available online at https://doi.org/10.1080/08941939.2021.1922553 .
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Affiliation(s)
- Jie Luo
- Department of Anesthesiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Qibin Chen
- Department of Anesthesiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Su Min
- Department of Anesthesiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Jian Yu
- Department of Anesthesiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
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Dos Santos Rocha A, Fodor GH, Kassai M, Degrugilliers L, Bayat S, Petak F, Habre W. Physiologically variable ventilation reduces regional lung inflammation in a pediatric model of acute respiratory distress syndrome. Respir Res 2020; 21:288. [PMID: 33129315 PMCID: PMC7602830 DOI: 10.1186/s12931-020-01559-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Accepted: 10/26/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Benefits of variable mechanical ventilation based on the physiological breathing pattern have been observed both in healthy and injured lungs. These benefits have not been characterized in pediatric models and the effect of this ventilation mode on regional distribution of lung inflammation also remains controversial. Here, we compare structural, molecular and functional outcomes reflecting regional inflammation between PVV and conventional pressure-controlled ventilation (PCV) in a pediatric model of healthy lungs and acute respiratory distress syndrome (ARDS). METHODS New-Zealand White rabbit pups (n = 36, 670 ± 20 g [half-width 95% confidence interval]), with healthy lungs or after induction of ARDS, were randomized to five hours of mechanical ventilation with PCV or PVV. Regional lung aeration, inflammation and perfusion were assessed using x-ray computed tomography, positron-emission tomography and single-photon emission computed tomography, respectively. Ventilation parameters, blood gases and respiratory tissue elastance were recorded hourly. RESULTS Mechanical ventilation worsened respiratory elastance in healthy and ARDS animals ventilated with PCV (11 ± 8%, 6 ± 3%, p < 0.04), however, this trend was improved by PVV (1 ± 4%, - 6 ± 2%). Animals receiving PVV presented reduced inflammation as assessed by lung normalized [18F]fluorodeoxyglucose uptake in healthy (1.49 ± 0.62 standardized uptake value, SUV) and ARDS animals (1.86 ± 0.47 SUV) compared to PCV (2.33 ± 0.775 and 2.28 ± 0.3 SUV, respectively, p < 0.05), particularly in the well and poorly aerated lung zones. No benefit of PVV could be detected on regional blood perfusion or blood gas parameters. CONCLUSIONS Variable ventilation based on a physiological respiratory pattern, compared to conventional pressure-controlled ventilation, reduced global and regional inflammation in both healthy and injured lungs of juvenile rabbits.
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Affiliation(s)
- Andre Dos Santos Rocha
- Unit for Anaesthesiological Investigations, Department of Acute Medicine, University Hospitals of Geneva and University of Geneva, rue Willy Donzé 6, 1205, Geneva, Switzerland.
| | - Gergely H Fodor
- Unit for Anaesthesiological Investigations, Department of Acute Medicine, University Hospitals of Geneva and University of Geneva, rue Willy Donzé 6, 1205, Geneva, Switzerland.,Department of Medical Physics and Informatics, University of Szeged, 9 Korányi fasor, Szeged, 6720, Hungary
| | - Miklos Kassai
- Unit for Anaesthesiological Investigations, Department of Acute Medicine, University Hospitals of Geneva and University of Geneva, rue Willy Donzé 6, 1205, Geneva, Switzerland
| | - Loic Degrugilliers
- Department of Pediatric Intensive Care, Amiens University Hospital, Amiens, France
| | - Sam Bayat
- Inserm UA7 STROBE Laboratory &, Department of Clinical Physiology, Sleep and Exercise, Grenoble University Hospital, Boulevard de La Chantourne, 38700, Grenoble, La Tronche, France
| | - Ferenc Petak
- Department of Medical Physics and Informatics, University of Szeged, 9 Korányi fasor, Szeged, 6720, Hungary
| | - Walid Habre
- Unit for Anaesthesiological Investigations, Department of Acute Medicine, University Hospitals of Geneva and University of Geneva, rue Willy Donzé 6, 1205, Geneva, Switzerland
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Malaspinas I, Petak F, Baudat A, Doras C, Eigenmann PA, Habre W. Blockade of the cholinergic system during sensitization enhances lung responsiveness to allergen in rats. Clin Exp Pharmacol Physiol 2018; 45:1293-1301. [PMID: 29992592 DOI: 10.1111/1440-1681.13009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Revised: 06/18/2018] [Accepted: 06/26/2018] [Indexed: 11/27/2022]
Abstract
