WILL YOU HAVE A BREATHING TUBE DOWN YOUR THROAT DURING YOUR SURGERY?

the anesthesia consultant

Physician anesthesiologist at Stanford at Associated Anesthesiologists Medical Group
Richard Novak, MD is a Stanford physician board-certified in anesthesiology and internal medicine.Dr. Novak is an Adjunct Clinical Professor in the Department of Anesthesiology, Perioperative and Pain Medicine at Stanford University, the Medical Director at Waverley Surgery Center in Palo Alto, California, and a member of the Associated Anesthesiologists Medical Group in Palo Alto, California.
email rjnov@yahoo.com
phone 650-465-5997

One of the most common questions I hear from patients immediately prior to their surgical anesthetic is, “Will I have a breathing tube down my throat during anesthesia?”

The answer is: “It depends.”

placing anesthesia breathing tube

Let’s answer this question for some common surgeries:

KNEE ARTHROSCOPY: Common knee arthroscopy procedures are meniscectomies and anterior cruciate ligament reconstructions. Anesthetic options include general anesthesia, regional anesthesia, or local anesthesia. Most knee arthroscopies are performed under a general anesthetic, in which the anesthesiologist injects propofol into your intravenous line to make you fall asleep. After you’re asleep, the most common airway tube used for knee arthroscopy is a laryngeal mask airway (LMA). The LMA in inserted into your mouth, behind your tongue and past your uvula, to a depth just superior to your voice box. The majority of patients will breath on their own during surgery. The LMA keeps you from snoring or having significant obstruction of your airway passages. In select patients, including very obese patients, an endotracheal tube (ETT) will be inserted instead of an LMA. The ETT requires the anesthesiologist to look directly into your voice box and insert the tube through and past your vocal cords. With either the LMA or the ETT, you’ll be asleep and will have no awareness of the airway tube except for a sore throat after surgery. A lesser number of knee arthroscopies are performed under a regional anesthetic which does not require a breathing tube. The regional anesthetic options include a blockade of the femoral nerve located in your groin or numbing the entire lower half of your body with a spinal or epidural anesthetic injected into your low back. A small number of knee arthroscopies are done with local anesthesia injected into your knee joint, in combination with intravenous sedative medications into your IV. Why are most knee arthroscopies performed with general anesthesia, which typically requires an airway tube? Because in an anesthesiologist’s hands, an airway tube is a common intervention with an acceptable risk profile. A light general anesthetic is a simpler anesthetic than a femoral nerve block, a spinal, or an epidural anesthetic.

Laryngeal Mask AIrway (LMA) Tube

 

Endotracheal Tube (ETT)

NOSE AND THROAT SURGERIES SUCH AS TONSILLECTOMY AND RHINOPLASTY: Almost all nose and throat surgeries require an airway tube, so anesthetic gases and oxygen can be ventilated in and out through your windpipe safely during the time the surgeon is working on these breathing passages.

ABDOMINAL SURGERIES, INCLUDING LAPAROSCOPY: Almost all intra-abdominal surgeries require an airway tube to guarantee adequate ventilation of anesthetic gases and oxygen in and out of your lungs while the surgeon works inside your abdomen.

CHEST SURGERIES AND OPEN HEART SURGERIES: Almost all intra-thoracic surgeries require an airway tube to guarantee adequate ventilation of anesthetic gases and oxygen in and out of your lungs while the surgeon works inside your chest.

TOTAL KNEE REPLACEMENT AND TOTAL HIP REPLACEMENT: The majority of total knee and hip replacement surgeries are performed using spinal, epidural and/or nerve block anesthesia anesthesia to block pain to the lower half of the body. The anesthesiologist often chooses to supplement the regional anesthesia with intravenous sedation, or supplement with a general anesthetic which requires an airway tube. Why add sedation or general anesthesia to the regional block anesthesia? It’s simple: most patients have zero interest in being awake while they listen to the surgeon saw through their knee joint or hammer their new total hip into place.

CATARACT SURGERY: Cataract surgery is usually performed using numbing local anesthetic eye drop medications. Patients are wake or mildly sedated, and no airway tube is used.

