BJA Education, 17 (7): 235–241 (2017)

doi: 10.1093/bjaed/mkw077
Advance Access Publication Date: 15 February 2017
Matrix reference
1C01, 2A01, 3A01

Postoperative management of the difficult airway

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B Batuwitage MBBCh MRCS FRCA1,* and P Charters MD MRCP FRCA2
1
Consultant Anaesthetist, Portsmouth Hospitals NHS Trust, Southwick Hill Road, Cosham, Portsmouth
PO6 3LY, UK and 2Consultant Anaesthetist, Aintree University Hospital Foundation Trust, Longmoor Lane,
Liverpool L9 7AL, UK
*To whom correspondence should be addressed. E-mail: bisanth.batuwitage@porthosp.nhs.uk

management of the difficult airway after surgery. The Difficult

Key points Airway Society (DAS) extubation guidelines5 identifies ‘at risk’
patients and provides a useful framework for managing difficult
• Airway obstruction in the postoperative period is airways. These patients will often be managed on the intensive
associated with a high incidence of morbidity. care unit (ICU), and good communication between anaesthe-
• A strategy on how to manage the difficult airway tists, surgeons, and intensivists is essential to decision making.
after surgery should be agreed by the multidiscip-
linary team.
• The Difficult Airway Society extubation guidelines Predicting postoperative difficulty
should be followed for ‘at risk’ patients, with the
General
consideration of advanced extubation techniques.
• Patients If there has been difficulty with the initial intubation then extu-
at risk of deterioration should be
bation may also prove to be difficult. It is important to consider
observed and monitored closely after surgery for
the airway at the end of surgery because trauma and resultant
signs and symptoms of airway compromize and
oedema may cause life-threatening airway obstruction. Obese
the need for re-intubation.
patients are at increased risk of postoperative airway complica-
• If there is significant concern about the patency tions. If there is a history of obstructive sleep apnoea (OSA) then
of the airway then the patient should either re- return of airway tone may be delayed, and consideration to
main intubated or have a tracheostomy. postoperative airway support such as non-invasive ventilation
and the use of a nasopharyngeal airway should be considered.
OSA patients may already have a continuous positive airway
pressure (CPAP) machine at home and should be asked to bring
this equipment to hospital so it can be used during the periop-
erative period. Those patients who are at risk of aspiration (e.g.
In recent years, there have been major advances in airway man- emergency patients, gastro-oesophageal reflux disease) may
agement, including the development of intubation guidelines benefit from decompression of the stomach with a nasogastric
and recognition of the importance of human factors and non- tube before extubation.
technical skills.1,2 It is important to appreciate that airway man- The accessibility of the trachea is important, and this may
agement continues into the postoperative period and that the preclude extubation if there is a concern about the ability to re-
incidence of airway problems during emergence and extubation intubate the patient. The diagnosis of unrelieved trismus (e.g.
accounts for significant morbidity. The fourth National Audit because of fibrosis) may also raise the possibility of difficulty. A
Project of major airway complications identified a number of re- laryngeal mask airway or oral tube may be totally occluded by
ported events at the end of surgery.3 A similar finding was the patient biting on it during emergence from anaesthesia; the
found in an analysis of the ASA closed claims database.4 It is use of a oropharyngeal airway or bite block (e.g. rolled gauze)
therefore essential that a clear plan is formulated for can mitigate this risk.

Editorial decision: November 26, 2016; Accepted: December 5, 2016

C The Author 2017. Published by Oxford University Press on behalf of the British Journal of Anaesthesia. All rights reserved.
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235
Postoperative management of the difficult airway

At induction unsuccessful during the initial management of the patient’s

airway.
Difficult mask ventilation at induction may predict problems
during emergence. This may be because of facial asymmetry,
airway pathology (e.g. tumour masses), sleep apnoea,
Factors affecting airway management strategy
increased BMI, bull neck, Mallampati grade 3/4, male gender,
age >55 yr, beards, or limited jaw protrusion. It has been History
argued that avoiding muscle relaxants before establishing ease
A clear history of the patient’s symptoms may help in deciding
of bag-and-mask ventilation initially gives useful information
how to manage the airway after surgery. If there are symptoms
as to how the emergent airway will behave. If difficult bag-
of airway obstruction such as stridor, hoarseness of voice, or
and-mask ventilation is found then the option of waking the
difficulty managing secretions (drooling) then this would usu-
patient or using a short-acting neuromuscular blocking drug
ally preclude extubation. Preoperative nasendoscopy is useful
can be used. This, however, remains controversial as there is a
as it provides important information of the ‘starting’ airway. In

