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Chapter: Clinical Anesthesiology: Anesthetic Management: Airway Management

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Problems Following Intubation

Following apparently successful intubation, several scenarios may develop that require immediate attention.

PROBLEMS FOLLOWING INTUBATION

Following apparently successful intubation, several scenarios may develop that require immediate atten-tion. Anesthesia staff MUST confirm that the tube is correctly placed with bilateral ventilation imme-diately following placement. Detection of end-tidal CO2 remains the gold standard in this regard, with the caveat that cardiac output must be present for end-tidal CO 2 production.

Decreases in oxygen saturation can occur fol-lowing tube placement. This is often secondary to endobronchial intubation, especially in small chil-dren and babies. Decreased oxygen saturation peri-operatively may be due to inadequate oxygen delivery (oxygen not turned on, patient not ventilated) or to ventilation/perfusion mismatch (almost any form of lung disease). When saturation declines, the patient’s chest is auscultated to confirm bilateral tube place-ment and to listen for wheezes, rhonchi, and rales consistent with lung pathology. The breathing cir-cuit is checked. An intraoperative chest radiograph may be needed to identify the cause of desaturation. Intraoperative fiberoptic bronchoscopy can also be performed and used to confirm proper tube place-ment and to clear mucous plugs. Bronchodilators and deeper planes of inhalation anesthetics are administered to treat bronchospasm. Obese patients may desaturate secondary to a reduced FRC and atelectasis. Application of positive end-expiratory pressure may improve oxygenation.

Should the end-tidal CO2 decline suddenly, pul-monary (thrombus) or venous air embolism should be considered. Likewise, other causes of a sudden decline in cardiac output or a leak in the circuit should be considered.

A rising end-tidal CO2 may be secondary to hypoventilation or increased CO 2 produc-tion, as occurs with malignant hyperthermia, sep-sis, a depleted CO 2 absorber, or breathing circuit malfunction.

Increases in airway pressure may indicate an obstructed or kinked endotracheal tube or reduced pulmonary compliance. The endotracheal tube should be suctioned to confirm that it is patent and the lungs auscultated to detect signs of broncho-spasm, pulmonary edema, endobronchial intuba-tion, or pneumothorax.

Decreases in airway pressure can occur second-ary to leaks in the breathing circuit or inadvertent extubation.

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