COLONOSCOPY OR STOMACH ENDOSCOPY: These procedures are performed under intravenous sedation and almost never require an airway tube.

HAND OR FOOT SURGERIES: The anesthesiologist will choose the simplest anesthetic that suffices. Sometimes the choice is local anesthesia, with or without intravenous sedation. Sometimes the choice will be a regional nerve block to numb the extremity, with or without intravenous sedation. Many times the choice will be a general anesthetic, often with an airway tube. An LMA is used more frequently than an ETT.

CESAREAN SECTION: The preferred anesthetic is a spinal or epidural block which leaves the mother awake and alert to bond with her newborn immediately after childbirth. If the Cesarean section is an urgent emergency performed because of maternal bleeding or fetal distress, and there is inadequate time to insert a spinal or epidural local anesthetic into the mother’s lower back, a general anesthetic will be performed. An ETT is always used.

PEDIATRIC SURGERIES: Tonsillectomies are a common procedure and require a breathing tube as described above. Placement of pressure ventilation tubes into a child’s ears requires general anesthetic gases to be delivered via facemask only, and no airway tube is required. Almost all pediatric surgeries require general anesthesia. Infants, toddlers, and children need to be unconscious during surgery, for emotional reasons, because their parents are not present. The majority of pediatric general anesthetics require an airway tube.

CONCLUSIONS: The safe placement of airway tubes for multiple of types of surgeries, in patients varying from newborns to 100-year-olds, is one of the reasons physician anesthesiologists train for many years.

Prior to surgery, some patients are alarmed at the notion of such a breathing tube invading their body. They fear they’ll be awake during the placement of the breathing tube, or that they’ll choke on the breathing tube.

Be reassured that almost every breathing tube is placed after your unconsciousness is assured, and breathing tubes are removed prior to your return to consciousness. A sore throat afterward is common, but be reassured this is a minor complaint that will clear in a few days.

If you have any questions, be sure to discuss them with your own physician anesthesiologist when you meet him or her prior to your surgical procedure.

 

The most popular posts for laypeople on The Anesthesia Consultant include:

How Long Will It Take To Wake Up From General Anesthesia?

Why Did Take Me So Long To Wake From General Anesthesia?

Will I Have a Breathing Tube During Anesthesia?

What Are the Common Anesthesia Medications?

How Safe is Anesthesia in the 21st Century?

Will I Be Nauseated After General Anesthesia?

What Are the Anesthesia Risks For Children?

 

The most popular posts for anesthesia professionals on The Anesthesia Consultant  include:

10 Trends for the Future of Anesthesia

Should You Cancel Anesthesia for a Potassium Level of 3.6?

12 Important Things to Know as You Near the End of Your Anesthesia Training

Should You Cancel Surgery For a Blood Pressure = 178/108?

Advice For Passing the Anesthesia Oral Board Exams

What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

 

 

LEARN MORE ABOUT RICK NOVAK’S FICTION WRITING AT RICK NOVAK.COM BY CLICKING ON THE PICTURE BELOW:

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LANDING THE ANESTHESIA PLANE: WHEN SHOULD YOU EXTUBATE THE TRACHEA?

the anesthesia consultant

Physician anesthesiologist at Stanford at Associated Anesthesiologists Medical Group
Richard Novak, MD is a Stanford physician board-certified in anesthesiology and internal medicine.Dr. Novak is an Adjunct Clinical Professor in the Department of Anesthesiology, Perioperative and Pain Medicine at Stanford University, the Medical Director at Waverley Surgery Center in Palo Alto, California, and a member of the Associated Anesthesiologists Medical Group in Palo Alto, California.
email rjnov@yahoo.com
phone 650-465-5997

This column is for my readers who are anesthesia professionals. When should you extubate the trachea? Clinical Case for Discussion: You’re anesthetizing a 60-year-old woman for a thyroidectomy. The surgeon tells you, “If this woman bucks on the endotracheal tube on awakening it could cause a neck hematoma and damage my surgical closure. Can you extubate her deep?”

