EXTUBATION OF THE
DIFFICULT
AIRWAY
Carin A. Hagberg, MD
Joseph C. Gabel Professor & Chair∣
Dept of Anesthesiology	

The Un...
EXTUBATION
compared to management of the
potentially difficult intubation, 	

extubation has received relatively
little scr...
ASA
CLOSED CLAIMS
significant reduction in airway claims
arising from injury at induction, 	

not intraoperatively, during ...
Identified 25 cases associated with a peri-operative arrest or
major anesthetic complication	

8 anesthesia-related, 7 ane...
EXTUBATION SIDE EFFECTS

minor

coughing
hemodynamic changes
laryngospasm
bronchospasm
laryngeal edema
pulmonary edema
air...
DIFFICULT INTUBATION
“Any situation in which you are too scared to remove the endotracheal tube.”
Richard M. Cooper, BSc, ...
PRACTICE
GUIDELINES
MANAGEMENT
OF THE
DIFFICULT
AIRWAY
A Report by the American
Society of Anesthesiologists Task
Force on...
Consider relative merits of awake vs deep extubation
Evaluate factors that may interfere w/ upper airway patency	

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

Simple, pragmatic, useful in day-to-day practic...
Human Factors	

❖

❖

❖

❖

❖

Distraction	

Time pressure	

Operator fatigue	

Poor communication	

Lack of equipment or ...
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 Airway

Pathways A & B refer
to reintubation

!

a...
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
most	 comm...
DECISION TO
EXTUBATE
who is the patient’s designated attorney?	

how was the patient intubated?
what anesthetic technique?...
IDENTIFY HIGHRISK PATIENTS
Unable to Tolerate Extubation
Airway obstruction
Hypoventilation syndromes
Inability to meet ex...
Extubation Potential Reintubation
Re-Intubation potential challenge	

even if previously easily managed
Combative	

Secret...
Strategies
Strategies
Extubation Trial
optimal staffing required
Plan B
re-intubation
Difficult airway cart
Important Considerations

Anesthetic Class
Cardiopulmonary status
Airway establishment
Setting
Circumstances
Surgical proc...
Standard Methods & Delivery
Direct laryngoscopy
Fiberoptic endoscopy
Nasogastric tube
Vascular catheter & guide wire
Retro...
ROLE OF
THE LMA

“EXTUBATION BRIDGE”
--HIGH-RISK PATIENTS
--COMPLEX SURGERIES
--MODIFIED DEEP EXTUBATION

ADVANTAGES
Minim...
PRACTICE
GUIDELINES
PERIOPERATIVE
MANAGEMENT
OBSTRUCTIVE
SLEEP APNEA

A Report by the
American Society of
Anesthesiologist...
EXTUBATION
RECOMMENDATIONS
Strict adherence to extubation criteria

! Full reversal of NMB
Patient positioning
Awake extub...
JETSTYLET

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

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

EXTUBATION
21 yo male s/p MVC

multiple orthopedic injuries

!

prolonged intubation
trach
stopped talking

!

...
DIFFICULT
EXTUBATION
DIFFICULT
EXTUBATION
Hagberg CA, Westofen P. A two-person technique for
fiberscope-aided tracheal extubation/reintubation in intensive
care unit...
EXTUBATE
OR NOT?
48 yo male s/p MVC
h/o HTN, DM, EtOH abuse
combative
extensive facial fractures
left maxilla
ethmoids
nas...
expect the unexpected
extubation strategies
appropriate equipment available	

good judgement	

appropriate monitoring
prac...
17th Annual Society
Airway Management Scientific Meeting

Philadelphia PA

September 20-22, 2013
 

Abstract 770
ASA 2012 Annual Meeting

Combined	
  Use	
  of	
  Airway	
  Exchange	
  Catheter	
  and	
  Cuff	
  Leak	
  ...
Extubation of the Difficult Airway
Extubation of the Difficult Airway
Extubation of the Difficult Airway
Extubation of the Difficult Airway
Extubation of the Difficult Airway
Extubation of the Difficult Airway
Extubation of the Difficult Airway
Extubation of the Difficult Airway
Extubation of the Difficult Airway
Extubation of the Difficult Airway
Extubation of the Difficult Airway
Extubation of the Difficult Airway
Extubation of the Difficult Airway
Extubation of the Difficult Airway
Extubation of the Difficult Airway
Extubation of the Difficult Airway
Extubation of the Difficult Airway
Extubation of the Difficult Airway
Extubation of the Difficult Airway
Extubation of the Difficult Airway
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Extubation of the Difficult Airway

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Extubation of the Difficult Airway