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growing body of evidence that neuromuscular block makes
patients where the postoperative strategy is less obvious, an
facemask ventilation more effective and therefore should be
airway assessment is essential before deciding on how to pro-
given early.6
ceed. The simplest way of doing this is by starting at the mouth
and working down.
Surgical factors
Table 2 lists surgical procedures that may cause problems after Examination
surgery. This is more common in head and neck surgery where It is important to ensure that general factors are assessed such
the airway has been changed from the preoperative state but it as haemodynamic status, respiratory function, metabolic fac-
may also be seen where patient positioning has resulted in oe- tors, and level of consciousness.
dema (e.g. prone positioning, steep Trendelenburg). Similarly,
Vasalva manoeuvres (coughing and straining) and change
from sitting upright to supine posture may make the ‘at risk’ Table 2 Surgical operations associated with postoperative airway
airway suddenly obstruct because of increased oedema. If it is compromise
clear that the airway may be compromised and that oxygen-
Neck pathology (bleeding after neck dissection/ thyroidectomy;
ation may be difficult or if re-intubation may also be hazard-
postoperative carotid blow out)
ous then the patient should remain intubated or have a
Tongue biopsy
tracheostomy. This will depend on the availability of local
Tonsillectomy
resources.
Pan-endoscopy (reactive cord oedema)
Radical neck dissection (tied Internal Jugular vein (IJV), likelihood of
vocal cord oedema attributable to venous congestion)
Anaesthetic factors
Operations on the cervical vertebrae (multi-factorial)
There are a number of requirements that are necessary before Infections (dental abscess, Ludwig’s angina, incomplete drainage, or
safe extubation of the difficult airway and these should be met disease progression)
(Table 3). Incomplete reversal of neuromuscular blocking agents Abnormal airway morphology—tumour still present (biopsy/exami-
and excessive opioid use may result in airway obstruction and nation under anaesthesia only for diagnosis)
resultant hypoxia. The different muscle recovery rates after De-bulking tumour issues—continued oozing/ redundant tissue ob-
neuromuscular block (e.g. diaphragm then upper airway structing narrow glottis
muscles) makes monitoring for residual effects in difficult air- Oedema following surgery—bi-maxillary osteotomy, any major air-
way surgery
way patients essential; therefore, quantitative neuromuscular
Surgical packing of nose (less common)
monitoring has recently been recommended.7 The postopera-
tive obstructed airway may also lead to postoperative negative
pressure pulmonary oedema, which can be life threatening if
not managed expeditiously.
Postoperative airway management should be an informed
Table 3 Suggested technique for awake extubation of the difficult
decision that incorporates preoperative information and pre-
airway
extubation assessment in conjunction with knowledge gained
from techniques that were successful and those that were Position patient appropriately/ sit up
Skilled assistance
Table 1 Causes of postoperative airway obstruction Direct suctioning of the airway
Airway adjunct/bite block (e.g. rolled gauze)
Laryngospasm 100% Oxygen
Laryngeal oedema (e.g. prolonged Trendelenburg position) Ensure cardiovascular stability
Vocal cord paralysis Ensure adequate gas exchange/regular breathing
Reduced venous drainage Reversal of neuromuscular blocking agents
Bleeding into the airway (including clots blocking the inlet) Adequate analgesia (avoiding excessive or insufficient)
Local infection Patient awake and eye opening/obeying commands
Neck haematoma Apply positive pressure, deflate cuff and remove tube
Foreign body (e.g. retained throat pack) Ensure airway patency
Obesity/obstructive sleep apnoea Continue with oxygen delivery
Inadequate reversal of neuromuscular blocking drug Safe transfer/high flow oxygen/close observation and monitoring

