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3\margtsxn133\margbsxn80\cols3\colno1\colw3466\colsr-0\colno2\colw6253\colsr-0\c
olno3\colw1720\pard\li973\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li973\ri0\sl-213
\slmult0 \fs18\cf0\par\pard\li973\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li973\ri
0\sl-426\slmult0 \fs26\cf2\f0\charscalex100 {ORIGINAL ARTICLE}\par\column\pard\l
i0\ri0\sl-173\slmult0 \fs18\cf0\f1\charscalex100 {Downloaded from}{ }\fs14\cf1\f
1\charscalex100 {{\field{\*\fldinst{HYPERLINK "http://qshc.bmj.com"}}{\fldrslt {
qshc.bmj.com}}}}\fs18\cf0\f1\charscalex100 {{\field{\*\fldinst{HYPERLINK "http:/
/qshc.bmj.com"}}{\fldrslt { on }}}18 August 2008}\par\column\pard\li0\ri0\sl-360
\slmult0 \fs14\cf3\f0\charscalex100 {1 of 6}\par\pard\sect\sectd\sbknone\pgwsxn1
2240\pghsxn15840\marglsxn666\margrsxn133\pard\li706\ri0\sl-586\slmult0 \fs38\cf3
\f0\charscalex100 {Crisis management during anaesthesia: bronchospasm}\par\pard\
li706\ri0\sl-453\slmult0 \fs22\cf3\f0\charscalex100 {R N Westhorpe, G L Ludbrook
, S C Helps}\par\pard\li706\ri0\sl-213\slmult0 \fs12\cf3\f0\charscalex100 {. . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . .}\par\pard\li2360\ri0\sl-306\slmult0 \fs14\cf3\f0\charscalex100 {Qual Sa
f Health Care}{ }\fs14\cf3\f0\charscalex100 {2005;}\fs14\cf3\f0\charscalex100 {1
4}\fs14\cf3\f0\charscalex100 {:e7 (http://www.qshc.com/cgi/content/full/14/3/e7)
. doi: 10.1136/qshc.2002.004457}\par\pard\li2640\ri0\sl-213\slmult0 \fs18\cf0\pa
r\pard\li2640\ri0\sl-293\slmult0 \fs14\cf3\f0\charscalex100 {Background:}{ }\fs1
4\cf3\f0\charscalex100 {Bronchospasm in association with anaesthesia may appear
as an entity in its own right or be}\par\pard\li2640\ri0\sl-200\slmult0 \fs14\cf

3\f0\charscalex100 {a component of another problem such as anaphylaxis. It may p


resent with expiratory wheeze, prolonged}\par\pard\li2640\ri0\sl-213\slmult0 \fs
16\cf3\f0\charscalex100 {exhalation or, in severe cases, complete silence on aus
cultation.}\par\pard\li2640\ri0\sl-200\slmult0 \*\tx3520\fs14\cf3\f0\charscalex1
00 {Objectives:}\tab \fs14\cf3\f0\charscalex100 {To examine the role of a previo
usly described core algorithm \uc1\u8216X\uc1\u8216XCOVER ABCD\uc1\u8211XA SWIFT
}\par\pard\li2640\ri0\sl-200\slmult0 \fs14\cf3\f0\charscalex100 {CHECK\uc1\u8217
X\uc1\u8217X, supplemented by a specific sub-algorithm for bronchospasm, in the
diagnosis and management}\par\pard\li2640\ri0\sl-213\slmult0 \fs16\cf3\f0\charsc
alex100 {of bronchospasm occurring in association with anaesthesia.}\par\pard\li
2640\ri0\sl-200\slmult0 \fs14\cf3\f0\charscalex100 {Methods:}{ }\fs14\cf3\f0\cha
rscalex100 {The potential performance of this structured approach for each of th
e relevant incidents among}\par\pard\li2640\ri0\sl-213\slmult0 \fs14\cf3\f0\char
scalex100 {the first 4000 reported to the Australian Incident Monitoring Study (
AIMS) was compared with the actual}\par\pard\li2640\ri0\sl-200\slmult0 \fs16\cf3
\f0\charscalex100 {management as reported by anaesthetists involved.}\par\pard\s
ect\sectd\sbknone\pgwsxn12240\pghsxn15840\marglsxn666\margrsxn133\cols2\colno1\c
olw2640\colsr-0\colno2\colw8800\pard\li706\ri0\sl-226\slmult0 \fs14\cf3\f0\chars
calex100 {See end of article for}\par\pard\li706\ri0\sl-173\slmult0 \fs14\cf3\f0
\charscalex100 {authors\uc1\u8217X affiliations}\par\pard\li706\ri0\sl-173\slmul
t0 \fs12\cf3\f0\charscalex100 {. . . . . . . . . . . . . . . . . . . . . . .}\pa
r\pard\li706\ri0\sl-266\slmult0 \fs14\cf3\f0\charscalex100 {Correspondence to:}\
par\pard\li706\ri0\sl-173\slmult0 \fs14\cf3\f0\charscalex100 {Professor W B Runc
iman,}\par\pard\li706\ri0\sl-173\slmult0 \fs14\cf3\f0\charscalex100 {President,
Australian}\par\pard\li706\ri0\sl-173\slmult0 \fs14\cf3\f0\charscalex100 {Patien
t Safety Foundation,}\par\pard\li706\ri0\sl-173\slmult0 \fs14\cf3\f0\charscalex1
00 {GPO Box 400, Adelaide,}\par\pard\li706\ri0\sl-173\slmult0 \fs14\cf3\f0\chars
calex100 {South Australia 5001,}\par\pard\li706\ri0\sl-173\slmult0 \fs14\cf3\f0\
charscalex100 {Australia; research@apsf.}\par\pard\li706\ri0\sl-173\slmult0 \fs1
4\cf3\f0\charscalex100 {net.au}\par\pard\li706\ri0\sl-253\slmult0 \fs12\cf3\f0\c
harscalex100 {Accepted 1 January 2005}\par\pard\li706\ri0\sl-173\slmult0 \fs10\c
f3\f0\charscalex100 {. . . . . . . . . . . . . . . . . . . . . . .}\par\column\p
ard\li0\ri0\sl-200\slmult0 \*\tx640\fs16\cf3\f0\charscalex100 {Results:}\tab \fs
16\cf3\f0\charscalex100 {There were 103 relevant incidents among the first 4000
AIMS reports, 22 of which were}\par\pard\li0\ri0\sl-213\slmult0 \fs16\cf3\f0\cha
rscalex100 {associated with allergy or anaphylaxis. Common presenting signs, in
addition to wheeze, were decreased}\par\pard\li0\ri0\sl-200\slmult0 \fs16\cf3\f0
\charscalex100 {pulmonary compliance and falling oxygen saturation. Of the non-a
llergy/anaphylaxis related incidents,}\par\pard\li0\ri0\sl-213\slmult0 \fs16\cf3
\f0\charscalex100 {80% occurred during induction or maintenance of anaesthesia.
Of these, the principal causes of}\par\pard\li0\ri0\sl-213\slmult0 \fs16\cf3\f0\
charscalex100 {bronchospasm were airway irritation (35%), problems with the endo
tracheal tube (23%), and aspiration of}\par\pard\li0\ri0\sl-200\slmult0 \fs16\cf
3\f0\charscalex100 {gastric contents (14%). It was considered that, properly use
d, the structured approach recommended}\par\pard\li0\ri0\sl-213\slmult0 \fs16\cf
3\f0\charscalex100 {would have led to earlier recognition and/or better manageme
nt of the problem in 10% of cases, and}\par\pard\li0\ri0\sl-200\slmult0 \fs16\cf
3\f0\charscalex100 {would not have harmed any patient had it been applied in all
of them.}\par\pard\li0\ri0\sl-200\slmult0 \*\tx920\fs16\cf3\f0\charscalex100 {C
onclusion:}\tab \fs16\cf3\f0\charscalex100 {Bronchospasm may present in a variet
y of ways and may be associated with other life}\par\pard\li0\ri0\sl-213\slmult0
\fs16\cf3\f0\charscalex100 {threatening conditions. Although most cases are han
dled appropriately by the attending anaesthetist, the}\par\pard\li0\ri0\sl-213\s
lmult0 \fs16\cf3\f0\charscalex100 {use of a structured approach to its diagnosis
and management would lead to earlier recognition and/or}\par\pard\li0\ri0\sl-20
0\slmult0 \fs16\cf3\f0\charscalex100 {better management in 10% of cases.}\par\pa
rd\sect\sectd\sbknone\pgwsxn12240\pghsxn15840\marglsxn666\margrsxn133\cols2\coln
o1\colw5600\colsr-0\colno2\colw5840\pard\li706\ri0\sl-213\slmult0 \fs18\cf0\par\
pard\li706\ri0\sl-213\slmult0 \fs18\cf0\par{\trowd\trleft706\trkeep\trftsWidth1\
trpaddl0\trpaddr0\trpaddfl3\trpaddfr3 \clvertalt\clbrdrt\brdrnone\clbrdrl\brdrno

ne\clbrdrb\brdrnone\clbrdrr\brdrnone\cltxlrtb\clNoWrap\clftsWidth3\clwWidth346\c
lpadt0\clpadr0\clpadft3\clpadfr3\cellx1720 \pard\li0\ri0\sl-826\widctlpar\intbl
\fs58\cf3\f0\charscalex100 {B}\cell\clvertalt\clbrdrt\brdrnone\clbrdrl\brdrnone\
clbrdrb\brdrnone\clbrdrr\brdrnone\cltxlrtb\clNoWrap\clftsWidth3\clwWidth4333\clp
adt0\clpadr0\clpadft3\clpadfr3\cellx5933 \pard\li0\ri0\sl-306\widctlpar\intbl \f
s16\cf3\f0\charscalex100 {ronchospasm usually manifests during anaesthesia}\par\
pard\li0\ri0\sl-200\widctlpar\intbl \fs16\cf3\f0\charscalex100 {as an expiratory
wheeze, prolonged expiration and/or}\par\pard\li0\ri0\sl-200\widctlpar\intbl \f
s16\cf3\f0\charscalex100 {increased inflation pressures during intermittent posi
-}\cell\row}\column\pard\li0\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li0\ri0\sl-21
3\slmult0 \fs18\cf0\par\pard\li0\ri0\sl-306\slmult0 \fs16\cf3\f0\charscalex100 {
the situation.}{\super \fs8\up3\cf3\f0\charscalex100 {2}}\fs16\cf3\f0\charscalex
100 {This was validated against the first 2000}\par\pard\li0\ri0\sl-186\slmult0
\fs16\cf3\f0\charscalex100 {incidents reported to the Australian Incident Monito
ring}\par\pard\li0\ri0\sl-200\slmult0 \fs16\cf3\f0\charscalex100 {Study (AIMS).
AIMS is an ongoing study which involves the}\par\pard\sect\sectd\sbknone\pgwsxn1
2240\pghsxn15840\marglsxn666\margrsxn133\cols2\colno1\colw5600\colsr-0\colno2\co
lw5840\pard\li706\ri0\sl-160\slmult0 \fs16\cf3\f0\charscalex100 {tive pressure v
entilation (IPPV). Wheeze may be audible}\par\pard\li706\ri0\sl-160\slmult0 \fs1
4\cf3\f0\charscalex100 {either with or without auscultation, but can only be pre
sent if}\par\pard\li706\ri0\sl-160\slmult0 \fs14\cf3\f0\charscalex100 {there is
gas flow in the patient\uc1\u8217Xs airways. Thus, in cases of}\par\pard\li706\r
i0\sl-200\slmult0 \fs14\cf3\f0\charscalex100 {severe bronchospasm, the chest may
be silent on auscultation}\par\pard\li706\ri0\sl-200\slmult0 \fs14\cf3\f0\chars
calex100 {and the diagnosis may rest on correct assessment of}\par\pard\li706\ri
0\sl-200\slmult0 \fs16\cf3\f0\charscalex100 {increased inflation pressures.}\par
\pard\li880\ri0\sl-200\slmult0 \fs14\cf3\f0\charscalex100 {Bronchospasm may appe
ar as an entity in its own right or}\par\pard\li706\ri0\sl-200\slmult0 \fs14\cf3
\f0\charscalex100 {be a component of another problem such as anaphylaxis}\par\pa
rd\li706\ri0\sl-200\slmult0 \fs14\cf3\f0\charscalex100 {(which is dealt with els
ewhere in this series of articles}{\super \fs6\up2\cf3\f0\charscalex100 {1}}\fs1
4\cf3\f0\charscalex100 {) and}\par\pard\li706\ri0\sl-200\slmult0 \fs14\cf3\f0\ch
arscalex100 {is usually triggered by some manoeuvre, often in patients}\par\pard
\li706\ri0\sl-200\slmult0 \fs16\cf3\f0\charscalex100 {with a pre-existing airway
disease such as asthma.}\par\pard\li880\ri0\sl-200\slmult0 \fs14\cf3\f0\charsca
lex100 {Wheeze may occur not only as a result of bronchospasm}\par\pard\li706\ri
0\sl-200\slmult0 \fs14\cf3\f0\charscalex100 {but may be heard with misplacement
of the endotracheal}\par\pard\li706\ri0\sl-200\slmult0 \fs14\cf3\f0\charscalex10
0 {tube (in the oesophagus or a bronchus, for example) and}\par\pard\li706\ri0\s
l-200\slmult0 \fs14\cf3\f0\charscalex100 {with pulmonary oedema or adult respira
tory distress syn-}\par\pard\li706\ri0\sl-200\slmult0 \fs14\cf3\f0\charscalex100
{drome (ARDS). Increased inspiratory pressures may occur}\par\pard\li706\ri0\sl
-200\slmult0 \fs14\cf3\f0\charscalex100 {not only with any of these conditions b
ut with obstruction of}\par\pard\li706\ri0\sl-200\slmult0 \fs14\cf3\f0\charscale
x100 {the natural or an artificial airway or of any component of the}\par\pard\l
i706\ri0\sl-200\slmult0 \fs14\cf3\f0\charscalex100 {breathing circuit (including
any respiratory filters) and}\par\pard\li706\ri0\sl-200\slmult0 \fs14\cf3\f0\ch
arscalex100 {decreased compliance of the lung (for example, with}\par\pard\li706
\ri0\sl-200\slmult0 \fs14\cf3\f0\charscalex100 {atelectasis) or chest (for examp
le, haemopneumothorax,}\par\pard\li706\ri0\sl-200\slmult0 \fs14\cf3\f0\charscale
x100 {fentanyl induced rigidity). It was therefore decided to}\par\pard\li706\ri
0\sl-200\slmult0 \fs14\cf3\f0\charscalex100 {examine the role of a structured ap
proach to the diagnosis}\par\pard\li706\ri0\sl-200\slmult0 \fs14\cf3\f0\charscal
ex100 {and management of bronchospasm or wheeze in association}\par\pard\li706\r
i0\sl-200\slmult0 \fs16\cf3\f0\charscalex100 {with anaesthesia.}\par\pard\li880\
ri0\sl-213\slmult0 \fs14\cf3\f0\charscalex100 {In 1993 a \uc1\u8216X\uc1\u8216Xc
ore\uc1\u8217X\uc1\u8217X crisis management algorithm, represented}\par\pard\li7
06\ri0\sl-200\slmult0 \fs14\cf3\f0\charscalex100 {by the mnemonic COVER ABCD\uc1
\u8211XA SWIFT CHECK (the AB}\par\pard\li706\ri0\sl-200\slmult0 \fs14\cf3\f0\cha
rscalex100 {precedes COVER for the non-intubated patient), was}\par\pard\li706\r

