STRATEGIES FOR EXTUBATION OF THE DIFFICULT AIRWAY

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STRATEGIES FOR EXTUBATION OF THE DIFFICULT AIRWAY

• Pejakov Ljubica
• Medical faculty Podgorica, Montenegro
• Clinical Centre, Montenegro

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DFFICULT AIRWAY-DEFINITION

• THE DIFFICULT AIRWAY IS CLINICAL SITUATION IN
  WHICH A CONVENTIONALLY TRAINED ANESTHETIST
  EXPERIENCES DIFFICULTY WITH MASK VENTILATION OF
  THE UPPER AIRWAY, TRACHEAL INTUBATION, OR BOTH.

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STRATEGIES FOR EXTUBATION OF THE DIFFICULT AIRWAY

• The ASA Task Force on Difficult Airway
  Management PREFORMULATED PLAN FOR EXTUBATING
  THE DIFFICULT AIRWAY SHOULD BE A STANDARD
  CONSIDERATION.
• Caplan RA, Benumof JL et al. Anesthesiology
  2003
• PLAN DEPENDS ON
• INDIVIDUAL CONDITION OF THE PATIENT
• SKILLS OF THE PRACTITIONER
• EXPERIENCE OF THE PRACTITIONER
• PREFERENCES OF THE PRACTITIONER
• DEVICES AVAILABLE AT THE HOSPITAL

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STRATEGIES FOR EXTUBATION OF THE DA

• THE GOAL EXTUBATE IN A SECURE BUT REVERSIBLE
  FASHION
• EFFECTIVE EXTUBATION STRATEGY low reintubation
  rate, should not cause patient discomfort, should
  enable oxygenation and ventilation and facilitate
  reintubation, if necessary.
• THE ART AND SCIENCE OF KNOWLEDGEABLE AND SAFE
  EXTUBATION PRACTICE IS IN INFANCY
• EACH EXTUBATION IS A TRIAL-THERE IS NO
  GUARANTEE THAT IT WILL BE TOLERATED.
• Mort CT, Hartford, Connecticut, 2008
• PREDICTION OF SUCCESSFUL OR FAILED EXTUBATION
  IMPRECISE (rapidly changing clinical
  circumstances)
• Epstein SK Crit Care Med 2006
• Esteban A et al,. N Engl J Med 2004

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REINTUBATION OF THE DA

• TRACHEAL REINTUBATION MORE DIFFICULT THAN
  INITIALLY
• - emergent nature,
• - accompanying hypoxemia,
• - cardiovascular instability,
• - limited access to the airway (e.g. cervical or
  intermaxillary fixation, lingual, pharyngeal and
  laryngeal edema, neck swelling)
• - the lack of patient cooperation,
• EXTUBATION OF THE DA SHOULD ALWAYS BE VIEWED AS A
  POTENTIALLY DIFFICULT REINTUBATION!
• REPEATED INTUBATION ATTEMPTSWORSE OUTCOME
  (DEATH, BRAIN DAMAGE)
• Peterson GN et al. Anesthesiology 2005

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REINTUBATION OF THE DA

• EPIDEMIOLOGY
• Reintubation rate IN THE OPERATING ROOM folowing
  elective surgery inceased in procedures performed
  in the proximity to the airway.
• Risk factors for failed extubation and difficult
  reintubation difficult intubation, requirement
  for aditional airway devices during induction of
  anaesthesia, airway problems since intubation,
  obesity, history of obstructive sleep apnea.
• Peterson GN et al. Anesthesiology 2005

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REINTUBATION OF THE DA

• CRITICAL CARE UNIT
• UP TO 20 OF ALL CRITICAL INCIDENT REPORTS ARE
  AIRWAY RELATED
• DA is commonly cause of adverse events (including
  airway injury, hypoxic brain injury, death)
• In ICU reintubation within 12 h after extubation
  up to 25 patients- alterations in the
  neurologic, cardiovascular, metabolic,
  psychological and nutritional status, fluid
  derangements chronic dependence on mechanical
  ventilation, alterations in airway reflexes.

