Anesthesia for adults with upper respiratory infection

INTRODUCTION — An acute upper respiratory infection (URI) is the most common illness in the general population [1]. Thus, it is not uncommon for patients with active or recent URI to present for elective or emergency surgery. An acute viral URI may result in a variety of signs and symptoms, including sneezing, nasal congestion and discharge (rhinorrhea), sore throat, cough, low-grade fever, headache, and malaise (ie, the "common cold"), as well as sinusitis or simple bronchitis. Implications for patients undergoing general anesthesia depend on the anatomical involvement of the infection, patient comorbidities, and the planned surgical procedure or intervention.

This topic will discuss anesthetic risks for adult patients with acute or recent URI, as well as management to prevent perioperative complications. Anesthetic management of children with acute or recent URI is addressed elsewhere. (See "Anesthesia for the child with a recent upper respiratory infection".)

General principles for diagnosis and treatment of URI or acute bronchitis in adults are discussed separately:

●(See "The common cold in adults: Diagnosis and clinical features".)

●(See "The common cold in adults: Treatment and prevention".)

●(See "Acute bronchitis in adults".)

RISKS OF GENERAL ANESTHESIA — Although data guiding anesthetic management of adults with a URI are sparse, decisions are individualized to balance risks and benefits of proceeding with general anesthesia or another anesthetic technique against potential risks of postponing the procedure.

One prospective cohort study in adults noted that history of either upper or lower respiratory infection with fever and antibiotic treatment in the month before surgery was associated with a composite adverse pulmonary outcome that included respiratory infection, respiratory failure, pleural effusion, atelectasis, pneumothorax, bronchospasm, or aspiration pneumonitis [2]. Other studies addressing anesthetic management in patients with a URI have included only children, due to a higher incidence of respiratory complications in the pediatric population compared with adults [3,4]. (See "Anesthesia for the child with a recent upper respiratory infection", section on 'Risks of anesthesia for the child with an upper respiratory infection'.)

Laryngospasm (upper airway effects) — Similar to pediatric patients, the major risks for adult patients with acute or recent URI are due to upper airway hyperreactivity, particularly development of laryngospasm during induction or emergence from general anesthesia. However, laryngospasm may occur at any time during the procedure if a supraglottic airway (SGA) device, such as a laryngeal mask airway, is selected. (See "Anesthesia for the child with a recent upper respiratory infection", section on 'Risks of anesthesia for the child with an upper respiratory infection'.)

Bronchospasm (lower airway effects) — A URI also increases bronchial hyperreactivity due to increased vagal tone and decreased function of inhibitory M2 muscarinic receptors on lower airway parasympathetic nerve endings. These effects potentiate reflex bronchoconstriction and airway hyperresponsiveness [5]. For these reasons, monitoring for clinical signs and symptoms of bronchoconstriction should continue throughout the procedure and in the early postoperative period.

PREANESTHETIC EVALUATION — Preoperative anesthetic assessment and planning differ for elective versus urgent/emergency surgery in a patient with acute or recent URI.

Elective surgery

Preoperative assessment

●History – The history should include the onset and any current symptoms suggestive of URI, as well as the presence of pulmonary comorbidities such as asthma or chronic obstructive pulmonary disease (COPD).

●Physical examination – Patients are examined for obvious signs of a URI such as nasal discharge, repeated coughing, a sick appearance, and/or fever. Assessment of the upper airway for evidence of inflamed laryngeal mucosa or pronounced tonsillar enlargement is particularly important. Also, the chest should be auscultated for wheezing, crackles, rhonchi, or pulmonary rales as possible signs of lower respiratory infection.

●Laboratory and radiological examination – If an infection such as pneumonia or sinusitis is suspected, a complete blood cell count (CBC) with differential is obtained to exclude systemic involvement. Although not routinely performed, a rapid viral test may be obtained to confirm viral etiology (eg, during seasonal influenza epidemics).

A preoperative chest radiograph (CXR) is unnecessary in the majority of surgical patients, including those with a recent URI. However, we would obtain a CXR in patients with chronic lung disease and a new exacerbation of respiratory symptoms or new lung auscultation findings to rule out active pulmonary infection and/or heart failure. (See "Evaluation of perioperative pulmonary risk", section on 'Chest radiographs' and "Anesthesia for patients with chronic obstructive pulmonary disease", section on 'Preoperative assessment'.)

Timing of elective procedures — Timing of anesthesia and elective surgery depends on the acuity of the URI, the persistence and severity of symptoms, any exacerbation of chronic symptoms in a patient with respiratory disease, as well as the risks of delaying the planned procedure.

