| Complication | Etiology/risk factors |
| Inability to tolerate extubation |
| Airway obstruction | - Laryngospasm
- Laryngeal edema
- Airway swelling after laryngoscopy or prolonged intubation
- Macroglossia
- Postsurgical changes after neck surgery: wound swelling, hematoma, recurrent laryngeal nerve injury, or hypoglossal nerve injury
- Obesity
- Obstructive sleep apnea
- Parkinson disease
- Rheumatoid arthritis
- Paradoxical vocal fold motion
|
| Inadequate ventilation | - Residual neuromuscular blockade
- Residual sedation, anesthetics, or opioids
- Diaphragmatic splinting
- Central sleep apnea
- Severe COPD (increased dead space, impaired mechanics, diminished CO2 responsiveness)
- Increased CO2 production
- Neuromuscular disease
|
| Inadequate oxygenation | - Postoperative atelectasis or reduced FRC
- Insufficient FiO2
- Increased metabolic demand
- Postobstructive pulmonary edema
- Chronic lung disease
- Pulmonary vascular disease
- Interstitial lung disease
|
| Failure of pulmonary toilet | - Reduced level of consciousness
- Impaired cough
- Increased respiratory secretions
|
| Inability to protect the airway | - Neuromuscular disorder
- Reduced level of consciousness
- Airway swelling
|
| Difficulty re-establishing the airway |
| Anatomic challenge | - Known multiple attempts, devices, or operators during prior laryngoscopy
- Airway edema due to prolonged Trendelenburg or prone positioning or significantly positive fluid balance
- Postsurgical distortion after major head and neck surgery
- Airway trauma
- Maxillomandibular fixation
- Cervical immobilization or instability
|
| Physiologic challenge | - Hemodynamic instability
- Hypoxia
- Hypercapnia
- Acidosis
|
| Contextual challenge (emergent setting) | - Inadequate knowledge of prior airway difficulty
- Insufficient equipment or medication
- Lack of qualified personnel
- Time pressure
|
