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CRNA 150 | Post-Extubation Emergencies

In this third episode with our guest host David Warren, he explores post-extubation emergencies that would require your attention. Tune in as he discusses laryngospasm, the most common emergency you will encounter after such a procedure. David presents several ways to address it as quickly as you can. He also talks about treating post-extubation obstructions and the importance of ensuring that the patient is breathing properly before moving them to PACU.

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Emergence And Extubation: Waking Someone Up From Anesthesia Part 3 Post-Extubation Emergencies

I have a very special episode lined up for you, and it is part of our guest host series where I am bringing SRNAs on the show for you as a guest host on the show. My thought process behind doing this is I wanted you to learn from a variety of students who are at different stages of their CRNA journey, step into their world, and learn about what it’s like to be a current student dealing with things like difficult preceptors, anesthesia topics, clinical topics, and maybe even things like time management, stress management, and things like that. These episodes are going to be gold. I hope you enjoy them as much as I always do, hearing from current students.

I know for a fact that the reason why CRNA School Prep Academy is where it is now and the reason why I have learned so much is from diving all in, listening to current students along with CRNAs, sharing a wealth of information, taking all of that information, and compiling it into the system that we have created. I know that you are doing the same thing by tuning in to the show week after week and developing your own method, strategy, and system for success. I hope you enjoy these guest episodes. Let’s go ahead and get into this episode.

I’m David Warren and welcome back to this episode of the show. I will be your guest host. We are wrapping up with our Part 3 of Emergence and Extubation. If you haven’t tuned in or seen the first two parts, go back and check those out. This might make a little more sense. Part 1 deals with Deep Extubations. Part 2 deals with Awake Extubations and the variations that go with those techniques of waking a patient up. We are going to talk about some of the most common things that you might see post-extubation that would require your immediate attention. We are talking about those post-extubation nightmares and things that we would want to be aware of after we pull the ET tube out of the patient.

The first thing I want to mention to you is to make sure the patient is extubatable. In 80% to 90% of the surgeries that we do, you are going to extubate the patient. You are going to extubate your lap choles and your lap apes, and all of the typical general surgery things that we do, unless for some reason the patient can’t come off the ventilator because they are not breathing. Whatever that may be, you may have to leave them intubated, but for the vast majority, you will extubate in the OR.

Whenever you get to your specialty cases like neurosurgery, cardiac surgery, and things like that, just make sure that the patient is extubatable. Verify with a surgeon if you are doing an open craniotomy for a brain tumor, “Do you want the patient intubated or do you want me to extubate here in the OR?” The surgeon will communicate and tell you exactly what they want.

Just verify. Before you get to the end of the case, you haven’t talked to anybody about it and you are trying to extubate the patient, make sure that the surgeon wants the patient extubated or that the patient needs to be extubated. If they come to you intubated from the ICU, typically we won’t extubate those patients. We will send them back to the ICU intubated and let the ICU extubate the patient whenever they want to. Verify that the patient is extubatable.

All of those things at the end of the case that we have talked about in the other two episodes. If you are going to extubate the patient, make sure they are pulling good tidal volumes, have good minute ventilation, and have a good respiratory rate. They are fully reversed from their muscle relaxant. Make sure that they meet all those criteria to extubate the patient before you try to pull that tube. Just common sense type things.

Laryngospasm

Now we are going to move on to some of the things that we might see post-extubation that we would want to be aware of. The first of those is a laryngospasm. Laryngospasm is essentially where the musculature that controls the vocal cord movement during stage two anesthesia and the period of hyperreactivity, those muscles will spasm and contract and slam the cord shut. That prevents the movement of air.

Essentially, whenever you have cords that are closed completely and a patient is trying to breathe against a closed glottis, you can have negative pressure pulmonary edema, which could potentially be lethal to the patient. That’s the main thing that we worry about during extubation. You can get a laryngospasm during your induction, especially if you are doing a mask induction for a pediatric patient or even for an adult patient for whatever reason. You could get a laryngospasm during induction. However, it’s most commonly associated with emergence and extubation. That’s where we see that.

Going back to our first two episodes, we want to get the patient either through stage two before we pull the tube or pull the tube when they are super deep so they go through stage two naturally. You don’t want to pull the tube when they are in stage two anesthesia period of hyper-reactivity, their breath holding, they are tachycardic, they have nystagmus, and their eyes are pointing in opposite directions. All of those things would let us know that we are in that period of hyper-reactivity stage two anesthesia. We don’t want to pull the tube now unless you want to deal with the laryngospasm.