●For a healthy adult patient with severe symptoms or any evidence of systemic involvement, we postpone most surgical procedures until one to two weeks after symptoms subside.

●For a healthy adult patient who has an acute URI with minimal symptoms or for a patient with recent URI who is currently asymptomatic, we typically do not postpone a procedure. However, we recognize that airway hyperreactivity may last for two to six weeks after a URI [6].

●For an adult patient with a history of asthma and acute URI with severe symptoms, we postpone most elective surgical procedures until one to two weeks after symptoms subside. Perioperative bronchospasm or laryngospasm is uncommon in patients with well-controlled asthma, even after recent URI [7]. However, the effects of general anesthesia in patients with chronic asthma and acute URI have not been described. (See "Anesthesia for adult patients with asthma", section on 'Recent upper respiratory infection'.)

●For an adult patient with moderate or severe COPD and signs and symptoms of acute URI, we postpone elective surgery to initiate treatment that may include inhaled bronchodilators, systemic glucocorticoid therapy, and, if indicated, antibiotic therapy. Since timing for return to baseline after a COPD exacerbation is variable, duration of postponement is individualized. (See "Anesthesia for patients with chronic obstructive pulmonary disease", section on 'Preoperative interventions to optimize pulmonary function'.)

Urgent or emergency surgery — Urgent or emergency surgical procedures may be necessary in adult patients with acute URI. Except in truly life-threatening emergencies, there is usually time to conduct a basic upper and lower airway evaluation, and to administer an inhaled bronchodilator in a patient with wheezing due to URI and/or a history of asthma or COPD. (See "Anesthesia for adult patients with asthma", section on 'Emergency surgery'.)

Management of preoperative medications

●Chronically administered prescription medications – Inhaled beta-agonist and anticholinergic bronchodilators, as well as inhaled glucocorticoids, are continued in the perioperative period in patients with asthma or COPD, including the usual dose on the morning of surgery, with resumption shortly after surgery. (See "Anesthesia for adult patients with asthma", section on 'Preoperative medication management' and "Anesthesia for patients with chronic obstructive pulmonary disease", section on 'Perioperative medication management'.)

●Commonly used over-the-counter medications – Many patients use nasal decongestants for comfort, but these rarely have a systemic effect. Notably, antihistamines are a component of many over-the-counter medications for URI, and their sedative effects may interact with anesthetic agents in a synergistic fashion and it should be taken in consideration.

ANESTHETIC MANAGEMENT

Choice of anesthetic technique — Monitored anesthesia care (MAC), neuraxial anesthesia, or other regional anesthetic techniques are good choices for patients with recent URI or those with acute URI undergoing urgent or emergency surgery, if feasible. Avoiding general anesthesia with laryngoscopy and endotracheal intubation or use of a supraglottic airway (SGA) may decrease risk of laryngeal irritation and bronchospasm.

However, general anesthesia is necessary for performance of many surgical procedures (eg, abdominal laparoscopy, thoracic procedures, or surgical incisions involving the head, neck, or multiple extremities) and is usually selected for emergency or prolonged procedures.

Management during general anesthesia

Airway management — The risk of laryngospasm and bronchospasm is lower with mask ventilation compared with insertion of an endotracheal tube (ETT) or SGA [8]. Although the choice of airway device depends primarily on patient-specific factors other than the URI, as well as procedure-specific factors, we choose to use an SGA when either SGA or ETT would be appropriate.  

Induction and maintenance of anesthesia — Management of induction and maintenance of anesthesia in adults with a URI are similar to management for those with asthma, as discussed separately. (See "Anesthesia for adult patients with asthma", section on 'Induction of anesthesia' and "Anesthesia for adult patients with asthma", section on 'Maintenance of anesthesia'.)

Lung-protective ventilation is employed (eg, low tidal volumes [6 to 8 mL/kg predicted body weight], positive end-expiratory pressure [PEEP, plateau pressures ≤16 mmHg]) to avoid complications due to either atelectasis or barotrauma [9]. Recruitment maneuvers are performed only when indicated to improve oxygenation (eg, patients with obesity; during open abdominal surgery; and before, during, and after insufflation for laparoscopy and thoracoscopy), and in specific circumstances (eg, after disconnect from the ventilator for suctioning). (See "Mechanical ventilation during anesthesia in adults", section on 'Lung protective ventilation during anesthesia'.)

Emergence — Emergence should be planned to avoid airway irritation and/or ventilator dyssynchrony. Laryngospasm, coughing and "bucking" on the ETT, or bronchospasm may occur prior to extubation, as the patient transitions through Stage II anesthetic depth to an awake state. Reflex airway reactions to the noxious stimulus of the ETT or airway suctioning may be attenuated by allowing spontaneous ventilation or by administering a small dose of small doses of intravenous lidocaine or an opioid. (See "Emergence from general anesthesia", section on 'Airway or respiratory problems'.)