 

Discussion: The patient has a normal airway, and she is healthy and slender. You decide to comply with the surgeon’s request and remove the endotracheal tube (ET tube) at the end of surgery while the patient is still fully anesthetized. You turn off the nitrous oxide, allow the patient to breath 100% oxygen and 3% sevoflurane, and suction the patient’s throat. You deflate the cuff on the ET tube and remove the tube. Once the tube is withdrawn, you turn off all anesthetics. At this point the patient coughs and her mouth fills with yellow gastric contents. You suction the mouth again, but the patient develops upper airway obstruction. The oxygen saturation drops to 80%. Your diagnosis is laryngospasm. You attempt to apply continuous positive airway pressure with an anesthesia mask, but her oxygen saturation falls to 70%. Panicked, you inject 100 mg of IV succinylcholine to re-paralyze the patient, and you perform laryngoscopy and reintubate her. After the ET tube is replaced, the oxygen saturation returns to 100%. You suction through the lumen of the ET tube, and you find yellow gastric material inside the lungs. You diagnose aspiration.

After a 10½ hour flight from Seoul, Korea, an Asiana airplane crashed on landing at San Francisco Airport on July 6, 2013. Aviation and anesthesia have similarities. The takeoff and landing of an airplane, just as induction and emergence from anesthesia, are more complex events than piloting the middle of a plane flight or managing the maintenance phase of a long anesthetic.

The timing of the removal of the endotracheal tube at the end of an anesthetic requires skill and judgment. Does deep extubation ever make sense? During my first year after residency training, a gray-haired anesthesia attending at my new medical center told me, “Richard, in private practice you never extubate anyone deep.” Twenty-seven years later, I’m writing to convince you he was right.

Let’s define “deep extubation.” Per Miller’s Anesthesia, 7th Edition, 2009, Chapter 50, “Extubation may be performed at different depths of anesthesia, with the terms ‘awake,’ ‘light,’ and ‘deep’ often being used. ‘Light’ implies recovery of protective respiratory reflexes and ‘deep’ implies their absence. ‘Awake’ implies appropriate response to verbal stimuli. ‘Deep’ extubation is performed to avoid adverse reflexes caused by the presence of the tracheal tube and its removal, at the price of a higher risk of hypoventilation and upper airway obstruction. Straining, which could disrupt the surgical repair, is less likely with ‘deep’ extubation. Upper airway obstruction and hypoventilation are less likely during ‘light’ extubation, at the price of adverse hemodynamic and respiratory reflexes.”

The medical literature describes deep extubation as extubating a patient who is still breathing 1.5 times the minimal alveolar concentration (MAC) of inhaled anesthetic. A 2004 study examined 48 children tracheally extubated while deeply anesthetized with 1.5 times the MAC of desflurane (Group D) or sevoflurane (Group S). No serious complications occurred in either group, and the time to discharge was not significantly different between groups. The study concluded that deep extubation of children can be performed safely with desflurane or sevoflurane. (Valley RD, Anesth Analg. 2003 May;96(5):1320-4, Tracheal extubation of deeply anesthetized pediatric patients: a comparison of desflurane and sevoflurane.)

In a prospective trial, 100 children age<16 years, each with at least one risk factor for perioperative respiratory adverse events (e.g. current or recent upper respiratory tract infection or asthma) were randomized to extubation under deep anesthesia or extubation when fully awake after tonsillectomy. There were no differences in respiratory adverse events (laryngospasm, bronchospasm, persistent coughing, airway obstruction, or desaturation <95%). Tracheal extubation in fully awake children was associated with a greater incidence of persistent coughing (60 vs. 35%, P = 0.028), however the incidence of airway obstruction relieved by simple airway maneuvers in children extubated while deeply anaesthetized was greater (26 vs. 8%, P = 0.03).

Seventy healthy patients between 2 and 8 yr of age who had elective strabismus surgery or tonsillectomy were randomly assigned to group 1 (awake extubation) or group 2 (anesthetized extubation). The incidence of airway-related complications such as laryngospasm, croup, sore throat, excessive coughing, and arrhythmias was not different between the two groups. The authors concluded that the anesthesiologist’s preference or surgical requirements may dictate the choice of extubation technique in otherwise healthy children undergoing elective surgery. (Patel RI, Anesth Analg. 1991 Sep;73(3):266-70. Emergence airway complications in children: a comparison of tracheal extubation in awake and deeply anesthetized patients).

