Anästhesie bei Asthma bronchiale

Zusammenfassung.

Asthma bronchiale wird heute als grundsätzlich entzündliche Atemwegserkrankung unterschiedlicher Ätiologie definiert, deren Leitsymtome die bronchiale Hyperreagibilität, Atemwegsobstruktion, Giemen und Dyspnoe sind. Die Prävalenz und der Schweregrad der Erkrankung nimmt weltweit zu, so dass Anästhesiologen immer häufiger mit der perioperativen Betreuung von Asthmatikern im Operationssaaal, im Aufwachraum und auf der Intensivstation konfrontiert sind. Die anästhesiologische Verantwortung beginnt bei der Prämedikationsvisite und der Einschätzung der Erkrankungsschwere. Bei Elektiveingriffen ist präoperativ eine Optimierung der Lungenfunktion und eine Kontrolle der obstruktiven Symtomatik durch eine patientengerechte pharmakologische Behandlung mit antiinflammatorischen und bronchodilatierenden Medikamenten anzustreben, da Patienten mit Asthma bronchiale nur im asymptomatischen Intervall eine der Normalbevölkerung vergleichbare Rate perioperativer respiratorischer Komplikationen haben. Die charakteristische Voll- bzw. Teilreversibilität der Atemwegsobstruktion wird präoperativ im Rahmen der Lungenfunktionsprüfung mit dem Bronchospasmolysetest nachgewiesen. Eine Verbesserung der FEV₁ um 15 % wird dabei als signifikant angesehen. Bei Allgemeinanästhesien mit und ohne Intubation ist die Inhalationsanästhesie weiterhin Verfahren der Wahl. Propofol hat sich als das optimale Induktionsmedikament bei Asthmatiker erwiesen und scheint selbst dem Ketamin überlegen zu sein. Die Anwendung rückenmarknaher Regionalanästhesieverfahren ist bei Asthmatikern im asymtomatischen Intervall bezüglich perioperativer respiratorischer Komplikationen der Allgemeinanästhesie zwar vergleichbar, bei symptomatischen Patienten haben rückenmarknahe Anästhesieverfahren allerdings den Vorteil, die Manipulation der Atemwege als mögliche Trigger des perioperativen Bronchospasmus zu vermeiden. Schwangere Asthmatikerinnen repräsentieren eine besondere Risikogruppe für den behandelnden Anästhesisten, vor allem, wenn sich im Rahmen geburtshilflicher Eingriffe rückenmarknahe Anästhesieverfahren verbieten oder Prostaglandinderivate zur Anwendung kommen müssen. Asthmatiker sind perioperativ immer zu einem Bronchospasmus prädisponiert. Der perioperative Bronchospasmus stellt eine lebensbedrohliche anästhesiologische Komplikation dar, deren Häufigkeit zwischen 0,17 - 4,2 % angegeben wird und die zu einem schweren hypoxischen Hirnschaden und zum Tod des Patienten führen kann. Ziel der Narkoseführung ist es, das Risiko eines Bronchospasmus zu minimieren. Einmal eingetreten, steht die adäquate Oxygenierung des Patienten im Vordergrund, was nach zweifelsfreier Sicherung der Diagnose durch Vertiefen der Narkose und frühzeitigen, aggressiven Einsatz von selektiven β₂-Sympathomimetika und Kortikosteroiden erreicht werden kann.

Anesthesia for the Asthmatic Patient.

