What is the management of respiratory failure during anesthesia?

Management of Respiratory Failure During Anesthesia

The most effective management of respiratory failure during anesthesia requires immediate recognition, securing the airway with the most experienced operator available, and following a structured algorithmic approach prioritizing oxygenation above all other considerations. 1

Immediate Recognition and Response

Signs of Respiratory Failure

• Desaturation (SpO₂ < 92%)
• Abnormal breathing pattern
• Increased work of breathing
• Accessory muscle use
• Paradoxical chest movement
• Absence of end-tidal CO₂

Initial Management

1. Call for help early - The most experienced anesthesiologist should be summoned immediately
2. Deliver 100% oxygen - Increase FiO₂ to 100%
3. Stop anesthetic agents if appropriate
4. Position optimization - Head-up position (30°) for most patients, especially those with obesity 1

Airway Management Algorithm

Step 1: Assess Ventilation and Oxygenation

• Attempt mask ventilation with proper technique:
  • Two-handed technique with jaw thrust
  • Oral/nasal airway insertion if needed
  • Consider two-person technique for difficult cases

Step 2: If Mask Ventilation Possible but Intubation Failed

• Insert supraglottic airway device (SAD) 1
  • Maximum of two insertion attempts
  • If successful, decide whether to:
    • Wake patient if appropriate
    • Proceed with surgery using SAD
    • Attempt intubation through SAD with fiberoptic guidance

Step 3: If SAD Fails or Is Contraindicated

• Return to mask ventilation
• Consider optimizing position, neuromuscular blockade
• Prepare for advanced techniques:
  • Video laryngoscopy
  • Fiberoptic intubation
  • Rigid bronchoscopy (if available and indicated)

Step 4: "Can't Intubate, Can't Oxygenate" (CICO) Scenario

• Declare emergency and call for additional help
• Ensure full neuromuscular blockade to optimize conditions 1
• Proceed to front-of-neck airway access if oxygenation cannot be maintained 1
  • Surgical technique preferred over needle cricothyroidotomy due to higher success rate 1

Special Considerations

Obesity

Obesity significantly increases risk of airway complications during anesthesia 1:

• 2× higher risk with BMI >30 kg/m²
• 4× higher risk with BMI >40 kg/m²
• Complications include difficult intubation (16%), severe hypoxemia (39%), cardiovascular collapse (22%), and cardiac arrest (11%)
• Position in 30° head-up to improve functional residual capacity

Difficult Airways

For patients with known difficult airways 1:

• Identify and mark the airway plan at bedside
• Consider awake techniques in experienced hands
• For anticipated difficult intubation, consider "double set-up" approach:
  • Mark cricothyroid membrane before induction
  • Have one operator attempt intubation while second operator is prepared for front-of-neck access

Mechanical Ventilation Strategies

• Use lung-protective ventilation strategies:
  • Tidal volumes 6-8 mL/kg ideal body weight
  • PEEP 5-10 cmH2O
  • Minimize mechanical power to reduce risk of postoperative respiratory failure 2
• For bronchoscopy under mechanical ventilation 1:
  • Maintain cuff pressure 25-30 cmH2O
  • Use 100% FiO₂
  • Maintain PEEP during procedure
  • Clamp ventilation circuit before bronchoscope insertion/removal

Extubation After Respiratory Failure

Extubation requires careful planning 1, 3:

Pre-Extubation Assessment

• Ensure adequate oxygenation (SpO₂ >92% on FiO₂ ≤0.4)
• Confirm effective spontaneous breathing (RR 10-30/min)
• Verify complete reversal of neuromuscular blockade (TOF ratio >90%)
• Perform cuff leak test to assess for laryngeal edema
• Confirm hemodynamic stability

Extubation Procedure

1. Position patient appropriately (typically seated)
2. Pre-oxygenate with 100% oxygen
3. Suction oropharyngeal secretions
4. Apply positive pressure via breathing circuit
5. Deflate cuff and remove tube during positive pressure
6. Provide supplemental oxygen post-extubation

Post-Extubation Monitoring

• Continue monitoring for signs of respiratory distress
• Be prepared for reintubation with appropriate equipment
• Consider ICU admission for high-risk patients

Common Pitfalls to Avoid

1. Delayed recognition of respiratory failure
2. Inadequate preparation for difficult airway management
3. Multiple intubation attempts without changing approach
4. Failure to call for help early
5. Proceeding with surgery despite borderline respiratory status
6. Extubating without confirming adequate reversal of neuromuscular blockade 3
7. Using succinylcholine in patients with neuromuscular disorders (e.g., Duchenne muscular dystrophy) 1

By following this structured approach to respiratory failure during anesthesia, clinicians can minimize morbidity and mortality while optimizing patient outcomes.