Repeated Respiratory Failure and Failed Extubation Following Intraoperative Advanced Airway Device Endotracheal Intubation

Intraoperative airway management by anesthesiology providers has evolved over the years to include many specialized devices and techniques that can have tremendous impact on the care of the perioperative critically ill patient. When perioperative patient care issues arise, anesthesiologists and perioperative critical care specialists should both be actively involved in a dialogue regarding many the relevant patient care issues, including any airway and respiratory function problems. Additionally, critical care specialists should be familiar with the use and potential complications of the increasingly diverse airway (and non-airway) tools and devices used by anesthesiologists in the operating room. The authors present a case report of a 66-year-old man who suffered repeated postoperative respiratory failure following an uncomplicated upper extremity orthopedic procedure. The patient developed unexplained, repeated postoperative respiratory failure that necessitated reintubation related to the accidental and unrecognized retention of a plastic tip extender from a Bullard fiber-optic laryngoscope. After transfer to the ICU, the patient continued to have significant respiratory distress requiring aggressive post-extubation noninvasive mechanical ventilation. The cause of this complication was not diagnosed by the anesthesiologist or the intensive care team throughout the course of this patient’s respiratory failure. Ultimately, the patient spontaneously expectorated the tip extender with rapid improvement in his respiratory function. This case highlights the importance of the dialogue that should occur between anesthesiologists and critical care specialists when unexpected and/or unexplained perioperative complications occur.