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Does bilateral thoracic sympathectomy predispose to reflex bronchospasm following tracheal intubation?

Ahed Zeidan, MD^*, Nazih Nahle, MD^* and Anis Baraka, MD FRCA

^* Sahel General Hospital,
American University of Beirut Medical Center, Beirut, Lebanon, E-mail: abaraka{at}aub.edu.lb

To the Editor:

Thoracic endoscopic sympathectomy has become the technique of choice for treating intractable essential hyperhidrosis.¹ We report severe bronchospasm following tracheal intubation in a patient with a previous history of bilateral thoracic sympathectomy. Consent for publication was obtained from the patient.

A 31-yr-old non-smoking woman, 60 kg, without a history of allergy, or asthma, was scheduled for left knee arthroscopy. Two months previously, she had an uneventful general anesthetic for bilateral thoracoscopic sympathectomy to treat essential hyperhidrosis. Preoperative examination revealed clear lungs. Following preoxygenation, anesthesia was induced with propofol 2.5 mg·kg^–1 iv, vecuronuim 0.15 mg kg^–1 iv, and fentanyl 2 µg·kg^–1 iv. Ventilation by facemask was easy. Following onset of neuromuscular block, tracheal intubation was easily performed by direct laryngoscopy. Immediately following intubation, ventilation became difficult. Chest auscultation revealed bilateral expiratory wheezing associated with decreased air entry and increased airway pressure up to 60 cm H₂0. Oxygen saturation, as monitored by pulse oximetry, decreased from 100% to 80%. Anesthesia was deepened by inhalation of sevoflurane (4–8% inspired concentration) in 100% oxygen. Six doses of 20 µg ipratropium bromure and five doses of 100 µg salbutamol were administered via the endotracheal tube. During the following five minutes, ventilation became progressively easier, oxygen saturation increased to 100%, and breath sounds normalized. Anesthesia was continued with 2% to 4% sevoflurane. Throughout this event, no cutaneous flushing was observed, blood pressure ranged between 110/90 mmHg and 130/95 mmHg, with pulse rate between 65 and 115 beats·min^–1.Surgery and recovery proceeded uneventfully. Twelve weeks after surgery, an atopy skin patch test was negative.

The severe bronchospasm experienced by the patient may have been secondary to an anaphylactic reaction to the induction agents. In a recent French survey of anaphylaxis,² the most common features were cardiovascular manifestations (71.5%), followed by cutaneous symptoms (69%). The least frequent feature was bronchospasm which only occurred in 44.2% of the cases, and was associated with a history of atopy or asthma. In our patient, there was no history of atopy or reactive airway disease and the bronchospasm was not associated with any cardiovascular or cutaneous manifestations. The severe bronchospasm occurred immediately following tracheal intubation, suggesting that it may have been a reflex response which was triggered by instrumentation of the airway under a light level of anesthesia. Other causes of bronchospasm such as unrecognized aspiration, carinal irritation, secretions, or chemical irritants that may have contaminated the tracheal tube were also considered and excluded.

Patients with essential hyperhidrosis have sympathetic overactivity, associated with compensatory high parasympathetic tone. Sympathectomy results in a decrease of plasma norepinephrine,³ and parasympathetic predominance4 which may increase airway resistance.⁵ Intraoperative bronchospasm is usually cholinergically-mediated. Thus, patients with essential hyperhidrosis who have undergone bilateral thoracic sympathectomy, may be more liable to develop reflex bronchospasm under light levels of anesthesia.

References

1 Hashmonai M, Kopelman D, Assalia A. The treatment of primary palmar hyperhidrosis: a review. Surg Today 2000; 30: 211–8.[Medline]

2 Laxenaire MC, Mertes PM; Groupe d’Études des Réactions Anaphylactoides Peranesthésiques. Anaphylaxis during anaesthesia. Results of a two-year survey in France. Br J Anaesth 2001; 87: 549–58.[Abstract/Free Full Text]

3 Noppen M, Sevens C, Gerlo E, Vincken W. Plasma catecholamine concentrations in essential hyperhidrosis and effects of thoracoscopic D2–D3 sympathicolysis. Eur J Clin Invest 1997; 27: 202–5.[Medline]

4 Wiklund U, Koskinen LO, Niklasson U, Bjerle P, Elfversson J. Endoscopic transthoracic sympathicotomy affects the autonomic modulation of heart rate in patients with palmar hyperhidrosis. Acta Neurochir (Wien) 2000; 142: 691–6.[Medline]

5 Tseng MY, Tseng JH. Thoracoscopic sympathectomy for palmar hyperhidrosis: effects on pulmonary function. J Clin Neurosci 2001; 8: 539–41.[Medline]

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