Alhaj Zachrieh, Almubaid Zaid, Irshad Omayr, Choucair Gilan, Mohamed Sharif
Medicine, John Sealy School of Medicine, University of Texas Medical Branch, Galveston, USA.
Anesthesiology, John Sealy School of Medicine, University of Texas Medical Branch, Galveston, USA.
Cureus. 2024 Aug 31;16(8):e68293. doi: 10.7759/cureus.68293. eCollection 2024 Aug.
Laryngeal edema, a frequent manifestation of acute inflammation, is particularly significant due to the potential obstruction of the laryngeal orifice caused by swelling of the epiglottis and vocal cords. This presents as a risk factor that can lead to severe airway obstruction. Traditionally, deep extubation is the preferred form of extubation because it is more comfortable for the patient, eliminates the airway reflexes, and minimizes the risk of laryngeal edema. Difficult mask ventilation (DMV), characterized by an unassisted anesthesiologist's inability to maintain oxygen saturation levels above 92% or to prevent or correct signs of inadequate ventilation during positive-pressure mask ventilation under general anesthesia, necessitates an awake extubation approach. In the following case, combining the need to minimize airway reflexes through a deep extubation with the need for an awake intubation required an alternative method. Our patient is a 10-year-old male who presented with obstructive sleep apnea and tonsillar hypertrophy. The patient had a history of snoring and difficult intubation (three attempts), classifying him as a DMV risk. However, due to the difficult intubation, there was concern for laryngeal edema following the procedure that would necessitate a deep extubation. To effectively combine the two procedures, a retrograde lidocaine spray was used to numb the airway, which would allow for awake extubation without the associated coughing and bucking. Deep extubation is a common anesthetic technique used in laryngeal surgeries, but it is often not an option for high-risk patients. For such patients, awake extubation is an alternative. In our case, our patient was at high risk for laryngeal edema. In awake extubation, lidocaine spray is used for minimal coughing and bucking because it numbs the upper airway and allows the patient to tolerate the breathing tube without stimulating the gag reflex. The use of retrograde lidocaine spray for awake extubation in patients at high risk for laryngeal edema presents a promising alternative to traditional methods. This case demonstrates the effectiveness of retrograde lidocaine spray in awake extubation to reduce coughing and bucking by numbing the upper airway in a DMV situation while also avoiding complications in a high-risk patient.
喉水肿是急性炎症的常见表现，由于会厌和声带肿胀可能导致喉口阻塞，因而尤为严重。这是一个可能导致严重气道阻塞的危险因素。传统上，深拔管是首选的拔管方式，因为它让患者更舒适，消除气道反射，并将喉水肿风险降至最低。困难面罩通气（DMV）的特征是，在全身麻醉下进行正压面罩通气时，麻醉医生无法在无辅助的情况下将氧饱和度维持在92%以上，或无法预防或纠正通气不足的体征，这就需要采用清醒拔管方法。在以下病例中，既要通过深拔管将气道反射降至最低，又需要清醒插管，这就需要一种替代方法。我们的患者是一名10岁男性，患有阻塞性睡眠呼吸暂停和扁桃体肥大。该患者有打鼾和插管困难史（三次尝试），属于DMV风险患者。然而，由于插管困难，担心术后会出现喉水肿，需要进行深拔管。为了有效结合这两种操作，使用了逆行利多卡因喷雾使气道麻醉，这样就可以进行清醒拔管，而不会出现相关的咳嗽和挣扎。深拔管是喉部手术中常用的麻醉技术，但对于高危患者来说往往不是一个选择。对于这类患者，清醒拔管是一种替代方法。在我们的病例中，我们的患者发生喉水肿的风险很高。在清醒拔管中，使用利多卡因喷雾可减少咳嗽和挣扎，因为它能使上呼吸道麻醉，让患者耐受呼吸管，而不会刺激咽反射。对于有喉水肿高风险的患者，使用逆行利多卡因喷雾进行清醒拔管是一种有前景的传统方法替代方案。本病例证明了逆行利多卡因喷雾在清醒拔管中通过使上呼吸道麻醉来减少咳嗽和挣扎的有效性，适用于DMV情况，同时也避免了高危患者出现并发症。
