Extubation of the Difficult Airway
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Transcript of Extubation of the Difficult Airway
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
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