Anaesthetic management in asthma
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MINERVA MEDICA COPYRIGHT®
MINERVA ANESTESIOL 2007;73:357-65
R EV I EW A RT I C L E
Anaesthetic management in asthma
S. M. BURBURAN 1, 2, D. G. XISTO 2, P. R. M. ROCCO 2
1Division of Anaesthesiology, Department of Surgery, Faculty of Medicine, Federal University of Rio de Janeiro, Rio de Janeiro,
Brazil; 2Laboratory of Pulmonary Investigation Carlos Chagas Filho Biophysics Institute, Federal University of Rio de
Janeiro, Rio de Janeiro, Brazil
ABSTRACT
Anaesthetic management in asthmatic patients has been focused on avoiding bronchoconstriction and inducing bron-
chodilation. However, the definition of asthma has changed over the past decade. Asthma has been defined as a clin-
ical syndrome characterized by an inflammatory process that extends beyond the central airways to the distal airways
and lung parenchyma. With this concept in mind, and knowing that asthma is a common disorder with increasing preva-
lence rates and severity worldwide, a rational choice of anaesthetic agents and procedures is mandatory. Thus, we pur-
sued an update on the pharmacologic and technical anaesthetic approach for the asthmatic patient. When feasible, region-
al anaesthesia should be preferred because it reduces airway irritation and postoperative complications. If general
anaesthesia is unavoidable, a laryngeal mask airway is safer than endotracheal intubation. Lidocaine inhalation, alone
or combined with albuterol, minimizes histamine-induced bronchoconstriction. Propofol and ketamine inhibit bron-
choconstriction, decreasing the risk of bronchospasm during anaesthesia induction. Propofol yields central airway
dilation and is more reliable than etomidate or thiopental. Halothane, enflurane, and isoflurane are potent bron-
chodilators and can be helpful even in status asthmaticus. Sevoflurane has shown controversial results in asthmatic
patients. Vecuronium, rocuronium, cisatracurium, and pancuronium do not induce bronchospasm, while atracurium
and mivacurium can dose-dependently release histamine and should be cautiously administered in those patients.
Further knowledge about the sites of action of anaesthetic agents in the lung, allied with our understanding of asth-
ma pathophysiology, will establish the best anaesthetic approach for people with asthma.
Key words: Asthma - Anaesthesia - Anaesthetics - Bronchial spasm - Bronchial hypereactivity.
A sthma is a major public health issue with high
and increasing prevalence rates 1 and a con-
comitant increase in morbidity and mortality.2
The pathophysiological hallmark of asthma is a
reduction in airway diameter due to the contrac-
tion of smooth muscle, vascular congestion, oede-
Studies have shown that the lifetime prevalence of ma of the bronchial wall, and tenacious secretions.5
asthma among adults is 11%,3 and it is even high- The chronic inflammatory process leads to tissue
er among children.4 These data contribute to make injury and subsequent reorganization. The term
challenging adverse events due to asthma a wide- “airway remodelling” is widely used to refer to the
spread situation in anaesthesiological practice. development of those structural changes,6, 7 such
Therefore, in order to avoid increasing the risk as: epithelial shedding, subepithelial fibrosis,
of perioperative complications, a good understand- increased numbers and volume of mucous cells in
ing of asthma pathophysiology, an adequate pre- the epithelium, airway smooth muscle hyperpla-
operative evaluation, and optimisation of the sia and hypertrophy, and increased vascularization
patient’s condition, allied with the best pharmaco- of the airway wall.8 These changes in the extracel-
logical and technical approach, are imperative. lular matrix, smooth muscle, and mucous glands
Vol. 73 - No. 6 MINERVA ANESTESIOLOGICA 357MINERVA MEDICA COPYRIGHT®
BURBURAN ANAESTHETIC MANAGEMENT IN ASTHMA
have the capacity to influence airway function and patient’s pulmonary function. Warner et al.15
reactivity in asthmatic patients manifested by a observed that the frequency of perioperative bron-
decline in forced expiratory volume in 1 s (FEV1) chospasm and laryngospasm was surprisingly low
and bronchial hyper-responsiveness.9 in asthmatic patients. They identified 3 factors
Bronchospasm and mucous plugging obstruct correlated with perioperative bronchospasm: the
both inspiratory and expiratory airflow. Resistance use of antibronchospastic medications; recent
to expiratory airflow results in positive alveolar symptomatic exacerbation; and recent visit to a
pressures at the end of expiration, which causes medical facility for treatment of asthma. Therefore,
air-trapping and hyperinflation of the lungs and they reached the following conclusions: 1) per-
thorax, increased work of breathing, and alter- sons with asthma but no symptoms are at low risk
ations in respiratory muscle function. Airflow for severe morbidity from anaesthesia; 2) persons