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EXTUBATION COMPLICATIONS

• Laryngospasm (upper airway obstruction?negative
  pressure pulmonary edema!), hipoxemia,
  hypercarbia
• Hemodynamic alterations (hypertension,
  tachycardia, bradicardia, dysrhythmias,
  myocardial injury)
• Glottic incompetence (aspiration, ineffective
  cough, phonation difficulties)
• Periglottic injury (supraglottic edema, vocal
  cord edema and paralysis-paresis, subglottic
  narrowing, cartilaginous dislocation)
• Coughing, breathe holding, aspiration of gastric
  contents
• Unintentional or self-extubation

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EXTUBATION STRATEGY

• STRATEGY SHOULD INCLUDE
• A) MERITS OF EXTUBATION IN THE AWAKE VERSUS
  UNCOSCIOUS STATE
• B) CONSIDERATION OF CLINICAL FACTORS THAT MAY
  IMPAIR RESPIRATION AFTER EXTUBATION
• C) PREFORMULATED PLAN IN CASE THE PATIENT IS
  UNABLE TO TOLERATE EXTUBATION
• D) CONSIDERATION OF THE USE OF A DEVICE THAT CAN
  FACILITATE REINTUBATION

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EXTUBATION STRATEGY

• PATIENTS AT HIGH RISK FOR EXTUBATION FAILURE-
  METHODICAL PREPARATION.
• Preparation phases
• 1. General and specific assessment of past and
  current medical and surgical pathophysiologic
  factors related to the airway or respiratory
  system
• 2. Physical assessment of the airway
• 3. Formulation of an extubation strategy with
  the goal of providing a reversible extubation

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EXTUBATION STRATEGY

• Phase 1 GENERAL ASSESSMENT
• - Review of the patients medical records for
  previous airway instrumentation, condition and
  extubation failures
• - Elective/emergent airway interventions,
  extubations
• - Surgical /medical factors affecting the
  airways
• - Postoperative/miscellaneous conditions
  (massive fluid resuscitation, burns, inhalational
  injuries, subglottic stenosis, laringo/tracheo/bro
  nchitis, cervical spine injury, halo traction
  vert)
• - Current and past medical illnesses affecting
  extubation tolerance (CVS, pulmonary, renal,
  hepatic, coagulopathy, sepsis, etc)
• - Review of current ventilatory requirements
  (FiO2, PEEP, MV, secretions, ETT tolerance during
  awake state)
• - Current vital signs, mental and neurologic
  status

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EXTUBATION STRATEGY

• CATEGORIZATION PATIENTS POSSIBLY AT HIGH RISK FOR
  EXTUBATION FAILURE
• Those with significant cardiopulmonary or related
  dieases-but are not expected to have a DA
• Those with a known or suspected DA
• Patient in both categories would be at greater
  risk for extubation
• Risk rises sharply when experienced personnel
  with advanced intubation skills and equipment are
  not available
• (Cooper RM. Anesthesiol Clin North
  America, 1995)

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EXTUBATION STRATEGY

• Phase 2 COMPREHENSIVE AIRWAY EVALUATION
• Assessment of ability to ventilate, oxygenate
  and reintubate the patient, if required.
• - Discussion with care providers (physicians,
  nurses, respiratory therapists, midlevel
  parctitioners)
• - External evaluation, direct or indirect airway
  assessment
• - Discussion of plan with patient (and family,
  if appropriate)
• - Acquisition of basic/advanced airway equipment
  at bedside, experienced personnel.
• Previous easy with mask ventilation,
  supraglottic airway placement or tracheal
  intubation, does not guarantee the same during
  the next airway management!

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EXTUBATION STRATEGY

• Phase 3 DEVELOPMENT OF A STRATEGY
• Cuff Leak? No
• - In case of excessive hydration, airway trauma
  (intubation related?), poor positioning,
  generalized edema, systemic reactions, sepsis,
  angioedema, infections, compromised head and neck
  venous drainage, oversized ETT.
• No Cuff Leak?DELAY IN EXTUBATION OR TRACHEOSTOMY
• Cuff Leak Test (no standardized) quantitative
  (volume of the leak)
• non quantitative (audible)
• No Cuff Leak higher likelihood of
  post-extubation stridor, reintubation,
  tracheostomy. Steroids pre-extubation lower
  stridor.
• Direct or indirect visualization of the airway
  (airflow obstruction)