i0\sl-186\slmult0 \fs14\cf3\f0\charscalex100 {proposed as the basis for a system


atic approach to any crisis}\par\pard\li706\ri0\sl-200\slmult0 \fs14\cf3\f0\char
scalex100 {during anaesthesia where it is not immediately obvious what}\par\pard
\li706\ri0\sl-200\slmult0 \fs14\cf3\f0\charscalex100 {should be done or where ac
tions taken have failed to remedy}\par\column\pard\li0\ri0\sl-160\slmult0 \fs16\
cf3\f0\charscalex100 {voluntary anonymous reporting of any unintended incident}\
par\pard\li0\ri0\sl-160\slmult0 \fs16\cf3\f0\charscalex100 {which reduced or cou
ld have reduced the safety margin for a}\par\pard\li0\ri0\sl-160\slmult0 \fs16\c
f3\f0\charscalex100 {patient.}{\super \fs8\up2\cf3\f0\charscalex100 {3}}\par\par
d\li160\ri0\sl-186\slmult0 \fs16\cf3\f0\charscalex100 {It was concluded that, if
this algorithm had been correctly}\par\pard\li0\ri0\sl-200\slmult0 \fs16\cf3\f0
\charscalex100 {applied, a functional diagnosis would have been reached}\par\par
d\li0\ri0\sl-200\slmult0 \fs16\cf3\f0\charscalex100 {within 40\uc1\u8211X60 seco
nds in 99% of applicable incidents and that}\par\pard\li0\ri0\sl-200\slmult0 \fs
16\cf3\f0\charscalex100 {the learned sequence of actions recommended by the COVE
R}\par\pard\li0\ri0\sl-200\slmult0 \fs16\cf3\f0\charscalex100 {portion would hav
e led to appropriate steps being taken to}\par\pard\li0\ri0\sl-200\slmult0 \fs16
\cf3\f0\charscalex100 {handle the 60% of problems relevant to this portion of th
e}\par\pard\li0\ri0\sl-186\slmult0 \fs16\cf3\f0\charscalex100 {algorithm.}{\supe
r \fs8\up2\cf3\f0\charscalex100 {2}}\fs16\cf3\f0\charscalex100 {However, this st
udy also showed that the 40% of}\par\pard\li0\ri0\sl-200\slmult0 \fs16\cf3\f0\ch
arscalex100 {problems represented by the remainder of the algorithm,}\par\pard\l
i0\ri0\sl-200\slmult0 \fs16\cf3\f0\charscalex100 {ABCD\uc1\u8211XA SWIFT CHECK,
were not always promptly diag-}\par\pard\li0\ri0\sl-200\slmult0 \*\tx2800\fs16\c
f3\f0\charscalex100 {nosed or appropriately managed.}\fs8\cf3\f0\charscalex100 {
2\uc1\u8211X4}\tab \fs16\cf3\f0\charscalex100 {It was decided that it}\par\pard\
li0\ri0\sl-200\slmult0 \fs16\cf3\f0\charscalex100 {would be useful, for these pr
oblems, to develop a set of sub-}\par\pard\li0\ri0\sl-200\slmult0 \fs16\cf3\f0\c
harscalex100 {algorithms in an easy-to-use crisis management manual.}{\super \fs
8\up2\cf3\f0\charscalex100 {5}}\par\pard\li0\ri0\sl-200\slmult0 \fs16\cf3\f0\cha
rscalex100 {This study reports on the potential place of the COVER}\par\pard\li0
\ri0\sl-200\slmult0 \fs16\cf3\f0\charscalex100 {ABCD\uc1\u8211XA SWIFT CHECK alg
orithm in the diagnosis and}\par\pard\li0\ri0\sl-200\slmult0 \fs16\cf3\f0\charsc
alex100 {initial management of bronchospasm, provides an outline of}\par\pard\li
0\ri0\sl-200\slmult0 \fs16\cf3\f0\charscalex100 {a specific crisis management su
b-algorithm for broncho-}\par\pard\li0\ri0\sl-200\slmult0 \fs16\cf3\f0\charscale
x100 {spasm, and provides an indication of the potential value of}\par\pard\li0\
ri0\sl-186\slmult0 \fs16\cf3\f0\charscalex100 {using this structured approach.}\
par\pard\li0\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li0\ri0\sl-253\slmult0 \fs18\
cf3\f0\charscalex100 {METHODS}\par\pard\li0\ri0\sl-186\slmult0 \fs16\cf3\f0\char
scalex100 {Of the first 4000 incidents reported to AIMS, those which}\par\pard\l
i0\ri0\sl-200\slmult0 \fs16\cf3\f0\charscalex100 {made reference to bronchospasm
or wheeze were extracted}\par\pard\li0\ri0\sl-200\slmult0 \fs16\cf3\f0\charscal
ex100 {and analysed for relevance, presenting features, type of}\par\pard\li0\ri
0\sl-200\slmult0 \fs16\cf3\f0\charscalex100 {surgery, cause, management, and out
come. The COVER}\par\pard\li0\ri0\sl-200\slmult0 \fs16\cf3\f0\charscalex100 {ABC
D\uc1\u8211XA SWIFT CHECK algorithm, described elsewhere in}\par\pard\li0\ri0\sl
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p3\cf3\f0\charscalex100 {5}}\fs16\cf3\f0\charscalex100 {was applied to each rele
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3\margtsxn133\margbsxn80\cols3\colno1\colw3466\colsr-0\colno2\colw4613\colsr-0\c
olno3\colw3360\pard\li680\ri0\sl-360\slmult0 \fs14\cf3\f0\charscalex100 {2 of 6}
\par\pard\li800\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li800\ri0\sl-213\slmult0 \
fs18\cf0\par\pard\li800\ri0\sl-413\slmult0 \fs18\cf3\f0\charscalex100 {BRONCHOSP
ASM}\par\pard\li800\ri0\sl-360\slmult0 \fs14\cf3\f0\charscalex100 {SIGNS (1)*}\p
ar\column\pard\li0\ri0\sl-173\slmult0 \fs18\cf0\f1\charscalex100 {Downloaded fro
m}{ }\fs14\cf1\f1\charscalex100 {{\field{\*\fldinst{HYPERLINK "http://qshc.bmj.c
om"}}{\fldrslt {qshc.bmj.com}}}}\fs18\cf0\f1\charscalex100 {{\field{\*\fldinst{H
YPERLINK "http://qshc.bmj.com"}}{\fldrslt { on }}}18 August 2008}\par\pard\li202
6\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li2026\ri0\sl-213\slmult0 \fs18\cf0\par\
pard\li2026\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li2026\ri0\sl-213\slmult0 \fs1
8\cf0\par\pard\li2026\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li2026\ri0\sl-320\sl
mult0 \fs14\cf3\f0\charscalex100 {FURTHER CARE:}\par\column\pard\li0\ri0\sl-360\
slmult0 \fs14\cf3\f0\charscalex100 {Westhorpe, Ludbrook, Helps}\par\pard\sect\se
ctd\sbknone\pgwsxn12240\pghsxn15840\marglsxn666\margrsxn133\cols2\colno1\colw549
3\colsr-0\colno2\colw5946\pard\li800\ri0\sl-200\slmult0 \fs14\cf3\f0\charscalex1
00 {Increasing circuit pressure}\par\pard\li800\ri0\sl-200\slmult0 \fs14\cf3\f0\
charscalex100 {Desaturation}\par\pard\li800\ri0\sl-200\slmult0 \fs14\cf3\f0\char
scalex100 {Wheeze (auscultate)}\par\pard\li800\ri0\sl-226\slmult0 \fs14\cf3\f0\c
harscalex100 {Rising ET}\fs12\cf3\f0\charscalex100 {CO}\fs10\cf3\f0\charscalex10
0 {2}{ }\fs14\cf3\f0\charscalex100 {and prolonged expiration}\par\pard\li800\ri0
\sl-200\slmult0 \fs14\cf3\f0\charscalex100 {Reduction in tidal volumes}\par\pard
\li800\ri0\sl-306\slmult0 \fs14\cf3\f0\charscalex100 {THINK OF (2)}\par\pard\li8
00\ri0\sl-200\slmult0 \fs14\cf3\f0\charscalex100 {Anaphylaxis/allergy to drugs/I
V fluids/latex}\par\pard\li800\ri0\sl-200\slmult0 \fs14\cf3\f0\charscalex100 {Ai
rway manipulation/irritation/secretions/soiling}\par\pard\li800\ri0\sl-200\slmul
t0 \fs14\cf3\f0\charscalex100 {Oesophageal/endobronchial intubation}\par\pard\li
800\ri0\sl-200\slmult0 \fs14\cf3\f0\charscalex100 {Pneumothorax}\par\pard\li800\
ri0\sl-200\slmult0 \fs14\cf3\f0\charscalex100 {Inadequate anaesthetic depth or f
ailure of anaesthetic delivery}\par\pard\li800\ri0\sl-200\slmult0 \fs14\cf3\f0\c
harscalex100 {system}\par\column\pard\li0\ri0\sl-200\slmult0 \fs14\cf3\f0\charsc
alex100 {Depends on patient's condition, and cause}\par\pard\li0\ri0\sl-200\slmu
lt0 \fs14\cf3\f0\charscalex100 {Bronchodilators as necessary}\par\pard\li0\ri0\s
l-200\slmult0 \fs14\cf3\f0\charscalex100 {Chest X-ray}\par\pard\li0\ri0\sl-200\s
lmult0 \fs14\cf3\f0\charscalex100 {Admit to HDU/ICU if necessary}\par\pard\li0\r
i0\sl-346\slmult0 \fs14\cf3\f0\charscalex100 {NOTES:}\par\pard\li0\ri0\sl-173\sl
mult0 \fs12\cf3\f0\charscalex100 {(1).30% of 103 relevant incidents described in
creased peak inflation pressures,}\par\pard\li0\ri0\sl-173\slmult0 \fs12\cf3\f0\
charscalex100 {. and a further 31% described bronchospasm/wheeze as the initial
sign.}\par\pard\li0\ri0\sl-173\slmult0 \fs12\cf3\f0\charscalex100 {. 21% reporte
d desaturation as the first sign.}\par\pard\li0\ri0\sl-173\slmult0 \*\tx1760\fs1
2\cf3\f0\charscalex100 {. 3% reported rising ET}\fs10\cf3\f0\charscalex100 {CO}\

fs10\cf3\f0\charscalex100 {2}\tab \fs12\cf3\f0\charscalex100 {and 1% revealed a


flat capnogram indicating no}\par\pard\li0\ri0\sl-173\slmult0 \fs12\cf3\f0\chars
calex100 {. gas flow.}\par\pard\li0\ri0\sl-173\slmult0 \fs12\cf3\f0\charscalex10
0 {(2).Allergy/anaphylaxis 22/103 (21%) of incidents.}\par\pard\li0\ri0\sl-173\
slmult0 \fs12\cf3\f0\charscalex100 {. Of the remaining 81 cases of bronchospasm:
}\par\pard\li0\ri0\sl-173\slmult0 \*\tx453\fs12\cf3\f0\charscalex100 {..}\tab \f
s12\cf3\f0\charscalex100 {44% occurred at induction and of these:}\par\pard\li0\
ri0\sl-173\slmult0 \*\tx693\fs12\cf3\f0\charscalex100 {...}\tab \fs12\cf3\f0\cha
rscalex100 {64% were due to airway irritation}\par\pard\sect\sectd\sbknone\pgwsx
n12240\pghsxn15840\marglsxn666\margrsxn133\cols3\colno1\colw5493\colsr-0\colno2\
colw693\colsr-0\colno3\colw5253\pard\li800\ri0\sl-200\slmult0 \fs14\cf3\f0\chars
calex100 {EMERGENCY MANAGEMENT}\par\pard\li800\ri0\sl-200\slmult0 \fs14\cf3\f0\c
harscalex100 {100% Oxygen}\par\pard\li800\ri0\sl-200\slmult0 \fs14\cf3\f0\charsc
alex100 {Cease stimulation/surgery}\par\column\pard\li0\ri0\sl-173\slmult0 \fs12
\cf3\f0\charscalex100 {...}\par\pard\li0\ri0\sl-173\slmult0 \fs12\cf3\f0\charsca
lex100 {...}\par\pard\li0\ri0\sl-173\slmult0 \fs12\cf3\f0\charscalex100 {...}\pa
r\column\pard\li0\ri0\sl-173\slmult0 \fs12\cf3\f0\charscalex100 {17% were due to
ETT misplacement}\par\pard\li0\ri0\sl-173\slmult0 \fs12\cf3\f0\charscalex100 {1
1% were due to aspiration}\par\pard\li0\ri0\sl-173\slmult0 \fs12\cf3\f0\charscal
ex100 {8% were due to other causes.}\par\pard\sect\sectd\sbknone\pgwsxn12240\pgh
sxn15840\marglsxn666\margrsxn133\cols2\colno1\colw5493\colsr-0\colno2\colw5946\p
ard\li800\ri0\sl-200\slmult0 \fs14\cf3\f0\charscalex100 {Request immediate assis
tance}\par\pard\li800\ri0\sl-200\slmult0 \fs14\cf3\f0\charscalex100 {Deepen anae
sthesia}{ }\fs14\cf3\f0\charscalex100 {(3)}\par\pard\li800\ri0\sl-200\slmult0 \f
s14\cf3\f0\charscalex100 {If intubated exclude endobronchial or oesophageal posi
tion}{ }\fs14\cf3\f0\charscalex100 {(4)}\par\pard\li800\ri0\sl-200\slmult0 \fs14
\cf3\f0\charscalex100 {If mask/LMA in use consider early:}\par\pard\li800\ri0\sl
-200\slmult0 \fs14\cf3\f0\charscalex100 {. laryngospasm/airway obstruction}{ }\f
s14\cf3\f2\charscalex100 {\uc1\u8594X}{ }\fs14\cf3\f0\charscalex100 {pages 12 &
14**}\par\pard\li800\ri0\sl-200\slmult0 \fs14\cf3\f0\charscalex100 {. regurgitat
ion/vomit/aspiration}{ }\fs14\cf3\f2\charscalex100 {\uc1\u8594X}{ }\fs14\cf3\f0\
charscalex100 {page 16**}{ }\fs14\cf3\f0\charscalex100 {(5)}\par\pard\li800\ri0\
sl-200\slmult0 \fs14\cf3\f0\charscalex100 {Give adrenaline or salbutamol (see ov
er)}\par\pard\li800\ri0\sl-200\slmult0 \fs14\cf3\f0\charscalex100 {If you cannot
ventilate via an ETT consider:}\par\pard\li800\ri0\sl-200\slmult0 \fs14\cf3\f0\
charscalex100 {Misplaced/kinked/blocked ETT or circuit}{ }\fs14\cf3\f2\charscale
x100 {\uc1\u8594X}{ }\fs14\cf3\f0\charscalex100 {page 7**}\par\pard\li800\ri0\sl
-200\slmult0 \fs14\cf3\f0\charscalex100 {Pneumothorax}{ }\fs14\cf3\f2\charscalex
100 {\uc1\u8594X}{ }\fs14\cf3\f0\charscalex100 {page 46**}\par\pard\li800\ri0\sl
-200\slmult0 \fs14\cf3\f0\charscalex100 {Aspiration}{ }\fs14\cf3\f2\charscalex10
0 {\uc1\u8594X}{ }\fs14\cf3\f0\charscalex100 {page 16**}\par\pard\li800\ri0\sl-2
00\slmult0 \fs14\cf3\f0\charscalex100 {Anaphylaxis}{ }\fs14\cf3\f2\charscalex100
{\uc1\u8594X}{ }\fs14\cf3\f0\charscalex100 {page 48**}\par\pard\li800\ri0\sl-20
0\slmult0 \fs14\cf3\f0\charscalex100 {Pulmonary oedema}{ }\fs14\cf3\f2\charscale
x100 {\uc1\u8594X}{ }\fs14\cf3\f0\charscalex100 {page 24**}\par\pard\li800\ri0\s
l-200\slmult0 \fs14\cf3\f0\charscalex100 {Consider}{ }\fs14\cf3\f0\charscalex100
{possible obstruction distal to ETT}\par\pard\li800\ri0\sl-200\slmult0 \fs14\cf
3\f0\charscalex100 {Try pushing a small tube past it,}{ }\fs14\cf3\f0\charscalex
100 {or}{ }\fs14\cf3\f0\charscalex100 {push the obstruction down one}\par\pard\l
i800\ri0\sl-200\slmult0 \fs14\cf3\f0\charscalex100 {bronchus and ventilate the o
ther lung.}\par\pard\li800\ri0\sl-213\slmult0 \fs14\cf3\f0\charscalex100 {CONSID
ER ANAPHYLAXIS}{ }\fs14\cf3\f2\charscalex100 {\uc1\u8594X}{ }\fs14\cf3\f0\charsc
alex100 {page 48**}\par\pard\li800\ri0\sl-200\slmult0 \fs14\cf3\f0\charscalex100
{CONSIDER PULMONARY OEDEMA}{ }\fs14\cf3\f2\charscalex100 {\uc1\u8594X}{ }\fs14\
cf3\f0\charscalex100 {page 24**}\par\pard\li800\ri0\sl-373\slmult0 \fs14\cf3\f0\
charscalex100 {The sub-algorithm forms a facing page of the}\par\pard\li800\ri0\
sl-200\slmult0 \fs14\cf3\f0\charscalex100 {Crisis Management Manual}\fs10\cf3\f0
\charscalex100 {6}\fs14\cf3\f0\charscalex100 {.}\par\column\pard\li0\ri0\sl-173\
slmult0 \*\tx453\fs12\cf3\f0\charscalex100 {..}\tab \fs12\cf3\f0\charscalex100 {
36% occurred during maintenance and of these:}\par\pard\li0\ri0\sl-173\slmult0 \