That’s what a laryngospasm is and why we want to avoid it. For our scenario, we have been saying we have a 40-year-old who is getting a laparoscopic cholecystectomy. Let’s say for this particular scenario that we are going to wake the patient up. This is a common thread, honestly. We are going to wake the patient all the way up for whatever reason.

We have reversed our paralytic. We have put in an oral airway and we have suctioned out well. The patient’s on 100% FiO2, she’s pulling good volumes, and she has good minute ventilation and good respiratory rate, not insignificant pain based on the vital signs we see and based on our ventilator settings. Most of the gas is blown off. She’s at maybe 0.2 MAC. She is coughing and bucking a little bit on the tube and trying to reach her hand up to pull the tube out.

At this point, it’s safe to say she’s probably fine for extubation. We will deflate our cuff, pull our tube out, and hold our mask on to see if we are exchanging with the patient. We are holding our masks on and some signs and symptoms. Some things that we would see letting us know that the patient may be having a laryngospasm would be things like breath holding.

She’s not moving any air at all. After we put our mask on the patient, we are looking for fogging. We will see that mist in the mask, or we can look over at our monitor and see that there’s positive end-tidal CO2. If you are having a laryngospasm, you are not going to see any of that. You are not going to see any exchange at all. The patient may be trying to breathe, but since they are trying to breathe against a closed glottis, there’s no exchange of CO2 and oxygen. You are not going to see any end-tidal CO2 on there and you are not going to see any mist or fogging in the mask, but you will see the patient trying to breathe.

To determine if a patient is having laryngospasm, they are either holding their breath or not moving any air at all. Click To Tweet

You will see them trying to pull with their accessory muscles on their chest. You will see maybe some pulling here around the supraclavicular region. All of those things may be letting you know, “This patient is in spasm.” Those are the things that we want to watch out for. That’s why it’s so important that after you extubate your patient, it’s not just holding the mask, waiting for the bed to come in, and moving the patient over.

It’s truly after extubation, hold the mask and make sure the patient is moving air. We will look at the mask. Are they fogging? Are they misting? Do they have chest rise and fall? Do they have any pulling or tugging in the supraclavicular region? Are they exchanging? Do you see positive end-tidal CO2? If you don’t see positive end-tidal CO2, make sure you have a good seal because chances are maybe there’s a little leak around the mask. Make sure you are doing either a two-handed mask or a jaw thrust and you have a good seal. That way you can see if you have positive end-tidal CO2.

Let’s say we have done all those things. We don’t see any positive end-tidal CO2. The patient is tugging in the supraclavicular region and they are not exchanging any errors. At this point, it’s reasonable to go down our pathway of treating a laryngospasm. The most common reason that we would see a laryngospasm is there’s something irritating around the glottis, and usually before we extubate the patient, it’s the ET tube. When your ET tube is in place, those cords can’t snap shut because you have a tube there preventing that. You have a secure airway.

Even if they are in a laryngospasm, when the tube is in, the cords aren’t going to close because there’s no way for them to close because there’s a tube there. However, all bets are off whenever the tube is out that the cords will snap shut. After the cords have snapped shut, usually it’s because there’s some irritation in the airway.

Applying Positive Pressure

The first thing you could do is suction the patient out again. You hunker down the throat, suction out well, pull back out, and then do some positive pressure. We will either hold the mask on with one hand, crank your APL down, and provide some positive pressure. Typically, we will crank our APL down to 50 and then provide some good positive pressure, or you can do a two-handed mask, hold a good seal, crank your APL to 70, and hold it there, and then you can have the nurse come over and squeeze the bag for you if you don’t have a second set of hands. If you are getting a good seal, you could hold the mask yourself, crank it down a little further, and provide some positive pressure ventilation.

Suctioning out positive pressure ventilation. Those are the first two things we would think about in treating a laryngospasm. The positive pressure, I would say, at least in my practice so far, which has only been almost a year as a nurse anesthesia resident, positive pressure will take care of it. Usually, positive pressure a couple of times will break that spasm, and then you are good to go, and then turn your APL back to open, hold the mask, and see if you are exchanging.

A woman laying in a hospital bed, wearing an oxygen mask
Post-Extubation Emergencies: The first two things to do when treating laryngospasm is suctioning out and positive pressure ventilation.

Performing Larson’s Maneuver

If you are exchanging, then you know you have broken your spasm. Let’s say that doesn’t work. Let’s say you try positive pressure ventilation and it’s not working. The next step would be to do what we call a Larson’s maneuver. That’s where you are holding a two-handed mask and you are using either your index fingers or your two middle fingers while you are holding the mask on, and you want to press hard on both sides and what we call the laryngospasm notch.