obstruction is not uniform, and the mismatching with asthma are, however, at a low but increased
of ventilation to perfusion occurs, leading to risk for severe morbidity; and 3) adverse outcomes
changes in arterial blood gases.10, 11 from bronchospasm occur in patients with no pre-
The definition of asthma has changed over the vious history of asthma.16
past decade. Asthma has been defined as a clinical In view of this, the approach to the asthmatic
syndrome characterized by an inflammatory process patient should include a detailed history of the
that extends beyond the central airways to the dis- patient’s experience with reactive airway disease,
tal airways and the lung parenchyma. Small airways searching for the following: 1) a recent upper res-
have recently been recognized as a site of airflow piratory infection; 2) allergies; 3) possible precip-
obstruction and hyper-responsiveness.12-14 itating factors for asthma; 4) use of medications,
In view of these new pathophysiological find- including drugs that could precipitate the attack,
ings, we attempted this review to outline available as well as those used to prevent an attack; and 5)
data and the criteria for the anaesthetic manage- the occurrence of dyspnoea at night or in the ear-
ment in asthmatic patients. ly morning hours. Furthermore, to better under-
stand a patient’s bronchial reactivity, it is impor-
Methods tant to know whether he or she can tolerate cold
air, dust, or smoke and if he or she has ever under-
A computerized search of the English-language gone tracheal intubation under general anaesthe-
literature of PUBMED between 1995 and 2005 sia.17 Documentation of an episode of status asth-
was conducted using the terms airway obstruction, maticus requiring intubation portends of a diffi-
asthma, bronchial hyper-reactivity, anaesthesia, and cult perioperative course.10
anaesthetics. Various combinations of the terms Drugs are commonly associated with the induc-
were used to maximize the results. Bibliographies of tion of acute episodes of asthma, and it is impor-
original research, commentaries, textbooks, and tant to recognize drug-induced bronchial narrow-
symposia were reviewed for additional relevant ref- ing because its presence is often associated with
erences. These publications were abstracted and great morbidity. Even the selective β1-adrenergic
compiled into tabular form under types of study antagonists regularly obstruct the airways in indi-
design. Two-hundred twenty-two articles were select- viduals with asthma and should be avoided.5
ed for critical review. Of the articles excluded, most
The triad of bronchial asthma, nasal polyposis,
were reports that described anaphylactic reactions,
and intolerance to aspirin or aspirin-like chemicals
bronchial hyper-responsiveness, and bronchospasm
is designated aspirin-induced asthma (AIA) or
in nonasthmatic patients.
Samter’s syndrome. In these patients, marked cross-
sensitivity with nonsteroidal anti-inflammatory
Anaesthetic management strategy drugs may precipitate severe bronchospasm and
adverse reactions. Hence, it is important to refer
Preoperative evaluation these patients to allergy clinics to evaluate possible
The anaesthesiologist’s responsibility starts at analgesic cross reactivity and intolerance to anaes-
the preoperative phase with the evaluation of the thetic agents.18
358 MINERVA ANESTESIOLOGICA June 2007MINERVA MEDICA COPYRIGHT® ANAESTHETIC MANAGEMENT IN ASTHMA BURBURAN Physical examination of the lungs may be nor- ment in asthmatics should include the following mal or reveal wheezing and/or other adventitial measures: sounds. Preoperative wheezing is predictive of a 1. bronchospasm should be treated with inhaled difficult perioperative course. Indeed, if a severe β2-agonists; asthmatic history and auscultatory wheezing are 2. if a patient is at risk for complications, pre- encountered during the initial screening, a con- operative treatment with 40-60 mg of pred- sultation with the pulmonologist may be recom- nisone/day or hydrocortisone 100 mg every 8 h mended. In severe cases of asthma, laboratory stud- intravenously is suggested. Anyone with a preop- ies such as arterial blood gases and pulmonary erative FEV1
MINERVA MEDICA COPYRIGHT®
BURBURAN ANAESTHETIC MANAGEMENT IN ASTHMA
vascular permeability, bronchial smooth muscle and do not alter bronchial tone.17 In this context,
constriction, and local vasodilatation.27 The anaes- Kil et al.31 noticed that oral midazolam (0.5 mg/kg)
thesiologists’ goal should be to minimize the risk did not change oxygen saturation, respiratory rate,
of inciting bronchospasm and to avoid triggering and pulse rate in children with mild to moderate
stimuli. asthma undergoing dental treatment. Hence, mida-
The effect of endotracheal intubation, even in zolam at a dose of 0.5 mg/kg is a safe and effective
symptom-free asthmatics, was demonstrated by means for sedation of patients with mild to mod-
Groeben et al.28 in a randomized double-blind erate asthma.