*\tx693\fs12\cf3\f0\charscalex100 {...}\tab \fs12\cf3\f0\charscalex100 {31% were


due to ETT problem}\par\pard\li0\ri0\sl-186\slmult0 \*\tx693\fs12\cf3\f0\charsc
alex100 {...}\tab \fs12\cf3\f0\charscalex100 {14% were due to aspiration with an
LMA.}\par\pard\li0\ri0\sl-173\slmult0 \*\tx453\fs12\cf3\f0\charscalex100 {..}\t
ab \fs12\cf3\f0\charscalex100 {20% occurred during emergence/recovery and of the
se:}\par\pard\li0\ri0\sl-173\slmult0 \*\tx693\fs12\cf3\f0\charscalex100 {...}\ta
b \fs12\cf3\f0\charscalex100 {38% had no specific cause identified}\par\pard\li0
\ri0\sl-173\slmult0 \*\tx693\fs12\cf3\f0\charscalex100 {...}\tab \fs12\cf3\f0\ch
arscalex100 {25% were due to pulmonary oedema}\par\pard\li0\ri0\sl-173\slmult0 \
*\tx693\fs12\cf3\f0\charscalex100 {...}\tab \fs12\cf3\f0\charscalex100 {18% were
due to aspiration.}\par\pard\li0\ri0\sl-173\slmult0 \fs12\cf3\f0\charscalex100
{(3).55% of cases of bronchospasm at induction were idiopathic or}\par\pard\li0\
ri0\sl-173\slmult0 \fs12\cf3\f0\charscalex100 {. presumed to be due to airway ir
ritation from laryngoscopy and/or}\par\pard\li0\ri0\sl-173\slmult0 \fs12\cf3\f0\
charscalex100 {. intubation.}\par\pard\li0\ri0\sl-173\slmult0 \fs12\cf3\f0\chars
calex100 {(4).12% were associated with oesophageal intubation and 2.5% with}\par
\pard\li0\ri0\sl-173\slmult0 \fs12\cf3\f0\charscalex100 {. endobronchial intubat
ion.}\par\pard\li0\ri0\sl-173\slmult0 \fs12\cf3\f0\charscalex100 {(5).12% of cas
es were associated with aspiration.}\par\pard\li0\ri0\sl-240\slmult0 \fs12\cf3\f
0\charscalex100 {Recommended dosages:}\par\pard\li0\ri0\sl-173\slmult0 \fs12\cf3
\f0\charscalex100 {Salbutamol 0.5% 1ml (5mg) solution nebulised for adult}\par\p
ard\li0\ri0\sl-173\slmult0 \fs12\cf3\f0\charscalex100 {or aerosol puffer, 2 puff
s (0.1mg/puff)}\par\pard\li0\ri0\sl-173\slmult0 \fs12\cf3\f0\charscalex100 {or 0
.5% 0.1ml in 1ml, injected down ETT (0.5mg adult).}\par\pard\li0\ri0\sl-186\slmu
lt0 \fs12\cf3\f0\charscalex100 {Adrenaline 0.001mg/kg bolus (0.01ml/kg of 1:10 0
00 soln.)}\par\pard\li0\ri0\sl-173\slmult0 \fs12\cf3\f0\charscalex100 {Repeat bo
lus, or commence infusion 0.00015mg/kg/min}\par\pard\li0\ri0\sl-173\slmult0 \fs1
2\cf3\f0\charscalex100 {Adrenaline; easy dosing for adults, see page 71*}\par\pa
rd\li0\ri0\sl-320\slmult0 \fs12\cf3\f0\charscalex100 {Titrate to heart rate, blo
od pressure, and bronchodilator effect.}\par\pard\li0\ri0\sl-373\slmult0 \fs14\c
f3\f0\charscalex100 {These notes comprise a reverse side of a page of the}\par\p
ard\sect\sectd\sbknone\pgwsxn12240\pghsxn15840\marglsxn666\margrsxn133\pard\li80
0\ri0\sl-266\slmult0 \*\tx5493\fs14\cf3\f0\charscalex100 {*5 Numbers in brackets
refer to Notes in the right hand panel.}\tab \fs14\cf3\f0\charscalex100 {Crisis
Management Manual}\fs10\cf3\f0\charscalex100 {6}\fs14\cf3\f0\charscalex100 {.}\
par\pard\sect\sectd\sbknone\pgwsxn12240\pghsxn15840\marglsxn666\margrsxn133\cols
2\colno1\colw5493\colsr-0\colno2\colw5946\pard\li800\ri0\sl-200\slmult0 \fs14\cf
3\f0\charscalex100 {**5Page references refer to}{ }\fs14\cf3\f0\charscalex100 {C
risis Management Manual}\fs10\cf3\f0\charscalex100 {6}\fs14\cf3\f0\charscalex100
{.}\par\pard\li680\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li680\ri0\sl-333\slmul
t0 \*\tx1373\fs14\cf3\f0\charscalex100 {Figure 1}\tab \fs14\cf3\f0\charscalex100
{Bronchospasm.}\par\pard\li680\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li680\ri0\
sl-213\slmult0 \fs18\cf0\par\pard\li680\ri0\sl-266\slmult0 \fs16\cf3\f0\charscal
ex100 {would have led to appropriate initial steps being taken. As}\par\pard\li6
80\ri0\sl-200\slmult0 \fs14\cf3\f0\charscalex100 {bronchospasm is not dealt with
by this algorithm, a specific}\par\pard\li680\ri0\sl-200\slmult0 \fs14\cf3\f0\c
harscalex100 {sub-algorithm was developed for this problem (see fig 1), and}\par
\pard\li680\ri0\sl-200\slmult0 \fs14\cf3\f0\charscalex100 {its putative effectiv
eness was tested against the reports. How}\par\pard\li680\ri0\sl-200\slmult0 \fs
14\cf3\f0\charscalex100 {this was done is described elsewhere in this series of
articles.}{\super \fs6\up2\cf3\f0\charscalex100 {5}}\par\pard\li680\ri0\sl-200\s
lmult0 \fs14\cf3\f0\charscalex100 {The potential value of this structured approa
ch\uc1\u8212Xthat is, the}\par\pard\li680\ri0\sl-200\slmult0 \fs14\cf3\f0\charsc
alex100 {application of COVER ABCD\uc1\u8211XA SWIFT CHECK to the}\par\pard\li68
0\ri0\sl-213\slmult0 \fs14\cf3\f0\charscalex100 {diagnosis and initial managemen
t of this problem followed}\par\pard\li680\ri0\sl-200\slmult0 \fs14\cf3\f0\chars
calex100 {by the application of the sub-algorithm for bronchospasm\uc1\u8212X}\p
ar\pard\li680\ri0\sl-200\slmult0 \fs14\cf3\f0\charscalex100 {was assessed in the
light of the AIMS reports by comparing}\par\pard\li680\ri0\sl-200\slmult0 \fs14
\cf3\f0\charscalex100 {its potential effectiveness for each incident with that o

f the}\par\pard\li680\ri0\sl-200\slmult0 \fs16\cf3\f0\charscalex100 {actual mana


gement, as recorded in each report.}\par\pard\li680\ri0\sl-213\slmult0 \fs18\cf0
\par\pard\li680\ri0\sl-280\slmult0 \fs18\cf3\f0\charscalex100 {RESULTS}\par\pard
\li680\ri0\sl-200\slmult0 \fs14\cf3\f0\charscalex100 {Of the first 4000 AIMS rep
orts, 174 contained the words}\par\pard\li680\ri0\sl-200\slmult0 \fs14\cf3\f0\ch
arscalex100 {\uc1\u8216X\uc1\u8216Xwheeze\uc1\u8217X\uc1\u8217X or \uc1\u8216X\u
c1\u8216Xbronchospasm\uc1\u8217X\uc1\u8217X. Of these, 71 were excluded}\par\par
d\li680\ri0\sl-200\slmult0 \fs14\cf3\f0\charscalex100 {from further analysis. Re
asons for exclusion were those}\par\pard\li680\ri0\sl-200\slmult0 \fs14\cf3\f0\c
harscalex100 {reports in which bronchospasm or wheeze were specifically}\par\par
d\li680\ri0\sl-200\slmult0 \fs14\cf3\f0\charscalex100 {excluded by the reporter
or mentioned as not being present}\par\pard\li680\ri0\sl-200\slmult0 \fs14\cf3\f
0\charscalex100 {(59 reports); a further nine reports in which there were}\par\p
ard\li680\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li680\ri0\sl-213\slmult0 \fs18\c
f0\par\pard\li680\ri0\sl-346\slmult0 \fs14\cf3\f0\charscalex100 {www.qshc.com}\p
ar\column\pard\li0\ri0\sl-200\slmult0 \fs14\cf3\f0\charscalex100 {* Page referen
ces refer to the}{ }\fs14\cf3\f0\charscalex100 {Crisis Management Manual}\fs10\c
f3\f0\charscalex100 {6}\fs14\cf3\f0\charscalex100 {.}\par\pard\li0\ri0\sl-173\sl
mult0 \fs12\cf3\f0\charscalex100 {..}\par\pard\li66\ri0\sl-213\slmult0 \fs18\cf0
\par\pard\li66\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li66\ri0\sl-213\slmult0 \fs
18\cf0\par\pard\li66\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li66\ri0\sl-200\slmul
t0 \fs16\cf3\f0\charscalex100 {insufficient details to confirm a diagnosis or wh
ere broncho-}\par\pard\li66\ri0\sl-200\slmult0 \fs14\cf3\f0\charscalex100 {spasm
occurred during a regional anaesthetic or before}\par\pard\li66\ri0\sl-200\slmu
lt0 \fs14\cf3\f0\charscalex100 {induction; and three reports where mild bronchos
pasm or}\par\pard\li66\ri0\sl-200\slmult0 \fs14\cf3\f0\charscalex100 {wheeze occ
urred as part of another condition for which an}\par\pard\li66\ri0\sl-200\slmult
0 \fs14\cf3\f0\charscalex100 {AIMS report was generated, and the bronchospasm di
d not}\par\pard\li66\ri0\sl-200\slmult0 \fs16\cf3\f0\charscalex100 {require spec
ific treatment.}\par\pard\li240\ri0\sl-200\slmult0 \fs16\cf3\f0\charscalex100 {T
he remaining 103 reports were analysed as follows:}\par\pard\li66\ri0\sl-213\slm
ult0 \fs18\cf0\par\pard\li66\ri0\sl-253\slmult0 \fs16\cf3\f0\charscalex100 {Stag
e of anaesthesia}\par\pard\li66\ri0\sl-186\slmult0 \fs14\cf3\f0\charscalex100 {T
he stage of anaesthesia\uc1\u8212Xthat is, induction, maintenance,}\par\pard\li6
6\ri0\sl-200\slmult0 \fs14\cf3\f0\charscalex100 {emergence or recovery\uc1\u8212
Xat which bronchospasm or wheeze}\par\pard\li66\ri0\sl-200\slmult0 \fs16\cf3\f0\
charscalex100 {occurred is shown in table 1.}\par\pard\li66\ri0\sl-213\slmult0 \
fs18\cf0\par\pard\li66\ri0\sl-266\slmult0 \fs18\cf3\f0\charscalex100 {Induction}
\par\pard\li66\ri0\sl-200\slmult0 \fs14\cf3\f0\charscalex100 {The causes of bron
chospasm and/or wheeze during the}\par\pard\li66\ri0\sl-200\slmult0 \fs14\cf3\f0
\charscalex100 {induction phase of anaesthesia are summarised in table 2.}\par\p
ard\li66\ri0\sl-200\slmult0 \fs14\cf3\f0\charscalex100 {Of the total 42 reports,
23 were idiopathic or presumed to be}\par\pard\li66\ri0\sl-200\slmult0 \fs14\cf
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{\sp{\sn fFillOK}{\sv 1}}
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3\margtsxn133\margbsxn80\cols3\colno1\colw3466\colsr-0\colno2\colw6253\colsr-0\c
olno3\colw1720\pard\li706\ri0\sl-360\slmult0 \fs14\cf3\f0\charscalex100 {Broncho
spasm: }\fs14\cf3\f0\charscalex100 {crisis management}\par\column\pard\li0\ri0\s
l-173\slmult0 \fs18\cf0\f1\charscalex100 {Downloaded from}{ }\fs14\cf1\f1\charsc
alex100 {{\field{\*\fldinst{HYPERLINK "http://qshc.bmj.com"}}{\fldrslt {qshc.bmj
.com}}}}\fs18\cf0\f1\charscalex100 {{\field{\*\fldinst{HYPERLINK "http://qshc.bm
j.com"}}{\fldrslt { on }}}18 August 2008}\par\column\pard\li0\ri0\sl-360\slmult0
\fs14\cf3\f0\charscalex100 {3 of 6}\par\pard\sect\sectd\sbknone\pgwsxn12240\pgh
sxn15840\marglsxn666\margrsxn133\cols2\colno1\colw6160\colsr-0\colno2\colw5280\p
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f0\par\pard\li933\ri0\sl-266\slmult0 \*\tx1640\fs16\cf3\f0\charscalex100 {Table