It’s behind the earlobe here at the corner of the mandible, and you want to push hard right there on both sides as you are holding that mask. Push hold for about three seconds and then let go. Push hold for about 3 or 4 seconds and then let go, and then do it again. Do it 2 or 3 times, and I’m talking about pushing hard. Put some good pressure in that notch there.

Deep In Anesthesia

That will break the spasm if the positive pressure does not. After you do that, hold your two-handed mask, and see if the patient is exchanging. At this point, doing what we call the Larson’s maneuver pressuring that laryngospasm notch will usually break the spasm. If that doesn’t break the spasm, then we would need to go down to deepen the anesthetic pathway.

We would want to deepen the anesthetic. Turning on the gas isn’t a good way to deepen the anesthetic because if they are in spasm, their cords snap shut. The gas can’t get to the lungs to get to the brain anyway. We would use something like propofol. This is why we always have an extra stick of propofol handy. Usually, we give about 1 mg/kg of propofol or anywhere from 50 to 70 milligrams for an adult.

A person holding their side as if they're in pain
Post-Extubation Emergencies: Turning on the gas isn’t a good way to deepen the anesthetic. If the patient is in spasm, their chords snap shut and the gas cannot get to the lungs and the brain.

If you are still in spasm now and you are not exchanging at all and so end-tidal CO2, at this point, hopefully, you have pre-oxygenated the patient. This is during emergence and extubation. Hopefully, you pre-oxygenated the patient. Meaning before you pull the tube, you have to put them on 100% FiO2, so their end-tidal oxygen is 80% to 90%.

That’s going to buy you in a normal non-obese person like 7 to 9 minutes of apnea time before they start to DSAT. You have theoretically 7 to 9 minutes in a normal person, not significantly obese, with no medical problems, somebody that doesn’t have significant respiratory pathology. You have bought yourself a lot of time to deal with this.

That’s why we turn our FiO2 to 100% before we extubate because we want that FRC to be filled with 100% oxygen and not nitrogen so that if something like this happens, you have bought yourself some time. You have bought yourself 5 or 7 minutes of apnea so there’s still 100%. You have bought yourself a lot of time to deal with an emergency like this. That’s why we put the patient on 100% FiO2.

Administering Propofol

After we have deepened the anesthetic, usually that will work. Get the patient deep again to where those muscles relax, and then you can exchange. At that point, let them wake up again and hopefully, they will be over that spasm. Let’s say that doesn’t work. We have deepened our anesthetic and we have given propofol. Let’s say we have given 70 of propofol, the patient’s still in spasm. You could choose to deepen it more.

Maybe you could give another 100 milligrams of propofol. Put the patient out. These are getting towards intubating conditions without paralytic. Give them another dose of propofol and then see if you can break that spasm. All the while we are providing positive pressure ventilation, trying to break that spasm, and we are putting pressure in that laryngospasm notch, so we are doing Larson’s maneuver, all of that to try to break the spasm.

I have never gotten to this point of not breaking a spasm. I’m sure that happens. It’s not just super common that you have to get to this point in the pathway to break the spasm. At this point, you should have already called for help. Get another set of hands in the room to help you troubleshoot and go down that pathway of breaking a now significant spasm.

A Small Dose Of Hexachlorine

As I said earlier, usually, if you do have a spasm, it’s easily broken with some positive pressure ventilation, some suction, or some Larson’s maneuver. That breaks 90% of the spasms. If you get to the point where you have to deepen the anesthetic and you are given a bunch of propofol and they are still in spasm, the next step would be to give a very small dose of succinylcholine.

This is also why sucs is one of our emergency drugs, not just for RSI but for laryngospasm. We would give anywhere from 10 to 20 milligrams of succinylcholine IV to try to break the spasm. That’s just enough relaxant to make those muscles relax in the airway so that you are out of spasm and you can exchange air. It’s not enough muscle relaxant to completely paralyze the patient.

Reintegrating The Patient

It’s very important that we are not giving 100 or 200 milligrams of sucs unless you need to down the road. You are giving 10 to 20 milligrams to break the spasm, 0.5 CC to 1 CC of succinylcholine to break the spasm. Let’s say we do that and that doesn’t work. You have tried everything you can. You have suctioned the patient. You have tried positive pressure ventilation. You have tried Larson’s maneuver, and you have deepened the anesthetic with propofol, you have given sucs, and it’s still not working.