236 BJA Education | Volume 17, Number 7, 2017

 Postoperative management of the difficult airway

Face/oropharynx event of failed extubation is impossible. If there is any uncer-

If there is obvious swelling to the face (e.g. from steep head tainty of the ability of the patients to maintain oxygenation and
down positioning) or tongue (e.g. from a mouth gag) then this to re-intubate then it may be safer to keep these patients asleep,
may precipitate postoperative airway obstruction. transfer them to the intensive care unit, and extubate when the
clinical picture has improved.
Supraglottic/larynx
This should be examined at the end of surgery by direct or indir-
Investigations/magnetic resonance imaging
ect laryngoscopy. This will allow any intra-operative changes to
be identified such as airway oedema, bleeding, or surgical dis- The use of magnetic resonance imaging (MRI) of the airway
tortion. Particular consideration of clots in the postnasal space before extubation may provide useful information on potential
is important because they may dislodge after extubation and difficulties including oedema and inflammation. In patients
obstruct the laryngeal inlet. It is important to realize the tra- with Ludwig’s angina and deep infection of tissue planes MRI
cheal tube will distort the assessment of the postoperative air- imaging will clarify whether the infection is still spreading and

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way. It is likely that oedema will re-distribute and whether there is any evidence of mediastinitis.
inflammation will worsen if already established.

Subglottis
Airway management strategy
The subglottic region can be assessed by a cuff leak test. This in- Extubation
volves deflating the tracheal tube cuff in order to assess the
The decision whether to extubate will depend on the pathology
leak of air around the tube. This will give an assessment of
and the risk of airway obstruction. If an airway adjunct is con-
upper airway patency and is more commonly used on critical
sidered necessary then it is better to wake the patient up with
care where the cuff leak volume (defined as the difference be-
one in place. The patient should be extubated ideally where
tween the inspiratory tidal volume and the averaged expiratory
they were intubated (i.e. on the operating table) with the equip-
tidal volume while the cuff around the tracheal tube is deflated)
ment used immediately available. The use of humidified oxy-
can be recorded. A cuff leak volume less than 110 ml has been
gen and nebulized epinephrine may help in patients who have
shown to be predictive of postextubation stridor.8 The presence
some degree of laryngeal oedema after extubation. The optimal
of a leak is suggestive of space around the tracheal tube; how-
dosage is unclear, although 1 mg of epinephrine in 5 ml of nor-
ever, the redistribution of oedema may mean that this test is no
mal saline has been suggested.11 The use of high flow humidi-
guarantee of airway patency. A meta-analysis concluded that
fied oxygen treatment such as Trans-nasal High flow Rapid
the absence of a leak should alert the clinician to a higher risk
Inspiratory Ventilatory Exchange (THRIVE) may have a role.12
of upper airway obstruction; however, the presence of a leak
This treatment is ineffective in total airway obstruction and any
has a low predictive value and does not rule out the occurrence
deterioration requires a clearly communicated strategy for re-
of upper airway obstruction.9
intubation. These patients should be monitored closely, ideally
There have been several studies examining the use of ultra-
in recovery or in a critical care area with early intervention if
sound to assess airway patency. The air column width (ACW) is
the airway deteriorates. The evidence suggests that in intensive
defined as the width of the acoustic shadow measured at the
care patients there is little to choose between extubation to
level of the vocal cords. The ACW is measured before and after
non-invasive ventilation vs high flow nasal oxygen.13
cuff deflation allowing the air column width difference (ACWD)
The DAS extubation guidelines suggest three advanced tech-
to be calculated. A higher ACWD has been associated with
niques when extubating the ‘at risk’ airway (Fig. 1).
fewer airway complications. The current evidence for the use of
ultrasound suggests that it is unreliable, with a low positive pre-
dictive value, sensitivity and specificity, is limited to small- Laryngeal mask airway
scale studies and therefore results should be interpreted with In this technique, the tracheal tube is replaced with a laryngeal
caution.10 mask airway (LMA), which allows patency of the upper airway
to be maintained. It is a useful technique as it allows a
Lower airway smoother emergence from anaesthesia, potentially reducing
The simplest method of assessing the lower airways is clinical coughing and associated increased venous pressure, which
examination with auscultation of the chest and radiographs may disrupt the surgical repair. The LMA may also protect the
taken if there is clinical suspicion. Endobronchial intubation airway from blood and secretions in the mouth. It is not a rec-
may cause lobar collapse. If the patient has an episode of post- ommended technique in patients who may be difficult to re-
operative pulmonary oedema or aspiration this may show as bi- intubate or those with a risk of aspiration as the LMA may not
lateral pulmonary infiltration. The importance of gastric perform effectively (inadequate seal or unable to apply positive
aspiration was highlighted in the NAP 4 report.3 Trauma to the pressure ventilation). Ideally, the correct seating of the LMA at
airway may result in surgical emphysema or a pneumothorax. the laryngeal inlet should be checked with a fibrescope before
The presence of gastric distension is common when bag-and- starting reversal of anaesthesia. This will facilitate re-
mask ventilation has been difficult and this may splint the dia- intubation with an Aintree exchange catheter, should this be
phragm. This is more commonly seen in paediatrics where it considered necessary.
may impede spontaneous breathing. The stomach can be de-
compressed with a nasogastric tube before extubation if this is Remifentanil
considered likely. The ultra-short-acting opioid remifentanil can be used at the
end of surgery to obtund coughing and facilitate awake extuba-
Front of neck access tion. The infusion can be started at the end of the surgery, while
The presence of surgical frames (e.g. halo frame), swelling, or the maintenance agent (e.g. propofol or volatile) is stopped
infection may mean that emergency front of neck access in the and the patient allowed to wake up and breathe spontaneously.

