Asploro Journal of Biomedical and Clinical Case Reports
ISSN: 2582-0370
Article Type: Case Report
DOI: 10.36502/2023/ASJBCCR.6313
Asp Biomed Clin Case Rep. 2023 Aug 03;6(3):186-89

Postoperative Respiratory Dysfunction in Patients with Parkinson’s Disease

Xin Wang1*
1Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, Sichuan, People’s Republic of China

Corresponding Author: Xin Wang
Address: Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, China.
Received date: 20 July 2023; Accepted date: 27 July 2023; Published date: 03 August 2023

Citation: Wang X. Postoperative Respiratory Dysfunction in Patients with Parkinson’s Disease. Asp Biomed Clin Case Rep. 2023 Aug 03;6(3):186-89.

Copyright © 2023 Wang X. This is an open-access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium provided the original work is properly cited.

Keywords: Parkinson Disease, Deep Brain Stimulation, Levodopa, Laryngismus, Postoperative Care, Neuroleptic Malignant Syndrome, Airway Management, Perioperative Period, Anesthesiology


This case report presents a 67-year-old female with Parkinson’s disease who underwent deep brain stimulation (DBS) electrode replacement surgery. Following extubation, the patient developed persistent laryngospasm, requiring immediate intervention. Suspecting symptoms similar to levodopa withdrawal, the patient received intravenous propofol and enteral levodopa supplementation, leading to symptom improvement. The case underscores the importance of perioperative management, including timely medication supplementation and DBS functioning, in Parkinson’s patients to prevent neuroleptic malignant syndrome (NMS)-like complications. Anesthesiologists should be vigilant about potential airway issues and NMS in this population and maintain optimal fluid status during surgery. Prompt intervention can prevent irreversible damage and improve patient outcomes.


Parkinson’s disease is a progressive disorder characterized by resting tremors, muscle rigidity, and bradykinesia (slowness of movement), eventually leading to gait and postural instability. It is typically managed with medications such as levodopa to improve symptoms. In cases where symptoms are difficult to control with medication alone and there are no cognitive psychiatric impairments, surgical options such as deep brain stimulation (DBS) surgery may be considered. DBS involves the implantation of electrodes in specific areas of the brain to improve symptoms while reducing the dosage of medications such as levodopa. The neurostimulator used for deep brain stimulation usually needs to be replaced after 5-8 years of use.

The neurostimulator is not promptly replenished with medication or turned on after replacement, and patients may experience clinical manifestations similar to levodopa withdrawal reactions. We would like to share the case of a Parkinson’s disease patient who developed persistent laryngospasm following the replacement of the neurostimulator for deep brain stimulation. We hope to raise awareness among anesthesiologists regarding the importance of postoperative airway management in this patient population.

Case Presentation

The patient was a 67-year-old female with a height of 156 cm and a weight of 56 kg. She presented with right-sided limb tremors, rigidity, and bradykinesia 20 years ago but did not pay much attention to it and therefore did not receive any treatment. Subsequently, the patient developed worsening clinical manifestations of right-sided limb tremors and bradykinesia, along with the gradual onset of left-sided limb tremors, rigidity, and bradykinesia.

The patient sought medical attention at the local hospital, where the diagnosis of “Parkinson’s disease” was considered, and pharmacological treatment was initiated. Over the past decade, the patient’s symptoms of limb tremors, rigidity, and bradykinesia have progressively worsened while continuously adjusting medication under the guidance of the doctor. Seven years ago, the patient experienced motor fluctuations and required higher medication doses, leading to the implantation of deep brain stimulation electrodes. Following the surgery, the patient’s symptoms significantly improved, and the medication dosage was reduced.

In recent days, during a routine outpatient follow-up visit, the attending physician noted a significant decrease in the efficacy of the patient’s neurostimulator battery and recommended replacement. Therefore, the patient was scheduled for deep brain stimulation electrode replacement surgery. The patient had no significant medical history or recent history of respiratory tract infections. The ASA classification is grade II.