Although acute prophylactic administration of atropine modulates airway responsiveness, the role of the parasympathetic nervous system in the pathogenesis of sensitization and in antigen-induced bronchoconstriction remains unclear. The aim of the present study is to determine whether blocking muscarinic receptors during chronic allergen exposure modulates lung responsiveness to the specific allergen. Forty rats were randomly assigned to one of the following five treatment groups: sensitization with saline vehicle, intraperitoneal injection of ovalbumin (1 mg) with or without atropine treatment (10 mg/kg per day) and repeated ovalbumin aerosol (1.25 mg/mL for 20 minutes) either alone or combined with atropine. Lung responsiveness to methacholine (4-16 μg/kg per minute) and intravenous ovalbumin (2 mg) was established before and 21 days after treatment with forced oscillations following bilateral vagotomy. Lung cellularity was determined by analysis of bronchoalveolar lavage fluid (BALF). A lung inflammatory response in all sensitized animals was defined as an increase in the number of inflammatory cells in the BALF. Baseline respiratory mechanics and methacholine responsiveness on Days 0 and 21 were comparable in all groups. However, increases in airway resistance following intravenous allergen challenge were significantly exacerbated in rats that received atropine. Inhibition of the cholinergic nervous system during allergic sensitization potentiates bronchoconstriction following exposure to the specific allergen. These findings highlight the role of the cholinergic neuronal pathway in airway sensitization to a specific allergen.
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Affiliation(s)
- Iliona Malaspinas
- Anaesthesiological Investigation Unit, University of Geneva, Geneva, Switzerland
| | - Ferenc Petak
- Department of Medical Physics and Informatics, University of Szeged, Szeged, Hungary
| | - Aurélie Baudat
- Anaesthesiological Investigation Unit, University of Geneva, Geneva, Switzerland
| | - Camille Doras
- Anaesthesiological Investigation Unit, University of Geneva, Geneva, Switzerland
| | - Philippe A Eigenmann
- Department of Paediatrics, Geneva Children's Hospital, University Hospital of Geneva, Geneva, Switzerland
| | - Walid Habre
- Anaesthesiological Investigation Unit, University of Geneva, Geneva, Switzerland.,Pediatric Anaesthesia Unit, Geneva Children's Hospital, University Hospitals of Geneva, Geneva, Switzerland
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Babik B, Balogh AL, Sudy R, Ivankovitsne-Kiss O, Fodor GH, Petak F. Levosimendan prevents bronchoconstriction and adverse respiratory tissue mechanical changes in rabbits. Am J Physiol Lung Cell Mol Physiol 2017; 313:L950-L956. [DOI: 10.1152/ajplung.00213.2017] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2017] [Revised: 08/15/2017] [Accepted: 08/15/2017] [Indexed: 11/22/2022] Open
Abstract
Levosimendan has a calcium-sensitizing effect in the myocardium and opens ATP-sensitive potassium channels (KATP) in vascular smooth muscle. Because airway smooth muscle also expresses KATP, we characterized the protective potential of levosimendan against increased airway and respiratory tissue resistances. Animals were administered levosimendan alone ( group L), levosimendan after pretreatment with a KATP channel blocker (glibenclamide, group LG), glibenclamide only ( group G), or solvent alone (dextrose, group C). Airway resistance (Raw), tissue damping, and elastance were determined by forced oscillations under baseline conditions and following provocation tests with intravenous methacholine (MCh). Cardiac output (CO) was assessed by transpulmonary thermodilution. The same sequence of measurements was then repeated during intravenous infusion of levosimendan in groups L and LG or glucose in groups G and C. Sham treatments in groups C and G had no effect on lung responsiveness. However, levosimendan treatment in group L elevated CO and inhibited the MCh-induced airway responses [Raw changes of 87.8 ± 83% (SD) vs. 24.4 ± 16% at 4 μg·kg−1·min−1 MCh, P < 0.001], and in G (35.2 ± 12.7 vs. 25.2 ± 12.9%, P < 0.05). The preventive affect of levosimendan against lung constriction vanished in the LG group. Levosimendan exerts a KATP-mediated potential to prevent bronchoconstriction and may prohibit adverse lung peripheral changes both in the small bronchi and the pulmonary parenchyma. The identification of a further pleiotropic property of levosimendan that is related to the pulmonary system is of particular importance for patients with decreased cardiorespiratory reserves for which simultaneous circulatory support is complemented with prevention of adverse respiratory events.
