Corticosteroids and Inhaled Salbutamol in Patients with Reversible Airway Obstruction Markedly Decrease the Incidence of Bronchospasm after Tracheal Intubation

Background: In patients with bronchial hyperreactivity, airway instrumentation can evoke life-threatening bronchospasm. However, the best strategy for the prevention of bronchospasm has not been defined. Therefore, in a randomized, prospective, placebo-controlled study, the authors tested whether prophylaxis with either combined salbutamol-methylprednisolone or salbutamol alone (1) improves lung function and (2) prevents wheezing after intubation.

Methods: Thirty-one patients with partially reversible airway obstruction (airway resistance > 180%, forced expiratory volume in 1 s [FEV1] < 70% of predicted value, and FEV1 increase > 10% after two puffs of salbutamol), who were naive to anti-obstructive treatment, were randomized to receive daily for 5 days either 3 x 2 puffs (0.2 mg) of salbutamol alone (n = 16) or salbutamol combined with methylprednisolone (40 mg/day orally) (n = 15). Lung function was evaluated daily. Another 10 patients received two puffs of salbutamol 10 min before anesthesia. In all patients, wheezing was assessed before and 5 min after tracheal intubation.

Results: Within 1 day, both salbutamol and salbutamol-methylprednisolone treatment significantly improved airway resistance (salbutamol, 4.3 +/- 2.0 [SD] to 2.9 +/- 1.3 mmHg [middle dot] s [middle dot] l-1; salbutamol-methylprednisolone, 5.5 +/- 2.9 to 3.4 +/- 1.7 mmHg [middle dot] s [middle dot] l-1) and FEV1 (salbutamol, 1.79 +/- 0.49 to 2.12 +/- 0.61 l; salbutamol-methylprednisolone, 1.58 +/- 0.66 to 2.04 +/- 1.05 l) to a steady state, with no difference between groups. However, regardless of whether single-dose salbutamol preinduction or prolonged salbutamol treatment was used, most patients (8 of 10 and 7 of 9) experienced wheezing after intubation. In contrast, only one patient receiving additional methylprednisolone experienced wheezing (P = 0.0058).     

Der akute schwere Asthmaanfall

Acute dypnoea due to an acute asthma attack is a frequent cause of emergency treatment. Alternative diagnosis can be acute left heart failure with pulmonary edema, lung emboli, acute exacerbations of COPD and foreign body aspiration. Fatal asthma attacks are rare compared to the number of asthma attacks treated and due to underestimation of the severity of the attack. Cornerstones of acute treatment are oxygen, β₂-adrenergic agonists, systemic corticosteroids and parasymaptholytics. The addition of theophylline has not been shown to add any bronchodilatory but more side effects. Additional pharmacological options are magnesium, volatile anesthetics, lidocaine, ketamine, and propofol. Depending on the clinical development mechanical ventilation might be necessary. However, endotracheal intubation per se might cause an increase in bronchoconstriction with side effects like overdistension, compression atelectasis, pneumothoraces, and hemodynamic depression. Overall, with intensive pharmacological treatment severe asthma attacks can be significantly improved within 24 hours. Thus, fatal asthma attacks seem to be avoidable with early and intensive treatment.     

Work Place Health Promotion

This article deals with the question of whether and how much workplace health promotion measures have infiltrated the working world and which factors determined the results of health promotion programs for the enterprises. To answer this question we conducted a longitudinal study (measuring times: 1997 and 2003) in 150 enterprises in Hessen and Thueringen of the service sector and metal branch. A standardized questionnaire was used to collect the data. One of the results was that the high level of occupational safety and health (OSH) obtained was greatly appreciated by the enterprises interviewed. Many of the enterprises (82.7%) were able to implement at least one workplace health promotion (WHP) measure, mostly assessments of occupational health risks and behavior-oriented offers. The portion of businesses with a very good to sufficient level of workplace health promotion increased clearly from 16.0% in 1997 to 27.4% in 2003. Half of the enterprises interviewed confirmed the need for information and consultation in questions about occupational safety and health issues and workplace health promotion. They expected support particularly from the institutions for statutory occupational accident insurance, health insurance companies, public institutions for labor protection and safety engineering, as well as from the advisory boards of the trade unions. These institutions definitely need to address the consultation requests from the enterprises, as the lack of information and contact persons was one of the reasons why workplace health promotion measures could not be implemented.This study was commissioned by the Hans Boeckler Foundation and the SMBG and translated by Evelyn Jäck     