On the day of the surgery, the patient took levodopa tablets, pramipexole hydrochloride tablets, and entacapone tablets at 6 a.m. At 9 a.m., the patient entered the operating room and was connected to monitoring equipment, which showed that the patient’s heart rate, blood pressure, and oxygen saturation were within normal ranges. The anesthesiologist performed a physical examination and observed slight tremors in the patient’s upper limbs but no other positive signs.

After adequate preoxygenation, the anesthesiologist administered intravenous injections of fentanyl 12.5 μg, vecuronium bromide 6 mg, midazolam 2 mg, and propofol 60 mg. Once it was confirmed that the patient’s skeletal muscles were completely relaxed, the anesthesiologist performed endotracheal intubation using a size 7 reinforced tracheal tube placed orally with the assistance of a video laryngoscope. After intubation, the anesthesia machine was connected, and mechanical ventilation was initiated with a tidal volume of 350 ml, a respiratory rate of 14 breaths per minute, and an airway pressure of 12 mmH2O. Anesthesia was maintained using sevoflurane and remifentanil.

The entire surgical procedure lasted for 90 minutes, during which the patient’s vital signs remained stable, and there were no incidents of hypotension or allergies. After the surgery, the surgeon infiltrated the patient’s surgical incision with 0.5% ropivacaine. Ten minutes after discontinuing sevoflurane and remifentanil, the patient regained spontaneous breathing with a tidal volume of 300 ml, a respiratory rate of 17 breaths per minute, and the ability to open their eyes upon stimulation. The anesthesiologist administered dexmedetomidine intravenously and removed the patient’s endotracheal tube.

After extubation, the patient exhibited significant stridor, and a physical examination revealed a mild tracheal tug. Subsequently, the patient’s pulse oximetry decreased to 90%. The anesthesiologists provided verbal reminders to the patient, but there was no significant improvement in breathing. Therefore, the anesthesiologist immediately initiated mask positive pressure ventilation on the patient. Manual ventilation revealed elevated airway pressure of 32 mmH2O and a tidal volume of 120 ml, with no significant improvement in oxygen saturation and a gradual downward trend. Considering the possibility of laryngospasm, another anesthesiologist administered propofol 50 mg intravenously. One minute later, the patient’s breathing gradually stabilized, and mechanical ventilation was resumed with a tidal volume of 300 ml and an airway pressure of 18 mmH2O.

Approximately 3 minutes later, the patient regained consciousness but experienced recurrent episodes of laryngospasm. The anesthesiologist administered an additional dose of propofol 30 mg intravenously. It was suspected that the patient was exhibiting symptoms similar to a levodopa withdrawal reaction, despite it being 5 hours since the patient took levodopa tablets. Therefore, a gastric tube was placed, and the patient received a standard dose of levodopa via enteral feeding. Simultaneously, the surgeon activated the neurostimulator. Approximately 5 minutes later, the patient responded to verbal stimuli by opening his eyes, had stable spontaneous breathing, and did not exhibit further stridor or tracheal tug.

Approximately 20 minutes later, the patient fully recovered consciousness, followed commands for limb movement, and was subsequently transferred back to the ward. The patient was discharged home three days later.


Parkinson’s disease is a common neurodegenerative disorder that primarily affects dopaminergic neurons in the substantia nigra, leading to progressive degeneration and the formation of Lewy bodies. Biochemical changes include reduced dopamine neurotransmission in the striatum and an imbalance between dopamine and acetylcholine neurotransmitters.

The clinical manifestations of Parkinson’s disease include prominent motor symptoms such as tremors, muscle rigidity, bradykinesia, and postural instability, as well as nonmotor symptoms such as sleep disorders, olfactory dysfunction, autonomic dysfunction, cognitive impairment, and psychiatric disorders. The first-line treatment for Parkinson’s disease is medication therapy, and in the advanced stages, surgical implantation of deep brain electrodes may be considered when medication therapy is ineffective or requires high doses to achieve symptom relief and reduce medication dosage.