BJA Education | Volume 17, Number 7, 2017 237

Postoperative management of the difficult airway

DAS Extubation Guidelines: ‘At risk’ algortithm

Step 1 Plan ‘At risk’ extubation

Ability to oxygenate uncertain
Plan extubation Assess airway and general risk factors Reintubation potentially difficult
and/or general risk factors present

Step 2 Optimize patient factors Optimize other factors

Prepare Cardiovascular Location
Prepare for Optimize patient and other factors Respiratory Skilled help / assistance
extubation Metabolic / temperature Monitoring
Neuromuscular Equipment
Key question: is it safe to remove the tube?

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Step 3
Perform Yes No
extubation

Advanced Techniques*
Awake 1 Laryngeal mask exchange Postpone
Tracheostomy
extubation 2 Remifentanil technique extubation
3 Airway Exchange Catheter

Step 4
Postextubation Recovery / HDU / ICU
care
Safe transfer Analgesia
Handover / communication Staffing
*Advanced techniques: require training and experience O2 and airway management Equipment
Observation and monitoring Documentation
General medical and surgical management

Difficult Airway Society Extubation Algorithm 2011

Fig 1 DAS extubation guidelines for the ‘At risk’ airway. Reproduced from Popat M, Mitchell V, Dravid R, Patel A, Swampillai C, Higgs A. Difficult Airway Society
Guidelines for the management of tracheal extubation. Anaesthesia 2012; 67: 318–340, with permission from the Association of Anaesthetists of Great Britain &
Ireland/Blackwell Publishing Ltd.

The dose is dependent on multiple factors and will need to be has been tolerated for up to 72 h.16 In general, it should be kept
titrated to effect (too low may result in coughing, too in until the complications that may lead to re-intubation have
high delayed recovery). A target controlled infusion dose of been ruled out.17 It is not advisable to administer oxygen via the
1.5 ng ml 1 was shown to reduce haemodynamic changes and AEC because of the risk of barotrauma and/or pneumothorax in
coughing in patients undergoing endoscopic sinus surgery.14 If the event of any outflow obstruction.
the infusion is discontinued after extubation, rapid metabolism A ‘staged extubation set’ has recently been introduced
by non-specific tissue esterases results in a clear wake up with (Fig. 2). It consists of a wire and catheter system where the wire
minimum haemodynamic disturbance and return of airway can be passed through the tracheal tube, which is then removed
reflexes. However, remifentanil may cause apnoeic episodes over it. The wire remains in place and the catheter can be rein-
and the patient will need close monitoring. troduced over the wire to then facilitate re-insertion of a tra-
cheal tube, if required. There have been reports of its
effectiveness as a means to reintubation.17
Airway exchange catheter/staged extubation
There is increasing evidence for the use of airway exchange
catheters (AECs) in patients with difficult airways.15 The AEC is
Keep asleep and transfer to ITU
a long hollow bougie that comes in several sizes and can be This may appear to be the safest option; however, there re-
placed into the trachea through the tracheal tube. The tracheal mains a risk of obstruction and displacement of the tracheal
tube is then removed and the AEC left in the airway with the tip tube. This may occur during transfer of the patient or in critical
at the level of the mid trachea. It is important that the catheter care during interventions such as turning the patient. If the pa-
remains above the carina, and the recommendation is that it tient has an oral tube with a narrow lumen or acutely angled
should not be inserted beyond 25 cm in an adult patient. The nasal tube, suctioning may prove difficult. This can allow a
AEC can then be used in the same way as a bougie to help re- build-up of secretions and eventual obstruction. These issues
intubate the trachea in case of deterioration. The correct pos- should be anticipated before transfer from theatre and, where
ition should be documented, and the AEC should be correctly possible, the tube exchanged to a larger (and preferably) oral
labelled and taped to the patient. A chest X-ray and capnogra- tube. While this can be a potentially hazardous procedure, it is
phy can be performed to confirm correct placement. It is usually important to use the expertise of the theatre team rather than
well tolerated by patients and has been used in head and neck risk tube blockage or displacement on the critical care unit. The
surgery in the postoperative recovery unit and on critical care. patient should be nursed head up and a positive fluid balance
The AEC can be left in for several hours after extubation and avoided to prevent accumulation of fluid in inflamed tissues.

