How to manage tongue swelling in an intubated patient?

Management of Tongue Swelling in Intubated Patients

The most effective management of tongue swelling in intubated patients requires maintaining the airway, administering corticosteroids, and treating the underlying cause while carefully planning for potential complications during and after extubation. 1

Assessment and Immediate Management

• Assess the extent and location of swelling - edema limited to anterior tongue and lips may not require additional intervention, while edema involving larynx, palate, floor of mouth, or oropharynx with rapid progression poses higher risk of requiring continued intubation 1
• Position the patient in 35° head-up position to reduce airway swelling 2
• Administer intravenous dexamethasone to reduce inflammation and swelling, with repeated doses every 6 hours through and after planned extubation 2
• Consider discontinuing medications that may contribute to angioedema, particularly angiotensin-converting enzyme inhibitors (ACEIs) 1

Pharmacological Management

• Administer IV methylprednisolone 125 mg 1
• Administer IV diphenhydramine 50 mg 1
• Administer ranitidine 50 mg IV or famotidine 20 mg IV 1
• If there is further increase in angioedema, administer epinephrine (0.1%) 0.3 mL subcutaneously or by nebulizer 0.5 mL 1
• For severe cases, consider icatibant (a selective bradykinin B receptor antagonist) 30 mg subcutaneously in the abdominal area; additional injections may be administered at 6-hour intervals (maximum 3 injections in 24 hours) 1
• Plasma-derived C1 esterase inhibitor (20 IU/kg) may be considered for cases related to hereditary angioedema or ACEI-related angioedema 1

Extubation Planning and Airway Management

• Begin corticosteroid therapy at least 12-24 hours before planned extubation in high-risk patients 2
• Perform a leak test prior to extubation; a negative leak test indicates increased risk of laryngeal edema and should prompt continuation of dexamethasone therapy 2
• Have equipment for reintubation readily available, including consideration of airway exchange catheters in high-risk cases 2, 3
• For patients with severe tongue swelling, consider awake fiberoptic intubation as the optimal approach if reintubation becomes necessary 1, 4
• Nasal-tracheal intubation may be required but poses risk of epistaxis if the patient has received thrombolytics 1
• Cricothyroidotomy should be considered only as a last resort, especially in patients who have received thrombolytics 1

Post-Extubation Monitoring

• Monitor closely for signs of airway compromise after extubation, including stridor, difficulty breathing, arterial oxygen desaturation, and tachypnea 2
• For post-extubation stridor caused by laryngeal edema, consider epinephrine nebulization as adjunctive therapy 2
• Be aware that angioedema is typically self-limiting, with swelling usually resolving spontaneously in 2-3 days 5

Special Considerations

• If tongue swelling is related to trauma or surgical procedures, consider the possibility of hematoma formation requiring manual decompression in severe cases 4, 6
• For cases of massive tongue swelling causing life-threatening airway obstruction, manual decompression of the tongue combined with fiberoptic-guided nasotracheal intubation may be necessary 6
• Be vigilant for less common causes of apparent tongue swelling, such as edema of the floor of the mouth and submandibular space secondary to sialadenitis from submandibular duct obstruction by the tracheal tube 7
• If extubation is at risk due to laryngeal anomaly or trauma, obtain an assessment by an ENT surgeon 2

Pitfalls and Caveats

• Avoid early extubation in patients with significant tongue swelling as this may lead to emergency reintubation or surgical airway 5, 8
• Recognize that large volume fluid resuscitation can worsen airway swelling, making early definitive airway management crucial 3
• Be aware that the beneficial effect of dexamethasone has been clearly demonstrated in neonates at risk for laryngeal edema but is less definitively proven in older children 2
• Early recognition and management of tongue swelling is critical, as delayed intervention may lead to complete airway obstruction requiring emergency surgical airway 5, 4