fashion study of 10 volunteers with mild asthma
who underwent endotracheal intubation under INHALATIONAL ANAESTHETICS
local anaesthesia. They performed lung function
tests before and after intubation and observed over Inhalational agents possess bronchodilatory
a 50% reduction in FEV1 after the procedure. effects, decrease airway responsiveness, and atten-
However, after prophylactic administration of a uate histamine-induced bronchospasm.10 The
β2-adrenergic agonist and topical lidocaine, the mechanism is thought to be β-adrenergic receptor
reduction in FEV1 was lower (20%). stimulation leading to increased intracellular cyclic-
In summary, it is preferable to avoid airway AMP. This has a direct bronchial muscle relaxing
instrumentation in asthmatic patients, and region- effect. Increased cAMP may bind free calcium
al anaesthesia should always be considered for this within bronchial myoplasm and cause relaxation
purpose, as well as for reducing postoperative com- by negative feedback. It may impede antigen-anti-
plications.17 body mediated enzyme production and the release
Pregnancy can adversely affect the course of of histamine from leukocytes as well.11
asthma, increasing perioperative risk in these For all these reasons, volatile agents such as
patients. For this reason, regional anaesthesia is halothane and isoflurane have been recommend-
the technique of choice for pregnant asthmatics ed for general anaesthetic techniques in patients
and parturients, especially if prostaglandins and with obstructive airway diseases for many years,
their derivates are administered for abortion or and they are even helpful to treat status asthmati-
operative delivery.20, 29 cus. An exception should be made for desflurane,
When regional anaesthesia is not feasible and which can lead to increased secretions, coughing,
general anaesthesia is required, prophylactic antiob- laryngospasm, and bronchospasm.32
structive treatment, volatile anaesthetics, propofol, Thus far, studies using sevoflurane have shown
opioids, and an adequate choice of muscle relax- controversial results. Rooke et al.33 compared the
ants minimize the anaesthetic risk.17 In addition to bronchodilating efficacy of sevoflurane, isoflu-
this, the use of face masks and laryngeal mask air- rane, and halothane after tracheal intubation in
ways have been reported to cause less airway irri- patients without asthma. In their study, halothane
tation. Kim and Bishop 30 randomized 52 nonasth- was not significantly better than isoflurane at
matic patients to receive an endotracheal tube or reducing Rrs. Nonetheless, sevoflurane decreased
a laryngeal mask airway under general anaesthesia; Rrs more than either halothane or isoflurane.
they observed that respiratory system resistance Habre et al.34 studied lung function in children
(Rrs) was lower in patients receiving laryngeal with and without asthma receiving anaesthesia
mask airways than in those submitted to endotra- with sevoflurane and concluded that, in children
cheal intubation. This result supports the idea that with mild to moderate asthma, endotracheal intu-
use of a laryngeal mask might be a more reliable bation during sevoflurane anaesthesia was associ-
alternative than endotracheal intubation. ated with an increase in Rrs that was not seen in
nonasthmatic children. In spite of this, no appar-
ent clinical adverse event was observed, and accord-
PREMEDICATION
ing to the Scalfaro et al. study,35 a pre-anaesthet-
Adequate sedation of the patient should be ic treatment with inhaled salbutamol adminis-
achieved in order to avoid perioperative complica- tered before sevoflurane anaesthesia can prevent
tions. For this purpose, benzodiazepines are safe that increase of Rrs.