238 BJA Education | Volume 17, Number 7, 2017

 Postoperative management of the difficult airway

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Fig 2 Staged extubation equipment (guide wire, catheter and securing device). Permission for use granted by Cook Medical, Bloomington, Indiana.

The depth of the tracheal tube should be assessed and docu- which may require an examination of the airway under
mented regularly; the position should be checked on chest X- anaesthesia.
ray and under direct vision if there is a concern about tube mi-
gration. Humidification of gases and capnography is now rou-
Laryngeal compromise
tine on critical care and should be used whilst the patient is
intubated. The cuff pressure should be tested to ensure exces- ‘Laryngeal compromise’ is caused by oedema and malfunction
sive pressure is not applied to the tracheal mucosa. The use of of the glottis and may be an indication of impending airway ob-
deep sedation and muscle relaxation should also be considered. struction20 (Fig. 3). It is seen in patients who have had surgical
A clear action plan is essential in case difficulties are encoun- drainage of dental abscesses and Ludwig’s angina. It can be a
tered (this may involve transferring the patient to theatre where subtle sign, such as a postoperative sore throat which may then
a more complete range of options is available). progress to deterioration in voice quality (soft, hoarse or barking
in nature), poor cough, pain, and difficulty swallowing, finally
resulting in stridor and orthopnoea, which are likely to be asso-
Tracheostomy ciated with a difficult tracheal intubation. The key to successful
The decision to perform a tracheostomy will depend on the management of these patients is close monitoring and early
need for longer-term airway protection, but may also have been intervention. There should be senior anaesthetist involvement
performed if tracheal intubation has failed or has been deemed because any delay may result in the need for advanced airway
too hazardous. The problems of displacement and obstruction techniques (e.g. fibreoptic intubation).
are the same as for a tracheal tube. There should be a clear bed-
head sign to identify whether the airway is a temporary trache-
Bleeding
ostomy or laryngectomy. There are clear guidelines for emer-
gency tracheostomy management in both cases.18 The type of Major bleeding (e.g. carotid blow out) or rapidly expanding
tracheostomy should also be identified (Slit, Bjork flap or percu- haematoma will, in most instances, require urgent interven-
taneous). For elective maxilla-facial surgery, the decision to per- tion. The removal of surgical skin clips may help improve a rap-
form a temporary tracheostomy or alternatively ‘overnight’ idly deteriorating airway. The patient will need to be
intubation is contentious and will usually depend on local transferred to theatre, and a small tracheal tube may be needed
practice. to re-intubate because of airway oedema. Valsalva manoeuvres
should be avoided in ‘at risk’ patients (e.g. radical neck
dissection).
Postoperative airway problems
Post extubation stridor Obstructed tracheal tube/tracheostomy
The most common cause for immediate stridor Post extubation The presence of a tracheal tube or tracheostomy does not pre-
is oedema from trauma to the airway. This can be managed by vent problems with the airway from occurring. The use of regu-
sitting the patient up, giving nebulized epinephrine and i.v. lar suctioning and humidified oxygen may help prevent
steroids—a dose of 5 mg dexamethasone before extubation has secretions from building up. If there is a concern that the tube is
been shown to reduce laryngeal oedema.19 If there is a concern obstructed or dislodged then expert help should be immediately
that the airway is deteriorating then a surgical cause must be sought and the documented action plan activated with early in-
ruled out (this includes blood clot or retained throat pack), volvement of the surgical team.

