Etiology, presentation, and management of postoperative respiratory failure

• Depressed level of consciousness due to opioid, sedative, residual anesthetic, or NMBA effects, OSA, neurologic complication (eg, stroke).

• Bradypnea, shallow breathing, hypercapnic acidosis, hypoxemia, reduced level of consciousness.

• Encourage adequate ventilation, airway support measures, and NIV, if indicated. In some cases, admin istration of a reversal agent may be indicated. Refer to related UpToDate content on dosing.
• Supportive ventilation (noninvasive or invasive), if indicated.

• Recent extubation or removal of NIV, vocal cord irritation due to secretions, blood, foreign body.

• Sudden stridor, dyspnea, decreased air entry if severe, intercostal and suprasternal retractions, and paradoxical motion of abdominal muscles during inspiration.

• Airway support with jaw thrust/chin lift maneuver and if needed, positive pressure bag-mask ventilation and followed by removal of the noxious stimulant (eg, blood secretions, foreign body).
• Larson's maneuver – Apply pressure with fingertips to the "laryngospasm notch" (ie, area between the mastoid process, the ramus of the mandible, and the base of the skull).
• An anesthetic dose (eg, 0.5 to 1 mg/kg/propofol) administered alone or together with a small dose of succinylcholine (eg, 0.1 mg/kg IV) may be considered to relax the vocal cords in the appropriate monitored setting.
• Anesthesia reinduction and intubation is sometimes needed if the above measures fail.
• Occasionally if partial laryngospasm is suspected on the floor, nebulized lidocaine (eg, 10 mL 2%) or racemic epinephrine (2.25% solution, one vial) may be administered.

• NMBA use, opioids, anesthetics, obesity, OSA (known or previously unsuspected), tonsillar or adenoid hypertrophy.

• Stridor or snoring, dyspnea, decreased air entry if severe, with intercostal and suprasternal retractions, and paradoxical motion of abdominal muscles during inspiration.
• Mental status changes, hypoxemia, hypercapnia, and snoring may occur with OSA.

• Perform a chin lift or jaw thrust or lateral decubitus positioning. Oro- or nasopharyngeal airway is a useful adjunct.
• Consider reversal agent (eg, flumazenil, naloxone, sugammadex). Refer to "hypoventilation" bullet above.
• Consider NIV for OSA.
• Intubation is sometimes needed.

• Impaired cough, inspissation of secretions, history of pre-existing pulmonary disease.

• Reduced level of consciousness may exacerbate inability to effectively clear secretions.

• Suction and remove secretions.
• Following removal of obstructing secretions, pulmonary toilet with oropharyngeal or nasotracheal suctioning and chest physical therapy may be beneficial if secretions are >30 mL/day.
• In some cases, bronchoscopy may be needed to clear mucous plugging below the vocal cords.

• Tooth dislodgement, retained surgical throat pack or other item.

• Cough, stridor, intercostal and suprasternal retractions, and paradoxical motion of abdominal muscles during inspiration. Chest radiograph may show calcification from tooth or other radiodense material.

• Airway support with a chin lift or jaw thrust.
• Foreign body removal with direct laryngoscopy (above the vocal cords) or bronchoscopy (below vocal cords).
• Rarely, emergency cricothyrotomy or tracheostomy may be necessary if upper airway obstruction is complete.
• Observe for airway edema for 12 hours post removal.

Rarely, diagnosis is delayed until patient visits a dentist or develops obstructive pneumonia later in the postoperative period.

• Airway or major neck surgery, prolonged head-down or prone positioning, large volumes of fluid resuscitation, traumatic intubation, angioedema, anaphylaxis.

• Facial and scleral edema, stridor, dyspnea, decreased air entry if severe, intercostal and suprasternal retractions, and paradoxical motion of abdominal muscles during inspiration.

• Airway support with a chin lift or jaw thrust.
• Treatment depends on the etiology and may include corticosteroids and antihistamines, diuretic (fluid overload), epinephrine (anaphylaxis).
• Intubation is often needed while medical therapy is ongoing.

