What is the recommended management for a patient who is actively coughing during cataract extraction?

Management of Active Coughing During Cataract Extraction

Immediately pause the surgical procedure and address the cough before resuming, as coughing during cataract extraction can cause catastrophic complications including posterior capsule rupture, vitreous loss, expulsive hemorrhage, and iris prolapse.

Immediate Intraoperative Management

Stop and Stabilize

• Halt all surgical manipulation immediately when coughing begins, particularly if instruments are inside the eye or during critical steps like phacoemulsification or capsulorrhexis 1
• The surgeon must withdraw instruments to a safe position or completely exit the eye depending on the surgical phase 1
• Maintain instrument position just outside the incision if mid-procedure to allow rapid re-entry once coughing resolves 1

Pharmacologic Suppression

• Administer intravenous lidocaine 0.5 mg/kg therapeutically to abort established coughing, which has demonstrated 80% efficacy compared to 38.5% with placebo 2
• This therapeutic approach is superior to prophylactic administration, which shows only 28.1% efficacy and is not recommended as routine practice 2
• The anesthesiologist should be prepared to deepen anesthesia if coughing persists despite lidocaine 1

Anesthetic Considerations

Choice of Airway Management

• Laryngeal mask airway (LMA) is strongly preferred over endotracheal intubation for cataract surgery under general anesthesia, as it significantly reduces coughing at all phases: pre-extubation (P < 0.001), during removal (P < 0.001), and post-removal (P < 0.001) 3
• If endotracheal intubation is necessary, filling the ETT cuff with alkalized and warmed 4% lidocaine (5 ml lidocaine + 1 ml 7% sodium bicarbonate warmed to 38°C) reduces coughing episodes from 9.70 per patient to 3.95 per patient 4

Preoperative Risk Assessment

• Identify patients with chronic obstructive pulmonary disease or active respiratory conditions during preoperative evaluation, as these represent relative contraindications requiring optimization before proceeding 1
• Assess the patient's ability to cooperate and remain still during surgery, as this is a mandatory component of surgical planning 1
• Consider whether the patient can safely undergo surgery given coexisting medical conditions that may precipitate coughing 1

Prevention Strategies

Patient Selection

• Patients with uncontrolled cough, active upper respiratory infections, or severe COPD should have surgery deferred until the condition is optimized 1
• The ophthalmologist must ensure the patient can safely undergo the planned anesthesia type 1

Anesthetic Technique

• Regional anesthesia (topical, sub-Tenon's, or retrobulbar) eliminates airway instrumentation and associated cough risk entirely, making it the preferred approach when feasible 1, 3
• If general anesthesia is required, use LMA rather than endotracheal intubation 3
• Prophylactic IV lidocaine before extubation is not recommended given its poor efficacy (only 28.1%) 2

Critical Pitfalls to Avoid

• Never continue operating through active coughing, as the sudden increase in intraocular pressure and globe movement can convert a routine case into one requiring anterior vitrectomy 5
• Do not rely on prophylactic lidocaine administration, as evidence shows it is ineffective; instead, treat coughing when it occurs 2
• Avoid endotracheal intubation when LMA is a viable alternative, as intubation increases coughing risk substantially 3
• Do not proceed with surgery in patients with poorly controlled respiratory disease without medical optimization first 1

Postoperative Implications

• Document any intraoperative coughing episodes and their management in the operative note 1
• Perform careful examination for complications including posterior capsule integrity, vitreous prolapse, and wound integrity 1
• If anterior vitrectomy was required due to cough-induced complications, adjust postoperative management and counseling accordingly 5