Occurrence bilateral bronchospasm consequently after unilateral bronchospasm

provided the original work is properly cited. CC Patients, especially pediatric patients, with a recent history of an upper respiratory tract infection (URI) are at a significantly increased risk for the development of intraoperative airway complications due to airway hyperreactivity. For these patients, the incidence for bronchospasm can be 10 times the incidence for those patients who did not have recent URI [1]. We have managed a case of bilateral bronchospasm after unilateral bronchospasm that was not reported until now. A 5-year-old, 18.65 kg, 87 cm female patient was scheduled for Hotz’s operation for an entropion. During preoperative evaluation, her parents did report a history of URI symptoms 2 weeks prior to the visit. However, child appeared healthy without significant physical exam findings besides clear rhinorrhea. All of the preoperative laboratory studies were within normal ranges. Thus, the operation was scheduled without delay. After the induction of anesthesia with thiopental 5 mg/kg, rocuronium 0.6 mg/kg was administered for endotracheal intubation. A 5 mm cuffed endotracheal tube (ETT) was placed 15 cm away from the incisor. Upon ascultation, the left respiratory sounds were normal, but the right respiratory sounds were markedly decreased. A left endobronchial intubation was suspected, and the ETT was withdrawn by 1 cm. The accuracy of tube positioning was re-evaluated by auscultation several times. General anesthesia was maintained using 50% oxygennitrous oxide mixture and sevoflurane (1.5-3.0 vol%) according to blood pressure and heart rate under volume controlled ventilation. The peak inspiratory pressure (PIP) was 14 mmHg, and the end tidal carbon dioxide concentrations (ETCO2) were between 30 and 35 mmHg. The vital signs remained stable. At the end of surgery, sevoflurane and nitrous oxide administration was discontinued. Within 3 min of this, the SpO2 decreased to 90% with a high PIP (28 mmHg). On auscultation, the left respiratory sounds were markedly decreased with a slight wheeze. Under the suspicion of a blocked tube, ETT was gently suctioned, but no secretion or blood was aspirated. Subsequently, an inadvertent right bronchus intubation was suspected from head movements during the operation, and the tube was withdrawn in stepwise increments while lung fields were auscultated. During this process, the tube was unintentionally extubated out of the trachea, and the patient was reintubated after mask ventilation using 100% oxygen and sevoflurane (3.0-5.0 vol%). The tracheal tube position was confirmed by fiberoptic bronchoscopy. Approximately 10 minutes after intravenous administration of hydrocortisone 50 mg, the SpO2 improved to 99%, and the PIP decreased to 15 mmHg with clear breath sound in both lung fields. Sevoflurane was discontinued again. After an additional 10 minutes, the SpO2 gradually dropped to under 70% with marked decreases in tidal volume. Again, wheezing was heard in both lung fields. Because of this, the patient was manually ventilated with 100% O2 and sevoflurane (3.0 vol%), with the PIP measurements over 35 cmH2O at this point. Two puffs of ventolin (albuterol) from a metered dose inhaler were discharged down the ETT, and intravenous atropine 0.1 mg was administered. With the bronchodilation therapy, SpO2 returned to 99%, while PIP gradually decreased under 20 mmHg. The wheezing disappeared and the tidal volume increased near to the initial levels. A chest X-ray did not reveal any specific pulmonary changes with the end of ETT positioned 1.0 cm above