Bronchospasm during anaesthesia: definition, causes and treatment

Anyone planning cosmetic surgery rarely gives much thought to the term ‘anaesthesia-induced bronchospasm’, and yet this complication is one of the anaesthetic risks about which every patient should be informed. According to the specialist literature, perioperative bronchospasm occurs in general anaesthesia at a rate of approximately 0.2 to 2 %. The risk is significantly higher in people with bronchial asthma or COPD. A good understanding of the underlying factors helps patients to assess their own risk profile and to have an informed discussion with the anaesthesia team.

Causes and triggers of bronchospasm during anaesthesia

Bronchospasm during anaesthesia: triggers, intraoperative detection and prioritised management pathway at a glance. Updated: July 2026.

Bronchospasm during anaesthesia occurs when the airways respond to a stimulus with an excessive protective reaction. The smooth bronchial muscles contract; a mechanism which, whilst awake, protects against the inhalation of harmful substances, but which becomes a problem during anaesthesia because the patient is unable to actively counteract it.

Pre-existing conditions: asthma, COPD and bronchial hyperreactivity

Bronchial asthma is the most significant risk factor for perioperative bronchospasm. According to a study published in the Anaesthetology & Intensive Care Medicine According to a published review, people with asthma only have a rate of perioperative respiratory complications comparable to that of the general population during symptom-free periods. Those with active symptoms – such as wheezing, shortness of breath or an increased need for bronchodilators – are at a significantly higher risk.

COPD (chronic obstructive pulmonary disease) also increases the risk, although the mechanism differs from that of asthma: Whilst asthma is primarily characterised by inflammatory hyper-reactivity, the airway obstruction in COPD is partly structural, resulting from emphysema and mucus production. Both conditions predispose the airways to hypersensitivity reactions to mechanical and chemical stimuli.

Even people who have not been diagnosed with asthma but who experience a coughing reflex in response to cold, pollen or cigarette smoke may have subclinical bronchial hyperreactivity. This is often not recognised pre-operatively unless a targeted medical history is taken.

Mechanical and pharmacological triggers caused by intubation and anaesthetics

Endotracheal intubation is the most potent mechanical trigger of bronchospasm during anaesthesia. The tube comes into contact with the mucous membranes of the larynx and trachea, areas with a high density of receptors for the cough reflex. If the depth of anaesthesia is insufficient, this contact triggers a vagus nerve-mediated reflex: the vagus nerve sends signals to the smooth bronchial muscles, which then go into spasm.

From a pharmacological perspective, histamine-releasing agents play an important role. Certain muscle relaxants, such as atracurium, can release histamine from mast cells, which has a direct bronchoconstrictive effect. Anaphylaxis to latex, antibiotics or other substances used perioperatively can also trigger severe bronchospasm, which is clinically almost indistinguishable from reflex bronchospasm but requires a different emergency protocol.

Symptoms and intraoperative detection of bronchospasm

A bronchospasm during anaesthesia initially manifests itself to the anaesthesia team as a change in ventilation parameters: the pressure required to force air into the lungs rises sharply. At the same time, the exhalation phase is prolonged, as the constricted bronchial muscles allow air to escape only slowly. This phenomenon is known as „air trapping“ and can lead to a dangerous rise in pulmonary pressure.

On auscultation – that is, when listening to the lungs with a stethoscope – the anaesthesia team hears a characteristic expiratory wheeze. However, in the event of complete bronchospasm, the breath sound is completely absent: this „silent lung“ is an alarming sign that requires immediate action.

Important for patients: You will not feel a bronchospasm yourself, as you will be unconscious during general anaesthesia. The anaesthesia team continuously monitors all relevant parameters – heart rate, blood pressure, oxygen saturation and ventilation pressure – and is therefore able to detect bronchospasm at an early stage.

Distinguishing it from similar complications: What is not a bronchospasm?