In an informal poll of the private practice anesthesiologists at Stanford University, the incidence of deep extubation (i.e. patient extubated asleep while breathing >1.5 MAC of inhaled anesthetic) approached zero. Why do I and my colleagues avoid deep extubation? If you have a life-saving and life-preserving device such as an endotracheal tube safely in place in your patient, and your goal is to maintain the values of Airway, Breathing, and Circulation, why remove that life-preserving device prematurely without any evidence that such a removal is beneficial? Why leave your anesthetized patient with an unprotected airway?

I cannot cite you outcome data that shows awake extubation provides superior outcomes to deep extubation, but with modern short-acting anesthetics such as propofol, sevoflurane, and desflurane, a well-trained anesthesiologist can decrease anesthetic depth quickly and have their patient very awake within minutes after the conclusion of surgery. Per Miller’s Aesthesia, “Rapid recovery of consciousness shortens the at-risk time during extubation and may reduce morbidity, particularly in obese patients. … Nitrous oxide, sevoflurane, and desflurane all contribute to rapid recovery, particularly after prolonged procedures.”

If your patient vomits on emergence and the ET tube is still in situ, the cuff on the ET tube will protect their lower airway. And if you choose to extubate your patient awake, the occurrence of laryngospasm will be, in this author’s experience, rare.

It’s true that coughing on an ET tube can disrupt surgical repairs, increase intracranial pressure, increase intraocular pressure, or cause hypertension and tachycardia, but per Miller’s Anesthesia, “Marked increases in arterial blood pressure and heart rate occur frequently at the time of ‘light’ extubation. These effects are alarming but normally transient, and there is little evidence of adverse consequences.”

My advice: Use light levels of general anesthetics on your intubated patients, and learn how to wake your patients from general anesthesia quickly at the conclusion of surgery. Don’t suction the patient until you are ready to remove the ET tube, because the suction catheter stimulates early coughing.

The ET tube is your friend. I’d recommend you don’t pull it out until you’re certain you don’t need it any more.

The definitive reference from the medical literature on this topic is Difficult Airway Society Guidelines for the management of tracheal extubation, written by Popat M.

 

The most popular posts for laypeople on The Anesthesia Consultant include:

How Long Will It Take To Wake Up From General Anesthesia?

Why Did Take Me So Long To Wake From General Anesthesia?

Will I Have a Breathing Tube During Anesthesia?

What Are the Common Anesthesia Medications?

How Safe is Anesthesia in the 21st Century?

Will I Be Nauseated After General Anesthesia?

What Are the Anesthesia Risks For Children?

 

The most popular posts for anesthesia professionals on The Anesthesia Consultant  include:

10 Trends for the Future of Anesthesia

Should You Cancel Anesthesia for a Potassium Level of 3.6?

12 Important Things to Know as You Near the End of Your Anesthesia Training

Should You Cancel Surgery For a Blood Pressure = 178/108?

Advice For Passing the Anesthesia Oral Board Exams

What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

 

 

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Published in September 2017:  The second edition of THE DOCTOR AND MR. DYLAN, Dr. Novak’s debut novel, a medical-legal mystery which blends the science and practice of anesthesiology with unforgettable characters, a page-turning plot, and the legacy of Nobel Prize winner Bob Dylan.

KIRKUS REVIEW

In this debut thriller, tragedies strike an anesthesiologist as he tries to start a new life with his son.