360 MINERVA ANESTESIOLOGICA June 2007MINERVA MEDICA COPYRIGHT®
ANAESTHETIC MANAGEMENT IN ASTHMA BURBURAN
Correa et al.36 analysed the respiratory mechan- mined by an inhibition of neurally-induced bron-
ics and lung histology in normal rats anaesthetised choconstriction.
with sevoflurane. They observed that sevoflurane Propofol, a widely used short-acting i.v. anaes-
anaesthesia did not act at the airway level but at the thetic, has been associated with less bronchocon-
lung periphery, stiffening lung tissues and increas- striction during anaesthetic induction than other
ing mechanical inhomogeneities. In addition, anaesthetic agents.42 In vitro data suggest that
Takala et al.37 evaluated pulmonary inflammato- propofol has a direct airway smooth muscle relax-
ry mediators in bronchoalveolar lavage fluid after ant action.43 Pizov et al.44 in a randomized con-
sevoflurane anaesthesia in pigs and reported that trolled clinical trial evaluated the incidence of
sevoflurane increased pulmonary leukotriene C4, wheezing in asymptomatic asthmatic and nonasth-
NO3-, and NO2- production, suggesting an matic patients receiving i.v. anaesthetic agents for
inflammatory response. induction of anaesthesia. They observed that both
asthmatic and nonasthmatic patients who received
INTRAVENOUS ANAESTHETICS a thiobarbiturate for induction had a greater inci-
dence of wheezing than did patients receiving
Ketamine is an i.v. general anaesthetic that is
considered an attractive choice because of its sym- propofol. Similarly, Eames et al.45 assessed Rrs in
pathomimetic bronchodilatory properties and its a nonasthmatic patient population with a high
effectiveness at preventing and reversing wheezing incidence of smoking and compared thiopental,
in patients with asthma who require anaesthesia etomidate, and propofol. They observed that tra-
and intubation.38 Ketamine relaxes the bronchi- cheal intubation with propofol anaesthesia pro-
olar musculature and prevents the bronchocon- duced a lower Rrs than when thiopental or a rel-
striction induced by histamine, decreasing the atively high dose of etomidate was used. To com-
risk of bronchospasm during the induction of pare the effects of propofol anaesthesia in children
anaesthesia. These effects derive from a direct with and without asthma, Habre et al.46 induced
action on bronchial muscle as well as a potentia- anaesthesia with propofol, fentanyl, and atracuri-
tion of catecholamines. Nonetheless, ketamine um and maintained with an infusion of propofol
increases bronchial secretions and it is usual to and 50% nitrous oxide in oxygen. Final results
administer an anticholinergic agent such as showed that respiratory mechanics were not altered
atropine or glycopyrrolate in conjunction. by propofol anaesthesia in children both with and
Hallucinations are the most unpleasant side effect without asthma. In this context, Peratoner et al.47
of ketamine and can be minimized with concomi- analysed the effects of propofol on respiratory
tant sedation with benzodiazepines.10 However, its mechanics in normal rats and correlated these
effectiveness has not been demonstrated in a con- parameters with lung histology, to define the sites
trolled trial.39, 40 Although previous studies of action of propofol. They observed that propo-
analysed the effects of ketamine on central air- fol acts at the airway level, decreasing respiratory
ways, Alves-Neto et al.41 observed in rats without system and lung impedances as a result of central
pre-existing airway constriction that ketamine airway dilation.
acted not at the airway level but at the lung periph- On the basis of the aforementioned, propofol
ery, increasing mechanical inhomogeneities, which is considered safe for patients with asthma who
may result from dilation of distal airways and require timely intubation. Nevertheless,
alveolar collapse. Nishiyama and Hanaoka 48 reported 2 cases of
Brown and Wagner 38 examined the local air- bronchoconstriction following propofol induc-
way effects of ketamine and propofol on attenuat- tion. Both patients had allergic problems, and it
ing direct and reflex-induced airway constriction. was postulated that it was the particular formula-
They developed a nonasthmatic animal model in tion of propofol which contained yolk lecithin
which they administered ketamine and propofol and soybean oil that caused the problem.
directly to the airways via the bronchial artery and Accordingly, propofol should be used with caution
concluded that the major mechanism of bron- in patients with allergic disease or drug-induced
choprotection of ketamine and propofol is deter- asthma.
Vol. 73 - No. 6 MINERVA ANESTESIOLOGICA 361MINERVA MEDICA COPYRIGHT®
BURBURAN ANAESTHETIC MANAGEMENT IN ASTHMA
OPIOIDS choconstriction and can be used to attenuate the
response to airway irritations like endotracheal suc-
Although opioids could release histamine, they
are considered safe for patients with increased tion or intubation. Groeben et al.51 demonstrated
bronchial reactivity. Fentanyl and its analogues that, in awake humans, both i.v. lidocaine and
are frequently used in the induction of anaesthe- inhaled albuterol significantly increased the hista-
sia, and they can lead to thorax rigidity that can be mine threshold when given alone. They recom-
misinterpreted as bronchospasm. With slow injec- mended preoperative treatment with inhaled
tion, this effect is hardly observed. albuterol and i.v. lidocaine to prevent reflex bron-
Moreover, the suppression of the cough reflex chospasm with tracheal intubation. Alternatively,
and the deepening of anaesthesia level achieved Maslow et al.22 studied 60 asthmatic patients and
after opioid administration can be helpful in asth- found that inhaled albuterol attenuated the airway
matic patients.17 response to tracheal intubation in asthmatic
patients, while i.v. lidocaine did not.
