Extubation Process

Andy Higgs

Warrington Hospitals

Cheshire

UK

Extubation Process

Extubation is easy?

Is it?

Extubation Process

RCA: 4th National Audit Project – NAP4Major complications airway management in UK

• Deaths• Brain damage• Sub-glottic access• Unplanned ICU

• 138 anaesthesia cases• 38 extubation (28%)

•Major Complications of Airway Management in the UK•1/9/08 – 31/8/09

•Major Complications of Airway Management in the UK•1/9/08 – 31/8/09

•March 2011•March 2011

Extubation Process

Difficult extubation – WHY?

Extubation Process

Difficult extubation – WHY?• Initial cause of difficult intubation is still there• You have traumatised / worsened the airway at intubation

• FRC ↓O2

• CVS ↑CO2

• Post GA ↓GCS ↓pH• Pain Agitated• New airway factors have developed:

oedema, ↓access, bleeding...

‘The Scream.’ Edvard Munch

Extubation Process

Difficult extubation – WHO?• History difficult intubation / extubation KNOW• Impending airway obstruction / oedema pre-op• Difficult intubation at induction - multiple ≥3 attempts

- alternative techniques FIND

- traumatic intubation• Intra-op airway events inc. 2nd airway device• Airway surgery / trauma • Poor post-op access to or immobility of airway MAKE • Category of surgery – thoracic, neck surgery• Burns FILL• Massive fluid resuscitation• Obesity – OSA BIG

Extubation Process

Training

Basic Level Training: - explain how to remove tracheal tube and

- describe the associated problems and

- complications

- demonstrate assessment of reflexes

- describe adequate ventilation

• Intermediate Level: NIL• Advanced Level: NIL

• We emphasize intubation but ignore extubation

E Sans-Solachi & J Hadlow. 2010

Extubation Process

Training

• We emphasize take-off but ignore landing

Extubation Process

Extubation plan – DAS guideline

Extubation Process

Extubation plan – DAS guideline in CANADA Nov 2013

Extubation Process

Extubation Process

Extubation Process

Extubation Process

Step 1: PLAN - assessment1. Assess general condition

2. Assess airway

1. ‘General airway’factors

2. Supra-glottis

3. Glottis and sub-glottis

4. Lower airway

5. Emergency sub-glottic access!

A

Extubation Process

Step 1: PLAN - assess1. Assess airway – general airway risk factors

2. Supra-glottis – Direct or VL / FO laryngoscopy

Don’t be fooled!

ETTs tell you where larynx is

ETTs stent airway - elevate supra-glottis

Molding

Expect minor oedema to progress

Infection spreads

Ask the surgeon

A

Extubation Process

Step 1: PLAN - assessAssess glottis & sub-glottis

This is difficult: anatomical & functional

Laryngoscopy Cuff leak

CT

(limitations)

A

Extubation Process

Step 1; PLAN - assessAssess lower airway

Consider: aspiration

collapse (RMB intubation)

gastric distension (?NGT) ? CXR

pneumothorax

surgical emphysema

Airway trauma

ETT position ? Fibrescopy

Secretions

Blood

A

Extubation Process

Step 1: PLAN - assessment1. Assess general condition

2. Assess airway

1. General airway factors

2. Supra-glottis

3. Glottis and sub-glottis

4. Lower airway

5. Emergency sub-glottic access!

A

Extubation Process

Extubation Process

Step 2: PREPARE - Steroids

• > 12 hours• Hydrocortisone 100mg 6 hourly

Extubation Process

Extubation Process

Extubation Process

Extubation Process

Extubation Process

Step 3: Leave the ETT in situ

…for the medical SHO

Extubation Process

AECs: If patient deteriorates

Railroading the ETT• Any railroading procedure• ‘Mind the gap’ between ETT & stylet

# 11 COOK AEC

Aintree Catheter

# 7.0mm ETT

Higgs et al 2010

Airway Exchange Catheters

Catheter Catheter Catheter ETT

Fr Length /cm ID / mm ID / mm

8 45 1.6 ≥ 3

11 83 2.3 ≥ 4

14 83 3.0 ≥ 5

19 83 3.4 ≥ 7

Extra Firm Soft Tipped

11 100 2.3 ≥ 4

14 100 3.0 ≥ 5