EXTUBATION OF THE DIFFICULT

AIRWAY

Carin A. Hagberg, MD

Joseph C. Gabel Professor & Chair∣Dept of Anesthesiology The University of Texas Medical School at Houston

Medical Director∣Perioperative Services Memorial Hermann Hospital

EXTUBATION

Airway complications are significantly more likely with extubation than

intubation

compared to management of the potentially difficult intubation, extubation has received relatively little scrutiny

ASA CLOSED CLAIMS

significant reduction in airway claims arising from injury at induction, not intraoperatively, during extubation or recovery

death or brain injury more common in victims associated with extubation & recovery

problems at extubation were more common in obese and OSA patients !!

Identified 25 cases associated with a peri-operative arrest or major anesthetic complication

8 anesthesia-related, 7 anesthesia-contributing

All anesthesia-related deaths due to airway obstruction or hypoventilation took place during emergence & recovery, not

during induction

System errors played a role in the majority of cases

coughing hemodynamic changes

laryngospasm bronchospasm

laryngeal edema pulmonary edema

airway traumaaspiration

unplanned extubationentrapment

failed extubation

EXTUBATION SIDE EFFECTS

severeminor

DIFFICULT INTUBATION“Any situation in which you are too scared to remove the endotracheal tube.”

Richard M. Cooper, BSc, MSc, MD, FRCPC

A Report by the American Society of Anesthesiologists Task Force on Management of the

Difficult Airway

PRACTICE GUIDELINES

MANAGEMENT OF THE

DIFFICULT AIRWAY

Evaluate factors that may interfere w/ upper airway patency

Formulate immediate reintubation plan if airway becomes compromised

Consider a jet stylet

Consider relative merits of awake vs deep extubation

Simple, pragmatic, useful in day-to-day practice

Discuss problems arising during extubation & recovery

Promote a strategic, step-wise approach to extubation

Make recommendations for post-extubation care

Not intended to constitute a minimum standard of practice, nor as a substitute for good clinical judgement

Safe management of tracheal extubation in adult, peri-operative practice

Human Factors ❖ Distraction ❖ Time pressure ❖ Operator fatigue ❖ Poor communication ❖ Lack of equipment or skilled assistance

Anesth Analg 2013;116:368-83

Extubation Making the Unpredictable Safer

ANESTHESIOLOGY NEWS GUIDE TO AIRWAY MANAGEMENT AUGUST 2012

Figure I The Brambrick/Hagberg Algorithm for Extubation of the Difficult AirwayPathways A & B refer to reintubation !

ANESTHESIOLOGY NEWS GUIDE TO AIRWAY MANAGEMENT AUGUST 2012

aMultiple attempts at direct vision or use of alternative device because of expected difficulty performing direct vision. bIf there is no evidence of laryngeal edema or respiratory difficulty.

Figure II The “VSS+4S+2S” proposed algorithm for extubation

ANESTHESIOLOGY NEWS GUIDE TO AIRWAY MANAGEMENT AUGUST 2012

PROSPECTIVE STUDY all major airway events

⅓ events occurred at extubation, or in the recovery room

results confirm importance of developing pre-planned strategies for extubation of the DA to improve patient safety & outcomes

most common comorbidities were obesity (46%), COPD (34%), OSA (13%), & mortality rate (5%)

DECISION TO EXTUBATE

what

who is the patient’s designated attorney? how was the patient intubated?

anesthetic technique? surgery performed?

when should I extubate patient? deep vs. awake?

where should I extubate patient? do I have the necessary equipment? OR vs. PACU?

why should patient be extubated? do they meet extubation criteria?

IDENTIFY HIGH-RISK PATIENTS

Unable to Tolerate Extubation Airway obstruction Hypoventilation syndromes Inability to meet extubation criteria

Difficulty Re-Establishing Airway Previous difficult airway

Restricted airway access Airway injury or surgery

Combative

Extubation Potential Reintubation

Re-Intubation potential challenge even if previously easily managed

Secretions/vomitus obscure glottic view

Time, equipment & personnel may not be immediately available

Incomplete information regarding the patient

Extubation Trial optimal staffing required

StrategiesStrategies

Plan B re-intubation

Difficult airway cart

Important Considerations

Setting Circumstances

Surgical procedure

Anesthetic Class Cardiopulmonary status

Airway establishment

Disease Comorbidities

Standard Methods & Delivery

Direct laryngoscopy

Fiberoptic endoscopy Nasogastric tube

Vascular catheter & guide wire Retrograde catheter

Tube changer !

