Etiology | Risk factors | Clinical and imaging findings | Treatment | Comments |
Immediate postoperative life-threatening emergencies* |
Hypoventilation¶ | - 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.
| Patients with underlying neurologic deficits, neuromuscular disease, or obesity hypoventilation may be predisposed. |
Laryngospasm | - 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.
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Pharyngeal muscle weakness | - 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.
| Many cases are mild, but may be life-threatening if severe. |
Copious secretions | - 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.
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Foreign body aspiration | - 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. Refer to related UpToDate content. |
Upper airway edema (due to positioning, fluid, angioedema, anaphylaxis) | - 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.
| Inhaled heliox may reduce turbulent flow in large airways. |
Oropharyngeal trauma | - 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.
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Expanding cervical hematoma | - 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.
| Usually hematoma is minor and can be treated conservatively. |
Bronchospasm¶ | - 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).
| Refer to related UpToDate content. |
Pulmonary edema (cardiogenic and non-cardiogenic)¶ | - 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. Negative pressure pulmonary edema may present as late as 12 hours after relief of upper airway obstruction. |
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- Negative pressure pulmonary edema due to laryngospasm, pharyngeal obstruction, biting the ETT, relief of upper airway obstruction, naloxone.
| - 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.
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- Others such as fluid overload, neurogenic edema, or acute respiratory distress syndrome, reperfusion or transfusion lung injury.
| | - Supportive therapy with diuresis, oxygen, fluid restriction, and ventilatory support.
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Aspiration (chemical) pneumonitis¶ | - 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. Refer to related UpToDate content. |
Tension pneumothorax | - 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.
| Refer to related UpToDate content. |
Rare etiologies (arytenoid dislocation, TMJ dislocation, unilateral vocal cord paralysis, tracheal laceration) | - Fat embolism – Large bone orthopedic surgery or major trauma.
| - Sudden onset dyspnea and hypoxemia.
| - Supportive therapy (eg, oxygenation, ventilation).
| Refer to related UpToDate content. Laceration is mostly minor but can be life-threatening if severe or tracheal wall ruptures. |
- Air embolism – Neurosurgical or otolaryngological procedures.
| - Sudden onset dyspnea and hypoxemia.
| - Supportive therapy (eg, oxygenation, ventilation).
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- Amniotic fluid embolism – Labor and delivery.
| - Sudden onset dyspnea and hypoxemia during labor.
| - Supportive therapy (eg, oxygenation, ventilation).
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- 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.
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- 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.
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- 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).
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Early postoperative pulmonary conditions (hours to days)Δ |
Atelectasis | - 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.
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Pulmonary embolism | - 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.
| Refer to related UpToDate content. |
Pneumonia | - Thoracic and abdominal surgery, mechanical ventilation, hospitalization >48 hours, aspiration.
| - Fever, cough, sputum, dyspnea, leukocytosis, radiograph infiltrates.
| | Frequently caused by Gram-negative bacteria and Staphylococcus aureus. Up to a third may have more than one organism. Refer to related UpToDate content. |
Pleural effusion (including hemothorax and chylothorax) | - Upper abdominal and cardiothoracic surgery.
| - Dyspnea, incidental imaging finding.
| - Thoracentesis or drainage if symptomatic due to the effusion, atypical in nature, or infected.
| Most are small and asymptomatic and resolve spontaneously. |
Rare etiologies (arytenoid dislocation, TMJ dislocation, unilateral vocal cord paralysis) | - 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.
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- 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.
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- 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.
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Late postoperative pulmonary conditions (weeks to months) |
Tracheal stenosis | - 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.
| Refer to related UpToDate content. |
Obstructive pneumonia due to foreign body aspiration | - 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.
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Rare conditions (eg, unilateral diaphragmatic paralysis) | - 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.
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