Inhalation of lidocaine can attenuate the
MUSCLE RELAXANTS
response to airway irritation with plasma concen-
Depending on which type of muscarinic receptor trations lower than those following systemic
is stimulated, increased or decreased bronchial tone administration.17 Nevertheless, the attenuation of
and reactivity can be expected. It has been shown bronchial reactivity is preceded by a mild airway
that muscle relaxants which affect M2 receptors more irritation 52, 53 that can be avoided with pretreat-
than M3 receptors (gallamin, pipecuronium, ment with a β2-adrenergic agonist or minimized by
rapacuronium) can cause and enhance bronchocon- using lidocaine inhalation in a dose of 2 mg/kg as
striction.49 Otherwise, muscle relaxants which seem a 4% solution for topical anaesthesia.50 This is the
to bind M3 receptors more or at least the same way regimen that attenuates bronchial hyper-reactivi-
as M2 receptors do not induce bronchospasm. ty with the least airway irritation.54 In addition,
Among those, vecuronium, rocuronium, cisatracuri- Hunt et al.55 recruited 50 subjects with mild to
um, and pancuronium are considered safe.11 moderate asthma to receive either an inhaled place-
In addition to these direct effects on muscarinic bo or inhaled lidocaine 4% for 8 weeks. Their
receptors, atracurium and mivacurium dose- results showed that nebulized lidocaine was an
dependently release histamine and have been iden- effective therapy in those patients.
tified as triggers of bronchoconstriction and should Moreover, local anaesthetics, absorbed from the
be used carefully in asthmatic patients.17 epidural space to the blood, attenuate bronchial
Furthermore, the reversal of muscle relaxation hyper-reactivity to chemical stimuli. Shono et al.56
at the end of surgery should be avoided since reported a case of a man with bronchial asthma
neostigmine and physostigmine cause bradycar- under continuous epidural anaesthesia with 2%
dia, increased secretion, and bronchial hyper-reac- lidocaine in which wheezing gradually diminished
tivity. For this purpose, doses of muscle relaxants after the epidural injection and completely disap-
should be timed so as to be worn off at the end of peared over 155 min during continuous epidural
surgery.11 injection of lidocaine. Wheezing reappeared 55
min after termination of the continuous epidural
LOCAL ANAESTHETICS injection of lidocaine. This corroborates the
Local anaesthetics of the amide type that atten- hypothesis that regional anaesthesia in asthmatic
uate and even block afferent and efferent nerve patients, alone or in combination with general
conduction of autonomic nerve fibres and auto- anaesthesia, is advantageous.
