儿童哮喘患者的围手术期处理的更新Word下载.docx
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儿童哮喘患者的围手术期处理的更新Word下载.docx
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4
(2):
e19.
Publishedonline2012April5.
doi:
10.4081/pr.2012.e19
PMCID:
PMC3395977
Updateonperioperativemanagementofthechildwithasthma
FrancescoDones,
GraziaForesta,and
VincenzoRussotto
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Abstract
Asthmarepresentstheleadingcauseofmorbidityfromachronicdiseaseamongchildren.Dealingwiththisdiseaseduringtheperioperativeperiodofpediatricsurgicalproceduresis,therefore,quitecommonfortheanesthesiologistandotherprofessionalitiesinvolved.Preoperativeassessmenthasakeyroleindetectingchildrenatincreasedriskofperioperativerespiratorycomplications.Forchildrenwithoutanoptimalcontrolofsymptomsorwitharecentrespiratorytractinfectionelectivesurgeryshouldbepostponed,ifpossible,aftertheoptimizationoftherapy.Accordingtoclinicalsetting,loco-regionalanesthesiarepresentsthedesirableoptionsinceitallowstoavoidairwayinstrumentation.Airwaymanagementgoalsarepreventingtheincreaseofairflowresistanceduringgeneralanesthesiaalongwithavoidingtriggersofbronchospasm.Whentheiruseispossible,facemaskventilationandlaringealmaskareconsideredmorereliablethantrachealintubationforchildrenwithasthma.Sevofluraneisthemostcommonlyusedanestheticforinductionandmanteinance.Salbutamolseemstobeusefulinpreventingairflowresistanceriseafterendotrachealintubation.Mechanicalventilationshouldbetailoredaccordingtopathophysiologyofasthma:
anadequateexpiratorytimeshouldbesettedinordertoavoidapositiveend-expiratorypressureduetoexpiratoryairflowobstruction.Painshouldbepreventedandpromptlycontrolledwithaloco-regionalanesthesiatechniquewhenitispossible.Potentialallergicreactionstodrugsorlatexshouldalwaysbeconsideredduringthewholeperioperativeperiod.Creatingasereneatmosphereshouldbeadoptedasanimportantcomponentofinterventionsinordertoguaranteethebestcaretotheasthmaticchild.
Keywords:
pediatric,asthma,perioperativemanagement.
Introduction
Asthmaisoneofthemostcommonchronicdisease,affecting300millionpeopleworldwide,withanincreasingprevalenceespeciallyamongchildren.1
Inchildhooditrepresentstheleadingcauseofmorbidityfromachronicdisease.
Severalhostandenvironmentalfactorsinfluencingthedevelopmentofasthmahavebeenidentified.Sensitizationtoaeroallergens,maternaldietduringpregnancyand/orlactation,tobaccosmoke,infectionsandpsychosocialelementsarethemainenvironmentalfactorsidentified.Howevernointerventionhasyetbeenproventopreventtheonsetofasthmaortomodifyitslong-termnaturalcourse.2
Asthmaisachronicinflammatorydisorderoftheairwaycharacterizedbyairwayhyperresponsivenessassociatedwithrecurrentepisodesofwheezing,breathlessness,chesttightnessandcoughing.Thewidespreadbutvariableairflowobstructionisoftenreversibleeitherspontaneouslyorwithtreatment.1Inyoungerchildren,however,symptomscouldbelessspecific.2
Theimprovementsofmedicalcarehavedecreasedmorbidityandmortalityandtheincidenceofperioperativeseverecomplicationsinasthmaticchildrenundergoinganesthesiaandsurgery.Neverthelessbronchospasmcanstillrepresentalifethreateningcomplication3
andanaccurateattentionfordetailsisnecessaryduringthewholeperioperativecaretopreventthemostsevereadverseevents.Thegoalsoftheanaesthesiologicmanagementofthepatientwithasthmaaretopreventthepotentiallycatastrophiceventofintraoperativebronchospasm4
andtotailorananaestheticplantothechildinordertoensureanadequateairflow,avoidingdrugsandtechniquesassociatedwithapotentialriskofincreasingpulmonaryresistance.
Theaimofthisreviewistofocusonthemostdebatedtopicsoftheanesthesiologicmanagementofthechildwithasthmatryingtoclarifythelatestobservations.
Pathophysiologyandclinicalconsiderations
Airwayinflammationisthekeyfeatureofasthma.Itcharacterizespatientsofallagesanditispermanentevenifsymptomsareepisodic.1
Thecorrelationbetweeninflammationandairwayhyperresponsivenesshasbeenestablished,butthemechanismsinvolvedarenotcompletelyclear.Airwayhyperresponsivenesscontributestoairwaynarrowingandairflowobstructionthroughseveral(incompletelyunderstood)mechanismslikechangesinsmoothmusclecontractilityorsensorynerveandautonomicactivity.5,6
Severaltriggersofairwayobstructionandsymptomshavebeenidentifiedinchildhood:
infections,coldair,outdoorairpollution,laughing,crying,activity.2
Inflammatoryedemaandmucouspluggingcontributetoairwaynarrowingbyluminalobstruction.3
Chronicinflammationisassociatedwithcomplexstructuralchangesoftheairwa
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