1}\tab \fs16\cf3\f0\charscalex100 {Stage of anaesthesia at which bronchospasm or


}\par\pard\li933\ri0\sl-200\slmult0 \fs16\cf3\f0\charscalex100 {wheeze was detec
ted}\par\column\pard\li0\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li0\ri0\sl-213\sl
mult0 \fs18\cf0\par\pard\li0\ri0\sl-266\slmult0 \*\tx720\fs16\cf3\f0\charscalex1
00 {Table 3}\tab \fs16\cf3\f0\charscalex100 {Bronchospasm or wheeze occurring}\p
ar\pard\li0\ri0\sl-200\slmult0 \fs16\cf3\f0\charscalex100 {during the maintenanc
e phase of anaesthesia}\par\pard\sect\sectd\sbknone\pgwsxn12240\pghsxn15840\marg
lsxn666\margrsxn133\cols5\colno1\colw2333\colsr-0\colno2\colw1266\colsr-0\colno3
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\slmult0 \fs12\cf3\f0\charscalex100 {Stage of}\par\pard\li1000\ri0\sl-160\slmult
0 \fs12\cf3\f0\charscalex100 {anaesthesia}\par\pard\li1000\ri0\sl-280\slmult0 \f
s12\cf3\f0\charscalex100 {Induction}\par\column\pard\li0\ri0\sl-293\slmult0 \fs1
2\cf3\f0\charscalex100 {Bronchospasm due}\par\pard\li0\ri0\sl-160\slmult0 \fs12\
cf3\f0\charscalex100 {to any cause}\par\pard\li66\ri0\sl-280\slmult0 \fs12\cf3\f
0\charscalex100 {42}\par\column\pard\li0\ri0\sl-293\slmult0 \fs12\cf3\f0\charsca
lex100 {Bronchospasm due to}\par\pard\li0\ri0\sl-160\slmult0 \fs12\cf3\f0\charsc
alex100 {allergy/anaphylaxis}\par\pard\li66\ri0\sl-280\slmult0 \fs12\cf3\f0\char
scalex100 {6}\par\column\pard\li0\ri0\sl-293\slmult0 \fs12\cf3\f0\charscalex100
{Cause}\par\pard\li0\ri0\sl-280\slmult0 \fs12\cf3\f0\charscalex100 {Anaphylaxis
(or severe allergy)}\par\pard\li0\ri0\sl-160\slmult0 \fs12\cf3\f0\charscalex100
{Bronchospasm (no defined cause)}\par\column\pard\li0\ri0\sl-293\slmult0 \fs12\c
f3\f0\charscalex100 {No}\par\pard\li0\ri0\sl-280\slmult0 \fs12\cf3\f0\charscalex
100 {15}\par\pard\li80\ri0\sl-160\slmult0 \fs12\cf3\f0\charscalex100 {9}\par\par
d\sect\sectd\sbknone\pgwsxn12240\pghsxn15840\marglsxn666\margrsxn133\cols4\colno
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26\pard\li1000\ri0\sl-160\slmult0 \fs12\cf3\f0\charscalex100 {Maintenance}\par\c
olumn\pard\li0\ri0\sl-160\slmult0 \fs12\cf3\f0\charscalex100 {44}\par\column\par
d\li0\ri0\sl-160\slmult0 \fs12\cf3\f0\charscalex100 {15}\par\column\pard\li0\ri0
\sl-160\slmult0 \*\tx2640\fs12\cf3\f0\charscalex100 {Endotracheal tube or ventil
ator problem}\tab \fs12\cf3\f0\charscalex100 {10}\par\pard\sect\sectd\sbknone\pg
wsxn12240\pghsxn15840\marglsxn666\margrsxn133\cols5\colno1\colw2333\colsr-0\coln
o2\colw1266\colsr-0\colno3\colw2613\colsr-0\colno4\colw2640\colsr-0\colno5\colw2
586\pard\li1000\ri0\sl-160\slmult0 \fs12\cf3\f0\charscalex100 {Emergence}\par\pa
rd\li1000\ri0\sl-173\slmult0 \fs12\cf3\f0\charscalex100 {Recovery}\par\pard\li10
00\ri0\sl-160\slmult0 \fs12\cf3\f0\charscalex100 {Total}\par\column\pard\li146\r
i0\sl-160\slmult0 \fs12\cf3\f0\charscalex100 {7}\par\pard\li66\ri0\sl-173\slmult
0 \fs12\cf3\f0\charscalex100 {10}\par\pard\li0\ri0\sl-160\slmult0 \fs12\cf3\f0\c
harscalex100 {103}\par\column\pard\li66\ri0\sl-160\slmult0 \fs12\cf3\f0\charscal
ex100 {0}\par\pard\li66\ri0\sl-173\slmult0 \fs12\cf3\f0\charscalex100 {1}\par\pa
rd\li0\ri0\sl-160\slmult0 \fs12\cf3\f0\charscalex100 {22}\par\column\pard\li0\ri
0\sl-160\slmult0 \fs12\cf3\f0\charscalex100 {Aspiration associated with LMA}\par
\pard\li0\ri0\sl-173\slmult0 \fs12\cf3\f0\charscalex100 {Aspiration not associat
ed with LMA}\par\pard\li0\ri0\sl-160\slmult0 \fs12\cf3\f0\charscalex100 {Pneumot
horax}\par\pard\li0\ri0\sl-160\slmult0 \fs12\cf3\f0\charscalex100 {Pulmonary oed
ema}\par\pard\li0\ri0\sl-160\slmult0 \fs12\cf3\f0\charscalex100 {Profuse bronchi
al mucus}\par\pard\li0\ri0\sl-160\slmult0 \fs12\cf3\f0\charscalex100 {Drug induc
ed}\par\pard\li0\ri0\sl-160\slmult0 \fs12\cf3\f0\charscalex100 {Total}\par\colum
n\pard\li80\ri0\sl-160\slmult0 \fs12\cf3\f0\charscalex100 {4}\par\pard\li80\ri0\
sl-173\slmult0 \fs12\cf3\f0\charscalex100 {1}\par\pard\li80\ri0\sl-160\slmult0 \
fs12\cf3\f0\charscalex100 {1}\par\pard\li80\ri0\sl-160\slmult0 \fs12\cf3\f0\char
scalex100 {1}\par\pard\li80\ri0\sl-160\slmult0 \fs12\cf3\f0\charscalex100 {1}\pa
r\pard\li80\ri0\sl-160\slmult0 \fs12\cf3\f0\charscalex100 {2}\par\pard\li0\ri0\s
l-160\slmult0 \fs12\cf3\f0\charscalex100 {44}\par\pard\sect\sectd\sbknone\pgwsxn
12240\pghsxn15840\marglsxn666\margrsxn133\cols2\colno1\colw5600\colsr-0\colno2\c
olw5840\pard\li706\ri0\sl-240\slmult0 \fs16\cf3\f0\charscalex100 {morphine admin
istration; six were related to misplacement}\par\pard\li706\ri0\sl-186\slmult0 \
fs14\cf3\f0\charscalex100 {of the endotracheal tube; and four were caused by asp
iration}\par\pard\li706\ri0\sl-200\slmult0 \fs14\cf3\f0\charscalex100 {of regurg
itated gastric contents. There was one report of}\par\pard\li706\ri0\sl-200\slmu
lt0 \fs14\cf3\f0\charscalex100 {bronchospasm associated with pulmonary oedema fo

llowing}\par\pard\li706\ri0\sl-200\slmult0 \fs14\cf3\f0\charscalex100 {a failed


intubation and two reports where the cause of}\par\pard\li706\ri0\sl-200\slmult0
\fs14\cf3\f0\charscalex100 {bronchospasm was unknown but was thought to be due
to}\par\pard\li706\ri0\sl-200\slmult0 \fs16\cf3\f0\charscalex100 {allergy.}\par\
pard\li706\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li706\ri0\sl-226\slmult0 \fs16\
cf3\f0\charscalex100 {Bronchospasm presumed due to }\fs16\cf3\f0\charscalex100 {
airway irritation on}\par\pard\li706\ri0\sl-186\slmult0 \fs16\cf3\f0\charscalex1
00 {induction}\par\pard\li706\ri0\sl-186\slmult0 \fs14\cf3\f0\charscalex100 {Of
the 23 reports where there was no other cause, 16}\par\pard\li706\ri0\sl-200\slm
ult0 \fs14\cf3\f0\charscalex100 {concerned patients who may be considered to be
predisposed}\par\pard\li706\ri0\sl-200\slmult0 \fs14\cf3\f0\charscalex100 {to br
onchospasm from airway irritation. They included those}\par\pard\li706\ri0\sl-20
0\slmult0 \fs14\cf3\f0\charscalex100 {with pre-anaesthetic histories of asthma,
chronic or acute}\par\pard\li706\ri0\sl-200\slmult0 \fs14\cf3\f0\charscalex100 {
bronchitis, chronic obstructive airway disease (COAD), reflux}\par\pard\li706\ri
0\sl-200\slmult0 \fs14\cf3\f0\charscalex100 {oesophagitis, or heavy smoking. Som
e patients had histories}\par\pard\li706\ri0\sl-200\slmult0 \fs14\cf3\f0\charsca
lex100 {which included more than one of the predisposing factors}\par\pard\li706
\ri0\sl-200\slmult0 \fs14\cf3\f0\charscalex100 {and several had not volunteered
the information when}\par\pard\li706\ri0\sl-200\slmult0 \fs14\cf3\f0\charscalex1
00 {questioned by the anaesthetist preoperatively. One report}\par\pard\li706\ri
0\sl-200\slmult0 \fs14\cf3\f0\charscalex100 {described bronchospasm occurring af
ter a difficult intuba-}\par\pard\li706\ri0\sl-186\slmult0 \fs14\cf3\f0\charscal
ex100 {tion, presumably also due to irritation of the airway; one}\par\pard\li70
6\ri0\sl-200\slmult0 \fs14\cf3\f0\charscalex100 {mentioned wheeze occurring in a
ssociation with resolution of}\par\pard\li706\ri0\sl-200\slmult0 \fs14\cf3\f0\ch
arscalex100 {laryngospasm on induction in a child; and one described}\par\pard\l
i706\ri0\sl-200\slmult0 \fs14\cf3\f0\charscalex100 {bronchospasm in association
with laryngospasm resulting}\par\pard\li706\ri0\sl-200\slmult0 \fs16\cf3\f0\char
scalex100 {from traumatic insertion of a laryngeal mask airway.}\par\pard\li706\
ri0\sl-213\slmult0 \fs18\cf0\par\pard\li706\ri0\sl-226\slmult0 \fs16\cf3\f0\char
scalex100 {Bronchospasm associated with misplacement of the}\par\pard\li706\ri0\
sl-186\slmult0 \fs16\cf3\f0\charscalex100 {endotracheal tube}\par\pard\li706\ri0
\sl-186\slmult0 \fs14\cf3\f0\charscalex100 {Six reports mentioned problems of in
tubation in association}\par\pard\li706\ri0\sl-200\slmult0 \fs14\cf3\f0\charscal
ex100 {with bronchospasm. Five occurred with oesophageal intuba-}\par\pard\li706
\ri0\sl-200\slmult0 \fs14\cf3\f0\charscalex100 {tion; however, bronchospasm was
described as being present}\par\pard\li706\ri0\sl-200\slmult0 \fs14\cf3\f0\chars
calex100 {during oesophageal intubation in only two cases, the other}\par\pard\l
i706\ri0\sl-200\slmult0 \fs14\cf3\f0\charscalex100 {three developing bronchospas
m after the endotracheal tube}\par\pard\li706\ri0\sl-200\slmult0 \fs14\cf3\f0\ch
arscalex100 {was correctly placed. There was one report of bronchospasm}\par\par
d\li706\ri0\sl-200\slmult0 \fs16\cf3\f0\charscalex100 {with endobronchial intuba
tion.}\par\pard\li706\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li706\ri0\sl-240\slm
ult0 \fs18\cf3\f0\charscalex100 {Maintenance}\par\pard\li706\ri0\sl-200\slmult0
\fs14\cf3\f0\charscalex100 {There were 44 reports of bronchospasm and/or wheeze
in}\par\pard\li706\ri0\sl-186\slmult0 \fs14\cf3\f0\charscalex100 {association wi
th the maintenance phase of anaesthesia}\par\pard\li706\ri0\sl-200\slmult0 \fs14
\cf3\f0\charscalex100 {(table 3). Of these, 15 were related to instances of}\par
\pard\li1280\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li1280\ri0\sl-213\slmult0 \fs
18\cf0\par\pard\li1280\ri0\sl-266\slmult0 \*\tx2000\fs16\cf3\f0\charscalex100 {T
able 2}\tab \fs16\cf3\f0\charscalex100 {Causes of bronchospasm or wheeze}\par\pa
rd\li1280\ri0\sl-200\slmult0 \fs16\cf3\f0\charscalex100 {during the induction ph
ase of anaesthesia}\par\column\pard\li613\ri0\sl-333\slmult0 \fs12\cf3\f0\charsc
alex100 {LMA, laryngeal mask airway.}\par\pard\li0\ri0\sl-213\slmult0 \fs18\cf0\
par\pard\li0\ri0\sl-333\slmult0 \fs16\cf3\f0\charscalex100 {anaphylaxis (or seve
re allergy), nine were due to broncho-}\par\pard\li0\ri0\sl-200\slmult0 \fs16\cf
3\f0\charscalex100 {spasm of no defined cause, five were due to endobronchial}\p
ar\pard\li0\ri0\sl-213\slmult0 \fs16\cf3\f0\charscalex100 {intubation, one was d
ue to pulmonary oedema, and one was}\par\pard\li0\ri0\sl-200\slmult0 \fs16\cf3\f