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Affiliation(s)
- Barna Babik
- Department of Anesthesiology and Intensive Therapy, University of Szeged, Szeged, Hungary; and
| | - Adam L. Balogh
- Department of Anesthesiology and Intensive Therapy, University of Szeged, Szeged, Hungary; and
- Department of Medical Physics and Informatics, University of Szeged, Szeged, Hungary
| | - Roberta Sudy
- Department of Anesthesiology and Intensive Therapy, University of Szeged, Szeged, Hungary; and
- Department of Medical Physics and Informatics, University of Szeged, Szeged, Hungary
| | | | - Gergely H. Fodor
- Department of Medical Physics and Informatics, University of Szeged, Szeged, Hungary
| | - Ferenc Petak
- Department of Medical Physics and Informatics, University of Szeged, Szeged, Hungary
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Zhou J, Iwasaki S, Yamakage M. Time- and Dose-Dependent Effects of Desflurane in Sensitized Airways. Anesth Analg 2017; 124:465-471. [PMID: 28067710 DOI: 10.1213/ane.0000000000001754] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Although the bronchodilatory actions of volatile anesthetics, such as halothane, isoflurane, and sevoflurane, have been well documented in previous studies, the properties of desflurane remain controversial. The aim of this study was to investigate the effects of desflurane at different concentrations and durations in an ovalbumin-sensitized guinea pig model of airway hyper-responsiveness. METHODS Ovalbumin-sensitized animals (n = 176) were randomly assigned to 5 groups according to the minimum alveolar concentration (MAC) of desflurane they received: 0.0, 0.5, 1.0, 1.5, and 2.0 MAC. Total lung resistance in vivo, airway smooth muscle tension in vitro, and intracellular cyclic adenosine monophosphate (AMP) levels were measured to evaluate the effects of desflurane. RESULTS In 5 sensitized groups, total lung resistance increased from baseline to peak at approximately 8 minutes and then decreased slowly until about 17 minutes with extended administration of desflurane. Desflurane dose-dependently increased total lung resistance with or without incremental doses of acetylcholine and reduced muscle tension with increasing concentrations of carbacholine. Cyclic AMP levels were increased by desflurane: at the 60-minute time point, cyclic AMP concentrations (means ± SD) with 0.5 MAC (1.96 ± 0.40) and 1.0 MAC (2.11 ± 0.50) desflurane were higher than those at the 8-minute time point (1.11 ± 0.23 and 1.32 ± 0.32). CONCLUSIONS Desflurane exerted time- and dose-dependent effects and could be used at 0.5 and 1.0 MAC concentrations without significant bronchoconstriction in ovalbumin-sensitized guinea pigs. Cyclic AMP-mediated airway smooth muscle relaxation might be one mechanism by which desflurane induces bronchodilation.