nomic reflexes, such as the coughing or bron-
choconstriction reflex, can be suppressed with plas- Treatment of intraoperative bronchospasm
ma concentrations of lidocaine below the toxic
threshold of 5 mg/mL.50 In asthmatic volunteers, If intraoperative wheezing should develop, non-
i.v. lidocaine doses of 1-2 mg/kg of body weight bronchospastic causes of wheezing (mechanical
significantly attenuated histamine-induced bron- obstruction of the endotracheal tube, endo-
362 MINERVA ANESTESIOLOGICA June 2007MINERVA MEDICA COPYRIGHT®
ANAESTHETIC MANAGEMENT IN ASTHMA BURBURAN
bronchial intubation, pulmonary aspiration, pul- relieved by usual therapy in 30 to 60 min. The
monary embolism, pulmonary oedema, tension term refractory status asthmaticus describes those
pneumothorax, and negative pressure inspiration) cases in which the patient’s condition continues
must be ruled out.19 The first step is to deepen the to deteriorate despite aggressive pharmacologic
level of anaesthesia via the i.v. or inhalational route interventions and persists for more than 24 h.10
or both. Administration of 100% oxygen should When conventional bronchodilators fail, the
be instituted to prevent hypoxemia. intensivist may resort to the use of drugs such as
β2-agonists via metered dose inhaler should be ketamine and inhalation anaesthesia. In this con-
administered through the airway. It is important text, deep sedation is important not only to
to consider the fact that delivery of aerosolized improve oxygenation but also to reduce cerebral
agents during mechanical ventilation is not ade- metabolic requirements.57
quate, being estimated that as little as 1% to 3% of Therapy with inhalational anaesthetic agents
a dose of nebulized medication actually reaches the such as halothane, enflurane, isoflurane, and
lungs of a patient on positive pressure ventilation. diethyl ether has been successfully used in the
The amount of aerosol reaching the lungs could management of refractory status asthmaticus.10, 58
be improved by means of an increase in respirato- Iwaku et al.59 treated patients with status asthmati-
ry time, a reduction of respiratory rate, an increase cus with isoflurane inhalation and observed that
in the volume of nebulizer fill, and positioning of tidal volume, pH, and PaCO2 improved after
the nebulizer between the Y-piece and catheter anaesthesia and that these patients stayed in the
mount or on the inspiratory limb of the ventila- Intensive Care Unit (ICU) and underwent
tor circuit Y-piece when jet nebulizers are used.27 mechanical ventilation for a shorter period than
Epinephrine, either subcutaneously or intra- those who were not treated with isoflurane.
venously, can help in severely bronchospastic Que and Lusaya 60 successfully used sevoflu-
patients. Corticosteroids can be utilized, but their rane inhalation in a parturient in status asthmati-
onset of action takes place within 4 to 8 h of cus for caesarean section. Schultz 61 reported the use
administration.27 of sevoflurane in a 26-year-old woman who pre-
Leukotriene receptor antagonists and mast cell sented to a rural critical access hospital emergency
inhibitors have no use in acute bronchospasm. department in status asthmaticus and subsequent-
Intravenous aminophylline can be started, but side ly failed conventional therapy. Sevoflurane was
effects such as tachycardia and hypertension may administered for approximately 150 min, stabi-
limit its usefulness. As a result, methylxantines are lizing the patient’s condition enough to allow fixed-
no longer recommended for acute exacerbations. wing air transport to a tertiary facility. Likewise,
A smooth, slow emergence minimizes the risk Mazzeo et al.57 reported an 8-year-old boy treated
of bronchospasm. Deep extubation can be attempt- with ketamine and sevoflurane and observed no
ed if no airway difficulties were encountered dur- episode of haemodynamic instability despite severe
ing induction. If deep extubation is contraindi- prolonged hypercapnia. Oxygenation was main-
cated, the patient may be taken to the postanesthe- tained and successful recovery followed without
sia care unit intubated and opioids administered sequelae.
to facilitate tolerance to the endotracheal tube.
When the patient is awake and possesses appro-
priate airway reflexes, extubation can occur. Conclusions
Intravenous lidocaine may be of use in prevent- Some anaesthetics have been used even for
ing bronchospasm with extubation.19 intractable status asthmaticus. Despite this, and
the fact that the understanding of the pathophys-
Inhalation anaesthesia in status asthmaticus iology of asthma has changed, there are only a few
studies describing the sites and mechanisms of
Status asthmaticus refers to acute asthma attacks action of our frequently used anaesthetic agents
in which the degree of bronchial obstruction is in a chronically inflamed, hyper-responsive, and
either severe from the onset or worsens and is not remodelled lung, as seen in asthmatic patients.
Vol. 73 - No. 6 MINERVA ANESTESIOLOGICA 363MINERVA MEDICA COPYRIGHT®
BURBURAN ANAESTHETIC MANAGEMENT IN ASTHMA
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Supported by The Centres of Excellence Program (PRONEX-FAPERJ), Brazilian Council for Scientific and Technological Development (CNPq),
Carlos Chagas Filho Rio de Janeiro State Research Supporting Foundation (FAPERJ).
Acknowledgments.—The authors would like to express their gratitude to A. Benedito da Silva and S. Cezar da Silva Junior for their techni-
cal assistance.
Received January 26. 2006 - Accepted for publication October 24, 2006.
Address reprint requests to: P. R. M. Rocco, MD, PhD, Laboratório de Investigação Pulmonar, Instituto de Biofísica Carlos Chagas Filho,
C.C.S., Universidade Federal do Rio de Janeiro, Ilha do Fundão. CEP. 21.949-900 – Rio de Janeiro, RJ, Brazil. E-mail: prmrocco@biof.ufrj.br
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