BJA Education | Volume 17, Number 7, 2017 239

Postoperative management of the difficult airway

Mechanism Laryngeal compromise Management

symptoms/signs

Close observation in a
Sore throat
high dependency area

Sore throat +
Oedema/inflammation of the glottis region change in voice Consider tracheal

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causing poor vocal cord function (soft, hoarse, or barking in intubation
nature)

Sore throat + Tracheal intubation

Increasing oedema/inflammation of the glottis
change in voice + recommended
region causing poor vocal cord function
poor cough

Severe displacement and malfunctioning

Sore throat + change in
of the tongue during swallowing; Tracheal intubation now
voice + poor cough +
oedema/inflammation of the glottic region with critical and likely to
pain and/or difficulty in
poor vocal cord adduction and epiglottic be very difficult
swallowing
movement during swallowing

Tracheal intubation likely

Sore throat + change in voice
to very difficult +
Severe airway compromise from + poor cough +
emergency surgical
supraglottic and glottic oedema drooling +
airway needs to be
stridor + orthopnoea
considered as well

Fig 3 Signs and symptoms of laryngeal compromise with suggested clinical management. Reproduced from Anaesthesia and Intensive care with the kind permission of
the Australian Society of Anaesthetists.20

Post obstructive pulmonary oedema opening and clearing the oropharynx, applying CPAP with 100%
oxygen, followed by deepening of anaesthesia usually with an i.v.
This occurs most commonly at the end of surgery when the pa-
anaesthetic agent. The use of a short-acting muscle relaxant such
tient attempts to breath against a closed airway (e.g. biting on
as succinylcholine may also be required. If significant laryngo-
tracheal tube). The negative intrathoracic pressures generated
spasm occurs, then re-intubation should be considered.
can cause pulmonary oedema and further hypoxaemia. The use
of airway adjunct and bite blocks reduces this risk. Treatment is
based on relieving the cause of the obstruction (this may in- Mediastinitis
clude deflating the tracheal tube cuff so that the patient can
breathe around it). The use of CPAP may help; however, re- The risk of mediastinitis is high in patients who have Ludwig’s
intubation must not be delayed if there is significant hypoxia. If angina and deeper infection of the airway. The high mortality
the patient is managed with early re-intubation and ventilation associated with mediastinitis warrants an elevated index of
then a full recovery is likely. The incidence is higher in muscu- suspicion. The clinical picture is one of deep airway infection
lar patients where very high negative pressure can be (stridor, dysphagia, neck rigidity) with systemic toxicity and
generated. sub-sternal chest pain. The early use of MRI postsurgery will
help target surgical treatment/intervention.

Laryngospasm
This usually occurs because of stimulation during a light plane of
Management of the difficult airway on ITU
anaesthesia but may also occur because of blood, secretions, and The majority of patients with head and neck pathology where
foreign bodies (e.g. retained throat pack). The treatment includes there is serious concern about the postoperative airway will be

240 BJA Education | Volume 17, Number 7, 2017

 Postoperative management of the difficult airway

managed on the ICU. The key to successful management is good recovery 2015: Association of Anaesthetists of Great Britain
communication between all members of the multidisciplinary and Ireland. Anaesthesia 2016; 71: 85–93
team. There should be a clear verbal and written handover. Key 8. Miller RL, Cole RP. Association between reduced cuff leak
points to communicate include: a description of the problem and volume and postextubation stridor. Chest 1996; 110: 1035–40
how it was managed; surgical and anaesthetic interventions that 9. Ochoa ME, Marın Mdel C, Frutos-Vivar F et al. Cuff-leak test
may have affected the airway; the current state of the airway; on- for the diagnosis of upper airway obstruction in adults: a
going management plan; and importantly, who to call if the air- systematic review and meta-analysis. Intensive Care Med
way deteriorates. The use of bed-head signs with suggested 2009; 35: 1171
airway management and the availability of difficult airway equip-
10. Pluijms WA, van Mook WN, Wittekamp BH, Bergmans DC.
ment are essential. The decision on whether to manage postoper-
Postextubation laryngeal edema and stridor resulting in
ative difficult airway interventions on the ICU or in theatre will
respiratory failure in critically ill adult patients: updated
depend on the clinical problem, equipment available, the urgency
review. Crit Care 2015; 19: 295
of the situation, the expertise available, and the relative proximity

