By Matthew Newton, DNP, CRNA
Ever wonder why airway issues like laryngospasm, wheezing, and asthma attacks seem to spike toward the end of the year? Cold and flu season might be partly to blame, and it’s something that should always stay on our radar as anesthesia professionals. Each year, as cold and flu season rolls in, anesthesia providers are faced with the familiar dilemma of whether to proceed with or delay elective cases in patients who present with current or lingering upper respiratory tract infection (URI) symptoms. What may seem like a minor cough or nasal congestion can, in the perioperative environment, significantly increase the risk of airway complications. Even mild or resolving infections can lead to inflammation, airway hypersensitivity, and mucus hypersecretion that persist for up to 6 weeks in adults after the illness has subsided. This residual airway hyperreactivity can transform a basic routine anesthetic into a high-risk situation, particularly for patients with reactive airway disease or a history of smoking.
Determining when to proceed or delay surgery requires a balanced, patient-specific assessment. Elective procedures should be delayed for 2-4 weeks when patients present with fever, productive cough, wheezing, or evidence of lower respiratory tract involvement, which indicates ongoing airway inflammation and a heightened risk of laryngospasm and bronchospasm. Conversely, patients with mild nasal congestion or a nonproductive cough who are afebrile and otherwise healthy may proceed with caution, provided that the anesthesia plan and airway management strategy are adjusted accordingly. Those with recent URIs within the past 2 weeks, particularly smokers, asthmatics, or those with a history of reactivity, should be carefully evaluated and delayed if possible. Once the patient is asymptomatic for more than 2-4 weeks, it is generally safe to proceed; this assumes the patient has been properly assessed, and airway reactivity should have returned to baseline.
Proceeding with anesthesia too soon after a URI increases the likelihood of several complications, including laryngospasm, bronchospasm, hypoxemia, atelectasis, postoperative pneumonia, or, in the case of general anesthesia, delayed extubation. Studies have shown that patients with recent upper respiratory infections are 2-7 times more likely to experience airway-related complications, particularly when endotracheal intubation is required. Residual airway inflammation amplifies reflex responses to stimulation, while increased mucus production and impaired clearance promote obstruction and oxygen desaturation. These events not only jeopardize patient safety but also contribute to delayed emergence, unplanned hospital admissions, and increased postoperative morbidity.
If anesthesia must proceed, several strategies can reduce risk. Preoperatively, patients with reactive airways may benefit from bronchodilator therapy such as albuterol. Glycopyrrolate can be used judiciously to reduce secretions. Keep in mind, Glycopyrrolate can take up to 30 minutes to reach the desired antisialagogue effect we desire. Airway management should favor regional or monitored anesthesia care when appropriate to minimize airway stimulation. When general anesthesia is necessary, minimize stimulation during induction and, when possible, opt for an LMA instead of an endotracheal tube to reduce coughing and irritation. If intubation is necessary, ensure deep anesthesia and complete neuromuscular blockade before laryngoscopy; avoid desflurane, which can add to airway irritability. Throughout the case, maintain humidified gases and monitor airway pressures closely; rising peak pressures can be an early sign of bronchospasm or obstruction. Should bronchospasm occur, deepen anesthesia with propofol or a volatile agent, and administer inhaled β₂-agonists. If unrelieved, intravenous epinephrine may be required in severe cases.
Postoperatively, the timing of extubation is critical. The patient should be extubated either deeply or fully awake. Close observation in the PACU for wheezing, stridor, or desaturation is essential, and humidified oxygen or bronchodilator therapy may be required. Laryngospasm should be managed with continuous positive pressure and a jaw thrust; if unresolved, small doses of succinylcholine can rapidly relieve the spasm. Persistent wheezing may require nebulized bronchodilators or corticosteroids, and oxygen should be titrated to maintain adequate saturation.
As important as pharmacologic and technical management are, clear communication and professional collaboration often make the biggest difference. Surgeons or proceduralists sometimes perceive anesthesia delays as unnecessary and disruptive. Explaining that residual inflammation can turn an otherwise smooth case into a high-risk airway event helps others understand the “why” behind our decisions. Setting those expectations before the height of cold and flu season can prevent tension later when cancellations inevitably arise.
When in doubt, reach out. Consult your medical director, chief provider, or proceduralist for a second opinion. Two perspectives are always better than one, and collaboration is key to ensuring we balance patient safety with procedural efficiency. Postponing a scheduled case is inconvenient for all involved; that’s a small price compared with managing a preventable airway emergency. At the end of the day, our job is to safeguard the patient, and that begins long before induction, with sound judgment, teamwork, and a steadfast commitment to safety above all else.
