Also consider major bronchospasm, right mainstem intubation, or tension pneumothorax—these conditions happen often more than you think.

The sudden onset of peak inspiratory pressures and reduced or absent sounds after intubation can have many causes. In cases where intubation was confirmed by direct vision or by prior knowledge of ventilation, mechanical factors should be considered first. Mechanical factors (e.g., kinked endotracheal tube [ETT] or circuit), endobronchial intubation, mucous plug, or leaning on the ETT neck or chest can be resolved easily. If there is no reason to believe there is a pneumothorax (i.e., there is not hyperresonance on percussion on one side of the chest, shift in the mediastinum, or unilateral breath sounds), then bronchospasm should be considered.

Etiologies of bronchospasm include the patient’s intrinsic disease, chemical, or neurogenic causes. Bronchospasm is a common sequelae for those patients having intrinsic disease, such as reactive airway disease (RAD) and asthma. These patients are more sensitive to airway manipulation, which may result in severe bronchospasm with intubation. Furthermore, patients with a recent upper respiratory tract infection are more prone to bronchospasm because of the increased airway “irritability.” The second most common reason for severe bronchospasm is drugs. Histamine-releasing drugs, such as muscle relaxants, morphine, antibiotics (vancomycin), and gastrointestinal drugs (omeprazole), are usual culprits. Even nonsteroidal anti-inflammatory drugs have been related to an acute attack of asthma developing within minutes of the drug given. Other concomitant reactions to the histamine include profuse rhinorrhea, conjunctival injection, and scarlet flushing. However, any drug can be a suspect. If no other reasons for a change in pulmonary status are identified and the symptoms occurred just after a drug had been given, one should consider drug-induced bronchospasm as a cause. These reactions usually occur within a short period of time after the administration of drug and usually in patients with history of RAD or asthma.