In patients with acute or recent URI with symptoms of upper airway irritability (eg, pharyngitis), it is important to plan for extubation with consideration of the patient's comorbidities, the type of procedure, and the intraoperative course [10].

EARLY POSTOPERATIVE MANAGEMENT — Adverse respiratory events can occur during the intraoperative or postoperative periods. Laryngospasm is almost exclusively an intraoperative event and rarely occurs once the patient completely regains consciousness. However, oxygen desaturation, bronchospasm, and cough can occur in the recovery room and later in the postoperative course. (See "Respiratory problems in the post-anesthesia care unit (PACU)".)

Decisions regarding patient recovery in a post-anesthesia care unit (PACU) versus an intensive care unit (ICU) or other monitored setting depend primarily on case-specific and patient-specific factors rather than on the presence of a URI. However, temporary higher levels of postoperative monitoring may be appropriate in patients with a URI if intraoperative adverse respiratory events occurred.

Fortunately, adults have proportionately larger upper airways than children. Thus, there is little risk of significant subglottic edema with symptoms of croup (laryngotracheitis), and administration of inhaled epinephrine is rarely necessary. (See "Anesthesia for the child with a recent upper respiratory infection" and "Management of croup", section on 'Nebulized epinephrine'.)

SUMMARY AND RECOMMENDATIONS

●Risks of general anesthesia – Similar to pediatric patients, the major risks for general anesthesia in adult patients with acute or recent upper respiratory infection (URI) are due to upper and lower airway hyperreactivity, particularly development of laryngospasm during induction or emergence from general anesthesia and potentiation of reflex bronchoconstriction leading to bronchospasm. (See 'Risks of general anesthesia' above.)

•Induction and maintenance – Considerations for airway management during induction and maintenance of general anesthesia in adults with URI are similar to those in adults with asthma. (See 'Airway management' above and 'Induction and maintenance of anesthesia' above.)

•Emergence – Laryngospasm, coughing, and "bucking" on the endotracheal tube (ETT), or bronchospasm may occur prior to extubation as the patient emerges from general anesthesia. Reflex airway reactions to the noxious stimulus of the ETT or airway suctioning may be attenuated by allowing spontaneous ventilation or by administering a small dose of intravenous opioid (eg, fentanyl 50 mcg). In selected patients, extubation is performed while the patient is still deeply anesthetized (ie, "deep extubation") to avoid stimulation of airway reflexes. (See 'Emergence' above.)

●Choices of anesthetic technique – Monitored anesthesia care (MAC), neuraxial anesthesia, or other regional anesthetic techniques are good choices for patients with recent URI or those with acute URI undergoing urgent or emergency surgery, if feasible. Avoiding general anesthesia with laryngoscopy and endotracheal intubation or use of a supraglottic airway (SGA) may decrease risk of laryngeal irritation and bronchospasm. (See 'Choice of anesthetic technique' above.)

●Timing of elective procedures – Our approach to the timing of anesthesia in adult patients depends on acuity of a URI or persistence of severe symptoms due to exacerbation of chronic respiratory disease, balanced against the risks of delaying the planned procedure. (See 'Timing of elective procedures' above.)

•In a patient with recent URI who is currently asymptomatic, we rarely postpone a procedure, although airway hyperreactivity may persist for two to six weeks after URI.

•In a patient with acute URI and severe symptoms or a history of asthma, we postpone most elective surgical procedures until one to two weeks after symptoms subside.

•For a patient with moderate or severe chronic obstructive pulmonary disease (COPD), elective surgery is postponed if there are any signs and symptoms of acute URI and treatment is initiated (eg, inhaled bronchodilators, systemic glucocorticoid therapy, antibiotics if indicated). Since timing for return to baseline after a COPD exacerbation is variable, duration of postponement is individualized.

●Timing of urgent of emergency procedures – For urgent or emergency surgical procedures, there is usually time to conduct a basic upper and lower airway evaluation and administer an inhaled bronchodilator to a patient with wheezing (due to URI and/or history of asthma or COPD). (See 'Urgent or emergency surgery' above.)

●Postoperative considerations – Adverse respiratory events (eg, bronchospasm, desaturation) can occur during the early postoperative period. Decisions regarding a recovery setting (eg, post-anesthesia care unit [PACU] versus intensive care unit [ICU]) depend primarily on case-specific and patient-specific factors. However, temporary higher levels of postoperative monitoring may be appropriate in patients with a URI if intraoperative adverse respiratory events occurred. (See 'Early postoperative management' above.)