0\charscalex100 {due to profuse bronchial mucus in a heavy smoker.}\par\pard\li0


\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li0\ri0\sl-253\slmult0 \fs16\cf3\f0\chars
calex100 {Bronchospasm presumed due to airway irritation}\par\pard\li0\ri0\sl-20
0\slmult0 \fs16\cf3\f0\charscalex100 {There were nine reports where there was no
defined cause,}\par\pard\li0\ri0\sl-200\slmult0 \fs16\cf3\f0\charscalex100 {alt
hough five of these occurred in patients who were noted to}\par\pard\li0\ri0\sl200\slmult0 \fs16\cf3\f0\charscalex100 {have one or more of the following predis
posing factors: heavy}\par\pard\li0\ri0\sl-213\slmult0 \fs16\cf3\f0\charscalex10
0 {smoking, asthma or bronchitis.}\par\pard\li0\ri0\sl-213\slmult0 \fs18\cf0\par
\pard\li0\ri0\sl-253\slmult0 \fs16\cf3\f0\charscalex100 {Endotracheal tube and v
entilator problems}\par\pard\li0\ri0\sl-200\slmult0 \fs16\cf3\f0\charscalex100 {
Five of these reports cited endobronchial intubation as the}\par\pard\li0\ri0\sl
-200\slmult0 \fs16\cf3\f0\charscalex100 {precipitating cause of bronchospasm.}\p
ar\pard\li0\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li0\ri0\sl-266\slmult0 \fs16\c
f3\f0\charscalex100 {Aspiration}\par\pard\li0\ri0\sl-186\slmult0 \fs16\cf3\f0\ch
arscalex100 {There were five reports of pulmonary aspiration during}\par\pard\li
0\ri0\sl-200\slmult0 \fs16\cf3\f0\charscalex100 {maintenance of anaesthesia. Fou
r were associated with the}\par\pard\li0\ri0\sl-213\slmult0 \fs16\cf3\f0\charsca
lex100 {use of the laryngeal mask. In three of these reports the}\par\pard\li0\r
i0\sl-200\slmult0 \fs16\cf3\f0\charscalex100 {aspiration was of regurgitated gas
tric contents, and one was}\par\pard\li0\ri0\sl-200\slmult0 \fs16\cf3\f0\charsca
lex100 {aspiration of thick pharyngeal mucus in a child. There was}\par\pard\li0
\ri0\sl-200\slmult0 \fs16\cf3\f0\charscalex100 {one report of aspiration after i
ntubation with a non-cuffed}\par\pard\li0\ri0\sl-200\slmult0 \fs16\cf3\f0\charsc
alex100 {endotracheal tube in a child.}\par\pard\li0\ri0\sl-213\slmult0 \fs18\cf
0\par\pard\li0\ri0\sl-266\slmult0 \fs16\cf3\f0\charscalex100 {Drug induced bronc
hospasm}\par\pard\li0\ri0\sl-200\slmult0 \fs16\cf3\f0\charscalex100 {Rapid injec
tion of vancomycin was noted as the cause in one}\par\pard\li0\ri0\sl-200\slmult
0 \fs16\cf3\f0\charscalex100 {report, treatment being directed at the histamine
release by}\par\pard\li0\ri0\sl-200\slmult0 \fs16\cf3\f0\charscalex100 {the inje
ction of salbutamol, metaraminol and fluids. One}\par\pard\li0\ri0\sl-200\slmult
0 \fs16\cf3\f0\charscalex100 {report described bronchospasm after protamine inje
ction,}\par\pard\li0\ri0\sl-200\slmult0 \fs16\cf3\f0\charscalex100 {with the sig
ns settling in a few minutes without treatment.}\par\pard\li0\ri0\sl-213\slmult0
\fs18\cf0\par\pard\li0\ri0\sl-266\slmult0 \fs16\cf3\f0\charscalex100 {Pneumotho
rax}\par\pard\li0\ri0\sl-200\slmult0 \fs16\cf3\f0\charscalex100 {There was one c
ase of bronchospasm associated with}\par\pard\li0\ri0\sl-200\slmult0 \fs16\cf3\f
0\charscalex100 {pneumothorax in an elderly patient undergoing a difficult}\par\
pard\li0\ri0\sl-200\slmult0 \fs16\cf3\f0\charscalex100 {bronchoscopy using a Ven
turi ventilation technique.}\par\pard\li226\ri0\sl-213\slmult0 \fs18\cf0\par\par
d\li226\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li226\ri0\sl-266\slmult0 \*\tx946\
fs16\cf3\f0\charscalex100 {Table 4}\tab \fs16\cf3\f0\charscalex100 {Bronchospasm
or wheeze occurring during the}\par\pard\li226\ri0\sl-200\slmult0 \fs16\cf3\f0\
charscalex100 {emergence or recovery phase of anaesthesia}\par\pard\sect\sectd\s
bknone\pgwsxn12240\pghsxn15840\marglsxn666\margrsxn133\cols4\colno1\colw3973\col
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\ri0\sl-306\slmult0 \fs12\cf3\f0\charscalex100 {Cause}\par\column\pard\li0\ri0\s
l-306\slmult0 \fs12\cf3\f0\charscalex100 {No}\par\column\pard\li0\ri0\sl-306\slm
ult0 \fs12\cf3\f0\charscalex100 {Cause}\par\column\pard\li0\ri0\sl-306\slmult0 \
*\tx773\fs12\cf3\f0\charscalex100 {Emergence}\tab \fs12\cf3\f0\charscalex100 {Re
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133\cols5\colno1\colw3973\colsr-0\colno2\colw1906\colsr-0\colno3\colw2600\colsr0\colno4\colw693\colsr-0\colno5\colw2266\pard\li1333\ri0\sl-280\slmult0 \fs12\cf
3\f0\charscalex100 {Bronchospasm presumed due to airway}\par\pard\li1333\ri0\sl160\slmult0 \fs12\cf3\f0\charscalex100 {irritation}\par\pard\li1333\ri0\sl-160\s
lmult0 \fs12\cf3\f0\charscalex100 {Anaphylaxis}\par\pard\li1333\ri0\sl-160\slmul
t0 \fs12\cf3\f0\charscalex100 {Misplacement of endotracheal tube}\par\pard\li133
3\ri0\sl-173\slmult0 \fs12\cf3\f0\charscalex100 {Aspiration of gastric contents}
\par\pard\li1333\ri0\sl-160\slmult0 \fs12\cf3\f0\charscalex100 {Pulmonary oedema
(following}\par\pard\li1333\ri0\sl-160\slmult0 \fs12\cf3\f0\charscalex100 {fail

ed intubation)}\par\pard\li1333\ri0\sl-160\slmult0 \fs12\cf3\f0\charscalex100 {U
nknown, possibly allergy}\par\pard\li1333\ri0\sl-160\slmult0 \fs12\cf3\f0\charsc
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ard\li0\ri0\sl-360\slmult0 \fs14\cf3\f0\charscalex100 {Westhorpe, Ludbrook, Help
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ia, seven}\par\pard\li706\ri0\sl-200\slmult0 \fs14\cf3\f0\charscalex100 {during
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onchospasm}\par\pard\li706\ri0\sl-200\slmult0 \fs14\cf3\f0\charscalex100 {with n
o defined cause occurred in patients who exhibited}\par\pard\li706\ri0\sl-200\sl
mult0 \fs14\cf3\f0\charscalex100 {predisposing factors including asthma, a histo
ry of heavy}\par\pard\li706\ri0\sl-200\slmult0 \fs16\cf3\f0\charscalex100 {smoki
ng, or chronic obstructive airways disease.}\par\pard\li880\ri0\sl-200\slmult0 \
fs14\cf3\f0\charscalex100 {Three of the cases of pulmonary oedema were initially
}\par\pard\li706\ri0\sl-200\slmult0 \fs14\cf3\f0\charscalex100 {treated as bronc
hospasm. The fourth case of pulmonary}\par\pard\li706\ri0\sl-200\slmult0 \fs14\c
f3\f0\charscalex100 {oedema was recognised as being due to rapid infusion of}\pa
r\pard\li706\ri0\sl-200\slmult0 \fs14\cf3\f0\charscalex100 {colloid in an elderl
y patient. The patient in whom broncho-}\par\pard\li706\ri0\sl-200\slmult0 \fs14
\cf3\f0\charscalex100 {spasm was reported to have occurred upon extubation was}\
par\pard\li706\ri0\sl-200\slmult0 \fs14\cf3\f0\charscalex100 {managed as for lar
yngospasm with the appropriate outcome}\par\pard\li706\ri0\sl-200\slmult0 \fs14\
cf3\f0\charscalex100 {and, as such, the diagnosis of bronchospasm may be}\par\pa
rd\li706\ri0\sl-200\slmult0 \fs14\cf3\f0\charscalex100 {questioned. One patient
developed unilateral bronchospasm}\par\pard\li706\ri0\sl-186\slmult0 \fs14\cf3\f
0\charscalex100 {and pulmonary oedema which resolved over several days and}\par\
pard\li706\ri0\sl-200\slmult0 \fs16\cf3\f0\charscalex100 {for which no cause cou
ld be found.}\par\pard\li706\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li706\ri0\sl266\slmult0 \fs16\cf3\f0\charscalex100 {Presenting signs}\par\pard\li706\ri0\sl213\slmult0 \fs18\cf3\f0\charscalex100 {Bronchospasm associated with anaphylaxis
or}\par\pard\li706\ri0\sl-213\slmult0 \fs18\cf3\f0\charscalex100 {allergy}\par\
pard\li706\ri0\sl-186\slmult0 \fs14\cf3\f0\charscalex100 {There were 22 reports
of anaphylaxis or severe allergy in}\par\pard\li706\ri0\sl-200\slmult0 \fs14\cf3
\f0\charscalex100 {which bronchospasm was included in the signs exhibited by}\pa
r\pard\li706\ri0\sl-200\slmult0 \fs14\cf3\f0\charscalex100 {the patient. The ran
ge of presenting signs is shown in table 5.}\par\pard\li706\ri0\sl-200\slmult0 \
fs14\cf3\f0\charscalex100 {The appearance of a rash was the first sign of anaphy
laxis in}\par\pard\li706\ri0\sl-200\slmult0 \fs14\cf3\f0\charscalex100 {six of t
he 22 reports, but wheeze, bronchospasm or increased}\par\pard\li706\ri0\sl-200\
slmult0 \fs14\cf3\f0\charscalex100 {pulmonary inflation pressures\uc1\u8212Xwhen
appearing together}\par\pard\li706\ri0\sl-200\slmult0 \fs14\cf3\f0\charscalex10
0 {with hypotension\uc1\u8212Xwere often followed by the appearance}\par\pard\li
706\ri0\sl-186\slmult0 \fs14\cf3\f0\charscalex100 {of a rash. A rash or cutaneou
s flush was eventually present in}\par\pard\li706\ri0\sl-200\slmult0 \fs16\cf3\f
0\charscalex100 {16 of the 22 reports of anaphylaxis or severe allergy.}\par\par
d\li706\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li706\ri0\sl-280\slmult0 \fs18\cf3
\f0\charscalex100 {Bronchospasm not associat}\fs18\cf3\f0\charscalex100 {ed with
anaphylaxis or}\par\pard\li706\ri0\sl-213\slmult0 \fs18\cf3\f0\charscalex100 {s
evere allergy}\par\pard\li706\ri0\sl-186\slmult0 \fs14\cf3\f0\charscalex100 {All
reports apart from those where anaphylaxis or severe}\par\pard\li706\ri0\sl-200
\slmult0 \fs14\cf3\f0\charscalex100 {allergy was the cause of bronchospasm were
analysed to}\par\pard\li706\ri0\sl-200\slmult0 \fs14\cf3\f0\charscalex100 {deter
mine which sign first alerted the anaesthetist to the}\par\pard\li706\ri0\sl-200
\slmult0 \fs16\cf3\f0\charscalex100 {presence of a problem (table 6).}\par\pard\
li880\ri0\sl-200\slmult0 \fs14\cf3\f0\charscalex100 {Of the 81 reports examined,
27 first indicated a problem by}\par\pard\li706\ri0\sl-200\slmult0 \fs14\cf3\f0
\charscalex100 {the need for high inflation pressures; 23 reports described}\par

\pard\li706\ri0\sl-200\slmult0 \fs14\cf3\f0\charscalex100 {\uc1\u8216X\uc1\u8216


Xbronchospasm\uc1\u8217X\uc1\u8217X as being the first sign, although the}\par\p
ard\li706\ri0\sl-200\slmult0 \fs14\cf3\f0\charscalex100 {narrative description d
oes not indicate whether this was}\par\pard\li706\ri0\sl-200\slmult0 \fs14\cf3\f
0\charscalex100 {wheeze or high inflation pressure; and five described wheeze}\p
ar\pard\li706\ri0\sl-200\slmult0 \fs14\cf3\f0\charscalex100 {as the first sign.
Thus, it may be concluded that, in 55 of the}\par\pard\li706\ri0\sl-200\slmult0
\fs14\cf3\f0\charscalex100 {81 reports (68%), wheeze or increased inflation pres
sure was}\par\pard\li706\ri0\sl-186\slmult0 \fs14\cf3\f0\charscalex100 {the sign
which triggered the diagnostic and management}\par\pard\li706\ri0\sl-200\slmult
0 \fs16\cf3\f0\charscalex100 {process.}\par\pard\li880\ri0\sl-200\slmult0 \fs14\
cf3\f0\charscalex100 {Low oxygen saturation as shown by the pulse oximeter was}\
par\pard\li706\ri0\sl-200\slmult0 \fs14\cf3\f0\charscalex100 {the first sign of
a problem in 19 reports. A change in the}\par\pard\li706\ri0\sl-200\slmult0 \fs1
4\cf3\f0\charscalex100 {capnogram was the first sign in three reports, two showi
ng a}\par\pard\li706\ri0\sl-213\slmult0 \fs14\cf3\f0\charscalex100 {high end-tid
al CO}{\sub \fs8\cf3\f0\charscalex100 {2}}\fs14\cf3\f0\charscalex100 {and one wh
ere the capnogram fell to the}\par\pard\li706\ri0\sl-186\slmult0 \fs14\cf3\f0\ch
arscalex100 {baseline indicating no gas flow associated with very severe}\par\pa
rd\li706\ri0\sl-200\slmult0 \fs14\cf3\f0\charscalex100 {bronchospasm. There were
three reports of low tidal volume}\par\pard\li1280\ri0\sl-213\slmult0 \fs18\cf0
\par\pard\li1280\ri0\sl-306\slmult0 \*\tx1986\fs16\cf3\f0\charscalex100 {Table 5
}\tab \fs16\cf3\f0\charscalex100 {First presenting sign of anaphylaxis or}\par\p
ard\li1280\ri0\sl-200\slmult0 \fs16\cf3\f0\charscalex100 {severe allergy associa
ted with bronchospasm in}\par\pard\li1280\ri0\sl-200\slmult0 \fs16\cf3\f0\charsc
alex100 {all phases of anaesthesia}\par\pard\li1333\ri0\sl-293\slmult0 \fs12\cf3
\f0\charscalex100 {First presenting sign of anaphylaxis or}\par\pard\li1333\ri0\
sl-160\slmult0 \*\tx3840\fs12\cf3\f0\charscalex100 {severe allergy}\tab \fs12\cf
3\f0\charscalex100 {No}\par\column\pard\li0\ri0\sl-213\slmult0 \fs18\cf0\par\par
d\li0\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li0\ri0\sl-173\slmult0 \fs16\cf3\f0\
charscalex100 {as the first sign of bronchospasm and one report where}\par\pard\
li0\ri0\sl-200\slmult0 \fs16\cf3\f0\charscalex100 {hypotension led to the diagno
sis.}\par\pard\li0\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li0\ri0\sl-226\slmult0
\fs18\cf3\f0\charscalex100 {DISCUSSION}\par\pard\li0\ri0\sl-213\slmult0 \fs16\cf
3\f0\charscalex100 {Induction and maintenance}\par\pard\li0\ri0\sl-186\slmult0 \
fs16\cf3\f0\charscalex100 {When the COVER ABCD \uc1\u8216X\uc1\u8216Xcore\uc1\u8
217X\uc1\u8217X algorithm was applied to the}\par\pard\li0\ri0\sl-200\slmult0 \f
s16\cf3\f0\charscalex100 {103 reports as analysed, it was apparent that the basi
c}\par\pard\li0\ri0\sl-200\slmult0 \fs16\cf3\f0\charscalex100 {problem should ha
ve been at least detected and diagnosed by}\par\pard\li0\ri0\sl-200\slmult0 \fs1
6\cf3\f0\charscalex100 {the completion of \uc1\u8216X\uc1\u8216XB\uc1\u8217X\uc1
\u8217X in all cases. Diagnosis of pneumo-}\par\pard\li0\ri0\sl-200\slmult0 \fs1
6\cf3\f0\charscalex100 {thorax may have proved somewhat obscure, but the \uc1\u8
216X\uc1\u8216XB\uc1\u8217X\uc1\u8217X}\par\pard\li0\ri0\sl-200\slmult0 \fs16\cf
3\f0\charscalex100 {stage of the algorithm asks that it be considered as a}\par\
pard\li0\ri0\sl-200\slmult0 \fs16\cf3\f0\charscalex100 {possibility. The likely
diagnostic stages of the COVER ABCD}\par\pard\li0\ri0\sl-200\slmult0 \fs16\cf3\f
0\charscalex100 {algorithm are as follows:}\par\pard\li160\ri0\sl-200\slmult0 \*
\tx1066\fs14\cf3\f0\charscalex100 {C, Colour:}\tab \fs14\cf3\f0\charscalex100 {O
bserved desaturation or cyanosis, confirmed}\par\pard\li0\ri0\sl-200\slmult0 \fs
16\cf3\f0\charscalex100 {by pulse oximetry. Rash or other cutaneous manifestatio
n of}\par\pard\li0\ri0\sl-186\slmult0 \fs16\cf3\f0\charscalex100 {allergy.}\par\
pard\li160\ri0\sl-213\slmult0 \*\tx1413\fs16\cf3\f0\charscalex100 {Capnography:}
\tab \fs16\cf3\f0\charscalex100 {rising end-tidal CO}{\sub \fs10\cf3\f0\charscal
ex100 {2}}\fs16\cf3\f0\charscalex100 {being a diagnostic}\par\pard\li0\ri0\sl-18
6\slmult0 \fs16\cf3\f0\charscalex100 {sign of hypoventilation from any cause. Ve
ry severe}\par\pard\li0\ri0\sl-200\slmult0 \fs16\cf3\f0\charscalex100 {bronchosp
asm may be accompanied by a fall in end-tidal}\par\pard\li0\ri0\sl-213\slmult0 \
fs16\cf3\f0\charscalex100 {CO}{\sub \fs10\cf3\f0\charscalex100 {2}}\fs16\cf3\f0\
charscalex100 {to zero.}\par\pard\li160\ri0\sl-186\slmult0 \fs14\cf3\f0\charscal

