Post-extubation airway obstruction. Literature review
Abstract Introduction and objective: airway obstruction after extubation in any surgery is a critical event with low incidence, which may require reintubation or tracheostomy, which often otolaryngologist is required. Objective: To determine the prevalence of BVA and its causes through systematic literature review. Method: Literature review in PubMed, Scopus and Cochrane clinical trials, meta-analysis, reviews and case series and control over airway obstruction after extubation that requires reintubation in adults. Results: 6 studies and one clinical practice guidelines were selected. The most common cause of extubation failure is blocking the airway for various reasons (pharyngeal muscle weakness residual effect -often farmacologycal-, laryngospasm, vocal cord paralysis, edema of upper respiratory tract, cervical postoperative hematoma, foreign bodies or secretions). Most cases of re-intubation occurred within 2 hours after extubation. Conclusions: The most common cause of failure after general anesthesia extubation is blocking the airway generally caused by residual neuromuscular blocking effect. Airway obstruction risk increases in airway and head and neck surgery. Difficult intubation guidlines have improved performance and reduced adverse events and similar strategies must be implemented in extubation. The procedure extubation and reintubation should be documented. Working groups airway must be multidisciplinary and include specialists in otolaryngology.
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Boyd M, Chatterjee A, Chiles C, Chin R. Tracheobronchial foreign body aspiration in adults. South Med J 2009;102(2):171–4. https://doi.org/10.1097/SMJ.0b013e318193c9c8
Brull SJ, Murphy GS. Residual neuromuscular block: lessons unlearned. Part II: methods to reduce the risk of residual weakness. Anesth Analg 2010;111(1):129–40. https://doi.org/10.1213/ane.0b013e3181da8312
Chinachoti T, Chau-in W, Suraseranivongse S, Kitsampanwong W, Kongrit P. Postoperative reintubation after planned extubation in Thai Anesthesia Incidents Study (THAI Study). J Med Assoc Thai. 2005;88 Suppl 7:S84--94.
Chinachoti T, Poopipatpab S, Buranatrevedhya S, Taratarnkoolwatana K, Werawataganon T, Jantorn P. The Thai Anesthesia Incident Monitoring Study (Thai AIMS) of post anesthetic reintubation: an analysis of 184 incident reports. J Med Assoc Thai. 2008;91(11):1706–13.
Cook TM, Woodall N, Frerk C, Fourth National Audit Project. Major complications of airway management in the UK: results of the Fourth National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society. Part 1: anaesthesia. Br J Anaesth 2011;106(5):617–31. https://doi.org/10.1093/bja/aer058
Difficult Airway Society Extubation Guidelines Group, Popat M, Mitchell V, Dravid R, Patel A, Swampillai C, et al. Difficult Airway Society Guidelines for the management of tracheal extubation. Anaesthesia 2012;67(3):318–40. https://doi.org/10.1111/j.1365-2044.2012.07075.x
Epstein SK. Decision to extubate. Intensive Care Med 2002 May;28(5):535–46. https://doi.org/10.1007/s00134-002-1268-8
Grosse-Sundrup M, Henneman JP, Sandberg WS, Bateman BT, Uribe JV, Nguyen NT, et al. Intermediate acting non-depolarizing neuromuscular blocking agents and risk of postoperative respiratory complications: prospective propensity score matched cohort study. BMJ 2012;345:e6329. https://doi.org/10.1136/bmj.e6329
Hines R, Barash PG, Watrous G, O'Connor T. Complications occurring in the postanesthesia care unit: a survey. Anesth Analg 1992 Apr;74(4):503–9. https://doi.org/10.1213/00000539-199204000-00006
Kluger MT, Bullock MFM. Recovery room incidents: a review of 419 reports from the Anaesthetic Incident Monitoring Study (AIMS). Anaesthesia 2002;57(11):1060–6. https://doi.org/10.1046/j.1365-2044.2002.02865.x
Lee PJ, MacLennan A, Naughton NN, O'Reilly M. An analysis of reintubations from a quality assurance database of 152,000 cases. J Clin Anesth 2003;15(8):575–81. https://doi.org/10.1016/j.jclinane.2003.03.006
Lin H-T, Ting P-C, Chang W-Y, Yang M, Chang C-J, Chou A-H. Predictive risk index and prognosis of postoperative reintubation after planned extubation during general anesthesia: A single-center retrospective case-controlled study in Taiwan from 2005 to 2009. Acta Anaesthesiol Taiwanica 2013;51(1):3–9. https://doi.org/10.1016/j.aat.2013.03.004
Mathew JP, Rosenbaum SH, O'Connor T, Barash PG. Emergency tracheal intubation in the postanesthesia care unit: physician error or patient disease? Anesth Analg 1990;71(6):691–7. https://doi.org/10.1213/00000539-199012000-00020
Murphy GS, Brull SJ. Residual neuromuscular block: lessons unlearned. Part I: definitions, incidence, and adverse physiologic effects of residual neuromuscular block. Anesth Analg 2010;111(1):120–8. https://doi.org/10.1213/ane.0b013e3181da832d
Peterson GN, Domino KB, Caplan RA, Posner KL, Lee LA, Cheney FW. Management of the difficult airway: a closed claims analysis. Anesthesiology 2005;103(1):33–9. https://doi.org/10.1097/00000542-200507000-00009
Rosenthal LHS, Benninger MS, Deeb RH. Vocal fold immobility: a longitudinal analysis of etiology over 20 years. Laryngoscope 2007;117(10):1864–70. https://doi.org/10.1097/MLG.0b013e3180de4d49
Rubin AD, Sataloff RT. Vocal fold paresis and paralysis. Otolaryngol Clin North Am 2007;40(5):1109–31, viii–ix. https://doi.org/10.1016/j.otc.2007.05.012
Sagi HC, Beutler W, Carroll E, Connolly PJ. Airway complications associated with surgery on the anterior cervical spine. Spine (Phila Pa 1976) 2002 1;27(9):949–53.