Asthma is defined as a chronic inflammatory airway disease in response to a wide variety of provoking stimuli. Characteristic clinical symptoms of asthma are bronchial hyperreactivity, reversible airway obstruction, wheezing and dyspnea. Asthma presents a major public health problem with increasing prevalence rates and severity worldwide. Despite major advances in our understanding of the clinical management of asthmatic patients, it remains a challenging population for anesthesiologists in clinical practice. The anesthesiologist's responsibility starts with the preoperative assessment and evaluation of the pulmonary function. For patients with asthma who currently have no symptoms, the risk of perioperative respiratory complications is extremely low. Therefore, pulmonary function should be optimized preoperatively and airway obstruction should be controlled by using steroids and bronchodilators. Preoperative spirometry is a simple means of assessing presence and severity of airway obstruction as well as the degree of reversibility in response to bronchodilator therapy. An increase of 15 % in FEV₁ is considered clinically significant. Most asymptomatic persons with asthma can safely undergo general anesthesia with and without endotracheal intubation. Volatile anesthetics are still recommended for general anesthetic techniques. As compared to barbiturates and even ketamine, propofol is considered to be the agent of choice for induction of anesthesia in asthmatics. The use of regional anesthesia does not reduce perioperative respiratory complications in asymptomatic asthmatics, whereas it is advantageous in symptomatic patients. Pregnant asthmatic and parturients undergoing anesthesia are at increased risk, especially if regional anesthetic techniques are not suitable and prostaglandin and its derivates are administered for abortion or operative delivery. Bronchial hyperreactivity associated with asthma is an important risk factor of perioperative bronchospasm. The occurrence of this potentially life-threatening condition in anesthesia practice varies from 0.17 to 4.2 %. The anesthesiologists' goal should be to minimize the risk of inciting bronchospasm and to avoid triggering stimuli. As increases in airway resistance are noticed, therapy should be directed towards optimizing oxygenation and proper diagnosis needs to be established. With deepening anesthesia level and aggressive pharmacological management utilizing both, β-agonists and steroids, respiratory failure may be properly controlled.

Schlüsselwörter:

Asthma bronchiale - bronchiale Hyperreaktivität - Bronchospasmus -

Key words:

Airway obstruction - Asthma - Bronchial hyperreactivity - Bronchospasm - Respiratory complications