Not every deterioration in ventilation during anaesthesia is a bronchospasm. The anaesthesia team must quickly distinguish between the various possible causes, as the treatment differs in each case:

Complication	Cause	Key distinguishing feature
Bronchospasm	Spasms of the bronchial muscles	Giemen, high ventilation pressure, bilateral
Laryngospasm	Tension in the vocal cord muscles	Stridor-like sound, lack of tidal volume despite attempts at ventilation
Tubal malposition	The tube is not in the trachea	Absence of breath sounds on one side, rapid drop in SpO₂
Pneumothorax	Air in the pleural space	Absence of breath sounds on one side, drop in blood pressure
Anaphylaxis	Immediate allergic reaction	In addition, a drop in blood pressure, skin changes, tachycardia

This distinction is clinically crucial: laryngospasm, or spasm of the vocal cords, often occurs during the emergence phase of anaesthesia, when the patient is no longer in a deep sleep but is not yet fully awake. Bronchospasm, on the other hand, typically occurs during induction. Both complications require different emergency measures.

Management and treatment of bronchospasm during anaesthesia

1. Deal with the cause straight away Stop mechanical stimulation: suspend intubation or suctioning; stop laryngoscopy. Avoid any further airway manipulation whilst the spasm persists.
2. 100 % Administer oxygen Ensure immediate oxygenation with pure oxygen. Administer manual ventilation using a resuscitation bag at a higher pressure, slowly and in a controlled manner, to avoid auto-PEEP.
3. Deepen the anaesthesia Administer propofol (1–2 mg/kg intravenously) or ketamine (1–2 mg/kg intravenously) to deepen anaesthesia. Ketamine has a direct bronchodilator effect and is particularly suitable in cases of severe bronchospasm.
4. Inhaled beta-2 sympathomimetics Administer salbutamol (2–8 puffs) via the tube adapter using a nebuliser. Alternatively: administer intravenously if there is no response to inhalation (250 µg salbutamol intravenously, administered slowly). The effect of inhaled treatment begins after 1–3 minutes.
5. Systemic glucocorticoids Methylprednisolone (1–2 mg/kg intravenously) or hydrocortisone (200 mg intravenously) for anti-inflammatory treatment. The effect sets in after 15–30 minutes; therefore, these should be administered early on, alongside bronchodilators.
6. Adjust the ventilation strategy Low respiratory rate (8–10/min), prolonged expiratory phase (I:E ratio 1:3 to 1:4), low tidal volumes. Accept permissive hypercapnia. Consult an anaesthetist and the intensive care team.

The management of bronchospasm during anaesthesia follows a clear step-by-step approach. It is crucial that the anaesthesia team identifies the cause of the bronchospasm, as the measures taken for reflex bronchospasm differ in some respects from those for an anaphylactic reaction.

1. Eliminate the cause: Where possible, the triggering stimulus is stopped immediately. If the intubation triggered the spasm, it is completed as quickly as possible. The anaesthesia is deepened to suppress reflex activity.
2. Oxygen administration and ventilation adjustment: The ventilator is switched to 100 % oxygen. The ventilator pressure is adjusted and the expiratory time is extended to reduce air trapping.
3. Inhaled bronchodilators: β2-sympathomimetics such as salbutamol are administered directly into the airways via the ventilator tube. Salbutamol relaxes the smooth bronchial muscles within minutes.
4. Systemic medicines: In cases of severe or persistent bronchospasm, intravenous salbutamol, theophylline or adrenaline are used. Glucocorticoids reduce the inflammatory response, but their effect is delayed.
5. Anaphylaxis protocol in the event of a suspected case: If an allergic reaction is suspected, intravenous adrenaline is the treatment of choice, combined with fluid replacement and, if necessary, subsequent intensive care monitoring.

Choice of anaesthetics: a comparison of propofol, ketamine and volatile anaesthetics

The choice of anaesthetic has a significant influence on the likelihood of bronchospasm occurring and on how effectively it can be treated. According to the specialist literature, propofol is considered the preferred induction agent for patients with obstructive lung diseases: it suppresses airway reflexes more effectively than comparable substances and has a mild bronchodilatory effect.