ex100 {V2, Ventilate by hand}\fs14\cf3\f0\charscalex100 {: observe and auscultat


e. This is the}\par\pard\li0\ri0\sl-200\slmult0 \fs16\cf3\f0\charscalex100 {leve
l of the core algorithm from which the sub-algorithm for}\par\pard\li0\ri0\sl-20
0\slmult0 \fs16\cf3\f0\charscalex100 {bronchospasm is most likely to stem.}\par\
pard\li160\ri0\sl-200\slmult0 \fs16\cf3\f0\charscalex100 {E1, Check endotracheal
tube:}{ }\fs16\cf3\f0\charscalex100 {This stage will diagnose}\par\pard\li0\ri0
\sl-200\slmult0 \fs16\cf3\f0\charscalex100 {and, in most cases, provide informat
ion for correct manage-}\par\pard\li0\ri0\sl-186\slmult0 \fs16\cf3\f0\charscalex
100 {ment of endotracheal tube problems such as oesophageal}\par\pard\li0\ri0\sl
-200\slmult0 \fs16\cf3\f0\charscalex100 {intubation, endobronchial intubation, a
nd a kinked or}\par\pard\li0\ri0\sl-200\slmult0 \fs16\cf3\f0\charscalex100 {obst
ructed tube. Importantly, if a laryngeal mask airway is}\par\pard\li0\ri0\sl-200
\slmult0 \fs16\cf3\f0\charscalex100 {in use, the pharynx should be inspected for
regurgitation and}\par\pard\li0\ri0\sl-200\slmult0 \fs16\cf3\f0\charscalex100 {
potential aspiration.}\par\pard\li160\ri0\sl-200\slmult0 \*\tx3786\fs16\cf3\f0\c
harscalex100 {E2, Ventilate with an alternative system:}\tab \fs16\cf3\f0\charsc
alex100 {such as a}\par\pard\li0\ri0\sl-200\slmult0 \fs16\cf3\f0\charscalex100 {
self-inflating resuscitation bag. This will eliminate all causes}\par\pard\li0\r
i0\sl-200\slmult0 \fs16\cf3\f0\charscalex100 {of high circuit pressure which are
equipment related and is}\par\pard\li0\ri0\sl-200\slmult0 \fs16\cf3\f0\charscal
ex100 {an important diagnostic step, even if the \uc1\u8216X\uc1\u8216Xbronchosp
asm\uc1\u8217X\uc1\u8217X}\par\pard\li0\ri0\sl-200\slmult0 \fs16\cf3\f0\charscal
ex100 {sub-algorithm has been commenced.}\par\pard\li160\ri0\sl-200\slmult0 \fs1
6\cf3\f0\charscalex100 {Although desaturation is a signal that a crisis is evolv
ing}\par\pard\li0\ri0\sl-186\slmult0 \fs16\cf3\f0\charscalex100 {and is thus a t
rigger for proceeding with a process for}\par\pard\li0\ri0\sl-200\slmult0 \fs16\
cf3\f0\charscalex100 {diagnosis and treatment of the crisis in anaesthesia, it w
ould}\par\pard\li0\ri0\sl-200\slmult0 \fs16\cf3\f0\charscalex100 {appear that it
is not a good discriminator for detecting}\par\pard\li0\ri0\sl-200\slmult0 \fs1
6\cf3\f0\charscalex100 {bronchospasm. However, changes in oxygen saturation are}
\par\pard\li0\ri0\sl-200\slmult0 \fs16\cf3\f0\charscalex100 {likely to be useful
as a guide to the efficacy of management.}\par\pard\li0\ri0\sl-213\slmult0 \fs1
8\cf0\par\pard\li0\ri0\sl-226\slmult0 \fs16\cf3\f0\charscalex100 {Emergence and
recovery}\par\pard\li0\ri0\sl-186\slmult0 \fs16\cf3\f0\charscalex100 {Although h
igh lung inflation pressures may be detected at}\par\pard\li0\ri0\sl-200\slmult0
\fs16\cf3\f0\charscalex100 {the time of emergence and should be dealt with appr
opriately}\par\pard\li0\ri0\sl-200\slmult0 \fs16\cf3\f0\charscalex100 {by the br
onchospasm sub-algorithm, other detection of}\par\pard\li0\ri0\sl-200\slmult0 \f
s16\cf3\f0\charscalex100 {bronchospasm during emergence and recovery will depend
}\par\pard\li0\ri0\sl-200\slmult0 \fs16\cf3\f0\charscalex100 {on the appearance
of wheeze, audible either with or without}\par\pard\li0\ri0\sl-200\slmult0 \fs16
\cf3\f0\charscalex100 {auscultation. In these cases, and especially during the}\
par\pard\li0\ri0\sl-200\slmult0 \fs16\cf3\f0\charscalex100 {postoperative recove
ry phase, care must be exercised to}\par\pard\li0\ri0\sl-200\slmult0 \fs16\cf3\f
0\charscalex100 {eliminate pulmonary oedema or aspiration as a cause of}\par\par
d\li0\ri0\sl-200\slmult0 \fs16\cf3\f0\charscalex100 {wheeze.}\par\pard\li0\ri0\s
l-213\slmult0 \fs18\cf0\par\pard\li0\ri0\sl-213\slmult0 \fs16\cf3\f0\charscalex1
00 {Diagnosis and treatment of bronchospasm}\par\pard\li0\ri0\sl-200\slmult0 \fs
16\cf3\f0\charscalex100 {A suggested sub-algorithm for the management of broncho
-}\par\pard\li0\ri0\sl-200\slmult0 \fs16\cf3\f0\charscalex100 {spasm is detailed
in fig 1. The sub-algorithm was applied to}\par\pard\li0\ri0\sl-200\slmult0 \fs
16\cf3\f0\charscalex100 {all reports not involving anaphylaxis or severe allergy
(that is,}\par\pard\li0\ri0\sl-186\slmult0 \fs16\cf3\f0\charscalex100 {to 81 re
ports). The authors consider that the sub-algorithm}\par\pard\li0\ri0\sl-200\slm
ult0 \fs16\cf3\f0\charscalex100 {would have performed satisfactorily in all case
s and, in 73}\par\pard\li0\ri0\sl-200\slmult0 \fs16\cf3\f0\charscalex100 {cases
(90%), it would have performed as well as the clinician}\par\pard\li0\ri0\sl-200
\slmult0 \fs16\cf3\f0\charscalex100 {as described in the report narrative. In ei
ght cases (10%) the}\par\pard\sect\sectd\sbknone\pgwsxn12240\pghsxn15840\marglsx
n666\margrsxn133\cols3\colno1\colw3840\colsr-0\colno2\colw1760\colsr-0\colno3\co

lw5840\pard\li1333\ri0\sl-160\slmult0 \fs12\cf3\f0\charscalex100 {Rash}\par\pard


\li1333\ri0\sl-160\slmult0 \fs12\cf3\f0\charscalex100 {Increased inflation press
ure}\par\pard\li1333\ri0\sl-160\slmult0 \fs12\cf3\f0\charscalex100 {Wheeze}\par\
pard\li1333\ri0\sl-173\slmult0 \fs12\cf3\f0\charscalex100 {Hypotension}\par\pard
\li1333\ri0\sl-160\slmult0 \fs12\cf3\f0\charscalex100 {Falling oxygen saturation
}\par\pard\li1333\ri0\sl-160\slmult0 \fs12\cf3\f0\charscalex100 {Capnography cha
nge with LMA}\par\pard\li1333\ri0\sl-160\slmult0 \fs12\cf3\f0\charscalex100 {Tot
al}\par\column\pard\li66\ri0\sl-160\slmult0 \fs12\cf3\f0\charscalex100 {6}\par\p
ard\li66\ri0\sl-160\slmult0 \fs12\cf3\f0\charscalex100 {4}\par\pard\li66\ri0\sl160\slmult0 \fs12\cf3\f0\charscalex100 {4}\par\pard\li66\ri0\sl-173\slmult0 \fs1
2\cf3\f0\charscalex100 {4}\par\pard\li66\ri0\sl-160\slmult0 \fs12\cf3\f0\charsca
lex100 {3}\par\pard\li66\ri0\sl-160\slmult0 \fs12\cf3\f0\charscalex100 {1}\par\p
ard\li0\ri0\sl-160\slmult0 \fs12\cf3\f0\charscalex100 {22}\par\column\pard\li0\r
i0\sl-200\slmult0 \*\tx720\*\tx1493\*\tx1960\*\tx2360\*\tx3560\*\tx4186\fs16\cf3
\f0\charscalex100 {authors}\tab \fs16\cf3\f0\charscalex100 {consider}\tab \fs16\
cf3\f0\charscalex100 {that}\tab \fs16\cf3\f0\charscalex100 {the}\tab \fs16\cf3\f
0\charscalex100 {sub-algorithm}\tab \fs16\cf3\f0\charscalex100 {would}\tab \fs16
\cf3\f0\charscalex100 {have}\par\pard\li0\ri0\sl-200\slmult0 \fs16\cf3\f0\charsc
alex100 {performed better than the clinical management as described.}\par\pard\l
i0\ri0\sl-200\slmult0 \fs16\cf3\f0\charscalex100 {In five of these cases no trea
tment was administered when it}\par\pard\li0\ri0\sl-200\slmult0 \fs16\cf3\f0\cha
rscalex100 {is considered that earlier resolution may have been achieved}\par\pa
rd\li0\ri0\sl-200\slmult0 \fs16\cf3\f0\charscalex100 {by the use of bronchodilat
or therapy. In two cases broncho-}\par\pard\li0\ri0\sl-200\slmult0 \fs16\cf3\f0\
charscalex100 {dilator therapy would have been instituted at an earlier stage}\p
ar\pard\sect\sectd\sbknone\pgwsxn12240\pghsxn15840\marglsxn666\margrsxn133\cols2
\colno1\colw5600\colsr-0\colno2\colw5840\pard\li1333\ri0\sl-266\slmult0 \fs12\cf
3\f0\charscalex100 {Note that 16 of the 22 cases eventually exhibited a rash.}\p
ar\pard\li706\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li706\ri0\sl-213\slmult0 \fs
18\cf0\par\pard\li706\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li706\ri0\sl-253\slm
ult0 \fs14\cf3\f0\charscalex100 {www.qshc.com}\par\column\pard\li0\ri0\sl-200\sl
mult0 \fs16\cf3\f0\charscalex100 {and in one case the delayed diagnosis could ha
ve been}\par\pard\li0\ri0\sl-186\slmult0 \fs16\cf3\f0\charscalex100 {avoided.}\p
ar\pard\sect\sectd\sbknone\pgwsxn12240\pghsxn15840\marglsxn666\margrsxn133\pard\
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{\sp{\sn pVerticies}{\sv 8;5;(0,0);(0,2653);(1306,2653);(1306,0);(0,0);}}
{\sp{\sn pSegmentInfo}{\sv 2;12;16384;45824;1;45824;1;45824;1;45824;1;45824;2457
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{\sp{\sn fFillOK}{\sv 1}}
{\sp{\sn fFilled}{\sv 1}}
{\sp{\sn fillColor}{\sv 16777215}}
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{\sp{\sn lineType}{\sv 0}}
{\sp{\sn fArrowheadsOK}{\sv 0}}
{\sp{\sn fBehindDocument}{\sv 1}}
{\sp{\sn fLayoutInCell}{\sv 1}}}}
{\shp{\*\shpinst\shpleft2680\shptop853\shpright9493\shpbottom866\shpfhdr0\shpwr3
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{\sp{\sn shapeType}{\sv 0}}
{\sp{\sn fFlipH}{\sv 0}}
{\sp{\sn fFlipV}{\sv 0}}
{\sp{\sn rotation}{\sv 0}}
{\sp{\sn geoRight}{\sv 6813}}
{\sp{\sn geoBottom}{\sv 13}}
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{\sp{\sn pVerticies}{\sv 8;5;(0,0);(0,13);(6813,13);(6813,0);(0,0);}}
{\sp{\sn pSegmentInfo}{\sv 2;12;16384;45824;1;45824;1;45824;1;45824;1;45824;2457
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{\sp{\sn fillColor}{\sv 2105123}}
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{\sp{\sn geoRight}{\sv 6813}}
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{\sp{\sn geoRight}{\sv 6360}}
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olno3\colw1733\pard\li706\ri0\sl-360\slmult0 \fs14\cf3\f0\charscalex100 {Broncho
spasm: }\fs14\cf3\f0\charscalex100 {crisis management}\par\column\pard\li0\ri0\s
l-173\slmult0 \fs18\cf0\f1\charscalex100 {Downloaded from}{ }\fs14\cf1\f1\charsc
alex100 {{\field{\*\fldinst{HYPERLINK "http://qshc.bmj.com"}}{\fldrslt {qshc.bmj