Literatur

• 1 Roche W R, Beasley R, Williams J H, Holgate S T. Subepithelial fibrosis in bronchi of asthmatics.  Lancet. 1989;  I (8637) 520-524
• 2 Kroegel C. Definition, Einteilung und begriffliche Abgrenzung des Asthma bronchiale. In: Kroegel C (Hrsg.): Asthma bronchiale. Pathogenetische Grundlagen, Diagnostik, Therapie. Georg Thieme Verlag, Stuttgart New York 1998
• 3 Kroegel C, Virchow J C jr, Walker C T. Lymphocyte activation in bronchial asthma.  N. Engl. J. Med.. 1993;  328 1639-1640
• 4 Gershel J C, Goldman H S, Stein R E, Shelov S P, Ziprkowski M. The usefulness of chest radiographs in first asthma attacks.  N. Engl. J. Med.. 1983;  309 336-339
• 5 Tai E, Read J. Blood gas tensions in bronchial asthma.  Lancet. 1967;  1 644-646
• 6 Quanjer P H, Tammeling G J, Cotes J E, Pedersen O F, Peslin R, Yernault J C. Lung volumes and forced ventilatory flows. Report working party standardisation of lung function tests.  Eur. Resp. J.. 1993;  16 (Suppl.) 5-40
• 7 American Thoracic Society . Standards for the diagnosis and care of patients with chronic obstructive pulmonary disease (COPD) and asthma.  Am. Rev. Respir. Dis.. 1987;  136 225-244
• 8 Laitinen A, Laitinen L A. Cellular infiltrates in asthma and chronic obstructive pulmonary disease.  Am. Rev. Respir. Dis.. 1991;  143 1159-1160
• 9 Romagnani S. Regulation and deregulation of human IgE synthesis.  Immunol. Today. 1990;  11 316-321
• 10 Anderson G P, Coyle A J. Th2 and Th2-like cells in allergy and asthma: pharmacological perspectives.  TIPS. 1994;  15 324-332
• 11 Wettengel R, Berdel D, Hofmann D, Krause J, Kroegel C, Kroidl R F, Leupold W, Lindemann H, Magnussen H, Meister R, Morr H, Nolte D, Rabe K F, Reinhardt D, Sauer R, Schultze-Werninghaus G, Ukena D, Worth H. Asthmatherapie bei Kindern und Erwachsenen. Empfehlungen der Deutschen Atemwegsliga in der Deutschen Gesellschaft für Pneumologie.  Med. Klin.. 1998;  93 639-650
• 12 Parish R C, Miller L J. Nedocromil sodium.  Ann. Pharmacother.. 1993;  27 599-606
• 13 Laitinen L A, Laitinen A, Haahtela T. A comparative study of the effects of an inhaled corticosteroid, budesonide, and a β₂-agonist, terbutaline, on airway inflammation in newly diagnosed asthma: a randomized, double-blind, parallel-group controlled trial.  J. Allergy Clin. Immunol.. 1992;  90 32-42
• 14 Barnes P J, Pedersen S. Efficacy and safety of inhaled corticosteroids in asthma.  Am. Rev. Respir. Dis.. 1993;  148 1-26
• 15 Her E, Frazer J, Austen K F, Owen W F jr. Eosinophil hematopoietins antagonize the programmed cell death of eosinophils. Cytokine and glucocorticoid effects on eosinophils maintained by endothelial cell-conditioned medium.  J. Clin. Invest.. 1991;  88 1982-1987
• 16 Shimura S, Sasaki T, Ikeda K, Yamauchi K, Sasaki H, Takishima T. Direct inhibitory action of glucocorticoid on glycoconjugate secretion from airway submucosal glands.  Am. Rev. Respir. Dis.. 1990;  141 1044-1049
• 17 Lundgren R, Soderberg M, Horstedt P, Stenling R. Morphological studies of bronchial mucosal biopsies from asthmatics before and after ten years of treatment with inhaled steroids.  Eur. Respir. J.. 1988;  1 (10) 883-889
• 18 Fraser C M, Venter J C. Beta-adrenergic receptors. Relationship of primary structure, receptor function, and regulation.  Am. Rev. Respir. Dis.. 1990;  141 22-30