Sanapala A, Nagaraju M, Rao LN, Nalluri K. Management of bilateral recurrent laryngeal nerve paresis after thyroidectomy. Anesth essays Res;9(2):251–3.
Sue RD, Susanto I. Long-term complications of artificial airways. Clin Chest Med 2003;24(3):457–71. https://doi.org/10.1016/S0272-5231(03)00048-0
Swanson KL, Edell ES. Tracheobronchial foreign bodies. Chest Surg Clin N Am 2001;11(4):861–72.
Ting PC, Chou AH, Yang MW, Ho AC-Y, Chang CJ, Chang SC. Postoperative reintubation after planned extubation: A review of 137,866 general anesthetics from 2005 to 2007 in a Medical Center of Taiwan. Acta Anaesthesiol Taiwanica 2010;48(4):167–71. https://doi.org/10.1016/j.aat.2010.12.003
Visvanathan T, Kluger MT, Webb RK, Westhorpe RN. Crisis management during anaesthesia: laryngospasm. Qual Saf Health Care 2005;14(3):e3. https://doi.org/10.1136/qshc.2002.004275
Weber S. Traumatic complications of airway management. Anesthesiol Clin North America 2002;20(3):503–12. https://doi.org/10.1016/S0889-8537(02)00014-7
Wittekamp BHJ, van Mook WNKA, Tjan DHT, Zwaveling JH, Bergmans DCJJ. Clinical review: post-extubation laryngeal edema and extubation failure in critically ill adult patients. Crit Care 2009;13(6):233. https://doi.org/10.1186/cc8142
Brull SJ, Murphy GS. Residual neuromuscular block: lessons unlearned. Part II: methods to reduce the risk of residual weakness. Anesth Analg 2010;111(1):129–40. https://doi.org/10.1213/ane.0b013e3181da8312
Chinachoti T, Chau-in W, Suraseranivongse S, Kitsampanwong W, Kongrit P. Postoperative reintubation after planned extubation in Thai Anesthesia Incidents Study (THAI Study). J Med Assoc Thai. 2005;88 Suppl 7:S84--94.
Chinachoti T, Poopipatpab S, Buranatrevedhya S, Taratarnkoolwatana K, Werawataganon T, Jantorn P. The Thai Anesthesia Incident Monitoring Study (Thai AIMS) of post anesthetic reintubation: an analysis of 184 incident reports. J Med Assoc Thai. 2008;91(11):1706–13.