Dr. Nico Antone, an anesthesiologist at Stanford University, is married to Alexandra, a high-powered real estate agent obsessed with money. Their son, Johnny, an 11th-grader with immense potential, struggles to get the grades he’ll need to attend an Ivy League college. After a screaming match with Alexandra, Nico moves himself and Johnny from Palo Alto, California, to his frozen childhood home of Hibbing, Minnesota. The move should help Johnny improve his grades and thus seem more attractive to universities, but Nico loves the freedom from his wife, too. Hibbing also happens to be the hometown of music icon Bob Dylan. Joining the hospital staff, Nico runs afoul of a grouchy nurse anesthetist calling himself Bobby Dylan, who plays Dylan songs twice a week in a bar called Heaven’s Door. As Nico and Johnny settle in, their lives turn around; they even start dating the gorgeous mother/daughter pair of Lena and Echo Johnson. However, when Johnny accidentally impregnates Echo, the lives of the Hibbing transplants start to implode. In true page-turner fashion, first-time novelist Novak gets started by killing soulless Alexandra, which accelerates the downfall of his underdog protagonist now accused of murder. Dialogue is pitch-perfect, and the insults hurled between Nico and his wife are as hilarious as they are hurtful: “Are you my husband, Nico? Or my dependent?” The author’s medical expertise proves central to the plot, and there are a few grisly moments, as when “dark blood percolated” from a patient’s nostrils “like coffee grounds.” Bob Dylan details add quirkiness to what might otherwise be a chilly revenge tale; we’re told, for instance, that Dylan taught “every singer with a less-than-perfect voice…how to sneer and twist off syllables.” Courtroom scenes toward the end crackle with energy, though one scene involving a snowmobile ties up a certain plot thread too neatly. By the end, Nico has rolled with a great many punches.

Nuanced characterization and crafty details help this debut soar.

Click on the image below to reach the Amazon link to The Doctor and Mr. Dylan:

41wlRoWITkL

Learn more about Rick Novak’s fiction writing at ricknovak.com by clicking on the picture below:  

DSC04882_edited

 

 

WHAT IF THE TRACHEAL TUBE FALLS OUT WHEN THE ANESTHESIOLOGIST AND THE ANESTHESIA MACHINE ARE AT THE PATIENT’S FEET?

the anesthesia consultant

Physician anesthesiologist at Stanford at Associated Anesthesiologists Medical Group
Richard Novak, MD is a Stanford physician board-certified in anesthesiology and internal medicine.Dr. Novak is an Adjunct Clinical Professor in the Department of Anesthesiology, Perioperative and Pain Medicine at Stanford University, the Medical Director at Waverley Surgery Center in Palo Alto, California, and a member of the Associated Anesthesiologists Medical Group in Palo Alto, California.
email rjnov@yahoo.com
phone 650-465-5997

Clinical Case for Discussion: It is the conclusion of a craniotomy for a tumor resection on a 50-year-old, 80 kg woman.  The operating room table is turned 180 degrees, you are the sole anesthesiologist. and you are at the patient’s feet.   The nurse and scrub tech are applying the head dressing.  The patient coughs, turns her head, and the endotracheal tube comes out above the vocal cords.  What do you do?

Discussion:    You have been peering intently at the monitors and the patient for the past 4 uneventful hours, seeking the perfect anesthetic, but now you have some urgent work to do.

The approach to acute medical care is always:  Airway, Breathing, and Circulation.

In this case, the airway is distant from you and your equipment, because the surgeon needed full access to the head for the surgery.  Your first move is to go to the head of the table, and attempt to push the endotracheal tube (ETT)  back into the trachea.  This is not successful.  The oxygen saturation is 100%, so the patient is in no immediate danger.  You unlock the OR table, and and rotate it back so that the patient’s head is next to the anesthesia equipment again.  You  remove the ETT, apply a mask to the patient, and manage the airway as the patient awakens from anesthesia.

What if the oxygen saturation had dropped below 90% when the ETT fell out?

The answer is the same.  You take the time to turn the table so that the patient’s head is back adjacent to your airway equipment and anesthesia machine, and then you use mask ventilation to return the patient’s oxygenation to a safe level.  To deliver continuous positive airway pressure (CPAP) or positive pressure ventilation to your patient, you need to be able to reach both the ventilation bag and hold the mask over the patient’s face.  You can not do this if the table is turned 180 degrees.  If the patient develops laryngospasm that you can not break with CPAP, a small dose of succinylcholine (10 – 20 mg) is recommended.

Any attempt to manage the airway problem with the table still turned 180 degrees, but relying on the surgeon or the circulating nurse to hand you drugs and equipment, or to squeeze the bag on the circle system, is not recommended by this author.  Their skill level may not be what you were used to in  your residency training, when you were sharing the responsibility with a second anesthesiologist.