• 19 Toogood J H, Jennings B, Greenway R W, Chuang L. Candidiasis and dysphonia complicating beclomethasone treatment of asthma.  J. Allergy. Clin. Immunolog.. 1980;  65 145-153
• 20 Newhouse M T. Is theophylline obsolete?.  Chest. 1990;  98 1-3
• 21 Littenberg B. Aminophylline treatment in severe, acute asthma. A meta-analysis.  JAMA. 1988;  259 1678-1684
• 22 Persson C GA. The profile of action of enprofylline, or why adenosine antagonism seems less desirable with xanthine antiasthmatic. In: Morley J, Rainsford KD (Hrsg.) Pharmacology of Asthma. Basel; Birkhäuser Verlag 1983
• 23 Polson J B, Krzanowski J J, Anderson W H, Fitzpatrick D F, Hwang D P, Szentivanyi A. Analysis of the relationship between pharmacological inhibition of cyclic nucleotide phosphodiesterase and relaxation of canine tracheal smooth muscle.  Biochem. Pharmacol.. 1979;  28 1391-1395
• 24 Barnes P J, Pauwels R A. Theophylline in the management of asthma: time for reappraisal?.  Eur. Respir. J.. 1994;  7 579-591
• 25 Milgrom H, Bender B. Current issues in the use of theophylline.  Am. Rev. Respir. Dis.. 1993;  147 33-39
• 26 Ukena D, Berdel D, Butt U, Criee C P, Leupold W, Loos U, Nolte D, Podszus T, Rabe K, Ruhle K H, Sill V, Schlimmer P, Schmidt M, Schmitz M, Sybrecht G W, Wettengel R, Wiesner B, Worth H. Theophyllin in der Therapie des Asthma bronchiale - Ist eine Neubewertung notwendig?.  Med. Klin.. 1996;  91 751-752
• 27 Nelson H S. Adrenergic therapy of bronchial asthma.  J. Allergy Clin. Immunol.. 1986;  77 771-785
• 28 Spitzer W O, Suissa S, Ernst P, Horwitz R I, Habbick B, Cockcroft D, Boivin J F, McNutt M, Buist A S, Rebuck A S. The use of β-agonists and the risk of death and near death from asthma.  , (Comment in: N. Engl. J. Med. 1992;20:560 - 561) N. Engl. J. Med.. 1992;  326 501-506
• 29 Vathenen A S, Knox A J, Higgins B G, Britton J R, Tattersfield A E. Rebound increase in bronchial responsiveness after treatment with inhaled terbutaline.  Lancet. 1988;  12 554-555
• 30 Van Schayck C P, Graafsma S J, Visch M B, Dompeling E, van Weel C, van Herwaarden C L. Increased bronchial hyperresponsiveness after inhaling salbutamol during one year is not caused by subsensitization to salbutamol.  J. Allergy Clin. Immunol.. 1990;  86 793-800
• 31 Beasley R, Pearce N, Crane J, Windom H, Burgess C. Asthma mortality and inhaled beta agonist therapy.  Aust. N. Z. J. Med.. 1991;  21 753-763
• 32 Gross N. Ipratropium bromide.  N. Engl. J. Med.. 1988;  319 486-494
• 33 Francis H P, Patel U P, Thompson A M, Carpenter T G, Gardiner P J, Abram T S. The effects of a novel sulphidopeptide leukotriene antagonist, BAY x7195, against elicited bronchoconstriction in the anaesthetized guinea-pig.  Br. J. Pharmacol.. 1998;  123 (1) 39-44
• 34 Sheffer A L. Expert panel on the management of asthma.  J. Allergy Clin. Immunol.. 1991;  88 425-534
• 35 Warner M A, Divertie M B, Tinker J H. Preoperative cessation of smoking and pulmonary complications in coronary artery bypass patients.  Anesthesiology. 1984;  60 380-383
• 36 Empey D W, Laitinen L A, Jacobs L, Gold W M, Nadel J A. Mechanisms of bronchial hyperreactivity in normal subjects after upper respiratory tract infection.  Am. J. Respir. Dis.. 1976;  113 131-139
• 37 Warner D O, Warner M A, Barnes R D, Offord K P, Schroeder D R, Gray D T, Yunginger J W. Perioperative respiratory complications in patients with asthma.  Anesthesiology. 1996;  85 460-467