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Affiliation(s)
- Jing Zhou
- From the *Department of Anesthesiology, Shengjing Hospital, China Medical University, Shenyang, China; and †Department of Anesthesiology, Sapporo Medical University, Sapporo, Japan
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Balogh AL, Peták F, Fodor GH, Sudy R, Babik B. Sevoflurane Relieves Lung Function Deterioration After Cardiopulmonary Bypass. J Cardiothorac Vasc Anesth 2017. [PMID: 28629872 DOI: 10.1053/j.jvca.2017.02.186] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To investigate sevoflurane's potential to alleviate the detrimental pulmonary changes after cardiopulmonary bypass (CPB). DESIGN Prospective, randomized clinical investigation. SETTING University hospital. PARTICIPANTS One hundred ninety patients undergoing elective cardiac surgery. INTERVENTIONS Ninety-nine patients under intravenous anesthesia were administered 1 minimal alveolar concentration of sevoflurane for 5 minutes after being weaned from CPB (group SEV); intravenous anesthesia was maintained in the other 91 patients (group CTRL). MEASUREMENTS AND MAIN RESULTS Measurements were performed with open chest: before CPB, after CPB, and after intervention. The lungs' mechanical impedance and capnogram traces were recorded, arterial and central venous blood samples were analyzed, and lung compliance was documented. Airway resistance, tissue damping, and elastance were obtained from the impedance spectra. The capnogram phase III slope was determined using linear regression. The partial pressure of oxygen in the arterial blood/fraction of inspired oxygen ratio and shunt fraction were calculated from blood gas parameters. After CPB, sevoflurane induced bronchodilation, reflected in marked drops in airway resistance and smaller improvements in lung tissue viscoelasticity indicated by decreases in tissue damping and elastance. These changes were reflected in a decreased capnogram phase III slope and shunt fraction and increased partial pressure of oxygen in the arterial blood/fraction of inspired oxygen ratio and lung compliance. The more severe deteriorations that occurred after CPB, the greater improvements by sevoflurane were observed. CONCLUSIONS Sevoflurane can alleviate CPB-induced bronchoconstriction, compromised lung tissue mechanics, and enhanced intrapulmonary shunt. This benefit has particular importance in patients with severe CPB-induced lung function deterioration.
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Affiliation(s)
- Adam L Balogh
- Department of Anesthesiology and Intensive Therapy, University of Szeged, Szeged, Hungary; Department of Medical Physics and Informatics, University of Szeged, Szeged, Hungary
| | - Ferenc Peták
- Department of Medical Physics and Informatics, University of Szeged, Szeged, Hungary.
| | - Gergely H Fodor
- Department of Medical Physics and Informatics, University of Szeged, Szeged, Hungary
| | - Roberta Sudy
- Department of Anesthesiology and Intensive Therapy, University of Szeged, Szeged, Hungary; Department of Medical Physics and Informatics, University of Szeged, Szeged, Hungary
| | - Barna Babik
- Department of Anesthesiology and Intensive Therapy, University of Szeged, Szeged, Hungary
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Trachsel D, Svendsen J, Erb T, von Ungern-Sternberg B. Effects of anaesthesia on paediatric lung function. Br J Anaesth 2016; 117:151-63. [DOI: 10.1093/bja/aew173] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
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Diagnosis and Management of Respiratory Adverse Events in the Operating Room. CURRENT ANESTHESIOLOGY REPORTS 2015. [DOI: 10.1007/s40140-015-0103-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Anesthesia and ventilation strategies in children with asthma: part II - intraoperative management. Curr Opin Anaesthesiol 2014; 27:295-302. [PMID: 24686320 DOI: 10.1097/aco.0000000000000075] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
PURPOSE OF REVIEW As asthma is a frequent disease especially in children, anesthetists are increasingly providing anesthesia for children requiring elective surgery with well controlled asthma but also for those requiring urgent surgery with poorly controlled or undiagnosed asthma. This second part of this two-part review details the medical and ventilatory management throughout the perioperative period in general but also includes the perioperative management of acute bronchospasm and asthma exacerbations in children with asthma. RECENT FINDINGS Multiple observational trials assessing perioperative respiratory adverse events in healthy and asthmatic children provide the basis for identifying risk reduction strategies. Mainly, animal experiments and to a small extent clinical data have advanced our understanding of how anesthetic agents effect bronchial smooth muscle tone and blunt reflex bronchoconstriction. Asthma treatment outside anesthesia is well founded on a large body of evidence.Perioperative prevention strategies have increasingly been studied. However, evidence on the perioperative management, including mechanical ventilation strategies of asthmatic children, is still only fair, and further research is required. SUMMARY To minimize the considerable risk of perioperative respiratory adverse events in asthmatic children, perioperative management should be based on two main pillars: the preoperative optimization of asthma treatment (please refer to the first part of this two-part review) and - the focus of this second part of this review - the optimization of anesthesia management in order to optimize lung function and minimize bronchial hyperreactivity in the perioperative period.
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