What if, in a parallel universe, at the onset of this same scenario a different anesthesia provider inserted the laryngoscope into the patient’s mouth to attempt to replace the ETT.    The patient bit down on the blade, and the anesthesiologist wrestled with a forceful laryngoscopy.  The oxygen saturation dropped below 90%.  He decided to inject succinylcholine to paralyze the patient, but his drugs and syringes were at the foot of the operating room table, six feet away and out of reach.  He instructed the nurse to draw up and inject the drug for him, but this took over 60 seconds of valuable time, during which the patient was hypoxic.  He finally inserted the ETT into the trachea, and was able to ventilate the lungs to increase the oxygen saturation to 100% again. But the blood pressure was now 180/110, the heart rate was 140 beats per minute, and the intracranial pressure was higher than the surgeon’s temper at this point.

Make a different choice:  turn the head end of the operating room table back to where your equipment is.

Regarding the possibility of the ETT coming out during surgery, I anticipate comments like:   “How could this happen?  Why didn’t you use Benzoin to hold the ETT tape to the skin overlying the maxilla?  Why did you tape the tube to the mandible instead of the mandible? You should hold the ETT yourself when you are awakening a patient and they are applying a head dressing.  You should keep the patient anesthetized until the dressing is done,” etc.

Alas, despite experience and planning, unexpected events do occur.  Your worth as a clinician will be proven and tested by how you handle the unexpected.

In sum:  If you are working alone, and an airway problem occurs with the airway six feet away from your anesthesia equipment, I advise you to bring the airway back to your equipment.

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Published in September 2017:  The second edition of THE DOCTOR AND MR. DYLAN, Dr. Novak’s debut novel, a medical-legal mystery which blends the science and practice of anesthesiology with unforgettable characters, a page-turning plot, and the legacy of Nobel Prize winner Bob Dylan.

KIRKUS REVIEW

In this debut thriller, tragedies strike an anesthesiologist as he tries to start a new life with his son.

Dr. Nico Antone, an anesthesiologist at Stanford University, is married to Alexandra, a high-powered real estate agent obsessed with money. Their son, Johnny, an 11th-grader with immense potential, struggles to get the grades he’ll need to attend an Ivy League college. After a screaming match with Alexandra, Nico moves himself and Johnny from Palo Alto, California, to his frozen childhood home of Hibbing, Minnesota. The move should help Johnny improve his grades and thus seem more attractive to universities, but Nico loves the freedom from his wife, too. Hibbing also happens to be the hometown of music icon Bob Dylan. Joining the hospital staff, Nico runs afoul of a grouchy nurse anesthetist calling himself Bobby Dylan, who plays Dylan songs twice a week in a bar called Heaven’s Door. As Nico and Johnny settle in, their lives turn around; they even start dating the gorgeous mother/daughter pair of Lena and Echo Johnson. However, when Johnny accidentally impregnates Echo, the lives of the Hibbing transplants start to implode. In true page-turner fashion, first-time novelist Novak gets started by killing soulless Alexandra, which accelerates the downfall of his underdog protagonist now accused of murder. Dialogue is pitch-perfect, and the insults hurled between Nico and his wife are as hilarious as they are hurtful: “Are you my husband, Nico? Or my dependent?” The author’s medical expertise proves central to the plot, and there are a few grisly moments, as when “dark blood percolated” from a patient’s nostrils “like coffee grounds.” Bob Dylan details add quirkiness to what might otherwise be a chilly revenge tale; we’re told, for instance, that Dylan taught “every singer with a less-than-perfect voice…how to sneer and twist off syllables.” Courtroom scenes toward the end crackle with energy, though one scene involving a snowmobile ties up a certain plot thread too neatly. By the end, Nico has rolled with a great many punches.

Nuanced characterization and crafty details help this debut soar.

Click on the image below to reach the Amazon link to The Doctor and Mr. Dylan:

41wlRoWITkL

Learn more about Rick Novak’s fiction writing at ricknovak.com by clicking on the picture below:  

DSC04882_edited