  1. 1. 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
  2. 2. EXTUBATION compared to management of the potentially difficult intubation, extubation has received relatively little scrutiny Airway complications are significantly more likely with extubation than intubation
  3. 3. 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 ! !
  4. 4. 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
  5. 5. EXTUBATION SIDE EFFECTS minor coughing hemodynamic changes laryngospasm bronchospasm laryngeal edema pulmonary edema airway trauma aspiration unplanned extubation entrapment failed extubation severe
  6. 6. DIFFICULT INTUBATION “Any situation in which you are too scared to remove the endotracheal tube.” Richard M. Cooper, BSc, MSc, MD, FRCPC
  7. 7. PRACTICE GUIDELINES MANAGEMENT OF THE DIFFICULT AIRWAY A Report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway
  8. 8. Consider relative merits of awake vs deep extubation Evaluate factors that may interfere w/ upper airway patency Formulate immediate reintubation plan if airway becomes compromised Consider a jet stylet
  9. 9. Safe management of tracheal extubation in adult, peri-operative practice 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
  10. 10. Human Factors ❖ ❖ ❖ ❖ ❖ Distraction Time pressure Operator fatigue Poor communication Lack of equipment or skilled assistance
  11. 11. Anesth Analg 2013;116:368-83
  12. 12. Extubation Making the Unpredictable Safer ANESTHESIOLOGY NEWS GUIDE TO AIRWAY MANAGEMENT AUGUST 2012
  13. 13. Figure I The Brambrick/ Hagberg Algorithm for Extubation of the Difficult Airway Pathways A & B refer to reintubation ! 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. ANESTHESIOLOGY NEWS GUIDE TO AIRWAY MANAGEMENT AUGUST 2012
  14. 14. Figure II The “VSS+4S+2S” proposed algorithm for extubation ANESTHESIOLOGY NEWS GUIDE TO AIRWAY MANAGEMENT AUGUST 2012
  15. 15. PROSPECTIVE STUDY all major airway events ⅓ events occurred at extubation, or in the recovery room most common comorbidities were obesity (46%), COPD (34%), OSA (13%), & mortality rate (5%) results confirm importance of developing pre-planned strategies for extubation of the DA to improve patient safety & outcomes
  16. 16. DECISION TO EXTUBATE who is the patient’s designated attorney? how was the patient intubated? what 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?
  17. 17. IDENTIFY HIGHRISK 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
  18. 18. Extubation Potential Reintubation Re-Intubation potential challenge even if previously easily managed Combative Secretions/vomitus obscure glottic view Incomplete information regarding the patient Time, equipment & personnel may not be immediately available
  19. 19. Strategies Strategies Extubation Trial optimal staffing required Plan B re-intubation Difficult airway cart
  20. 20. Important Considerations Anesthetic Class Cardiopulmonary status Airway establishment Setting Circumstances Surgical procedure Disease Comorbidities
  21. 21. Standard Methods & Delivery Direct laryngoscopy Fiberoptic endoscopy Nasogastric tube Vascular catheter & guide wire Retrograde catheter Tube changer !
  22. 22. 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
  23. 23. PRACTICE GUIDELINES PERIOPERATIVE MANAGEMENT OBSTRUCTIVE SLEEP APNEA A Report by the American Society of Anesthesiologists Task Force on Perioperative Management of Patients with OSA
  24. 24. EXTUBATION RECOMMENDATIONS Strict adherence to extubation criteria ! Full reversal of NMB Patient positioning Awake extubation
  25. 25. JETSTYLET definition small internal diameter, hollow, semi-rigid catheter specifically designed for extubation of DA CATHETER indications • • • re-intubation trial of extubation dual-function oxygenation + ventilation
  26. 26. C’mon, c’mon-it’s either one or the other
  27. 27. DIFFICULT EXTUBATION 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
  28. 28. DIFFICULT EXTUBATION
  29. 29. DIFFICULT EXTUBATION
  30. 30. 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.
  31. 31. 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
  32. 32. expect the unexpected extubation strategies appropriate equipment available good judgement appropriate monitoring practice vigilance
  33. 33. 17th Annual Society Airway Management Scientific Meeting Philadelphia PA September 20-22, 2013
  34. 34.   Abstract 770 ASA 2012 Annual Meeting Combined  Use  of  Airway  Exchange  Catheter  and  Cuff  Leak  Test  When  Extuba>ng  the   Difficult  Airway M. R. Salem, M.D., Michel J. Sabbagh, M.D., George J. Crystal, M.D., Advocate Illinois Masonic Med Ctr, Chicago, Illinois, United States 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.
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