If We Destroy Nature – We Destroy Ourselves

Natural disasters are increasing in frequency and scale. In the first 6 months of 2022 alone, natural disasters resulted in the death of at least 4,300 people and an estimated US$65 billion in losses, with the majority caused by extreme flooding, earthquakes, and storms.^1,2  Climate change increases the amount of dry plant debris, which helps to light and spread wildfires. The number of large fires in the United States doubled between 1984 and 2015.¹  The second half of 2022 started with extreme heat and drought conditions, leading to extensive wildfires in the Northern Hemisphere. Wildfires release large amounts of carbon dioxide, carbon monoxide, and fine particular matters, resulting in significant air pollution. The fine particular matter, when inhaled, causes inflammation with the potential of severe respiratory sequelae, particularly in those with reactive airway disease. The significant impact of wildfire-induced air pollution on perioperative outcomes of children with reactive airway disease is highlighted by Marsh et al. in this issue.³  In contrast, children without a history of reactive airways did not demonstrate a higher risk for respiratory adverse events.³ 

The differences in risk increase (or lack thereof) between children with and without reactive airways are in line with the observation that several changes to our anesthesia management (e.g., intravenous vs. inhalational induction, deep vs. awake airway removal) only exhibit a significant difference in the incidence of perioperative respiratory adverse events in children with reactive airways, but either compared technique is equally safe in children without reactive airways.⁴ 

The link between asthma exacerbations and smoke exposure is well established with a significant increase in respiratory emergency department visits and asthma hospitalizations within the first 3 days of exposure to wildfire smoke, particularly in younger children (under 5 yr).⁵  The results of this study reconfirm the link between a higher incidence of respiratory adverse events in children with airway hyperreactivity when exposed to wildfires.⁵ 

This study has some significant limitations, including the retrospective design, the small sample size, and the use of surrogate markers for the incidence of perioperative respiratory adverse events without standard definitions, and we do not know if the treating anesthesiologists adjusted their anesthesia practice within the wildfire periods.

What are the implications of the findings of Marsh et al. for clinical practice? First and most obviously, anesthesiologists should consider periods of wildfire smoke exposure as periods of higher risk for patients with bronchial hyperreactivity and consider lowering the threshold for routine premedication with inhaled albuterol, number of IV inductions, and intensified treatment with inhaled steroids via devices with the lowest carbon footprint pre- and postoperatively.^4,6 

It is likely that it would be of great benefit to notify clinical staff of wildfire exposure during at-risk times with regular updates on the level of air pollution. This would not only raise the level of awareness regarding the increased risk, but would also likely influence decision-making pathways for routine clinical management.⁴  Additionally, it would be useful if families would receive text messaging alerts regarding the increased risk at times of wildfire exposure as well as possibly questionnaires assessing whether a child presents with increased symptoms of bronchial hyperreactivity. The responses indicating worsening symptoms of bronchial hyperreactivity could then be reviewed by the treating team, and the parents could be given instructions to escalate their child’s therapy. Furthermore, if significant increases in symptoms are found, the families could be invited for a preoperative review to further assess the child’s health status and initiate treatment as required.

The study by Marsh et al.³  also reminds us that clinicians have wider responsibility to our future planet and its inhabitants and should advocate for policies that attenuate the impending climate change crisis. We teach our trainees about the importance of backup plans, we want them to not only have a sound plan A but also a plan B and C in case of any emergencies, but we must accept there is no planet B. We have to tackle the challenge here and now to avoid diving even deeper into the climate emergency. Desflurane use is a potential target—it has a large carbon footprint and increases not only respiratory resistance in children with bronchial hyperreactivity⁷  (similarly to wildfire smoke), but it is also linked to an increased risk of perioperative respiratory adverse events.⁸  Propofol only causes less than 1,000th of the carbon dioxide per case compared with desflurane and has a much better risk profile when it comes to respiratory adverse events.⁸ 

In cases of wildfire exposure, let us use our well-known protective strategies in anesthesia management,^4,8  particularly those that can even serve a dual purpose—the reduction in perioperative respiratory adverse events as well as a reduction in the carbon footprint! There are no passengers on Spaceship Earth—we are the crew—we all carry responsibility. Let us act now to keep our patients, our families, and our planet safe.