Downloaded from https://academic.oup.com/bjaed/article-abstract/17/7/235/2999282 by guest on 28 January 2020

11. MacDonnell SP, Timmins AC, Watson JD. Adrenaline admin-
to theatres. When possible, consideration should be given to
istered via a nebulizer in adult patients with upper airway
transferral of the patient to theatre where an airway strategy can
more easily be deployed with trained support staff and equipment obstruction. Anaesthesia 1995; 50: 35–6
ready to hand. 12. Patel A, Nouraei SA. Transnasal Humidified Rapid-
Insufflation Ventilatory Exchange (THRIVE): a physiological
method of increasing apnoea time in patients with difficult
Declaration of interest
airways. Anaesthesia 2015; 70: 323–9
None declared. 13. Spoletini G, Garpestad E, Hill NS. High-flow nasal oxy-
gen or non-invasive ventilation for post extubation
MCQs hypoxemia. Flow vs Pressure? [Editorial]. JAMA 2016; 315:
1340–2
The associated MCQs (to support CME/CPD activity) can be
14. Nho JS, Lee SY, Kang JM et al. Effects of maintaining a remi-
accessed at https://access.oxfordjournals.org by subscribers to
fentanil infusion on the recovery profiles during emergence
BJA Education.
from anaesthesia and tracheal extubation. Br J Anaesth 2009;
Dec; 103: 817–21
References 15. Mort TC. Continuous airway access for the difficult extuba-
1. Frerk C, Mitchell V, McNarry A et al. Difficult Airway Society tion: the efficacy of the airway exchange catheter. Anesth
2015 guidelines for management of unanticipated difficult Analg 2007; 105: 1357–62
intubation in adults. Br J Anaesth 2015; 115: 827–48 16. Cooper RM. The use of an endotracheal ventilation catheter
2. Gleeson S, Groom P, Mercer S. Human factors in complex in the management of difficult extubations. Can J Anaesth
airway management. BJA Education 2015; 16: 191–7 1996; 43: 90–3
3. Cook TM, Woodall N, Frerk C. Major complications of airway 17. Corso RM, Cattano D, Maitan S. Experience using a new
management in the UK: results of the 4th National Audit staged extubation kit in patients with a known difficult air-
Project of the Royal College of Anaesthetists and the way. Anaesth Intensive Care 2015; 43: 137–8
Difficult Airway Society. Part 1: anaesthesia. Br J Anaesth 18. McGrath BA, Bates L, Atkinson D, Moore JA. Multidisciplinary
2011; 106: 617–31 guidelines for the management of tracheostomy and laryng-
4. Peterson GN, Domino KB, Caplan RA, Posner KL, Lee LA, ectomy airway emergencies. Anaesthesia 2012; 67: 1025–41
Cheney FW. Management of the difficult airway: a closed 19. Lee CH, Peng MJ, Wu CL. Dexamethasone to prevent post
claims analysis. Anesthesiology 2005; 103: 33–9 extubation airway obstruction in adults: a prospective,
5. Popat M, Mitchell V, Dravid R, Patel A, Swampillai C, Higgs A. randomized, double-blind, placebo-controlled study. Crit
Difficult Airway Society Guidelines for the management of Care 2007; 11: R72
tracheal extubation. Anaesthesia 2012; 67: 318–40 20. Greenland KB, Acott C, Segal R, Riley RH, Merry AF. Delayed
6. Patel A. Facemask ventilation before or after neuromuscular airway compromise following extubation of adult patients
blocking drugs: where are we now? Anaesthesia 2014; 69: 801–15 who required surgical drainage of Ludwig’s angina: com-
7. Checketts MR, Alladi R, Ferguson K et al. Recommendations ment on three coronial cases. Anaesth Intensive Care 2011; 39:
for standards of monitoring during anaesthesia and 506–8

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