Atracurium-Induced Bronchospasm With Flat Capnograph at Induction of General Anaesthesia: A Case Report

Benzylisoquinolinium neuromuscular blocking agents can precipitate bronchospasm either through allergy/anaphylaxis or isolated stimulation of mast cell histamine release. This report presents a 75-year-old female who attended the day surgery unit for a rigid cystoscopy under general anaesthesia. She had a hyperreactive airway history of mild historic asthma and sensitivity to aerosols. After administration of atracurium at induction of anaesthesia, ventilation became challenging with no chest rise and a flat CO2 trace. Repeat video laryngoscopy confirmed correct endotracheal tube position. The patient remained cardiovascularly stable with no mucocutaneous signs of anaphylaxis. Administration of high flow oxygen, sevoflurane, salbutamol and magnesium sulfate led to gradual improvement and normalisation of respiratory parameters. Surgery was postponed. This report highlights atracurium as an important trigger of bronchospasm at induction of anaesthesia, and illustrates that in rare cases a flat capnograph does not always indicate a mispositioned airway device. Several aspects of the anaesthetic plan for this patient were suboptimal given her respiratory history, namely, the choice of mode of anaesthesia and choice of neuromuscular blocking agent. These factors are discussed in the context of anaesthetic planning for patients presenting with features suggesting high bronchospastic risk.