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rd\li2240\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li2240\ri0\sl-266\slmult0 \*\tx2
960\fs16\cf3\f0\charscalex100 {Table 6}\tab \fs16\cf3\f0\charscalex100 {Presenti
ng sign of bronchospasm (excluding cases of anaphylaxis/severe}\par\pard\li2240\
ri0\sl-200\slmult0 \fs16\cf3\f0\charscalex100 {allergy) during induction (I), ma
intenance (M), and emergency/recovery (E&R)}\par\pard\sect\sectd\sbknone\pgwsxn1
2240\pghsxn15840\marglsxn666\margrsxn133\cols5\colno1\colw5040\colsr-0\colno2\co
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\li2306\ri0\sl-280\slmult0 \fs12\cf3\f0\charscalex100 {Increased inflation press
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8216X\uc1\u8216XBronchospasm\uc1\u8217X\uc1\u8217X}\par\pard\li2306\ri0\sl-160\s
lmult0 \fs12\cf3\f0\charscalex100 {Wheeze}\par\pard\li2306\ri0\sl-173\slmult0 \f
s12\cf3\f0\charscalex100 {Change in capnogram}\par\pard\li2306\ri0\sl-160\slmult
0 \fs12\cf3\f0\charscalex100 {Hypoventilation (low tidal volume)}\par\pard\li230
6\ri0\sl-160\slmult0 \fs12\cf3\f0\charscalex100 {Hypotension}\par\pard\li2306\ri
0\sl-160\slmult0 \fs12\cf3\f0\charscalex100 {Total}\par\column\pard\li0\ri0\sl-2
93\slmult0 \fs12\cf3\f0\charscalex100 {I}\par\pard\li0\ri0\sl-280\slmult0 \fs12\
cf3\f0\charscalex100 {19}\par\pard\li80\ri0\sl-160\slmult0 \fs12\cf3\f0\charscal
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par\pard\li80\ri0\sl-173\slmult0 \fs10\cf3\f0\charscalex100 {1}\par\pard\li80\ri
0\sl-160\slmult0 \fs10\cf3\f0\charscalex100 {2}\par\pard\li80\ri0\sl-160\slmult0
\fs10\cf3\f0\charscalex100 {1}\par\pard\li0\ri0\sl-160\slmult0 \fs12\cf3\f0\cha
rscalex100 {29}\par\column\pard\li0\ri0\sl-293\slmult0 \fs12\cf3\f0\charscalex10
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\slmult0 \fs12\cf3\f0\charscalex100 {6}\par\pard\li66\ri0\sl-160\slmult0 \fs12\c
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}\par\pard\li0\ri0\sl-160\slmult0 \fs12\cf3\f0\charscalex100 {23}\par\pard\li80\
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t0 \fs12\cf3\f0\charscalex100 {3}\par\pard\li80\ri0\sl-160\slmult0 \fs12\cf3\f0\
charscalex100 {3}\par\pard\li80\ri0\sl-160\slmult0 \fs12\cf3\f0\charscalex100 {1
}\par\pard\li0\ri0\sl-160\slmult0 \fs12\cf3\f0\charscalex100 {81}\par\pard\sect\
sectd\sbknone\pgwsxn12240\pghsxn15840\marglsxn666\margrsxn133\cols2\colno1\colw5
586\colsr-0\colno2\colw5853\pard\li880\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li8
80\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li880\ri0\sl-213\slmult0 \fs18\cf0\par\
pard\li880\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li880\ri0\sl-200\slmult0 \fs16\
cf3\f0\charscalex100 {In recognising and managing bronchospasm due to various}\p
ar\pard\li706\ri0\sl-200\slmult0 \fs14\cf3\f0\charscalex100 {causes, diagnostic
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f3\f0\charscalex100 {inflation pressure, wheeze, falling oxygen saturation, and}
\par\pard\li706\ri0\sl-213\slmult0 \fs14\cf3\f0\charscalex100 {rising end-tidal
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. The appearance of a rash}\par\pard\li706\ri0\sl-200\slmult0 \fs16\cf3\f0\chars


calex100 {or hypotension will point to a diagnosis of anaphylaxis.}\par\pard\li8
80\ri0\sl-200\slmult0 \fs14\cf3\f0\charscalex100 {In a number of reports of bron
chospasm, intravenous}\par\pard\li706\ri0\sl-200\slmult0 \fs14\cf3\f0\charscalex
100 {salbutamol was used instead of nebulised or atomised}\par\pard\li706\ri0\sl
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be or breathing}\par\pard\li706\ri0\sl-213\slmult0 \fs14\cf3\f0\charscalex100 {c
ircuit. In all but one case this appeared to delay resolution}\par\pard\li706\ri
0\sl-200\slmult0 \fs14\cf3\f0\charscalex100 {of the problem. Some reports also a
lluded to difficulty in}\par\pard\li706\ri0\sl-200\slmult0 \fs14\cf3\f0\charscal
ex100 {applying nebulisers to circuits. A readily available method of}\par\pard\
li826\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li826\ri0\sl-213\slmult0 \fs18\cf0\p
ar\pard\li826\ri0\sl-253\slmult0 \fs18\cf2\f0\charscalex100 {Key messages}\par\p
ard\li826\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li826\ri0\sl-253\slmult0 \*\tx10
26\fs20\cf3\f0\charscalex100 {N}\tab \fs18\cf3\f0\charscalex100 {From the first
4000 incidents reported to AIMS, 103}\par\pard\li1026\ri0\sl-213\slmult0 \fs18\c
f3\f0\charscalex100 {reports of bronchospasm (3%) were subjected to}\par\pard\li
1026\ri0\sl-213\slmult0 \fs18\cf3\f0\charscalex100 {analysis.}\par\pard\li826\ri
0\sl-240\slmult0 \*\tx1026\fs20\cf3\f0\charscalex100 {N}\tab \fs18\cf3\f0\charsc
alex100 {Twenty two of the 103 reports were associated with}\par\pard\li1026\ri0
\sl-200\slmult0 \fs18\cf3\f0\charscalex100 {allergy or anaphylaxis.}\par\pard\li
826\ri0\sl-253\slmult0 \*\tx1026\fs20\cf3\f0\charscalex100 {N}\tab \fs18\cf3\f0\
charscalex100 {The most common first presenting signs of anaphylaxis}\par\pard\l
i1026\ri0\sl-200\slmult0 \fs18\cf3\f0\charscalex100 {or severe allergy in this s
eries were a rash (6 cases),}\par\pard\li1026\ri0\sl-200\slmult0 \fs18\cf3\f0\ch
arscalex100 {increased inflation pressure (4 cases), wheeze (4}\par\pard\li1026\
ri0\sl-213\slmult0 \fs18\cf3\f0\charscalex100 {cases), and hypotension (4 cases)
.}\par\pard\li826\ri0\sl-240\slmult0 \*\tx1040\fs20\cf3\f0\charscalex100 {N}\tab
\fs18\cf3\f0\charscalex100 {Overall, in the 81 reports examined (excluding}\par
\pard\li1040\ri0\sl-200\slmult0 \fs18\cf3\f0\charscalex100 {anaphylaxis/severe a
llergy), 27 reported the need}\par\pard\li1040\ri0\sl-200\slmult0 \fs18\cf3\f0\c
harscalex100 {for high inflation pressures as the first presenting sign}\par\par
d\li1040\ri0\sl-213\slmult0 \fs18\cf3\f0\charscalex100 {of bronchospasm.}\par\pa
rd\li826\ri0\sl-253\slmult0 \*\tx1026\fs20\cf3\f0\charscalex100 {N}\tab \fs18\cf
3\f0\charscalex100 {Eighty six of the 103 bronchospasm reports (83%)}\par\pard\l
i1026\ri0\sl-200\slmult0 \fs18\cf3\f0\charscalex100 {occurred during either the
induction or maintenance}\par\pard\li1026\ri0\sl-200\slmult0 \fs18\cf3\f0\charsc
alex100 {phase of anaesthesia.}\par\pard\li826\ri0\sl-253\slmult0 \*\tx1026\fs20
\cf3\f0\charscalex100 {N}\tab \fs18\cf3\f0\charscalex100 {Airway irritation acco
unted for half of the induction}\par\pard\li1026\ri0\sl-200\slmult0 \fs18\cf3\f0
\charscalex100 {occurrences.}\par\pard\li826\ri0\sl-240\slmult0 \*\tx1026\fs20\c
f3\f0\charscalex100 {N}\tab \fs18\cf3\f0\charscalex100 {Anaphylaxis or an endotr
acheal tube or ventilator}\par\pard\li1026\ri0\sl-200\slmult0 \fs18\cf3\f0\chars
calex100 {problem accounted for more than half of the occur-}\par\pard\li1026\ri
0\sl-200\slmult0 \fs18\cf3\f0\charscalex100 {rences during the maintenance phase
.}\par\pard\li826\ri0\sl-240\slmult0 \*\tx1040\fs20\cf3\f0\charscalex100 {N}\tab
\fs18\cf3\f0\charscalex100 {Of the 17 occurrences of bronchospasm during}\par\p
ard\li1040\ri0\sl-213\slmult0 \fs18\cf3\f0\charscalex100 {emergence or recovery,
six had no defined cause}\par\pard\li1040\ri0\sl-200\slmult0 \fs18\cf3\f0\chars
calex100 {and another four were due to pulmonary oedema.}\par\pard\li826\ri0\sl240\slmult0 \*\tx1026\fs20\cf3\f0\charscalex100 {N}\tab \fs18\cf3\f0\charscalex1
00 {Desaturation alone is not a good discriminator for}\par\pard\li1026\ri0\sl-2
13\slmult0 \fs18\cf3\f0\charscalex100 {detecting bronchospasm, but saturation ch
anges are a}\par\pard\li1026\ri0\sl-200\slmult0 \fs18\cf3\f0\charscalex100 {usef
ul guide during management.}\par\pard\li826\ri0\sl-240\slmult0 \*\tx1026\fs20\cf
3\f0\charscalex100 {N}\tab \fs18\cf3\f0\charscalex100 {The specific bronchospasm
sub-algorithm was applied}\par\pard\li1026\ri0\sl-213\slmult0 \fs18\cf3\f0\char
scalex100 {to 81 reports (anaphylaxis/severe allergy cases dealt}\par\pard\li102
6\ri0\sl-200\slmult0 \fs18\cf3\f0\charscalex100 {with in another paper in this s
eries were excluded). In}\par\pard\li1026\ri0\sl-213\slmult0 \fs18\cf3\f0\charsc

alex100 {90% the sub-algorithm was potentially as good as the}\par\pard\li1026\r


i0\sl-213\slmult0 \fs18\cf3\f0\charscalex100 {clinician\uc1\u8217Xs reported man
agement and in 10% was}\par\pard\li1026\ri0\sl-200\slmult0 \fs18\cf3\f0\charscal
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13\slmult0 \fs18\cf3\f0\charscalex100 {described.}\par\column\pard\li0\ri0\sl-21
3\slmult0 \fs18\cf0\par\pard\li0\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li0\ri0\s
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i0\sl-186\slmult0 \fs16\cf3\f0\charscalex100 {introducing salbutamol spray to th
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of the COVER ABCD core}\par\pard\li213\ri0\sl-200\slmult0 \fs16\cf3\f0\charscal
ex100 {algorithm.}\par\pard\li0\ri0\sl-240\slmult0 \*\tx213\fs20\cf3\f0\charscal
ex100 {N}\tab \fs16\cf3\f0\charscalex100 {If laryngeal mask airway (LMA) is in u
se, aspiration as the}\par\pard\li213\ri0\sl-200\slmult0 \fs16\cf3\f0\charscalex
100 {cause of bronchospasm should be considered early.}\par\pard\li0\ri0\sl-240\
slmult0 \*\tx213\fs20\cf3\f0\charscalex100 {N}\tab \fs16\cf3\f0\charscalex100 {T
hink of anaphylaxis or pulmonary oedema as alternative}\par\pard\li213\ri0\sl-20
0\slmult0 \fs16\cf3\f0\charscalex100 {diagnoses.}\par\pard\li0\ri0\sl-240\slmult
0 \*\tx213\fs20\cf3\f0\charscalex100 {N}\tab \fs16\cf3\f0\charscalex100 {Review
the patient\uc1\u8217Xs history, especially that which relates}\par\pard\li213\r
i0\sl-186\slmult0 \fs16\cf3\f0\charscalex100 {to respiratory disease.}\par\pard\
li0\ri0\sl-240\slmult0 \*\tx213\fs20\cf3\f0\charscalex100 {N}\tab \fs16\cf3\f0\c
harscalex100 {Review the anaesthetic for any drugs which may have}\par\pard\li21
3\ri0\sl-200\slmult0 \fs16\cf3\f0\charscalex100 {given rise to bronchospasm.}\pa
r\pard\li0\ri0\sl-240\slmult0 \*\tx213\fs20\cf3\f0\charscalex100 {N}\tab \fs16\c
f3\f0\charscalex100 {If the patient fails to respond to treatment as expected,}\
par\pard\li213\ri0\sl-200\slmult0 \fs14\cf3\f0\charscalex100 {think of the possi
bility of pulmonary oedema or pneumo-}\par\pard\li213\ri0\sl-200\slmult0 \fs16\c
f3\f0\charscalex100 {thorax.}\par\pard\li0\ri0\sl-240\slmult0 \*\tx213\fs20\cf3\
f0\charscalex100 {N}\tab \fs16\cf3\f0\charscalex100 {If wheeze or increased pulm
onary inflation pressures are}\par\pard\li213\ri0\sl-186\slmult0 \fs14\cf3\f0\ch
arscalex100 {accompanied by hypotension, consider the possibility of}\par\pard\l
i213\ri0\sl-200\slmult0 \fs16\cf3\f0\charscalex100 {anaphylaxis.}\par\pard\li0\r
i0\sl-213\slmult0 \fs18\cf0\par\pard\li0\ri0\sl-213\slmult0 \fs18\cf0\par\pard\l
i0\ri0\sl-213\slmult0 \fs18\cf3\f0\charscalex100 {CONCLUSION}\par\pard\li0\ri0\s
l-186\slmult0 \fs16\cf3\f0\charscalex100 {Perioperative bronchospasm may range i
n presentation from}\par\pard\li0\ri0\sl-200\slmult0 \fs16\cf3\f0\charscalex100
{complete silence on auscultation or a few quiet musical notes}\par\pard\li0\ri0
\sl-200\slmult0 \fs16\cf3\f0\charscalex100 {at the end of exhalation to loud dis
cordant expiratory noise.}\par\pard\li0\ri0\sl-200\slmult0 \fs16\cf3\f0\charscal
ex100 {Accompanying diagnostic signs may include a rise in}\par\pard\li0\ri0\sl186\slmult0 \fs16\cf3\f0\charscalex100 {pulmonary inflation pressure, falling ox
ygen saturation,}\par\pard\li0\ri0\sl-226\slmult0 \fs16\cf3\f0\charscalex100 {an
d a change in the slope of the end-tidal CO}{\sub \fs10\cf3\f0\charscalex100 {2}
}\fs16\cf3\f0\charscalex100 {trace. As}\par\pard\li0\ri0\sl-173\slmult0 \fs16\cf
3\f0\charscalex100 {such, these signs may be indicative of mild reactive airways
}\par\pard\li0\ri0\sl-213\slmult0 \fs16\cf3\f0\charscalex100 {disease, oesophage
al intubation, or a catastrophic anaphy-}\par\pard\li0\ri0\sl-186\slmult0 \fs16\
cf3\f0\charscalex100 {lactic reaction. Anaesthetists must therefore understand t
he}\par\pard\li0\ri0\sl-200\slmult0 \fs16\cf3\f0\charscalex100 {precipitating fa
ctors, recognise the presenting signs, and be}\par\pard\li0\ri0\sl-200\slmult0 \
fs16\cf3\f0\charscalex100 {prepared to undertake a logical plan of management. T
he}\par\pard\li0\ri0\sl-200\slmult0 \fs16\cf3\f0\charscalex100 {plan should not
only treat the problem and its pathophysio-}\par\pard\li0\ri0\sl-200\slmult0 \fs
16\cf3\f0\charscalex100 {logical consequences, but should also prompt the anaest
hetist}\par\pard\li0\ri0\sl-200\slmult0 \fs16\cf3\f0\charscalex100 {to re-review