• 38 Gold M I, Helrich M. A study of the complications related to anaesthesia in asthmatic patients.  Anesth. Analg.. 1963;  42 283-293
• 39 Shnider S M, Papper E M. Anaesthesia for the asthmatic patient.  Anesthesiology. 1961;  22 886-892
• 40 Cheney F W, Posner K L, Caplan R A. Adverse respiratory events infrequently leading to malpractice suits.  Anesthesiology. 1991;  75 932-939
• 41 Bishop M J, Cheney F W, Festa V. Anesthesia for patients with asthma. Low risk but not no risk.  Anesthesiology. 1996;  85 455-456
• 42 Warner D O, Warner M A, Offord K P, Schroeder D R, Maxson P, Scanlon P D. Airway obstruction and perioperative complications in smokers undergoing abdominal surgery.  Anesthesiology. 1999;  90 372-379
• 43 Haxhiu M A, van Lunteren E, Cherniack N S, Deal E C. Benzodiazepines acting on ventral surface of medulla cause airway dilation.  Am. J. Physiol.. 1989;  257 R810-R815
• 44 Koga Y, Sato S, Sodeyama N, Takahashi M, Kato M, Iwatsuki N, Hashimoto Y. Comparison of the relaxant effects of diazepam, flunitrazepam and midazolam on airway smooth muscle.  Br. J. Anaesth.. 1992;  69 65-69
• 45 Lampe G H, Roizen M F. Anesthesia for patients with abnormal function of the adrenal cortex.  Anesthesiol. Clin. North Am.. 1987;  5 245-251
• 46 Nathan R, Segall N, Schocket A. A comparison of the actions of H1 and H2 antihistamines on histamine-induced bronchoconstriction and cutaneous wheal response in asthmatic patients.  J. Allergy Clin. Immunol.. 1981;  67 171-177
• 47 Stoelting R K, Dierdorf S F, McCammon . Deutsche Ausgabe von Striebel HW, Eyrich K, Klettke U (Hrsg.) Anästhesie und Vorerkrankungen. Obstruktive Lungenerkrankungen. Stuttgart Jena; Gustav Fischer Verlag 1992: 159-169
• 48 Warner D O, Vettermann J, Brichant J F, Rehder K. Direct and neurally mediated effects of halothane on pulmonary resistance in vivo.  Anesthesiology. 1990;  72 1057-1063
• 49 Shah M V, Hirshman C A. Mode of action of halothane on histamine-induced airway constriction in dogs with reactive airways.  Anesthesiology. 1986;  65 170-174
• 50 Brichant J F, Gunst S G, Warner D O, Rehder K. Halothane, enflurane, and isoflurane depress the peripheral vagal motor pathway in isolated canine tracheal smooth muscle.  Anesthesiology. 1991;  74 325-332
• 51 Jones K A, Housemans P R, Warner D O, Lorenz R R, Rehder K. Effects of halothane on the relationship between cytosolic calcium and force in airway smooth muscle.  Am. J. Physiol.. 1994;  266 L199-L204
• 52 Jones K A, Housmans P R, Warner D O, Lorenz R R, Rehder K. Halothane alters cytosolic calcium transient in tracheal smooth muscle.  Am. J. Physiol.. 1993;  265 L80-L86
• 53 Bremerich D H, Hirasaki A, Jones K A, Warner D O. Halothane attenuation of Ca²⁺ sensitivity in airway smooth muscle: Mechanisms of action during muscarinic receptor stimulation.  Anesthesiology. 1997;  87 94-101
• 54 Yamakage M. Direct inhibitory mechanisms of halothane on canine tracheal smooth muscle contraction. Anesthesiology 1992
• 55 Forbes A R, Gamsu G. Depression of lung mucociliary clearance by thiopental and halothane.  Anesth. Analg.. 1979;  58 387-389
• 56 Hirsch J A, Tokayer J L, Robinson M J, Sackner M A. Effects of dry air and subsequent humidification on tracheal mucous velocity in dogs.  J. Appl. Physiol.. 1975;  39 242-246
• 57 Brown R H, Zerhouni E A, Hirshman C A. Comparison of low concentrations of halothane and isoflurane as bronchodilators.  Anesthesiology. 1993;  78 1097-1101
