Post-extubation stridor — FFICM MCQ

Correct answer: B — Proceed to controlled re-intubation

The correct answer is B, proceed to controlled re-intubation. This patient has progressive upper airway obstruction (inspiratory stridor, increased work of breathing, SpO2 91 percent) that has failed first-line medical therapy with nebulised adrenaline and intravenous dexamethasone. Post-extubation laryngeal oedema causing stridor and hypoxaemia despite these measures indicates critical airway narrowing that will worsen with fatigue and agitation, so with a skilled airway team already present the safest course is to secure the airway electively under controlled conditions rather than wait for a crisis re-intubation. This reflects the standard approach to extubation failure from fixed upper airway obstruction, where escalation of non-invasive measures beyond nebulised adrenaline and steroid is not appropriate once distress and desaturation persist. Why the other options are wrong: A. Commence NIV and review in 6 hours: positive pressure NIV does not relieve a fixed supraglottic or glottic obstruction and delaying reassessment risks complete airway loss. C. Give intravenous furosemide: there is no indication of pulmonary oedema or fluid overload here, stridor and this clinical picture are due to laryngeal swelling, not cardiogenic pulmonary congestion. D. Request urgent CT neck before intervention: imaging delays definitive airway management in a deteriorating hypoxic patient and is unsafe when the airway is unstable; the airway must be secured first. E. Observe because stridor is common after extubation: while mild transient stridor is common, this patient has failed treatment and is hypoxic and distressed, so observation risks respiratory arrest. Key point: when stridor with hypoxaemia persists despite nebulised adrenaline and steroids, controlled re-intubation with the airway team present takes priority over any imaging or non-invasive escalation.

Reference: Difficult Airway Society: Guidelines for the management of tracheal extubation (Popat et al., Anaesthesia 2012;67:318-340), 'at-risk' extubation algorithm; management of post-extubation stridor with escalation to re-intubation when medical measures fail. das.uk.com/guidelines/das-extubation-guidelines1/