#Case_11 How to improve my next post-thyroidectomy stridor if any?

[dhb]

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Laryngospam while moving 500cc TV is worthy of a Nature publication.

I haven't reread the whole sequence but if the tube was pulled under DL then stridor is audible while the patient is breathing 500ml then i don't see when the spasm happened.
Now if it's: DL pull the tube then no air movement then stridor then adequate TV then yes spasm and NPPE would be very likely.
We need a clarification of the events happening at extubation.

 

[GassYous]

Laryngospam while moving 500cc TV is worthy of a Nature publication.

I haven't reread the whole sequence but if the tube was pulled under DL then stridor is audible while the patient is breathing 500ml then i don't see when the spasm happened.
Now if it's: DL pull the tube then no air movement then stridor then adequate TV then yes spasm and NPPE would be very likely.
We need a clarification of the events happening at extubation.

Damnit I was just about to congratulate anbuitachi for being right even though I still disagree

 

[Arch Guillotti]

vent of stridor, I gave Dexamethasone and also gave 20 mg Laxis as I wad hearing crackles everywhere and feared of pulmonary edema. (passed urine)

Screams NPPE.

 

[anbuitachi]

Screams NPPE.

from most likely laryngospasm

 

[DrAmir0078]

Thanks all for the valuable information.
I spoke with the surgery resident - she said "ENT found to be the cause is bilateral recurrent laryngeal nerve injury during the procedure - aka fixed"
So where am I now?

Stridor - Yes
Possible NPPE - I treated with Laxis
Still weird - vT was OK only with jaw thrust
My view to the vocal cords weren't successful, as I mentioned it was mobile and apparently I saw them paramedian and the moving was totally confusing!

I am full...

Still surgeons here recommend to examine vocal cords under DL!

I truly want a suitable, scientific, within my resources non harmful technique to examine the cords? Any idea?

Many Thanks

 

[repititionition]

I truly

your surgeons are the ones who should be applying this level of introspection if they managed b/l RLN injury

 

[DrAmir0078]

your surgeons are the ones who should be applying this level of introspection if they managed b/l RLN injury

Please come and convince them !
Another surgery resident who is a final year board and he is studying for his exam told me "it is fine to examine the cords under DL by your team, it is not irritating - only if flexible one", I honestly didn't want to argue - it is like a battle who proves his theory!
To be honest, I believe most of our Anesthesiologists won't see the cords mobile enough as the patient is reversed - it is outdated!
I am so sorry, but living in Iraq and especially in certain places, we are behind !

 

[dhb]

Possible NPPE - I treated with

NPPE doesn't typically respond to lasix. Positive pressure ventilation CPAP or Bipap is better.

 

[DrAmir0078]

True - she was with jaw thrust on 20 - 25 APL, and during preoxygenation prior to re-intubation, I was using continuous oscillation of reservoir bag as I mentioned earlier.
She had crackles all over, but by Tracheostomy in and suction was negative and clear... That is why I said "was that rapidly my laxis worked - but I noticed noticeable urine output"

 

[repititionition]

NPPE doesn't typically respond to lasix. Positive pressure ventilation CPAP or Bipap is better.

first time I saw lasix given in this context I thought the same. did some research and found it is given because it is a direct pulmonary vasodilator as well.

 

[Arch Guillotti]

True - she was with jaw thrust on 20 - 25 APL, and during preoxygenation prior to re-intubation, I was using continuous oscillation of reservoir bag as I mentioned earlier.
She had crackles all over, but by Tracheostomy in and suction was negative and clear... That is why I said "was that rapidly my laxis worked - but I noticed noticeable urine output"

I have a hard time believing lasix worked this quick😎

 

[DrAmir0078]

I have a hard time believing lasix worked this quick😎

True, and how many times I had treated CHF during my rotation back in 2002 - 2005, we were using extra dosages of laxis with a special regime!
So there were 20 minutes between first dose of 10 mg of laxis and the other one!

An Anesthesiologist who I respect - used to work in UK - when I told him, he said "you have to be generous in giving laxis for Pulmonary edema"

That is why I questioned - was it rapidly working?

But how to explain no secretion and clear chest right after tracheostomy.

From extubation to re-intubation were like 25 minutes.
To Tracheostomy were like another 15 minutes...

I am still confused!

 

[MirrorTodd]

Dr Amir, what sort of bronchoscopes or video scopes do you have? ENT SHOULD have some sort of flexible scope that can go through the nares and examine them in an office based setting. All they need is a little local spray in the nostril. And I'd imagine that ENT would have some sort of scope easily available near the operating rooms that they could have called for.

 

[DrAmir0078]

Dr Amir, what sort of bronchoscopes or video scopes do you have? ENT SHOULD have some sort of flexible scope that can go through the nares and examine them in an office based setting. All they need is a little local spray in the nostril. And I'd imagine that ENT would have some sort of scope easily available near the operating rooms that they could have called for.

Yes, Dr MirrorTodd -
they do have them at their outpatient clinic in the hospital and in the other building OR... They didn't bring it, I don't know!