Airway and Respiratory Management
Airway assessment and devices
Assess Mallampati, mouth opening, thyromental distance, dentition, and neck mobility before anesthesia. In the PACU, verify tube position and securement, cuff pressure, and ventilator settings. Supraglottic airways do not protect against aspiration. Know signs of obstruction: snoring, stridor, accessory muscle use, falling SpO2, and rising end-tidal CO2.
Monitoring
Pulse oximetry detects hypoxemia but lags and can look normal with supplemental oxygen despite hypoventilation. Capnography detects hypoventilation and apnea earlier and confirms tube placement. Respiratory rate is the most sensitive early indicator of opioid-induced respiratory depression.
Traps
Do not treat a low SpO2 with oxygen alone without assessing airway patency and ventilation. Stridor after extubation may be laryngospasm, edema, or a foreign body; distinguish by timing and response. Negative-pressure pulmonary edema can follow laryngospasm and presents with hypoxemia, frothy sputum, and crackles. Obesity and OSA increase obstruction risk; position upright and use CPAP if ordered. Residual neuromuscular blockade can cause hypoventilation; check train-of-four when available.
Worked example
A patient develops inspiratory stridor and retractions minutes after extubation. First call for help, apply continuous positive airway pressure with 100% oxygen, suction, and prepare for jaw thrust or reintubation. If laryngospasm persists, small doses of propofol or succinylcholine may be ordered.
Rule of thumb: airway first-reposition, suction, provide CPAP and oxygen, then escalate.