Treatment of upper airway oedema prior to extubation
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Laryngeal or upper airway mucosal oedema is a common cause of airway obstruction after extubation and is thought to arise from direct mechanical trauma to the larynx by the endotracheal tube (ETT) or due to prolonged surgery. Upper airway oedema predisposes the patient to post-operative airway obstruction. It presents mostly as post-extubation stridor and at times warrants post-operative elective ventilation. The treatment involves parenteral administration of corticosteroids, epinephrine nebulisation and inhalation of a helium and oxygen mixture. Common practice is to attach a small volume Hudson nebuliser to the venturi mask after extubation with the patient propped up. However, Hudson nebuliser needs to be placed vertically for effective nebulisation and this is feasible only when the patient is in upright sitting posture which is not always possible in the immediate post-operative period. This limits effective nebulisation of the upper airway, and patients develop stridor on extubation even requiring intubation. A better option would be to reduce upper airway oedema before extubation. In patients without difficult airway except for risk of laryngeal oedema during extubation such as foreign body bronchus or microlaryngeal surgery, the tube can be replaced with laryngeal mask airway (LMA) while the patient is still anaesthetised (Bailey's Manoeuvre) and a T-piece connector is attached to the LMA for connecting a low volume gas driven nebuliser. LMA will ensure that nebulised epinephrine is directed and deposited in and around the laryngeal structures....
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