• 58 Kai T, Bremerich D H, Jones K A, Warner D O. Drug-specific effects of volatile anesthetics on Ca²⁺ sensitization in airway smooth muscle.  Anesth. Analg.. 1998;  87 425-429
• 59 Hirshman C A, Bergman N A. Halothane and enflurane protect against bronchospasm in an asthma dog model.  Anesth. Analg.. 1978;  57 629-633
• 60 Hirshman C A, Edelstein G, Peetz S, Wayne R, Downes H. Mechanisms of action of inhalational anesthesia on airways.  Anesthesiology. 1982;  56 107-111
• 61 Rooke G A, Choi J-H, Bishop M J. The effect of isoflurane, halothane, sevoflurane and thiopental/nitrous oxide on respiratory system resistance after tracheal intubation.  Anesthesiology. 1997;  86 1294-1299
• 62 Habre W, Scalfaro P, Sims C, Tiller K, Sly P D. Respiratory mechanics during sevoflurane anesthesia in children with and without asthma.  Anesth. Analg.. 1999;  89 1177-1181
• 63 Mazzeo A J, Cheng E Y, Bosnjak Z J, Coon R L, Kampine J P. Differential effects of desflurane and halothane on peripheral airway smooth muscle.  Br. J. Anaesth.. 1996;  76 841-846
• 64 Bierman M I, Brown M, Muren O, Keenan R L, Glauser F L. Prolonged isoflurane anesthesia in status asthmaticus.  Crit. Care Med.. 1986;  14 832-833
• 65 O'Rourke P P, Crone R K. Halothane in status asthmaticus.  Crit. Care Med.. 1982;  10 341-343
• 66 Johnston R G, Noseworthy T W, Friesen E G, Yule H A, Shustack A. Isoflurane therapy for status asthmaticus in children and adults.  Chest. 1990;  97 698-701
• 67 Roizen M F, Stevens W C. Multiform ventricular tachycardia due to the interaction of aminophylline and halothane.  Anesth. Analg.. 1978;  57 738-741
• 68 Horowitz L N, Spear J F, Moore E N, Rogers R. Effects of aminophylline on the threshold for initiating ventricular fibrillation during respiratory failure.  Am. J. Cardiol.. 1975;  35 376-379
• 69 Tobias J D, Kubos K L, Hirshman C A. Aminophylline does not attenuate histamine-induced airway constriction during halothane anesthesia.  Anesthesiology. 1989;  71 723-729
• 70 Wilson L E, Hatch D J, Rehder K. Mechanisms of the relaxant action of ketamine in isolated porcine trachealis muscle.  Br. J. Anaesth.. 1993;  71 544-550
• 71 Hempelmann G, Kuhn D FM. Klinischer Stellenwert des S-(+)- Ketamin.  Anaesthesist. 1997;  46 (Suppl. 1) 3-7
• 72 Pabelick C M, Rehder K, Jones K A, Chummy R, Lindahl S G, Warner D O. Stereospecific effects of ketamine enantiomers on canine tracheal smooth muscle.  Br. J. Pharmacol.. 1997;  121 1378-1382
• 73 Hirshman C A, Downes H, Farbood A, Bergman N A. Ketamine block of bronchospasm in experimental canine asthma.  Br. J. Anaesth.. 1979;  51 713-718
• 74 Lundy P M, Lockwood P A, Thompson G, Frew R. Differential effects of ketamine isomers on neuronal and extraneuronal catecholamine uptake mechanisms.  Anesthesiology. 1986;  64 359-363
• 75 Fisher M M. Ketamine hydrochloride in severe bronchospasm.  Anaesthesia. 1977;  32 771-772
• 76 Jahangir S M, Islam F, Aziz L. Ketamine infusion for postoperative analgesia in asthmatics: a comparison with intermittent meperidine.  Anesth. Analg.. 1993;  76 45-49
• 77 Pizov R, Brown R H, Weiss Y S, Baranov D, Hennes H, Baker S, Hirshman C A. Wheezing during induction of general anesthesia in patients with and without asthma.  Anesthesiology. 1995;  82 1111-1116
