**General management:**

Before safe extubation of the difficult airway we should consider number of requirements that are necessary and should be met.

The following techniques are suggested for a wake extubation of the difficult airway [12] (**Table 3**):

Excessive use of opioid and incomplete reversal of neuromuscular blocking agents may result in airway obstruction leading to hypoxia [12].

Therefore, quantitative neuromuscular monitoring is recommended.


#### **Table 3.**

*Techniques to ease awake intubation in a difficult airway case.*

**Figure 17.**

*(A) AEC introduced through the endotracheal tube. (B) AEC left inside trachea. (C) reintubation over the AEC.*

## **Extubation:**

Patient with expected difficult airway, extubation preferred to be on the operating table with all needed equipment are available. Patients with some degree of laryngeal oedema after extubation they will benefit from the use of humidified oxygen and nebulized Epinephrine [13].

But in case of total airway obstruction this treatment is not effective and there is a great possibility for re-intubation. Remifentanil used at the end of surgery to prevent coughing and facilitate a wake extubation.

#### **Staged extubation with airway exchange catheters (AECs)**

The AEC is usually used for patients known or suspected to have difficult airway, it is used to facilitate re-intubation if needed. The AEC (which is a long hollow boogie) introduced through the endotracheal tube (ETT) before extubation, and then the ETT can be safely removed (**Figure 17**).

In case the patient needs to be re-intubated, the AEC will be used as a guide for the ETT. The AEC can be left in place and tolerated for up to 72 H [14], but usually it is kept for few hours and removed after the patient is stable, fully awake and breathing normally.

#### **Tracheostomy**

Tracheostomy operation done within some of maxillofacial operations and in major head and neck operations where postoperatively the airway is expected to be compromised or the patient cannot protect his airway [15].

Usually the tracheostomy is temporary and patient can be weaned after healing of the wound, subsiding of the reactionary oedema and swelling and the patient is able to secure his airway.

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*Airway Management in Head and Neck Pathology DOI: http://dx.doi.org/10.5772/intechopen.94498*

**5.5 Postoperative airway problems**

**Immediate stridor**

**Laryngeal compromise**

tracheal tube may be needed [12].

ing the patient to breathe around it.

extubation [17].

these patients [12]. **Bleeding**

if needed.

not be delayed.

**Laryngospasm**

**Transferring the patient to intensive care unit (ICU)**

If you are going to transfer the patient to the ICU with the endotracheal tube in,

Oedema from trauma to the airway is the most common cause for immediate stridor post extubation. This can be avoided by sitting the patient up, giving a dose of 8 mg Dexamethasone i.v. and also giving nebulized Epinephrine before

If the stridor persists and patient is deteriorating, you should examine the airway under anesthesia to rule out other causes as blood clot or retained throat pack.

This is due to oedema and malfunctions of the glottis and can lead to airway obstruction. It is usually happened after Ludwig's angina or dental abscesses drainage. It can start with postoperative sore throat and then progress to hoarseness of voice, weak cough, deep throat pain, and odynophagia, finally end with stridor, this situation usually will be associated with a difficult intubation. Close monitoring and early intervention are the key to early prediction and successful management of

In case of major bleeding as carotid blow out or rapidly expanding haematoma

The removal of surgical skin clips may help to reduce airway deterioration. The patient should be immediately transferred to theater, and re-intubated with a small

Usually the obstruction of either tube is due to thick secretion or clotted blood, regular suction and the use of humidified oxygen helps to prevent tube obstruction. Extra care to be taken to support the tube during moving or changing patient position. If there is a concern that the tube is obstructed or dislodged then immediate activation of documented action plan with early involvement of the surgical team

This commonly happened in the immediate postoperative time when the patient

Using CPAP may help; but, if there is significant hypoxia, re-intubation should

Early management with re-intubation and ventilation will help for full recovery [12].

Usually most of patients with head and neck pathology with high concern about the postoperative airway will be managed on the ICU. Suggestions for successful

It usually happened due to stimulation during a light plane of anesthesia but may occur due to blood, secretions or foreign body in the larynx. The management is by clearing the oropharynx, applying CPAP with 100% oxygen, followed by deepening of anesthesia by an i.v. anesthetic agent. Also using short-acting muscle relaxant as Succinylcholine may be needed. But in case of significant laryngospasm,

the patient requires urgent surgical and anesthetic intervention [12].

**Post obstructive negative pressure pulmonary oedema**

re-intubation will be the proper immediate action [12]. **ICU Management of the difficult airway**

**Obstruction or dislodgment of tracheal tube or tracheostomy tube**

is trying to breathe while the airway is closed as he is biting on tracheal tube. This will create negative intrathoracic pressures, and this will lead to pulmonary oedema. Using bite blocks can reduce this risk. Deflating the cuff of the tube allow-

extra care to be taken to support the tube and avoid tube dislodgment [16].