Nasotracheal intubation with three indirect laryngoscopes assisted by standard or modified Magill forceps

We assessed the effect of modifying standard Magill forceps on the laryngeal introduction of an Eschmann stylet during nasotracheal intubations with three indirect laryngoscopes (Airtraq?, C‐MAC^® or GlideScope^®) in patients with predicted difficult intubation. We allocated 50 participants to each laryngoscope. The stylet was advanced by one forceps followed by the other (standard or modified), with each sequence allocated to 25/50 for each laryngoscope. There were no differences in rates of failed tracheal intubation with the allocated laryngoscopes: 6/50, 5/50 and 5/50, respectively. An Eschmann stylet was advanced into the trachea less often with the standard forceps (65% vs 93%, p < 0.0001). Mean (SD) time for stylet advancement was longer with the standard forceps, 38 (30) vs 19 (19) s, p < 0.0001. In conclusion, the modified Magill forceps facilitated nasotracheal intubation, independent of the type of indirect laryngoscope.     

Single-Access Retroperitoneoscopic Adrenalectomy (SARA) Versus Conventional Retroperitoneoscopic Adrenalectomy (CORA): A Case–Control Study

Background  

Stimulated by the concept of Natural Orifice Transluminal Endoscopic Surgery (NOTES), minimizing the access even further has become a new trend in minimally invasive surgery. We compare our recently described new method of endoscopic single-access adrenalectomy with the conventional retroperitoneoscopic approach in a matched-pairs study.     

Effects of high thoracic epidural anesthesia and local anesthetics on bronchial hyperreactivity

Bronchial hyperreactivity can cause life threatening bronchospasm after airway irritation. Therefore, endotracheal intubation is avoided in asthmatics when feasible. High thoracic epidural anesthesia can be used to avoid endotracheal intubation and offers less postoperative pulmonary complications when compared to systemic postoperative analgesia. However, there are concerns that it might also cause impaired ventilation by extended motor blockade, increased airway resistance, and increased bronchial reactivity because of pulmonary sympathicolysis. Nevertheless, high thoracic epidural anesthesia causes only a slight decrease in vital capacity and neither an increase in airway resistance nor increased bronchial reactivity. In fact, it causes a decrease in bronchial reactivity in patients with bronchial hyperreactivity mostly due to the systemic effect of the local anesthetic. The attenuation of bronchial hyperreactivity can be shown as a dose dependent effect of lidocaine and bupivacaine. The intravenous effect of lidocaine is comparable to the effect of a moderate dose of salbutamol and leads to an additive effect when both drugs are used in combination. Overall, high thoracic epidural anesthesia can be used safely in patients with bronchial hyperreactivity and intravenous administration of lidocaine (1.5–2.0 mg · kg⁻¹) can be used as a prophylactic treatment prior to airway instrumentation. This revised version was published online in July 2006 with corrections to the Cover Date.     

Influence of volatile anaesthetics on hypercapnoeic ventilatory responses in mice with blunted respiratory drive