• 78 Cigarini I, Bonnet F, Lorino A M, Harf A, Desmonts J M. Comparison of the effects of fentanyl on respiratory mechanics under propofol or thiopental anesthesia.  Acta Anaesthesiol. Scand.. 1990;  34 253-256
• 79 Pederson C M, Thirstrup S, Nielsen-Kudst J E. Smooth muscle relaxant effects of propofol and ketamine in isolated guinea-pig trachea.  Eur. J. Pharmacol.. 1993;  238 75-80
• 80 Lenox W C, Mitzner W, Hirshman C A. Mechanism of thiopental-induced constriction of guinea-pig trachea.  Anesthesiology. 1990;  72 921-925
• 81 Olsson G L. Bronchospasm during anesthesia. A computer-aided incidence study of 136 929 patients.  Acta Anaesthesiol. Scand.. 1987;  31 244-252
• 82 Curry C, Lenox W C, Spannhake E W, Hirshman C A. Contractile responses of guinea pig trachea to oxybarbiturates and thiobarbiturates.  Anesthesiology. 1991;  75 679-683
• 83 Clarke R SJ, Dundee J W, Garrett R T, McArdle G K, Sutton J A. Adverse reactions to intravenous anaesthetics.  Br. J. Anaesth.. 1975;  47 575-585
• 84 Toda N, Hatano Y. Contractile response of canine tracheal muscle during exposure to fentanyl and morphine.  Anesthesiology. 1980;  53 93-100
• 85 Yasuda I, Hirano T, Yusa T, Satoh M. Tracheal constriction by morphine and by fentanyl in man.  Anesthesiology. 1978;  49 117-119
• 86 Cohendy R, Lefrant J Y, Laracine M, Rebiere T, Eledjam J J. Effect of fentanyl on ventilatory resistances during barbiturate general anaesthesia.  Br. J. Anaesth.. 1992;  69 595-598
• 87 Rosow C E, Moss J, Philbin D M, Savarese J J. Histamine release during morphine and fentanyl anesthesia.  Anesthesiology. 1982;  56 93-96
• 88 Koga Y, Downes H, Leon D A, Hirshman C A. Mechanism of tracheal constriction by succinylcholine.  Anesthesiology. 1981;  55 138-142
• 89 Coakley J H, Nagendran K, Ormerod I EC, Ferguson C N, Hinds C J. Prolonged neurogenic weakness in patients requiring mechanical ventilation for acute airflow limitation.  Chest. 1992;  101 1413-1416
• 90 Downes H, Gerber N, Hirshman C A. I.V. lidocaine in reflex and allergic bronchoconstriction.  Br. J. Anaesth.. 1980;  52 873-878
• 91 Steinhaus J E, Gaskin L. A study of intravenous lidocaine as a suppressant of cough reflex.  Anesthesiology. 1963;  24 285-290
• 92 Miller W C, Awe R. Effect of nebulized lidocaine on reactive airways.  Am. Rev. Respir. Dis.. 1975;  111 739-741
• 93 Fish J E, Peterman V I. Effects of inhaled lidocaine on airway function in asthmatic subjects.  Respiration. 1979;  37 201-207
• 94 Downes H, Hirsman C A. Lidocaine aerosols do not prevent allergic bronchoconstriction.  Anesth. Analg.. 1981;  60 28-32
• 95 Bulut Y, Hirshman C A, Brown R H. Prevention of lidocaine aerosol-induced bronchoconstriction with intravenous lidocaine.  Anesthesiology. 1996;  85 853-859
• 96 Groeben H, Schwalen A, Irsfeld S, Stieglitz S, Lipfert P, Hopf H B. Intravenous lidocaine and bupivacaine dose-dependently attenuate bronchial hyperreactivity in awake volunteers.  Anesthesiology. 1996;  84 533-539
• 97 Groeben H, Silvanus M-T, Beste M, Peters J. Combined intravenous lidocaine and inhaled salbutamol protect against bronchial hyperreactivity more effectively than lidocaine or salbutamol alone.  Anesthesiology. 1998;  89 862-868
• 98 Jalowy A, Peters J, Groeben H. Stellenwert der bronchialen Hyperreagibilität in der Anästhesiologie.  AINS. 1998;  33 150-162
• 99 Kingston H GG, Hirshman C A. Perioperative management of the patient with asthma.  Anesth. Analg. . 1984;  63 844-855