• Oropharyngeal surgical procedures or traumatic instrumentation of the airway.

• Oropharyngeal bleeding, hematoma, or swelling.

• Suction and remove blood.
• Gentle airway support measures.
• In some cases, reintubation and/or reoperation may be necessary.

• Neck surgery (eg, carotid endarterectomy, thyroidectomy, parathyroidectomy) anterior cervical spine surgery, central line placement attempt in the IJ vein, interscalene block.
• Risk is higher when carotid endarterectomy is performed in conjunction with coronary artery bypass grafting.

• Nonrespiratory symptoms (eg, pain, pressure, voice changes, difficulty swallowing) often precede respiratory symptoms such as stridor.
• Neck swelling, dyspnea, tracheal deviation, supraglottic edema on upper airway examination.

• When rapidly expanding and causing respiratory distress, intubation and evacuation is required.
• Decompression at the bedside before intubation may be necessary in those with severe respiratory compromise since intubation can be difficult.
• Emergency cricothyrotomy or tracheostomy may be needed if obstruction is complete.

• Underlying obstructive lung disease, aspiration, allergy (eg, antibiotics, latex), bronchial irritation by secretions or suctioning, waning of anesthetics.

• Dyspnea, chest tightness, wheeze, tachypnea, small tidal volumes, a prolonged expiratory time, hypercapnia.

• Short-acting inhaled bronchodilators:
  • Albuterol 2.5 to 5 mg in 3 mL nebulization every 20 minutes for three doses.
  • Ipratropium bromide 0.5 mg in 3 mL for one dose.
  • Albuterol (2.5 mg) and ipratropium 0.5 mg combined in 3 mL.
  • Treat underlying cause (eg, secretion removal, treatment of allergies or anaphylaxis).

• Cardiogenic – Known intrinsic cardiac disease.

• Dyspnea, hypoxemia, orthopnea, ankle swelling, elevated jugular venous pressure.

• Supportive therapy with diuretic (eg, furosemide 40 mg IV, torsemide 20 mg IV, or bumetanide 1 mg IV), oxygen, and occasionally inotropes. Noninvasive or invasive support may be needed.

Refer to related UpToDate content.

• Noncardiogenic:

• Dyspnea, pink frothy sputum and hypoxemia following relief of obstruction, in the absence of systemic signs of congestive heart failure.

• Treat underlying cause. Supportive therapy with oxygen, ventilatory support, and, if indicated, diuretic administration.

• Supportive therapy with diuresis, oxygen, fluid restriction, and ventilatory support.

• Depressed consciousness with inability to protect the airway, witnessed aspiration (eg, during intubation and extubation).

• Dyspnea, hypoxemia, bilateral infiltrates.

• Witnessed event – Oropharyngeal suctioning with head in lateral position.
• Supportive (eg, oxygenation, bronchodilation, noninvasive or invasive ventilation).
• Monitored observation for chemical pneumonitis and bacterial superinfection.

If symptoms do not occur within 2 hours of the aspiration event chemical pneumonitis is less likely to ensue but bacterial superinfection is still a possibility.

Antibiotics and glucocorticoids are not routinely administered.

• Cardiothoracic or neck surgery.
• IJ or subclavian central line placement.

• Sudden chest pain and dyspnea, hypotension or cardiopulmonary collapse, subcutaneous emphysema, pneumothorax or pneumomediastinum evident on imaging.

• Chest tube insertion or emergency needle or finger decompression followed by chest tube insertion.

• Fat embolism – Large bone orthopedic surgery or major trauma.

• Sudden onset dyspnea and hypoxemia.

• Supportive therapy (eg, oxygenation, ventilation).

Refer to related UpToDate content.

• Air embolism – Neurosurgical or otolaryngological procedures.

• Sudden onset dyspnea and hypoxemia.

• Supportive therapy (eg, oxygenation, ventilation).

• Amniotic fluid embolism – Labor and delivery.