Ketamine also has bronchodilator properties via a sympathomimetic-like effect. In practice, ketamine is used as an emergency anaesthetic in cases of status asthmaticus – that is, a severe, difficult-to-control asthma attack – because it simultaneously dilates the airways and deepens the anaesthesia.

anaesthetic	Effect on the bronchi	Suitable for high-risk patients?
Propofol	Mildly bronchodilatory, strongly suppresses airway activity	Yes, preferred inducer
Ketamine	Bronchodilator (sympathomimetic)	Yes, particularly in cases of severe bronchospasm
Sevoflurane (volatile)	Bronchodilating, low potential for irritation	Yes, the inhaled anaesthetic of choice for asthma
Desflurane (volatile)	May cause respiratory irritation	Use with caution; avoid in cases of bronchial hyperreactivity
Atracurium (muscle relaxant)	Histamine-releasing, bronchoconstrictive	Avoid, choose an alternative

Volatile anaesthetics – that is, inhaled anaesthetic gases such as sevoflurane – have a direct relaxant effect on the smooth bronchial muscles. Sevoflurane is currently considered to be the inhalation anaesthetic with the most favourable pharmacological profile for patients with obstructive lung diseases. Desflurane, on the other hand, irritates the airways and should be avoided in cases where there is a known risk.

Prevention of bronchospasm before and during anaesthesia

Prevention begins long before the operating theatre. The most important tool is the informative discussion between the patient and the anaesthesia team – known as the pre-medication consultation. Openly discussing known risk factors enables the team to make individual preparations.

Pre-operative measures: Optimising lung function

In patients diagnosed with bronchial asthma or COPD, it should be checked prior to an elective procedure whether lung function is optimally controlled. The measure used is FEV₁, the one-second forced expiratory volume, i.e. the volume of air that can be exhaled in one second. According to the specialist literature, an improvement in FEV₁ of 15 % following inhalation of a bronchodilator is considered significant and indicates that the airways are still obstructed to a degree that can be treated.

Elective cosmetic surgery should not be performed if a patient has an acute cold or an active respiratory tract infection. Even a seemingly mild infection increases bronchial irritability for several weeks. Many anaesthesia teams recommend waiting at least four to six weeks after an infection.

Smokers benefit from giving up smoking, but there is one often surprising caveat: in the first two weeks after giving up, mucus production in the airways may temporarily increase, which can raise the risk of bronchospasm in the short term. It is only after eight weeks of nicotine abstinence that the perioperative risk to the airways decreases measurably.

Choice of anaesthetic technique: regional anaesthesia as an alternative

Regional anaesthesia techniques, such as those administered near the spinal cord—including spinal or epidural anaesthesia—avoid any manipulation of the airways. They are suitable for many cosmetic procedures on the abdomen, hips or legs. For high-risk patients with poorly controlled respiratory conditions, regional anaesthesia has the clear advantage of completely avoiding the most dangerous trigger of bronchospasm: intubation.

If general anaesthesia is unavoidable, using a laryngeal mask (LMA) instead of an endotracheal tube can reduce the risk. The laryngeal mask is positioned above the larynx and does not come into direct contact with the most sensitive parts of the airway, an advantage that can be utilised in patients with mild airway disease.

Bronchospasm as a complication of cosmetic surgery

Cosmetic procedures such as liposuction, rhinoplasty or abdominoplasty are predominantly carried out under general anaesthesia. This means that all anaesthetic complications, including bronchospasm, can in principle also occur during elective cosmetic surgery, even if the procedure itself is medically straightforward.

A bronchospasm is not in itself a complication of cosmetic treatment, but rather a reaction to the anaesthetic. Nevertheless, it can lead to a prolonged hospital stay, intensive care monitoring or, in rare, severe cases, further treatment. The costs of such follow-up treatment are often not covered by statutory health insurance schemes if the original procedure was purely cosmetic.

Experience shows that it is precisely this scenario that places patients under considerable financial strain following cosmetic surgery: it is not the planned operation that incurs the costs, but the unexpected complication that arises afterwards. A Consequential Costs Insurance This policy bridges this gap and covers medically necessary treatment arising in connection with the insured procedure, providing cover of up to 300,000 euros against health insurance funds. The policy can be taken out online up to 24 hours before the procedure. Further information on terms and conditions and frequently asked questions can be found in our FAQ section.

Frequently asked questions about bronchospasm during anaesthesia