ROLE OF THE LMA

“EXTUBATION BRIDGE” ---

HIGH-RISK PATIENTS ---

COMPLEX SURGERIES ---

MODIFIED DEEP EXTUBATION

ADVANTAGES Minimal airway trauma & complications Fast insertion time High success rate Reintubation possible Minimal cardiopulmonary responses

A Report by the American Society of

Anesthesiologists Task Force on Perioperative

Management of Patients with OSA

PERI- OPERATIVE MANAGEMENT

OBSTRUCTIVE SLEEP APNEA

PRACTICE GUIDELINES

EXTUBATION RECOMMENDATIONSStrict adherence to extubation criteria ! Full reversal of NMB

Patient positioning Awake extubation

JETSTYLET CATHETER

definition small internal diameter, hollow, semi-rigid catheter specifically designed for extubation of DA

indications • re-intubation • trial of extubation • dual-function

oxygenation + ventilation

C’mon, c’mon-it’s either one or the other

21 yo male s/p MVC multiple orthopedic injuries !prolonged intubation trach stopped talking !

tracheal stenosis s/p tracheal resection T1-3 wire-reinforced ET via trach site !

nasal rae ET + brace + chin sutured to chest !SCHEDULED FOR EXTUBATION 3X

DIFFICULT EXTUBATION

DIFFICULT EXTUBATION

DIFFICULT EXTUBATION

Hagberg CA, Westofen P. A two-person technique for fiberscope-aided tracheal extubation/reintubation in intensive care unit (ICU) patients. J Clin Anesth 2003; 15:467-70.

EXTUBATE OR NOT?

48 yo male s/p MVC h/o HTN, DM, EtOH abuse combative extensive facial fractures

left maxilla ethmoids nasal septum nasal bones zygoma mandible

multiple rib fractures + bilateral pulmonary contusions !oral intubation extubated day prior to surgery facial ORIF

expect the unexpected

extubation strategies appropriate equipment available

good judgement

appropriate monitoring

practice vigilance

17th Annual Society Airway Management Scientific Meeting

Philadelphia PA September 20-22, 2013

Introduction: The ASA task force on the management of difficult airway recommends that each anesthesiologist has a preformulated strategy for extubation of the difficult airway, and an airway management plan for managing postextubation-hypoventilation.1 In patients at high risk of extubation, various strategies have been recommended, including placement of an airway exchange catheter (AEC) prior to extubation.2 This report describes our experience in extubating high risk patients in whom an AEC was placed and the cuff leak test was used.Methods: After IRB approval, data were collected from 48 patients. In all patients, a difficult airway was predicted: 16 patients had documented intubation difficulties, and 24 patients had moderate or severe obstructive sleep apnea. The surgical procedures consisted of resection of airway lesions and tumors and surgery for obstructive sleep apnea (n=34), repair of mandibular fractures (wired jaw; n=8), and non-airway procedures (n=6). In 26 patients, an awake fiberoptic oral or nasal intubation was performed, whereas, in 22 patients, the intubation was facilitated using an introducer after direct laryngoscopy.After accepted criteria for extubation were met, a cuff leak test was performed in 44 patients. In the remaining 4 patients, a cuff leak test could not be performed because a cuff leak was not detected immediately after intubation. A cuff leak test was considered positive if expired tidal volume decreased by ≥ 20% after cuff deflation. A lubricated AEC (11.0 Fr) was placed inside the tracheal tube with the tip 2-4 cm below the distal end of the endotracheal tube. The tube was then withdrawn and the AEC was fixed in place. This procedure was facilitated with iv lidocaine. With close monitoring, and availability of intubation equipment and wire cutters (in case of wired jaws), the patients were taken to the PACU or ICU.Results: The 44 patients who received a cuff leak test had a positive result. There was no evidence of airway obstruction after extubation in any of the 48 patients and thus no reintubations were required. SpO2 was ≥ 95% with supplemental O2 in all patients. The AEC was removed in 1 - 4 hours in 43 patients and, after 4 hours in 5 patients. It was noted that 38 patients tolerated the AEC, while the rest had slight discomfort and cough.Discussion: Although no reintubations were necessary in the 48 patients studied, the use of an AEC in the management of the difficult airway should not be abandoned. It is a simple maneuver, tolerated by most patients, and can provide a means for reintubation, as well as, for oxygenation and drug administration. The current study was limited to surgical patients, and thus should not be extrapolated to other clinical scenarios, e.g., prolonged intubations in ICU patients. The positive leak test, as a predictor of airway patency, may be complementary to the use of the AEC in enhancing the safety of extubation of the difficult airway.References:1. American Society of Anesthesiologist: Practice Guidelines for Management of the Difficult Airway. Anesthesiology 2003;98:1269-1277.2. Cooper, RM. Extubation and changing endotracheal tubes. In: Hagberg CA, ed. Benumof's Airway Management. 2nd ed. Philadelphia, PA: Mosby Elsevier: 2007, pp. 1146-1180.

Combined  Use  of  Airway  Exchange  Catheter  and  Cuff  Leak  Test  When  Extuba>ng  the  Difficult  AirwayM. R. Salem, M.D., Michel J. Sabbagh, M.D., George J. Crystal, M.D., Advocate Illinois Masonic Med Ctr, Chicago, Illinois, United States

Abstract 770  ASA 2012 Annual Meeting