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Soto Garrucho, A. Martínez Navas, M. Echevarría Moreno" "autores" => array:3 [ 0 => array:4 [ "nombre" => "E." "apellidos" => "Soto Garrucho" "email" => array:1 [ 0 => "esme-92@hotmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "A." "apellidos" => "Martínez Navas" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "M." "apellidos" => "Echevarría Moreno" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Anestesiología y Reanimación, Hospital Universitario de Valme, Sevilla, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Anestesiología, Unidad Dolor Crónico, Hospital Universitario de Valme, Sevilla, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Servicio de Anestesiología, U.G.C. Anestesiología y Reanimación, Hospital Universitario de Valme, Sevilla, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "La ecografía en el diagnóstico del edema de glotis postextubación" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Recent studies have drawn attention to the role of ultrasound in airway management both in the operating room and the postanaesthesia care unit (PACU)<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,2</span></a>. The vocal cords appear as hyperechogenic structures, and are best seen in a transverse plane through the thyroid cartilage window. The glottic lumen can be visualised when the vocal cords are in abduction<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a>. We obtained approval from our hospital’s ethics committee and the patient's consent to present this report of post-extubation glottic oedema diagnosed by postoperative ultrasound in the PACU.</p><p id="par0010" class="elsevierStylePara elsevierViewall">The patient was a woman aged 67 years weighing 49 kg, with a diagnosis of incarcerated femoral hernia who underwent open surgery for intestinal resection and femoral hernioplasty. Her history included: panhypopituitarism under replacement therapy with hydrocortisone 20 mg and levothyroxine 25 μg; hypogonadotropic hypogonadism with no menarche or sexual development; permanent atrial fibrillation anticoagulated with dabigatran 150 mg that was interrupted more than 14 h prior to surgery; a DDD pacemaker for second-degree AV block; mild chronic kidney disease; and intellectual disability secondary to foetal distress and anoxia at delivery. Her anaesthesia history included an uneventful total left knee replacement under general anaesthesia. We were unable to confirm the airway device used in this intervention. In the pre-anaesthesia evaluation we observed dysmorphic facial features and predictors of difficult airway: Mallampati IV, retrognathia and oral opening < 4 cm. Heart and lung auscultation revealed no significant alterations and confirmed nil by mouth for 24 h. Non-invasive blood pressure, electrocardiogram, peripheral oxygen saturation and depth of anaesthesia (BIS) monitoring was started. Following this, general anaesthesia was induced and the patient was intubated using an Airtraq optical laryngoscope and a 7 mm tracheal tube. Slight resistance was detected when advancing the tracheal tube beyond the vocal cords, but this was overcome by applying slight pressure and rotating the tube. Hydrocortisone 100 mg was administered for adrenal insufficiency prophylaxis. Anaesthesia was maintained with IV sevoflurane and remifentanil. Surgery lasted 45 min, and was uneventful.</p><p id="par0015" class="elsevierStylePara elsevierViewall">At the end of the surgery, the patient was woken up and extubated (BIS 90) following reversal of the neuromuscular blockade, which was not monitored. We verified the patient’s ability to respond to orders (open the eyes and mouth, stick out the tongue and lift the head). Upon arrival at the PACU, mild stridor was heard without auscultation together with a slight cough with haemoptoic expectoration but no respiratory distress and normal breathing rate. Two hours after extubation, the stridor was more evident, the patient developed a barking cough with haemoptoic expectoration, and hypoventilation was observed in the left hemithorax accompanied by evident, progressive respiratory distress that the patient herself manifested with tachypnoea (SatO<span class="elsevierStyleInf">2</span> 99% with Ventimask 40% and 16 breaths/min). Residual neuromuscular block, muscle weakness secondary to panhypopituitarism, and traumatic injury to the vocal cords secondary to intubation were the diagnostic suspicions evaluated. We measured arterial blood gas, which showed hypoxemia with normocapnia. A chest X-ray ruled out a pulmonary complication, and point of care transverse ultrasound through the thyroid cartilage window showed a distorted hyperechoic line corresponding to the vocal cords, with a subjective (not quantified) reduction of the glottic lumen beyond the open vocal cords, suggestive of glottic oedema. The patient began to show some improvement 1 h after administration of methylprednisolone 250 mg, so she was transferred to her room, and discharged from the hospital on the fifth day after surgery.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Airway injury can occur as a result of trauma during tracheal intubation or manipulation of the trachea during anaesthesia. This can cause haematoma, bleeding and oedema. Post-extubation laryngeal oedema has been associated with several predisposing factors which, in the case our patient, were female sex and over-large endotracheal tube. The Difficult Airway Society (DAS) of the United Kingdom and Ireland has developed guidelines for safe extubation in adult patients<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> that lists the different intubation-related complications that can arise and puts forward various management strategies, placing particular emphasis on the importance of careful intubation planning. In our patient, we encountered slight resistance to the advancement of the endotracheal tube, which we believe could be related to a previously unknown subglottic stenosis. Airway trauma would probably have been minimised by choosing a smaller endotracheal tube. There is growing interest in the use of ultrasound to estimate the size of the airway and choose the appropriate endotracheal tube. Ultrasound has been favourably compared to magnetic resonance imaging and computed tomography for the evaluation of the subglottic airway, and has shown good correlation between the transverse subglottic diameter and the external diameter of the endotracheal tube. The correct position of the tube in the trachea can be confirmed by the “double lumen” ultrasound sign – a double hyperechoic line – and ultrasound measurement of air column width at the level of the vocal cords before and after cuff inflation been shown to be a predictor of post-extubation stridor, insofar as a narrow air column is predictive of stridor after extubation<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a>. In our patient, ultrasound was useful in identifying the presence of glottic oedema in the PACU.</p><p id="par0025" class="elsevierStylePara elsevierViewall">This report has some limitations: no ultrasound examination was performed prior to anaesthesia induction to aid in the selection of the endotracheal tube and to measure the glottic lumen. The strong evidence currently available for the use of ultrasound as a non-invasive, reproducible technique for evaluating the airway both in the operating room and the PACU will facilitate the creation of future standards for the use of this technique in airway management.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Soto Garrucho E, Martínez Navas A, Echevarría Moreno M. La ecografía en el diagnóstico del edema de glotis postextubación. Rev Esp Anestesiol Reanim. 2022;69:55–56.</p>" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Ultrasonography in the management of the airway" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "M.S. 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Cook" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/j.1365-2044.2007.05069.x" "Revista" => array:6 [ "tituloSerie" => "Anaesthesia" "fecha" => "2007" "volumen" => "62" "paginaInicial" => "708" "paginaFinal" => "712" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17567347" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0025" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Predicting laryngeal edema in intubated patients by portable intensive care unit ultrasound" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "Y. Sutherasan" 1 => "P. Theerawit" 2 => "T. Hongphanut" 3 => "C. Kiatboonsri" 4 => "S. 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Vol. 69. Issue 1.
Pages 55-56 (January 2022)
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Vol. 69. Issue 1.
Pages 55-56 (January 2022)
Letter to the Director
Ultrasound in diagnosis of glottis edema post-extubation
La ecografía en el diagnóstico del edema de glotis postextubación
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