The only other option is to re-intubate the patient, in which case we would give the rest of the sucs. Depending on whatever weight-based dosing they have, usually, 100 sucs does the trick. Give 100 of propofol or whatever you have got leftover and then re-intubate the patient. Remember, you were giving propofol for maybe 2 minutes ago 70 to 100 milligrams. The patient is already out. You can safely give your sucs, follow it up with maybe a little more propofol, and then re-intubate the patient because that level of muscle relaxant will relax all the muscles in there and you will get a perfect view. Hopefully, they weren’t a difficult airway.

You will get a perfect view of your cords when you go to DL and you will re-intubate the patient. At this point, I would let the patient wake up to where they are trying to pull. They have opened their eyes, leaning up in bed, and trying to pull the tube about themselves. Essentially, let the patient self-extubate and you shouldn’t get another spasm. If you do get another spasm, you go down the same pathway again. Maybe leave them intubated.

That’s how you deal with a laryngospasm. After you have broken the spasm, let’s say 90% of them do, let’s say the positive pressure works and Larson’s maneuver work so you start exchanging again, hold that mask on, and make sure they are going to breathe for maybe a minute or two and make sure they are not going to re-spasm. Usually, once they have passed that stage two of anesthesia, they are not going to spasm again. Put a non-rebreather on. Tilt their head to the side, open their airway, and do all the things that you would normally do. Make sure you see misting and fogging that they are exchanging, and then you are good to go to PACU.

Post-Extubation Obstruction

That’s how you deal with one of the most common problems we see, a laryngospasm. That’s how you troubleshoot and deal with that. Another thing that we see post-extubation is a post-extubation obstruction. Usually, that’s from soft tissue and the neck-mouth region collapsing back because they are not fully awake yet.

Again, putting that oral airway in goes a long way, especially before you extubate the patient. Sticking that oral airway in, and then after you extubate the patient, holding that mask on. I always start with a jaw thrust. Do a good jaw thrust and see if they are exchanging. If they are exchanging there, go to a chin lift. If they are still exchanging there, then hold the mask on with a couple of fingers and make sure they are still exchanging.

Doing a jaw thrust to a patient is a good way to see if they are exchanging air. Click To Tweet

Then you know that they are not going to obstruct you as you are wheeling down to PACU. Holding that mask on without any support before you leave the OR will give you a very good inkling as to whether or not the patient’s going to obstruct or not. If they are obstructing, then go back to a chin lift and see if they are exchanging, and then if they are exchanging well there, you will know after you put the non-rebreather on, “I need to go to PACU holding a chin lift so the patient’s not apneic and obstructing to PACU.” I have seen patients still obstructed with a big 100-millimeter oral airway in place. Just know that even if the oral airway is in place, it still can obstruct.

At that point, you could also consider a nasal trumpet. Slide a nasal trumpet in, see if that fixes, see if that does anything for you. The main point that I want to get across to you is to do all of this before you wheel off to PACU because you don’t want to take, especially if you’re in a big PACU, if you are in a big OR, you are in a 30 or 40-bed OR; it feels like half a mile to get to PACU. You want to make sure that your patient is exchanging before you start that journey because you want to deal with everything in your own environment in the OR and your anesthesia machine is right there.

Deal with everything before you start making that journey to PACU. It will save you so much time and such a headache. If something were to happen on the way there, now you are in the middle of the hallway trying to break a spasm or now you are in the middle of the hallway dealing with a patient who’s apneic. You don’t have the equipment that you need. This goes back to being prepared. Do what you can in your environment, not on the way to PACU where you don’t have any equipment with you.

Those are some of the most common things, By certainly no stretch, those are all the things that you will see or all the things that could go wrong post-activation, but those are some of the most common things that you will see. Laryngospasm, how to deal with that, how to assess it, how to diagnose it, and how to treat it. As a post-extubation obstruction, make sure the patient is exchanging air before you leave.

Those are two of the most common things that we see post-extubation before we take the patient to PACU and how to recognize and treat it. If you have any questions, comment below, and let us know what they are. I would be happy to answer those for you. Thank you so much for tuning in to this episode on emergence and extubation. If you haven’t read the other two episodes, go check those out. This episode might make a little more sense after you tune in to those two episodes. Thanks again so much for tuning in and I will see you next time.

Important Links

Have you gained acceptance to CRNA school? Congratulations! Prepare with the #1 pre-anesthesia curriculum, as recommended by CRNA program faculty. Start the NAR Boot Camp today: https://www.cspaedu.com/bootcamp

FREE! CRNA School Interview Prep Guide: https://www.cspaedu.com/uc9a5ih4

Get access to planning tools, mock interviews, valuable CRNA Faculty guidance, and mapped-out courses that have been proven to accelerate your CRNA success! Become a member of CRNA School Prep Academy:  https://www.crnaschoolprepacademy.com/join

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