Preoperative Preparation for Patients with Asthma

Assessment of Asthma Control

The American Academy of Allergy, Asthma, and Immunology recommends reviewing the level of asthma control, medication use, and pulmonary function before surgery, especially for patients with a history of oral systemic corticosteroids within the past 6 months 1, 2
Patients with suspected COPD should have spirometric parameters checked before procedures, and if severe, arterial blood gas tensions should also be measured, as recommended by the British Thoracic Society 3
For patients with poorly controlled asthma, the American Academy of Allergy, Asthma, and Immunology suggests considering postponing elective procedures until better control is achieved 1, 4

The American Academy of Allergy, Asthma, and Immunology recommends providing medications before surgery to improve lung function if not well controlled, and a short course of oral systemic corticosteroids may be necessary 1, 2, 5
The American Academy of Allergy, Asthma, and Immunology suggests continuing regular asthma medications through the perioperative period, including on the day of surgery 1, 4
Asthmatic patients should be premedicated with a bronchodilator before procedures, as recommended by the British Thoracic Society 3

The American Society of Anesthesiologists recommends considering regional anesthesia techniques when appropriate, as major conduction anesthesia should be considered for peripheral procedures 6, 7
For superficial procedures, the American Society of Anesthesiologists suggests considering local anesthesia or peripheral nerve blocks with or without moderate sedation 6
General anesthesia with a secure airway is preferable to deep sedation without a secure airway, particularly for procedures that may mechanically compromise the airway, as recommended by the American Society of Anesthesiologists 6, 7

The American Society of Anesthesiologists recommends monitoring oxygen saturation continuously via pulse oximetry during procedures 6, 3
Supplemental oxygen should be provided to maintain saturation of at least 90% to reduce the risk of significant arrhythmias, as recommended by the British Thoracic Society 3
Unless medically contraindicated, patients with asthma should be extubated while awake, as suggested by the American Society of Anesthesiologists 6, 7

The American Society of Anesthesiologists recommends continuing monitoring oxygen saturation in the recovery period 6, 3
Incentive spirometry, chest physiotherapy, and early mobilization should be considered to prevent pulmonary complications, as recommended by the American Journal of Hematology 8
Appropriate pain control should be maintained, as inadequate analgesia can lead to shallow breathing and atelectasis, as recommended by the American Journal of Hematology 8

Hypothermia should be avoided at all costs in the postoperative setting, as it can trigger bronchospasm, as recommended by the American Journal of Hematology 8
Patients with asthma may have difficult airways and should be managed according to difficult airway protocols, as recommended by the American Society of Anesthesiologists 6, 7
Poor asthma control increases the risk of perioperative complications, including bronchospasm, hypoxemia, hypercapnia, atelectasis, and respiratory infections, as recommended by the American Academy of Allergy, Asthma, and Immunology 2, 4

Modern inhaled corticosteroids, including budesonide, fluticasone, and mometasone, are safe to use at recommended doses and do not have clinically important adverse effects on bone mineral density, cortisol production, and glucose metabolism caused by equivalently effective doses of oral glucocorticoids 9

Maintaining baseline therapy with inhaled corticosteroids like budesonide is preferable to rescue treatment for preventing inflammatory airway edema from direct airway injury during intubation and anesthesia, as supported by evidence from Anaesthesia 10

The management of inhaled corticosteroids for respiratory disease does not involve the same restrictions as GLP-1 receptor agonists or SGLT2 inhibitors, according to recent guidelines from Anaesthesia 11

For patients receiving oral systemic corticosteroids within the past 6 months, the American Academy of Allergy, Asthma, and Immunology recommends giving 100 mg hydrocortisone intravenously during the surgical period, and selected patients on high-dose inhaled corticosteroids may also require stress-dose steroids 12
Patients with poorly controlled asthma may require optimization, including pulmonary function testing, before elective surgery, according to the American Academy of Allergy, Asthma, and Immunology 12

The American Society of Anesthesiologists recommends extubating patients while fully awake unless medically contraindicated, and placing the patient in a semi-upright position for extubation and recovery 13

The American College of Allergy and Clinical Immunology recommends that well-controlled asthma does not require surgery postponement, as indicated by regular inhaler use and absence of recent exacerbations, which are key indicators that surgery can proceed safely 14
Chest X-ray has no role in preoperative assessment of controlled asthma, as it does not predict perioperative risk or change management in stable asthmatic patients 14
Patients who have received oral systemic corticosteroid use within the past 6 months require stress-dose hydrocortisone (100 mg IV every 8 hours during surgery, rapidly tapered within 24 hours post-op) 14, 15
The American College of Allergy and Clinical Immunology suggests that surgery postponement is indicated when asthma is poorly controlled, or during active exacerbations, such as recent asthma exacerbation requiring emergency care 14
Frequent use of rescue inhaler (>2 days/week beyond exercise prevention) is an indicator for potential surgery postponement 16