Anesth Analg 2002;94:1045
© 2002 International Anesthesia Research Society
LETTERS TO THE EDITOR
Propofol-Induced Bronchoconstriction: Asthma or Allergy?
David L. Hepner, MD
Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA
To the editor: I read with interest the case reports by Nishiyama and Hanaoka (1) on propofol-induced bronchoconstriction. Propofol is not only safe for asthmatic patients, but also may be the drug of choice for induction of anesthesia in patients with a history of asthma without active symptoms (2–4). Propofol decreases respiratory resistance and may prevent bronchospasm that can result from airway instrumentation. However, propofol is more likely than other drugs used for induction of anesthesia to cause an allergic reaction, and 1.2% of cases of perioperative anaphylactic shock in France were attributable to propofol (5). The largest report of allergic reactions to propofol contains a total of 14 patients (6). Allergy to propofol was more likely in patients with a history of atopy (4/14) and in those with a history of a drug allergy (6/14). The authors of this report caution against the use of propofol in patients with several drug allergies or in those with prior reactions to muscle relaxants. They also urged caution when using propofol in patients with atopy, especially if other histamine-releasing medications are used during the same anesthetic (6).
Propofol (2–6 diisopropylphenol) is an alkyl phenol in a lipid vehicle (soybean oil, egg lecithin, and glycerol) (5). Allergic reactions to propofol on first exposure are usually because of the isopropyl groups that may act as epitopes and that are present in various medications and cosmetics (5–6). Allergic reactions to propofol upon re-exposure are usually because of the phenol molecule (7). Although I agree with the authors of this case report that the flush in case 2 suggests histamine release, it is impossible to conclude that this was indeed an allergic reaction. Most drugs used to induce anesthesia, including propofol, can cause a nonimmunologic, nonspecific histamine release, and this is more likely in patients with atopy (8). The measurement of a serum tryptase, skin tests, specific immunoglobulin E radioimmunoassay, or a leukocyte histamine release test may aid in the diagnosis, and should be done with propofol, fentanyl, and intralipid. Although exceedingly rare, allergic reactions to fentanyl and intralipid have been described (5).
The diagnosis of the first patient is even more confusing, as there were no signs of histamine release. Although bronchoconstriction could be the only presenting sign of anaphylaxis, an asthmatic attack is also in the differential diagnosis. This patient, known to have allergic rhinitis, may also have asthma of allergic etiology. As many as 50% of cases of asthma in adults are due to allergy. Therefore, this patient is more likely than a nonasthmatic or nonatopic patient to experience bronchospasm with airway instrumentation. Furthermore, as in the second patient, no tests were conducted to aid in the diagnosis of an allergic reaction or identification of a specific allergen.
When a patient has asthma, an attempt should probably be made to determine if it is allergic asthma. Propofol remains my drug of choice for induction of anesthesia in nonatopic asthmatic patients. If a patient has allergic asthma, then a history of the severity of the condition and of other allergies should be obtained. A risk-benefit analysis, including risk of postoperative nausea and vomiting, risk of bronchoconstriction, and risk of recovery from anesthesia should be conducted. If propofol is chosen as the anesthetic induction agent in a patient with atopy or multiple drug allergies, other histamine-releasing drugs should be avoided during the anesthetic and the anesthesiologist should be prepared to deal with an allergic reaction.
References
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Nishiyama T, Hanaoka K. Propofol-induced bronchoconstriction: two case reports. Anesth Analg 2001; 93: 645–6.[Abstract/Free Full Text]
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Cheney FW. Anesthesia for patients with asthma: low risk but not no risk. Anesthesiology 1996; 85: 455–6.[Medline]
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Pizov R, Brown RH, Weiss YS, et al. Wheezing during induction of general anesthesia in patients with and without asthma. Anesthesiology 1995; 82: 1111–6.[Web of Science][Medline]
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Eames WO, Rooke GA, Wu RS, et al. Comparison of the effects of etomidate, propofol, and thiopental on respiratory resistance after tracheal intubation. Anesthesiology 1996; 84: 1307–11.[Web of Science][Medline]
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Vervloet D, Pradal M, Castelain M. Drug allergy. 2nd ed. Pharmacia & Upjohn, 1999.
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Laxenaire MC, Mata-Bermejo E, Moneret-Vautrin DA, et al. Life-threatening anaphylactoid reactions to propofol (Diprivan). Anesthesiology 1992; 77: 275–80.[Web of Science][Medline]
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De Leon-Casasola OA, Weiss A, Lema MJ. Anaphylaxis due to propofol. Anesthesiology 1992; 77: 384–6.[Web of Science][Medline]
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Laxenaire MC, Mata E, Gueant JL, et al. Basophil histamine release in atopic patients after in vitro provocation with thiopental, Diprivan and chlormethiazole. Acta Anaesthesiol Scand 1991; 35: 706–10.[Medline]
Response
Tomoki Nishiyama, MD, PhD
Surgical Center, The Institute of Medical Science, The University of Tokyo, Tokyo, Japan
In Response: We thank Dr. Hepner for his interest and detailed comments in our case reports. We appreciate his opinion about isopropyl group and phenol molecule. However, as we mention in the paper, soybean oil is one of the inducing factors of allergy. Many Japanese have an allergy to soybean. If propofol (here, we use the word "propofol" as a product including soybean oil, not pure propofol), which usually does not induce histamine, induces histamine release we can consider it as one of the allergic reactions. Histamine release in atopic patients by a drug that usually does not induce histamine may be included in an allergic reaction. Of course, some tests should be done to confirm the diagnosis, as Dr. Hepner mentioned. Both cases had no asthma before and after surgery; therefore, the bronchoconstriction should not be an asthma attack. It is true that many of the asthmatic patients are allergic but the opposite is not. From these considerations, we can suggest, but not confirm, that the bronchoconstriction of these two patients might be an allergic reaction to propofol itself, soybean oil or some other solvents. We do not think that there are many differences between propofol anesthesia and others regarding nausea and vomiting or recovery.
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