Abstract
The coronavirus disease-19 (COVID-19) pandemic has prompted new interest among anesthesiologists and intensivists in controlling coughing and expectoration of potentially infectious aerosolized secretions during intubation and extubation. However, the fear of provoking laryngospasm may cause avoidance of deep or sedated extubation techniques which could reduce coughing and infection risk. This fear may be alleviated with clear understanding of the mechanisms and effective management of post-extubation airway obstruction including laryngospasm. We review the dynamic function of the larynx from the vantage point of head-and-neck surgery, highlighting two key concepts:1. The larynx is a complex organ that may occlude reflexively at levels other than the true vocal folds;2. The widely held belief that positive-pressure ventilation by mask can “break” laryngospasm is not supported by the otorhinolaryngology literature.We review the differential diagnosis of acute airway obstruction after extubation, discuss techniques for achieving smooth extubation with avoidance of coughing and expectoration of secretions, and recommend, on the basis of this review, a clinical pathway for optimal management of upper airway obstruction including laryngospasm to avoid adverse outcomes.
Highlights
BackgroundThe advent of the novel severe acute respiratory coronavirus 2 (SARS-CoV-2) and the ensuing coronavirus disease-19 (COVID-19) pandemic have transformed routine intubation and extubation of the trachea in affected patients into hazardous procedures during which the highly contagious virus has the potential to become aerosolized
We review the differential diagnosis of acute airway obstruction after extubation, discuss techniques for achieving smooth extubation with avoidance of coughing and expectoration of secretions, and recommend, on the basis of this review, a clinical pathway for optimal management of upper airway obstruction including laryngospasm to avoid adverse outcomes
When trainees in anesthesiology are queried about their level of knowledge concerning the diagnosis and treatment of laryngospasm, the authors frequently have encountered the following responses: 1. Laryngospasm is defined as sudden closure of the vocal cords; 2
Summary
The advent of the novel severe acute respiratory coronavirus 2 (SARS-CoV-2) and the ensuing coronavirus disease-19 (COVID-19) pandemic have transformed routine intubation and extubation of the trachea in affected patients into hazardous procedures during which the highly contagious virus has the potential to become aerosolized. To protect the airway during swallowing, the intrinsic muscles close the larynx at all three levels, superior to inferior - the laryngeal inlet including the epiglottis, the false cords, and the true vocal cords. The moment of greatest risk of upper airway obstruction, whether from laryngospasm or other causes, is the same for deep or awake extubation: it occurs when the endotracheal tube is removed [13,24]. In a patient of any age who is making vigorous effort to breathe spontaneously but is not achieving effective air exchange, immediate attempts to ventilate with positive pressure by mask may only make airway closure worse and risk inflating the stomach [9,12]. The successful diagnosis and management of upper airway obstruction depend on rapid analysis of whether the obstruction is complete or partial, and application of appropriate stepwise actions to open the airway and ensure ventilation
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