Background. Subanaesthetic concentrations of volatile anaestheticssignificantly affect the respiratory response to hypoxia andhypercapnoeia. Individuals with an inherited blunted respiratorydrive are more affected than normal individuals. To test thehypothesis that subjects with blunted hypercapnoeic respiratorydrive are diversely affected by different anaesthetics, we studiedthe effects of three volatile anaesthetics on the control ofbreathing in C3H/HeJ (C3) mice, characterized by a blunted hypercapnoeicrespiratory response. Methods. Using whole body plethysmography, we assessed respiratoryrate (RR) and pressure amplitude in 11 male C3 mice at rest,during anaesthesia with isoflurane, sevoflurane or desflurane,and during recovery. To test respiratory drive, mice were exposedto 8% carbon dioxide. Data were analysed by two-way-analysisof variance with post hoc tests and Bonferroni correction. Results. RR was unaffected during sevoflurane anaesthesia upto 1.0 MAC. Likewise, sevoflurane at 1.5 MAC affected RR lessthan either isoflurane (P=0.0014) or desflurane (P=0.0048).The increased RR to a carbon dioxide challenge was blocked byall three anaesthetics even at the lowest concentration, andremained depressed during recovery (P<0.0001). Tidal volumewas unaffected by all three anaesthetics. Conclusions. In C3 mice, spontaneous ventilation was less affectedduring sevoflurane compared with either isoflurane or desfluraneanaesthesia. However, the RR response to hypercapnoeia was abolishedat 0.5 MAC for all the anaesthetic agents and remained depressedeven at the end of recovery. Our data suggest that differentvolatile anaesthetics have varying effects on the control ofbreathing frequency but all block the respiratory response tocarbon dioxide. Therefore, a genetic predisposition to a bluntedcarbon dioxide response represents a susceptibility factor thatinteracts with hypercapnoeic hypoventilation during maintenanceof anaesthesia and in the emergence from anaesthesia, regardlessof the agent used. Br J Anaesth 2004; 92: 697–703     

Strategies in the patient with compromised respiratory function

Respiratory diseases are commonly divided into restrictive or obstructive lung diseases. For anaesthesiological considerations restrictive lung diseases appear as a static condition with minimal short-term development. Overall, restrictive lung diseases don't lead to acute exacerbations due to the choice of anaesthetic techniques or the choice of anaesthesia-specific agents. Compared to restrictive lung diseases, obstructive lung diseases such as asthma or chronic obstructive lung diseases have a high prevalence and are one of the four most frequent causes of death. Obstructive lung diseases can be significantly influenced by the choice of anaesthetic technique and anaesthetic agent. Basically, the severity of the chronic obstructive pulmonary disease (COPD) and the degree of bronchial hyperreactivity will determine the perioperative anaesthetic risk. This risk has to be assessed by a thorough preoperative evaluation and will provide the rationale on which to decide the adequate anaesthetic technique. In particular, airway instrumentation can cause severe reflex bronchoconstriction. The use of regional anaesthesia alone or in combination with general anaesthesia can help to avoid airway irritation and even leads to reduced postoperative complications. Prophylactic anti-obstructive treatment, volatile anaesthetics, propofol, opioids, and an adequate choice of muscle relaxants minimize the anaesthetic risk when general anaesthesia is required. If intraoperative bronchospasm occurs, despite all precautions, deepening of anaesthesia, repeated administration of β₂-adrenergic agents and parasympatholytics, and a single systemic dose of corticosteroids are the main treatment options.     

Rationale and management of perioperative atrial fibrillation

Atrial fibrillation is the most common clinically relevant arrhythmia. Anesthesiologists will be faced with atrial fibrillation of new or undetermined onset at their preoperative evaluation of patients as well as during intra- and post operative care. Because of fast electrophysical and structural remodeling, atrial fibrillation tends to persist and reoccur after successful conversion with increasing time of duration. Therefore, atrial fibrillation with an onset of less than 48 hours should be attempt to convert as soon as diagnostic work up has been made and possible causes have been corrected. New developments of electrophysiological and pharmacological treatment have improved the short term success rate of cardioversion. Further developments might give even more specific treatment options for the individual patient. In contrast, for treatment of chronic atrial fibrillation rate control therapy and thromboembolic prophylaxes seems to be more advisable with a lower risk of drug side effects and stroke. Anticoagulation should be initiated not later than 48 hours after the onset of atrial fibrillation. Finally, the development of implantable devices for the treatment of atrial fibrillation seem to be a promising therapeutic option for patients in end-stage heart diseases.