Answer:

Any muscle relaxants that do not release histamine, such as cisatracurium, vecuronium, rocuronium, and pancuronium may be used. Atracurium causes histamine release, especially in high doses, and should be avoided. Succinylcholine can cause slight histamine release, but there is no evidence that succinylcholine is associated with increased airway resistance in patients with asthma.

It may be advantageous to avoid the long-acting pancuronium and instead to use muscle relaxants of intermediate duration of action because the earlier recovery from neuromuscular blockade may allow avoidance of reversal with an anticholinesterase, which, theoretically, could precipitate bronchospasm due to stimulation of postganglionic cholinergic receptors in airway smooth muscle. However, avoidance of anticholinesterase antagonism requires monitoring with a quantitative peripheral nerve stimulator to ensure adequate spontaneous recovery, defined as a train-of-four (TOF) ratio greater than 0.90. If anticholinesterase is used, adequate dosing of a concomitant anticholinergic is necessary. Alternatively, sugammadex may be used for reversal of rocuronium-induced neuromuscular blockade.

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• Carron M, Zarantonello F, Tellaroli P, et al. Efficacy and safety of sugammadex compared to neostigmine for reversal of neuromuscular blockade: a meta-analysis of randomized controlled trials. J Clin Anesth. 2016;35:1-12.
• Gropper MA, Cohen NH, Eriksson LI, et al, eds. Miller’s Anesthesia. 9th ed. Philadelphia, PA: Elsevier; 2020:814-815.