As Parkinson’s disease progresses, patients may experience symptoms such as upper airway obstruction, restrictive ventilatory impairment, and abnormalities in central ventilatory control. Levodopa and benserazide hydrochloride tablets may help improve respiratory function in Parkinson’s patients [1]. Levodopa/benserazide hydrochloride tablets are a commonly used medication for Parkinson’s disease, which is a combination formulation of levodopa and benserazide. Levodopa is a precursor of dopamine that can increase dopamine levels in brain tissue by crossing the blood‒brain barrier. Case reports have documented respiratory difficulties or respiratory failure in patients who discontinued levodopa/benserazide hydrochloride tablets. Sudden discontinuation of these tablets can lead to a rapid decrease in dopamine concentration in the body, resulting in neuroleptic malignant syndrome (NMS). NMS is a potentially life-threatening complication characterized by altered mental status, increased muscle tone, severe rigidity, autonomic dysregulation, hyperactivity, and elevated body temperature. It can occur due to treatment with antipsychotic drugs or sudden discontinuation of dopamine receptor agonists. In this case, the patient’s last dose of levodopa/benserazide hydrochloride tablets was approximately 5 hours before the surgery, and the deep brain electrode stimulator was also turned off, further reducing dopamine concentration in the body and leading to autonomic dysregulation and respiratory dysfunction.

Research has found that rapid withdrawal of Parkinson’s medications, dehydration, and infection are major risk factors for triggering or exacerbating neuroleptic malignant syndrome [2]. When managing patients with Parkinson’s disease perioperatively, anesthesiologists should take into consideration the dosage and timing of the medications used by the patients, avoiding prolonged discontinuation of these medications, which can cause drastic changes in dopamine concentrations in the patient’s brain. Additionally, anesthesiologists should be mentally prepared and have the necessary supplies to deal with NMS. The half-life of levodopa is 1-3 hours; therefore, Parkinson’s patients should continue taking their medication as usual on the day of surgery. For patients whose surgery starts within 2 hours of their last dose, gastric tube feeding can be performed after endotracheal intubation. For patients undergoing long-duration surgery, supplemental levodopa should also be administered through a gastric tube during the procedure. Due to the fasting requirements before general anesthesia, patients may experience varying degrees of dehydration. Anesthesiologists need to consider how to optimize the patient’s fluid status during the perioperative period.

In Parkinson’s patients undergoing general anesthesia, if they develop hyperthermia, altered consciousness, or respiratory disturbances, the possibility of NMS should be considered first, along with differential diagnoses of malignant hyperthermia, infection, and intracranial diseases. In our case, the patient presented with respiratory dysfunction without symptoms such as fever or altered consciousness, making the diagnosis of NMS relatively clear. For patients who have undergone deep brain stimulation (DBS) surgery, in addition to timely supplementation with levodopa, it is also important to ensure the normal functioning of DBS or provide additional levodopa supplementation. Previous case reports have shown that a Parkinson’s patient developed a neuroleptic malignant syndrome-like condition due to failure to timely replace the battery 7 years after DBS surgery. After battery replacement, the patient’s symptoms significantly improved [3].

In summary, the perioperative management of Parkinson’s patients requires anesthesiologists to be vigilant about routine care, as well as the patient’s medication dosage, supplementation timing, and the functioning of deep brain stimulation (DBS). Prompt intervention is essential if symptoms of neuroleptic malignant syndrome-like conditions occur to prevent irreversible damage.

Conflict of Interest

The author has read and approved the final version of the manuscript. The author has no conflicts of interest to declare.


[1] Torsney KM, Forsyth D. Respiratory dysfunction in Parkinson’s disease. J R Coll Physicians Edinb. 2017 Mar;47(1):35-39. [PMID: 28569280]

[2] Hashimoto T, Tokuda T, Hanyu N, Tabata K, Yanagisawa N. Withdrawal of levodopa and other risk factors for malignant syndrome in Parkinson’s disease. Parkinsonism Relat Disord. 2003 Apr;9 Suppl 1:S25-30. [PMID: 12735912]

[3] Azar J, Elinav H, Safadi R, Soliman M. Malignant deep brain stimulator withdrawal syndrome. BMJ Case Rep. 2019 May 15;12(5):e229122. [PMID: 31092485]