Biting on the tracheal tube can occur during emergence and obstruct respiration. If hypoxia results, and is worsening, it may be necessary to paralyze with suxamethonium to enable ventilation.

If the situation is not deteriorating, a small dose of IV propofol
(0.5-1 mg/kg) will often allow the jaw to relax sufficiently to allow the insertion of an oral airway which will prevent tube obstruction. Many anaesthetists place an oral airway prophylactically to avoid this problem.

At all times great care must be taken to avoid dental trauma.

Hypoventilation or apnoea may occur even after the tracheal tube is removed. This is much less likely to occur if you have properly prepared for extubation.

Gently employ IPPV with 100 % oxygen via the anaesthetic face mask, and insert an oral airway if necessary. Carefully monitor vital signs (ECG, BP, pulse oximetry).

Try to work out the cause and treat appropriately. These will include factors already considered (e.g. residual neuromuscular block, hypocapnia, depressant action of drugs).

In addition, consider the possibility of:

• An obstruction to the airway e.g. throat pack in ENT
• Laryngospasm
• An inadvertent IV bolus of an anaesthetic drug
• In rare circumstances, a cerebrovascular event or pneumothorax