Snoring , flaring of the nostrils or a paradoxical breathing pattern ( where the thorax moves in but the abdomen moves out ) can signify that the patient is breathing against a partially or fully closed airway . If this happens , extend the neck and pull the tongue forward [ 38 ] .
There have been reports of ETTs becoming stuck at the larynx at the time of extubation , due to an annulus when the cuff was deflated . If this occurs , reinflate then deflate the cuff or lightly re-anaesthetise the patient so that lubrication can be applied to the cuff while applying gentle twisting and traction to the ETT [ 39 , 40 ] .
If a patient is at risk of airway obstruction after extubation , they should be kept under direct observation , with equipment ready to reintubate and ventilate them . An ‘ airway box ’ ( Figure 17 ) can be prepared by the patient ' s kennel , which includes the same size ETT as was originally placed and one a size smaller , anaesthesia induction agent and a laryngoscope .
Post-extubation observations should include monitoring for signs of dyspnoea : increased respiratory rate and effort , or progressive stridor . If the patient snorts or has reverse sneezing post-extubation , briefly hold their nostrils closed , which will cause them to take a breath through their mouth and dislodge the soft palate from the epiglottis .
Cats are prone to laryngospasm after extubation . It is usually self-limiting and can be managed by extending the head and neck forward while providing flow-by oxygen . If there is sustained laryngospasm in the recovery period , causing visible cyanosis or an oxygenation saturation of < 90 %, the patient should be re-anaesthetised and the larynx desensitised ( sometimes reintubated ), and recovery should be reattempted .
Traumatic intubation can cause laryngeal oedema . Signs may be seen directly with a laryngoscope at the time of intubation or they may be noted during the recovery period , due to stridorous or stertorous breathing sounds , dyspnoea or , in extreme cases , airway obstruction and paradoxical breathing . Corticosteroids or diuretics may need to be administered to reduce swelling [ 38 ] . Nebulising adrenaline ( 0.3 mg ) diluted in 5 ml saline has also been shown to reduce lifethreatening laryngeal oedema [ 41 ] ( Figure 16 ).
Figure 17 . Airway box and nebulising kit next to a patient ' s cage .
Conclusions
Endotracheal intubation should be mastered by VSs and VNs . If your practice routinely has students , you can help build their confidence with intubation during their clinical placement . When a student is intubating , it is recommended that the patient is preoxygenated and a time limit of 55 seconds is set [ 42 ] .
Airway management is multi-factorial and should be approached holistically , as how a patient is induced and intubated can affect their airway during the recovery period . All airway equipment should be prepared and checked before use .
To date , there are no published standardised protocols for cleaning single-use ETTs . Reusable ETTs should be disinfected after use , then rinsed thoroughly to remove any disinfectant solution before being left to dry , ready to be used again . Red rubber ETTs can be autoclaved but those sterilised by glutaraldehyde or ethylene oxide treatments may lose their cuff integrity over time [ 43 ] .
Figure 16 . Nebulising a French bulldog in the recovery period .
* Post-publication update from the author , added on 13 July 2023 , relating to the section on laryngeal mask airways and supraglottic airway devices : The v-gel Advanced has an improved airway seal of up to 24 cmH 2
O when using positive pressure ventilation , compared with 12 – 16 cmH 2
O in the original v-gel device .
54 Veterinary Nursing Journal