What is the management for wheezing after extubation?

Management of Wheezing After Extubation

For wheezing after extubation, apply continuous positive airway pressure with 100% oxygen via facemask while ensuring patent airway, followed by nebulized albuterol (2.5 mg) if wheezing persists. 1

Initial Assessment and Management

When wheezing occurs after extubation, follow this stepwise approach:

1. Immediate interventions:

   • Call for help if symptoms are severe
   • Apply continuous positive airway pressure (CPAP) with 100% oxygen using reservoir bag and facemask
   • Ensure upper airway patency
   • Avoid unnecessary upper airway stimulation which may worsen symptoms 1

2. If wheezing persists:

   • Administer nebulized albuterol (2.5 mg in 3 mL) via nebulizer 2, 3
   • Consider ipratropium bromide (0.5 mg) combined with albuterol in the nebulizer for enhanced bronchodilation 4

Management of Severe Cases

For severe wheezing with significant respiratory distress:

1. For laryngospasm-related wheezing:

   • Perform Larson's maneuver: place middle fingers in the "laryngospasm notch" between posterior mandible border and mastoid process while displacing mandible forward in jaw thrust 1
   • If oxygen saturation falls or symptoms persist: administer propofol (1-2 mg/kg IV) 1
   • For severe cases with worsening hypoxia: suxamethonium 1 mg/kg IV (or 2-4 mg/kg IM/intralingual if no IV access) 1

2. For bronchospasm-related wheezing:

   • Repeat nebulized albuterol treatments every 20-30 minutes as needed 2, 3
   • Consider IV magnesium sulfate for severe bronchospasm unresponsive to initial treatments 5
   • Monitor for post-obstructive pulmonary edema, which can develop from forceful inspiratory efforts against obstructed airways 1

Monitoring and Follow-up

After initial management:

• Continue oxygen administration during transfer to recovery
• Maintain close monitoring of respiratory rate, heart rate, blood pressure, and oxygen saturation
• Consider capnography to aid early detection of airway obstruction 1
• Watch for warning signs including stridor, obstructed breathing pattern, and agitation 1

Prevention Strategies

To prevent post-extubation wheezing:

• Consider prophylactic use of albuterol spray 20 minutes before extubation in patients with history of reactive airway disease or COPD 5
• Ensure upper airway is clear of debris by suctioning under direct vision while patient is still deeply anesthetized 1
• Consider topical lidocaine on vocal cords to reduce risk of laryngospasm 1

Important Considerations

• Wheezing after extubation may be due to laryngospasm, bronchospasm, or post-obstructive pulmonary edema
• Patients with history of asthma or COPD are at higher risk of post-extubation wheezing 3, 5
• Post-obstructive pulmonary edema presents with dyspnea, agitation, cough, pink frothy sputum, and low oxygen saturations 1
• Never ignore a patient who complains of difficulty breathing, even if objective signs are absent 1

The Difficult Airway Society guidelines emphasize that appropriate equipment, monitoring, and personnel should be available throughout the post-extubation period to manage potential complications like wheezing and laryngospasm 1.