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EXTUBATION STRATEGY

• Phase 3 DEVELOPMENT OF A STRATEGY
• Therapeutic options for high risk patients
• a) standard extubation
• b) extubation and evaluation via a FOB
• c) extubation followed by placement of
  supraglottic airway (SGA) for airway patency,
  oxygenation, ventilation and pathway for
  potential reintubation
• d) extubation over an airway excange catheter
  (AEC)

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EXTUBATION STRATEGY

• Extubation and evaluation with the FOB
• - brief evaluation of the airway
• - provides vital airway information to the
  clinician (obstruction from redundant pharyngeal
  tissues, traumatized supraglottic structures,
  arytenoid dislocation, vocal cord alterations,
  swelling or laryngeal dysfunction)
• Decision maintain current status
• extubate
• reintubate
• obtain ENT consultation
• schedule elective surgical airway
• Requires skill of practitioner!

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EXTUBATION STRATEGY

• Extubation with a supraglottic airway (SGA)
• Airway evaluation with FOB via SGA (not
  supraglottic and pharyngeal structures)
• Needs patient to be extubated risk
  safety/clinical information provided
• Periglottic obstruction- no benefit

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EXTUBATION STRATEGY

• Extubation over AEC
• First Bedger and Chang- passing jet stylet
• Bedger RC, Chang JL. Anesthesiology 1987
• Seldinger technique intubation conduits
• AEC is integral component of the DA cart and any
  extubation strategy
• Cooper RC, Chohen DR. Can J Anesth 1994
• Catheter size (adult) small (ED 3,7-4 mm)-
  phonation, good tolerance
• medium (4,7 mm)- for taller
  patients

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AEC in patient with hallo traction of cervical
spine
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AIRWAY EXCANGE CATHETERS

• The Ideal Airway Excange Catheter
• Appropriate rigidity
• Atraumatic distal tip
• Central lumen for suctioning, O2 delivery, CO2
  measurement
• Distal side ports, radiographically distinct
• Readible depth markings, minimal termal lability
• Multiple lengths and diameters available
• Reasonable cost

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AIRWAY EXCANGE CATHETERS

• POTENTIAL BENEFITS OF AEC
• Access for tracheal suctioning
• Continuous access to the airway
• Portal for administration of medication - local
  anesthetics, racemic epinephrine nebulization
• Portal for end-tidal CO2 monitoring
• Portal for ventilation (via adapters)
• Jet ventilation portal (skilled and knowledgable
  practitioners)
• Reintubation guide
• Oxygen delivery portal (preparation for
  reintubation)

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AIRWAY EXCANGE CATHETERS

• DYSADVANTAGES OF AEC
• Prolonged use
• - airway trauma
• - aspiration (glottal functional incompetence)
• - retention of tracheal secretions- impaired
  coughing
• - the tip of the ETT may impact on the
  epiglottis during advancement over the AEC
• - lung laceration if inappropriate use during
  tracheal extubation
• Biro P. Anaesthesia Analgesia, 2007

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EXTUBATION STRATEGY

• The ASA Task Force on Management of the
  Difficult Airway
• Practice guidelines
• Controlled, gradual and reversible withdrawal of
  airway support
• Approaches to extubation of the DA
• Extubate in a deep plane of anaesthesia
• Extubate awake conventionally and hope for the
  best
• Extubate awake with a bridge to full extubation
• Awake extubation is the most appropriate
  method of removing the
• ET in most patients with a difficult airway

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CONCLUSION

• THE HIGH RISK PATIENTS SHOULD BE IDENTIFIED IF AT
  ALL POSSIBLE
• BEFORE DECISION FOR EXTUBATION, OPTIMIZE MEDICAL
  CONDITION OF THE PATIENT
• APPROPRIATEKNOW-HOW AND EQUIPMENT SHOULD BE
  AVAILABLE AT THE TIME OF EXTUBATION, AND
  IMMEDIATELY AFTER
• BE PREPARED FOR EXTUBATION FAILURE
• SENIOR ANAESTHESIOLOGIST WITH EXPERIENCE IN
  DIFFICULT AIRWAY (AND TRAINED NURSE) SHOULD BE
  PRESENT ALONGSIDE THE AIRWAY MANAGER WHICH MAY
  IMPROVE PATIENT SAFETY