• 100 Tarhan S, Moffit E A, Sessler A D, Douglas W W, Taylor W F. Risk of anesthesia and surgery in patients with chronic bronchitis and chronic obstructive pulmonary disease.  Surgery. 1973;  74 720-726
• 101 Eldor J, Frankel D ZN, Barav E, Nyska M. Acute bronchospasm during epidural anesthesia in asthmatic patients.  J. Asthma. 1989;  26 15-16
• 102 Wang C Y, Ong G SY. Severe Bronchospasm during epidural anesthesia.  Anesthesiology. 1993;  48 514-515
• 103 McGough E K, Cohen J A. Unexpected bronchospasm during spinal anesthesia.  J. Clin. Anesth.. 1990;  2 35-36
• 104 Ravin M B. Comparison of spinal and general anesthesia for lower abdominal surgery in patients with chronic obstructive pulmonary disease.  Anesthesiology. 1971;  35 319-322
• 105 Urmey W F. Pulmonary function changes during interscalene brachial plexus block: effects of decreasing local anesthetic injection volume.  Reg. Anesth.. 1993;  18 244-249
• 106 Groeben H, Schwalen A, Irsfeld S, Tarnow J, Lipfert P, Hopf H B. High thoracic epidural anesthesia does not alter airway resistance and attenuates the response to an inhalational provocation test in patients with bronchial hyperreactivity.  Anesthesiology. 1994;  81 868-874
• 107 Pecora D V. Predictability of effects of abdominal and thoracic surgery upon pulmonary function.  Ann. Surg.. 1969;  170 101-108
• 108 Worth H, Butt U, Wettengel R. Empfehlungen zur Behandlung von Asthma in der Schwangerschaft.  Med. Klein.. 1996;  91 435-437
• 109 Klockenbusch W, Schrör K. Prostaglandine und Prostazyklin.  Der Gynäkologe. 1992;  25 205-211
• 110 Aranda J V, Sitar D S, Parson W D, Loughnan P M, Neims A M. Pharmacokinetic aspects of theophylline in premature newborns.  N. Engl. J. Med.. 1976;  295 413-424
• 111 Bishop M J, Kim E S. Endotracheal intubation, but not laryngeal mask airway insertion, produces reversible bronchoconstriction.  Anesthesiology. 1999;  90 391-394
• 112 Berry A, Brimacombe J, Keller C, Verghese C. Pulmonary airway resistance with the endotracheal tube versus laryngeal mask airway in paralyzed anesthetized adult patients.  Anesthesiology. 1999;  90 395-397
• 113 Patel A M, Axen D M, Bartling S L, Guarderas J C. Practical considerations for managing asthma in adults.  Mayo Clinic Proc.. 1997;  72 749-756
• 114 Fanta C H, Rossing T H, McFadden E R jr. Emergency room treatment of asthma. Relationships among therapeutic combinations, severity of obstruction and time course of response.  Am. J. Med.. 1982;  72 416-422
• 115 Fanta C H, Rossing T H, McFadden E R jr. Treatment of acute asthma. Is combination therapy with sympathomimetics and methylxanthines indicated?.  Am. J. Med.. 1986;  80 5-10
• 116 Kumeta Y, Hattori A, Mimura M, Kishikawa K, Namiki A. A survey of perioperative bronchospasm in 105 patients with reactive airway disease.  Masui - Japanese J. Anesthesiol.. 1995;  44 396-401

1 Cromoglycinsäure, Intal®, DNCG Stada®; Nedocromil, Tilade®

2 Beclometasonpropionat, Sanasthmax®, Sanasthmyl®; Flunisolid, Inhacort®, Budenosid, Pulmicort®; Fluticason, Atemur®, Flutide®

3 Salmeterol, Aeromax®, Salbulair®; Serevent®; Formoterol, Foradil®; Oxis®; Terbutalin, Bricanyl-Duriles®; Fenoterol, Berotec®; Salbutamol, Sultanol®

4 Glycopyrrolat, Robinul®; Ipratropium, Atrovent®

5 Montelukast, Singulair®; Zafirlukast, Acolate®

6 Cimetidin, Tagamet®; Ranitidin, Ranitic®, Zantic®; Sostril®

7 Sulproston, Nalador®; Gemeprost, Cergem®