• Sudden onset dyspnea and hypoxemia during labor.

• Supportive therapy (eg, oxygenation, ventilation).

• Bilateral diaphragmatic paralysis – Cervical cord surgery.

• Sudden onset dyspnea and lack of air movement following extubation.

• Supportive therapy (eg, ventilation). May resolve spontaneously unless complete transection of the phrenic nerves occurred, in which case emergency intubation is necessary.

• VC paralysis – Neck surgery, traumatic intubation.

• Sudden onset dyspnea and lack of air movement following extubation.

• Supportive therapy with emergency tracheostomy since intubation is traumatic and often unsuccessful. May resolve spontaneously unless complete transection of the laryngeal nerve occurred.

• Tracheal laceration or rupture – Traumatic intubation or extubation.

• Sudden onset dyspnea, pneumomediastinum, pneumothorax, subcutaneous emphysema.

• Surgical repair.
• Conservative therapy may be appropriate in select cases (eg, minor laceration).

• Abdominal and thoracoabdominal surgery.
• Pain and hypoventilation.
• Poor respiratory effort due to weakness or excessive sedation.

• Dyspnea, hypoxemia, shallow breathing.

• Adequate analgesia (avoid oversedation) and incentive spirometry to facilitate deep breathing and coughing.
• If secretions are abundant (eg, >30 mL/day), pulmonary toilet with oropharyngeal or nasotracheal suctioning and chest PT may be beneficial. Bronchoscopy may be useful in those who fail.
• If secretions are minimal, noninvasive ventilation may be trialed.

• Pelvic and lower extremity orthopedic surgery, major vascular surgery, neurosurgery, and cancer surgery.

• Pain and tenderness, acute dyspnea, pleuritic pain, and hypoxemia.

• Anticoagulation if no contraindications present.
• If anticoagulation is contraindicated, placement of an inferior vena cava filter is appropriate.
• Thrombolysis or thrombectomy may be indicated if the patient is hemodynamically unstable.

• Thoracic and abdominal surgery, mechanical ventilation, hospitalization >48 hours, aspiration.

• Fever, cough, sputum, dyspnea, leukocytosis, radiograph infiltrates.

• Targeted antibiotics.

Frequently caused by Gram-negative bacteria and Staphylococcus aureus. Up to a third may have more than one organism.

• Upper abdominal and cardiothoracic surgery.

• Dyspnea, incidental imaging finding.

• Thoracentesis or drainage if symptomatic due to the effusion, atypical in nature, or infected.

• Arytenoid dislocation – Poor visualization of the larynx during intubation, inflammatory joint diseases.

• Hoarseness a few days after surgery, hypophonia, weak cough.

• Arytenoid reduction by an otolaryngologist.

• TMJ dislocation – Mouth is opened widely, or procedures involving the mouth.

• Inability to close the jaw, periauricular pain, distorted speech, drooling.

• Early reduction by an oral surgeon.

• Unilateral VC paralysis – Laryngeal nerve injury or traumatic intubation.

• Hoarseness a few days after surgery, hypophonia, weak cough, aspiration.

• May self-resolve spontaneously; interim injections by an otolaryngologist may be needed during recovery. Surgery may be required, if transection of the laryngeal nerve was complete.

• Traumatic or prolonged intubation or tracheostomy placement.

• Dyspnea, failure to wean off mechanical ventilation.

• Local dilation using interventional bronchoscopic techniques are often initial interventions.
• Tracheal resection/reconstruction if recurrent dilation fails.

• History of surgery may be weeks or months prior to presentation.

• Fever, cough, sputum (may be foul smelling), dyspnea, leukocytosis, radiograph infiltrates (may be cavitating).

• Targeted antibiotics including anerobic coverage.

• Typically patients undergoing cardiothoracic or neck surgery, paravertebral or brachial plexus nerve blocks.

• Often asymptomatic, incidental finding on chest radiograph.
• May be symptomatic when lung disease or intercurrent pneumonia occurs.

• Mostly observation.