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Post-Extubation Obstruction — FRCA Final MCQ

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ModerateAirway ManagementPost-Extubation ObstructionFRCA Final

A 60-year-old man with obstructive sleep apnoea develops inspiratory stridor followed by complete upper-airway obstruction immediately after tracheal extubation following nasal surgery. He is making vigorous inspiratory efforts but there is no airflow. Help has been called, stimulation has been stopped, and direct inspection and suction have excluded blood, secretions or a foreign body. Jaw thrust and an oropharyngeal airway have not relieved the obstruction; a nasopharyngeal airway is contraindicated because of the surgery. What is the next immediate intervention?

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Correct answer: E — Apply CPAP via a face mask

This is complete post-extubation laryngospasm: there is vigorous inspiratory effort without airflow, and supraglottic obstruction, blood and foreign material have been addressed. The Association of Anaesthetists Quick Reference Handbook specifies CPAP with 100% oxygen via a face mask after jaw thrust and removal of airway stimulation or obstruction. If laryngospasm persists, CPAP is continued while anaesthesia is deepened and a neuromuscular blocker is administered; tracheal intubation is a subsequent escalation. A supraglottic airway is not the recommended next step and may provide further laryngeal stimulation. Emergency tracheostomy is reserved for failure to oxygenate by less invasive techniques. Doxapram stimulates ventilation but cannot relieve laryngospasm and is contraindicated in physical respiratory-tract obstruction.

Reference: Association of Anaesthetists, Quick Reference Handbook: Guideline 3-6, Laryngospasm and stridor, August 2019 edition. https://rcoa.ac.uk/media/9386