Is “Deep” Extubation Preferable in Patients at Risk for Bronchospasm?

Abstract

You walk up to your next patient, a slim 10-year-old boy, as his clubbed fingernails rapidly pound away at a keyboard, his eyes fixated on the screen. You sigh, recognizing this physical examination sign of chronic hypoxia (the fingers, not the video game addiction). As you suspect, he has cystic fibrosis complicated by recurrent lung infections and failure to thrive. He is scheduled for a soft tissue mass excision of the lower back. The parents are unsurprisingly nervous though the child is relatively calm. You introduce yourself to the child who shakes your hand but then immediately goes back to his game, pausing briefly first to cough up a tissue full of phlegm. The parents explain to you that he had a recent bronchial infection (on day 5 of 7 of antibiotics) that is now just resolving but is, unfortunately, par for the course. The patient is very compliant with his inhaler use. The parents are just as concerned as you about the increased pulmonary risks associated with general endotracheal anesthesia and recent lower respiratory infection, especially in light of his cystic fibrosis; however, this surgery has been cancelled twice already, and their son never seems to have a clear window to have the procedure done. In addition, the mass is deep and painful to lie on, and the surgeon states it cannot be done under local anesthesia. After a detailed discussion involving the parents and surgeon, you decide to proceed with the surgery. The parents accept the risks and appreciate your help.