Adenosine Induced Bronchospasm

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Adenosine Induced Bronchospasm

• Anes R3 ???

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Case report

• ??? 4129285
• ?? ??X
• ?? 169.5cm
• ?? 60 Kgw
• ?? 62 y/o
• ?? M
• ?? SURG-chest

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Lab.data 1

• WBC 10.1 K/µL
• RBC 5.06 M/µL
• HB 14.0 g/dL
• HCT 44.2
• PLT186.0 K/µL
• Alb 3.9 g/dL
• TP 6.1 g/dL
• PT, PTT WNL

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Lab. Data2

• UN12.2 mg/dL
• CRE 0.8 mg/dL
• UA 4.9 mg/dL
• Na 147.0 mmol/L
• K 4.0 mmol/L
• Cl 105.0 mmol/L
• Ca 2.34 mmol/L
• T-CHO 233.0 mg/dL

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EKG

• NORMAL SINUS RHYTHM, RATE 84 -- normal P axis,
  PR, rate rhythm

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Imaging study

• CXR shows normal heart size with increased lung
  markings. Mild fibrotic change is found at bil.
  lung fields with emphysematous change at lower
  lungs. COPD is suspected
• HRCT of chest for the pulmonary bullous
  disease1. multiple large bullae formation in
  the RML (lower lung fields, at the anterior
  aspect).2. diffuse pneumatoceles in both lung
  fields due to COPD with emphysematous change.3.
  nonspecific small nodes in the mediastinum.4.
  bilateral renal cysts.

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• Impression
• COPD with emphysema large bullae in the RML. 
• Surgical planning
• VATS for Wedge resection

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Induction for anesthesia

• Pre-oxygenation
• Drugs for intubation
• 37 ??
• Check position by fiberscope and fixed
• A-line
• CVP

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PSVT was noted during CVP insertion

• EKG showed PSVT when guide wire was inserted
• Adenosine was used for treatment via CVP
• 6 mg initial iv push , but in vain
• Another 12 mg iv push about 1 min later
• After bradycardia was showed for seconds,
• EKG was returned to sinus rhythm

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High pressure was alarmed by monitor!!

• Rechecked tube position
• High pressure was still noted
• EtCO2 and BS was decreased
• SpO2 was slight decreased
• Call VS, and check tube again
• High EtCO2 (around 70) was noted
• Bronchspasm was noted at RLL

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• Wheezing was heard after EtCO2 was showed
• Steroids and aminophylline were given
  immediately.
• Mild wheezing was noted 10mins later.
• No episode was noted during operation
• No wheezing was noted at the end of surgery

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Life Sciences. 69(11)1225-40, 2001 Aug 3

• Bronchospasm induced by adenosine is blocked by
  representatives of all the major classes of drugs
  used in the treatment of asthma.
• Clinical studies have suggested involvement of
  neural pathways, mast-like cells and mediators
  such as histamine, serotonin and lipoxygenase
  products. There is a strong link between
  responsiveness to adenosine and eosinophilia.
• In different animal models A1, A2b and A3
  adenosine receptor subclasses have all been
  implicated in inducing bronchospasm.
• At least two different mechanisms, both involving
  neural pathways, exist. One, involving the
  adenosine A1 receptor, functions in mast cell
  depleted animals the other requires interaction
  with a population of mast-like cells activated
  over A2b or A3 receptors.

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Life Sciences. 69(11)1225-40, 2001 Aug 3

• Not only histamine but also serotonin and
  lipoxygenase products released from the mast-like
  cells are potential mediators.
• As mast cells both release adenosine and respond
  to adenosine, adenosine provides a non-specific
  method of amplifying specific signals resulting
  from IgE/antigen interaction.
• This mechanism may not only have a pathological
  significance in asthma it may be part of a
  normal bodily defense response that in asthmatic
  subjects is inappropriately activated.

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Is the dyspnea during adenosine cardiac stress
test caused by bronchospasm? American Heart
Journal. 142(1)142-5, 2001 Jul.

• Adenosine cardiac stress is widely used as an
  alternative to exercise testing during myocardial
  perfusion imaging (MPI). Dyspnea often
  accompanies the adenosine stress test.
• Although known asthmatic patients are excluded
  from this test because of the danger of
  bronchospasm, there is incomplete information
  regarding the role of factors such as chronic
  obstructive pulmonary disease (COPD) and tobacco
  smoking in adenosine-induced dyspnea.

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American Heart Journal. 142(1)142-5, 2001 Jul.

• PATIENTS AND METHODS
• A total of 122 consecutive patients (75 male,
  47 female mean age 59 years, SD 10 years)
  undergoing pharmacologic stress testing with an
  intravenous infusion of adenosine also had
  volume-flow spirometry (Vitalograph Compact,
  Vitalograph Ltd) before, during, and after the
  test. The indices assessed were forced expiratory
  volume in one second, its ratio to the forced
  vital capacity, and peak expiratory flow rate.

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American Heart Journal. 142(1)142-5, 2001 Jul.

• RESULTS
• Mild to severe symptoms were experienced by
  81 of patients during adenosine infusion. More
  than half the patients had dyspnea, but there was
  no associated bronchospasm. Although the patients
  with COPD showed parameters indicative of
  bronchial resistance compared with those without
  this problem, there was no further deterioration
  after adenosine infusion. Similarly, patients
  with a history of tobacco abuse, despite showing
  a tendency toward increasing airways resistance,
  had no bronchospasm during the administration of
  adenosine.

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American Heart Journal. 142(1)142-5, 2001 Jul.

• CONCLUSIONS
• Although dyspnea is a common problem during
  adenosine stress MPI, it is not associated with
  any appreciable bronchospasm.
• COPD and tobacco abuse do not appear to be
  contraindications to adenosine stress MPI
  studies. However, it is probably safe to exclude
  patients with severe COPD from adenosine stress
  MPI until after further evaluation with larger
  numbers of patients.

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Pulmonary function monitoring during adenosine
myocardial perfusion scintigraphy in patients
with chronic obstructive pulmonary disease.

• CONCLUSION
• This study shows that adenosine can be safely
  administered intravenously to selected patients
  with known or suspected COPD to produce coronary
  vasodilatation for myocardial perfusion imaging.
  Patients who are within the guidelines
  established for this study should be considered
  for adenosine coronary vasodilatation with use of
  bronchodilator pretreatment, a graduated dose of
  adenosine, and regular chest auscultation during
  the infusion. Mayo Clinic Proceedings.
  74(4)339-46, 1999 Apr.

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• Prednisolone hastens recovery from
  histamine-induced bronchospasm in asthmatics. 
• Journal of Asthma. 37(5)435-40, 2000 Aug.

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Thank you for your attention!!