the patient\uc1\u8217Xs evolving condition.}\par\pard\li173\ri0\sl-186\slmult0


\fs14\cf3\f0\charscalex100 {Finally, it is important that a full explanation of
what}\par\pard\li0\ri0\sl-200\slmult0 \fs16\cf3\f0\charscalex100 {happened be gi
ven to the patient, that the problem be clearly}\par\pard\li0\ri0\sl-200\slmult0
\fs16\cf3\f0\charscalex100 {documented in the anaesthetic record, and that the
patient}\par\pard\li0\ri0\sl-200\slmult0 \fs16\cf3\f0\charscalex100 {be given a
letter to warn future anaesthetists. If a particular}\par\pard\li0\ri0\sl-213\sl
mult0 \fs16\cf3\f0\charscalex100 {precipitating event was significant or a parti
cular action was}\par\pard\li0\ri0\sl-186\slmult0 \fs16\cf3\f0\charscalex100 {us
eful in resolving the crisis, this should be clearly explained}\par\pard\li0\ri0
\sl-200\slmult0 \fs16\cf3\f0\charscalex100 {and documented.}\par\pard\li0\ri0\sl
-413\slmult0 \fs18\cf3\f0\charscalex100 {ACKNOWLEDGEMENTS}\par\pard\li0\ri0\sl-1
60\slmult0 \fs14\cf3\f0\charscalex100 {The authors would like to thank all the a
naesthetists in Australia and}\par\pard\li0\ri0\sl-173\slmult0 \fs14\cf3\f0\char
scalex100 {New Zealand who contributed to the 4000 incident reports upon}\par\pa
rd\li0\ri0\sl-173\slmult0 \fs14\cf3\f0\charscalex100 {which this and the other 2
4 papers in the Crisis Management Series}\par\pard\li0\ri0\sl-173\slmult0 \fs14\
cf3\f0\charscalex100 {are based. The coordinators of the project also thank Liz
Brown for}\par\pard\li0\ri0\sl-186\slmult0 \fs14\cf3\f0\charscalex100 {preparing
the draft of the original Crisis Management Manual;}\par\pard\li0\ri0\sl-160\sl
mult0 \fs14\cf3\f0\charscalex100 {Loretta Smyth for typing; Monika Bullock RN fo
r earlier coding and}\par\pard\li0\ri0\sl-173\slmult0 \fs14\cf3\f0\charscalex100
{classifying of data; Dr Charles Bradfield for the electronic version of}\par\p
ard\li3586\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li3586\ri0\sl-213\slmult0 \fs18
\cf0\par\pard\li3586\ri0\sl-360\slmult0 \fs12\cf3\f0\charscalex100 {www.qshc.com
}\par\pard\sect\sectd\sbknone\pgwsxn12240\pghsxn15840\marglsxn666\margrsxn133\pa
rd\sect\sectd\sbkpage\pgwsxn12240\pghsxn15840\marglsxn666\margrsxn133\margtsxn13
3\margbsxn80\cols3\colno1\colw3466\colsr-0\colno2\colw4640\colsr-0\colno3\colw33
33\pard\li706\ri0\sl-360\slmult0 \fs14\cf3\f0\charscalex100 {6 of 6}\par\column\
pard\li0\ri0\sl-173\slmult0 \fs18\cf0\f1\charscalex100 {Downloaded from}{ }\fs14
\cf1\f1\charscalex100 {{\field{\*\fldinst{HYPERLINK "http://qshc.bmj.com"}}{\fld
rslt {qshc.bmj.com}}}}\fs18\cf0\f1\charscalex100 {{\field{\*\fldinst{HYPERLINK "
http://qshc.bmj.com"}}{\fldrslt { on }}}18 August 2008}\par\column\pard\li0\ri0\
sl-360\slmult0 \fs14\cf3\f0\charscalex100 {Westhorpe, Ludbrook, Helps}\par\pard\
sect\sectd\sbknone\pgwsxn12240\pghsxn15840\marglsxn666\margrsxn133\cols2\colno1\
colw5600\colsr-0\colno2\colw5840\pard\li706\ri0\sl-213\slmult0 \fs18\cf0\par\par
d\li706\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li706\ri0\sl-133\slmult0 \fs14\cf3
\f0\charscalex100 {the algorithms; Dr Klee Benveniste for literature research; a
nd Drs}\par\pard\li706\ri0\sl-186\slmult0 \fs12\cf3\f0\charscalex100 {Klee Benve
niste, Michal Kluger, John Williamson and Andrew Paix}\par\pard\li706\ri0\sl-160
\slmult0 \fs14\cf3\f0\charscalex100 {for editing and checking manuscripts.}\par\
pard\li706\ri0\sl-360\slmult0 \fs12\cf3\f0\charscalex100 {. . . . . . . . . . .
. . . . . . . . . .}\par\pard\li706\ri0\sl-240\slmult0 \fs18\cf3\f0\charscalex10
0 {Authors\uc1\u8217X affiliations}\par\pard\li706\ri0\sl-173\slmult0 \fs12\cf3\
f0\charscalex100 {R N Westhorpe,}{ }\fs12\cf3\f0\charscalex100 {Deputy Director,
Department of Paediatric Anaesthesia}\par\pard\li706\ri0\sl-173\slmult0 \fs14\c
f3\f0\charscalex100 {and Pain Management, Royal Children\uc1\u8217Xs Hospital, P
arkville, Victoria,}\par\pard\li706\ri0\sl-173\slmult0 \fs14\cf3\f0\charscalex10
0 {Australia}\par\pard\li706\ri0\sl-173\slmult0 \fs14\cf3\f0\charscalex100 {G L
Ludbrook,}{ }\fs14\cf3\f0\charscalex100 {Professor, Department of Anaesthesia an
d Intensive Care,}\par\pard\li706\ri0\sl-186\slmult0 \fs14\cf3\f0\charscalex100
{University of Adelaide and Royal Adelaide Hospital, Adelaide, South}\par\pard\l
i706\ri0\sl-173\slmult0 \fs14\cf3\f0\charscalex100 {Australia, Australia}\par\pa
rd\li706\ri0\sl-186\slmult0 \fs14\cf3\f0\charscalex100 {S C Helps,}{ }\fs14\cf3\
f0\charscalex100 {Department of Medical Biochemistry, School of Medicine,}\par\p
ard\li706\ri0\sl-173\slmult0 \fs14\cf3\f0\charscalex100 {Flinders University, Be
dford Park, South Australia, Australia}\par\pard\li706\ri0\sl-253\slmult0 \fs14\
cf3\f0\charscalex100 {This study was coordinated by the Australian Patient Safet
y Foundation,}\par\pard\li706\ri0\sl-186\slmult0 \fs14\cf3\f0\charscalex100 {GPO
Box 400, Adelaide, South Australia 5001, Australia.}\par\pard\li706\ri0\sl-213\

slmult0 \fs18\cf0\par\pard\li706\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li706\ri0


\sl-213\slmult0 \fs18\cf0\par\pard\li706\ri0\sl-213\slmult0 \fs18\cf0\par\pard\l
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\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li706\ri0\sl-213\slmult0 \fs18\cf0\par\pa
rd\li706\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li706\ri0\sl-213\slmult0 \fs18\cf
0\par\pard\li706\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li706\ri0\sl-213\slmult0
\fs18\cf0\par\pard\li706\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li706\ri0\sl-213\
slmult0 \fs18\cf0\par\pard\li706\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li706\ri0
\sl-213\slmult0 \fs18\cf0\par\pard\li706\ri0\sl-213\slmult0 \fs18\cf0\par\pard\l
i706\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li706\ri0\sl-213\slmult0 \fs18\cf0\pa
r\pard\li706\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li706\ri0\sl-213\slmult0 \fs1
8\cf0\par\pard\li706\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li706\ri0\sl-213\slmu
lt0 \fs18\cf0\par\pard\li706\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li706\ri0\sl213\slmult0 \fs18\cf0\par\pard\li706\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li706
\ri0\sl-333\slmult0 \fs14\cf3\f0\charscalex100 {www.qshc.com}\par\column\pard\li
0\ri0\sl-213\slmult0 \fs18\cf0\par\pard\li0\ri0\sl-400\slmult0 \fs18\cf3\f0\char
scalex100 {REFERENCES}\par\pard\li66\ri0\sl-160\slmult0 \*\tx226\fs12\cf3\f0\cha
rscalex100 {1}\tab \fs12\cf3\f0\charscalex100 {Currie M}\fs12\cf3\f0\charscalex1
00 {, Kerridge R, Bacon AK,}{ }\fs12\cf3\f0\charscalex100 {et al.}{ }\fs12\cf3\f
0\charscalex100 {Crisis management during}\par\pard\li226\ri0\sl-146\slmult0 \fs
12\cf3\f0\charscalex100 {anaesthesia: anaphylaxis and allergy.}{ }\fs12\cf3\f0\c
harscalex100 {Qual Saf Health Care}{ }\fs12\cf3\f0\charscalex100 {2005;}\fs12\cf
3\f0\charscalex100 {14}\fs12\cf3\f0\charscalex100 {:e19.}\par\pard\li66\ri0\sl-1
60\slmult0 \*\tx226\fs12\cf3\f0\charscalex100 {2}\tab \fs12\cf3\f0\charscalex100
{Runciman WB}\fs12\cf3\f0\charscalex100 {, Webb RK, Klepper ID,}{ }\fs12\cf3\f0
\charscalex100 {et al.}{ }\fs12\cf3\f0\charscalex100 {Crisis management: validat
ion of}\par\pard\li226\ri0\sl-146\slmult0 \fs12\cf3\f0\charscalex100 {an algorit
hm by analysis of 2000 incident reports.}{ }\fs12\cf3\f0\charscalex100 {Anaesth
Intensive Care}\par\pard\li226\ri0\sl-146\slmult0 \fs12\cf3\f0\charscalex100 {19
93;}\fs12\cf3\f0\charscalex100 {21}\fs12\cf3\f0\charscalex100 {:579\uc1\u8211X92
.}\par\pard\li66\ri0\sl-160\slmult0 \*\tx226\fs12\cf3\f0\charscalex100 {3}\tab \
fs12\cf3\f0\charscalex100 {Webb RK}\fs12\cf3\f0\charscalex100 {, Currie M, Morga
n CA,}{ }\fs12\cf3\f0\charscalex100 {et al.}{ }\fs12\cf3\f0\charscalex100 {The A
ustralian Incident Monitoring}\par\pard\li226\ri0\sl-146\slmult0 \fs12\cf3\f0\ch
arscalex100 {Study: an analysis of 2000 incident reports.}{ }\fs12\cf3\f0\charsc
alex100 {Anaesth Intensive Care}\par\pard\li226\ri0\sl-146\slmult0 \fs12\cf3\f0\
charscalex100 {1993;}\fs12\cf3\f0\charscalex100 {21}\fs12\cf3\f0\charscalex100 {
:520\uc1\u8211X8.}\par\pard\li66\ri0\sl-173\slmult0 \*\tx226\fs12\cf3\f0\charsca
lex100 {4}\tab \fs12\cf3\f0\charscalex100 {Webb RK}\fs12\cf3\f0\charscalex100 {,
van der Walt JH, Runciman WB,}{ }\fs12\cf3\f0\charscalex100 {et al.}{ }\fs12\cf
3\f0\charscalex100 {Which monitor}\fs12\cf3\f0\charscalex100 {?}\par\pard\li226\
ri0\sl-146\slmult0 \fs12\cf3\f0\charscalex100 {An analysis of 2000 incident repo
rts.}{ }\fs12\cf3\f0\charscalex100 {Anaesth Intensive Care}\par\pard\li226\ri0\s
l-160\slmult0 \fs12\cf3\f0\charscalex100 {1993;}\fs12\cf3\f0\charscalex100 {21}\
fs12\cf3\f0\charscalex100 {:529\uc1\u8211X42.}\par\pard\li66\ri0\sl-146\slmult0

\*\tx226\fs12\cf3\f0\charscalex100 {5}\tab \fs12\cf3\f0\charscalex100 {Runciman


WB}\fs12\cf3\f0\charscalex100 {, Kluger MT, Morris RW,}{ }\fs12\cf3\f0\charscale
x100 {et al.}{ }\fs12\cf3\f0\charscalex100 {Crisis management during}\par\pard\l
i226\ri0\sl-146\slmult0 \fs12\cf3\f0\charscalex100 {anaesthesia: the development
of an anaesthetic crisis management manual.}\par\pard\li226\ri0\sl-160\slmult0
\fs12\cf3\f0\charscalex100 {Qual Saf Health Care}{ }\fs12\cf3\f0\charscalex100 {
2005;}\fs12\cf3\f0\charscalex100 {14}\fs12\cf3\f0\charscalex100 {:e1.}\par\pard\
li66\ri0\sl-146\slmult0 \*\tx226\fs12\cf3\f0\charscalex100 {6}\tab \fs12\cf3\f0\
charscalex100 {Australian Patient Safety Foundation}\fs12\cf3\f0\charscalex100 {
.}{ }\fs12\cf3\f0\charscalex100 {Crisis Management Manual: COVER}\par\pard\li226
\ri0\sl-146\slmult0 \fs12\cf3\f0\charscalex100 {ABCD A SWIFT CHECK}\fs12\cf3\f0\
charscalex100 {. Adelaide: Australian Patient Safety Foundation,}\par\pard\li226
\ri0\sl-146\slmult0 \fs12\cf3\f0\charscalex100 {1996, 74 pp. Available at http:/
/www.apsf.net.au/anaesthesia.htm}\par\pard\li226\ri0\sl-146\slmult0 \fs12\cf3\f0
\charscalex100 {(accessed 6 September 2004).}\par}