Cook TM, Woodall N, Frerk C, Fourth National Audit Project. Major complications of airway management in the UK: results of the Fourth National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society. Part 1: anaesthesia. Br J Anaesth 2011;106(5):617–31. https://doi.org/10.1093/bja/aer058
Difficult Airway Society Extubation Guidelines Group, Popat M, Mitchell V, Dravid R, Patel A, Swampillai C, et al. Difficult Airway Society Guidelines for the management of tracheal extubation. Anaesthesia 2012;67(3):318–40. https://doi.org/10.1111/j.1365-2044.2012.07075.x
Epstein SK. Decision to extubate. Intensive Care Med 2002 May;28(5):535–46. https://doi.org/10.1007/s00134-002-1268-8
Grosse-Sundrup M, Henneman JP, Sandberg WS, Bateman BT, Uribe JV, Nguyen NT, et al. Intermediate acting non-depolarizing neuromuscular blocking agents and risk of postoperative respiratory complications: prospective propensity score matched cohort study. BMJ 2012;345:e6329. https://doi.org/10.1136/bmj.e6329
Hines R, Barash PG, Watrous G, O'Connor T. Complications occurring in the postanesthesia care unit: a survey. Anesth Analg 1992 Apr;74(4):503–9. https://doi.org/10.1213/00000539-199204000-00006
Kluger MT, Bullock MFM. Recovery room incidents: a review of 419 reports from the Anaesthetic Incident Monitoring Study (AIMS). Anaesthesia 2002;57(11):1060–6. https://doi.org/10.1046/j.1365-2044.2002.02865.x
Lee PJ, MacLennan A, Naughton NN, O'Reilly M. An analysis of reintubations from a quality assurance database of 152,000 cases. J Clin Anesth 2003;15(8):575–81. https://doi.org/10.1016/j.jclinane.2003.03.006
Lin H-T, Ting P-C, Chang W-Y, Yang M, Chang C-J, Chou A-H. Predictive risk index and prognosis of postoperative reintubation after planned extubation during general anesthesia: A single-center retrospective case-controlled study in Taiwan from 2005 to 2009. Acta Anaesthesiol Taiwanica 2013;51(1):3–9. https://doi.org/10.1016/j.aat.2013.03.004
Mathew JP, Rosenbaum SH, O'Connor T, Barash PG. Emergency tracheal intubation in the postanesthesia care unit: physician error or patient disease? Anesth Analg 1990;71(6):691–7. https://doi.org/10.1213/00000539-199012000-00020
Murphy GS, Brull SJ. Residual neuromuscular block: lessons unlearned. Part I: definitions, incidence, and adverse physiologic effects of residual neuromuscular block. Anesth Analg 2010;111(1):120–8. https://doi.org/10.1213/ane.0b013e3181da832d
Peterson GN, Domino KB, Caplan RA, Posner KL, Lee LA, Cheney FW. Management of the difficult airway: a closed claims analysis. Anesthesiology 2005;103(1):33–9. https://doi.org/10.1097/00000542-200507000-00009
Rosenthal LHS, Benninger MS, Deeb RH. Vocal fold immobility: a longitudinal analysis of etiology over 20 years. Laryngoscope 2007;117(10):1864–70. https://doi.org/10.1097/MLG.0b013e3180de4d49
Rubin AD, Sataloff RT. Vocal fold paresis and paralysis. Otolaryngol Clin North Am 2007;40(5):1109–31, viii–ix. https://doi.org/10.1016/j.otc.2007.05.012
Sagi HC, Beutler W, Carroll E, Connolly PJ. Airway complications associated with surgery on the anterior cervical spine. Spine (Phila Pa 1976) 2002 1;27(9):949–53.
Sanapala A, Nagaraju M, Rao LN, Nalluri K. Management of bilateral recurrent laryngeal nerve paresis after thyroidectomy. Anesth essays Res;9(2):251–3.
Sue RD, Susanto I. Long-term complications of artificial airways. Clin Chest Med 2003;24(3):457–71. https://doi.org/10.1016/S0272-5231(03)00048-0
Swanson KL, Edell ES. Tracheobronchial foreign bodies. Chest Surg Clin N Am 2001;11(4):861–72.
Ting PC, Chou AH, Yang MW, Ho AC-Y, Chang CJ, Chang SC. Postoperative reintubation after planned extubation: A review of 137,866 general anesthetics from 2005 to 2007 in a Medical Center of Taiwan. Acta Anaesthesiol Taiwanica 2010;48(4):167–71. https://doi.org/10.1016/j.aat.2010.12.003
Visvanathan T, Kluger MT, Webb RK, Westhorpe RN. Crisis management during anaesthesia: laryngospasm. Qual Saf Health Care 2005;14(3):e3. https://doi.org/10.1136/qshc.2002.004275
Weber S. Traumatic complications of airway management. Anesthesiol Clin North America 2002;20(3):503–12. https://doi.org/10.1016/S0889-8537(02)00014-7
Wittekamp BHJ, van Mook WNKA, Tjan DHT, Zwaveling JH, Bergmans DCJJ. Clinical review: post-extubation laryngeal edema and extubation failure in critically ill adult patients. Crit Care 2009;13(6):233. https://doi.org/10.1186/cc8142
Sánchez-Tabernero, Álvaro, Pardal-Refoyo, J. L., & Cuello-Azcárate, J. J. (2017). Post-extubation airway obstruction. Literature review. Revista ORL, 8(1), 23–29. https://doi.org/10.14201/orl.15055
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