Extubation of the perioperative patient with a difficult airway

  • Carin A. Hagberg Department of Anesthesiology, University of Texas Medical School at Houston, Houston, TX, United States
  • Carlos A. Artime Department of Anesthesiology, University of Texas Medical School at Houston, Houston, TX, United States
Keywords: Airway management, Airway extubation, Perioperative period, Intubation intratracheal, Anesthesia

Abstract

A considerable amount of literature has been dedicated to the topic of difficult airway management and a number of algorithms and recommendations have been established to safely manage patients at risk for difficult intubation. Only recently, however, has extubation of the difficult airway gained more awareness since this procedure, although elective, is often fraught with complications. The importance of developing pre-planned strategies for extubation of the difficult airway to improve patient safety and outcomes is apparent from data from both the ASA Closed Claims Analysis and the UK's recent Fourth National Audit Project of major complications of airway management. The key to successful management of patients at risk for difficult extubation is accurate risk assessment, application of appropriate strategies, and preparedness by both the individual practitioner and the institution.

References

1. Practice guidelines for management of the difficult airway. A report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Anesthesiology. 1993;78:597-602.
2. Peterson GN, Domino KB, Caplan RA, Posner KL, Lee LA, Cheney FW. Management of the difficult airway: A closed claims analysis. Anesthesiology. 2005;103: 33-9.
3. Cook TM, Woodall N, Frerk C. Fourth National Audit P. Major complications of airway management in the UK: Results of the Fourth National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society. Part 1: Anaesthesia. Br J Anaesth. 2011;106:617-31.
4. Cook TM, Woodall N, Harper J, Benger J. Fourth National Audit P. Major complications of airway management in the UK: Results of the Fourth National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society. Part 2: Intensive care and emergency departments. Br J Anaesth. 2011;106:632-42.
5. Cavallone LF, Vannucci A. Review article: Extubation of the difficult airway and extubation failure. Anesth Analg. 2013;116:368-83.
6. Popat M, Mitchell V, Dravid R, Patel A, Swampillai C, Higgs A. Difficult Airway Society Guidelines for the management of tracheal extubation. Anaesthesia. 2012;67:318-40.
7. Apfelbaum JL, Hagberg CA, Caplan RA, Blitt CD, Connis RT, Nickinovich DG, et al. Practice guidelines for management of the difficult airway: An updated report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Anesthesiology. 2013;118:251-70.
8. American Society of Anesthesiologists Task Force on Management of the Difficult A. Practice guidelines for management of the difficult airway: An updated report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Anesthesiology. 2003;98:1269-77.
9. Epstein SK. Decision to extubate. Intensive Care Med. 2002;28:535-46.
10. Su WL, Chen YH, Chen CW, Yang SH, Su CL, Perng WC, et al. Involuntary cough strength and extubation outcomes for patients in an ICU. Chest. 2010;137:777-82.
11. MacIntyre N. Discontinuing mechanical ventilatory support. Chest. 2007;132:1049-56.
12. Savi A, Teixeira C, Silva JM, Borges LG, Pereira PA, Pinto KB, et al. Weaning predictors do not predict extubation failure in simple-to-wean patients. J Crit Care. 2012;27,e221-228.
13. Sorbello M, Frova G. When the end is really the end? The extubation in the difficult airway patient. Minerva Anestesiol. 2013;79:194-9.
14. Kheterpal S, Han R, Tremper KK, Shanks A, Tait AR, O'Reilly M, et al. Incidence and predictors of difficult and impossible mask ventilation. Anesthesiology. 2006;105:885-91.
15. Ellard L, Brown DH, Wong DT. Extubation of a difficult airway after thyroidectomy: Use of a flexible bronchoscope via the LMA-Classic. Can J Anaesth. 2012;59:53-7.
16. Spiekermann BF, Stone DJ, Bogdonoff DL, Yemen TA. Airway management in neuroanaesthesia. Can J Anaesth. 1996;43:820-34.
17. Kwon B, Yoo JU, Furey CG, Rowbottom J, Emery SE. Risk factors for delayed extubation after single-stage, multi-level anterior cervical decompression and posterior fusion. J Spinal Disord Tech. 2006;19:389-93.
18. Dosemeci L, Yilmaz M, Yegin A, Cengiz M, Ramazanoglu A. The routine use of pediatric airway exchange catheter after extubation of adult patients who have undergone maxillofacial or major neck surgery: A clinical observational study. Crit Care. 2004;8:R385-90.
19. Choby WA, Ung KA, Abadir AR. Management of the post extubation airway in patients with intermaxillary fixation. Anesth Prog. 1979;26:124-5.
20. Vidotto MC, Sogame LC, Gazzotti MR, Prandini MN, Jardim JR. Analysis of risk factors for extubation failure in subjects submitted to non-emergency elective intracranial surgery. Respir Care. 2012;57:2059-66.
21. Voulgari PV, Papazisi D, Bai M, Zagorianakou P, Assimakopoulos D, Drosos AA. Laryngeal involvement in rheumatoid arthritis. Rheumatol Int. 2005;25:321-5.
22. Cohen-Cymberknoh M, Shoseyov D, Goldberg S, Gross E, Amiel J, Kerem E. Late-onset central hypoventilation presenting as extubation failure. Isr Med Assoc J. 2010;12:249-50.
23. Rabinstein AA, Mueller-Kronast N. Risk of extubation failure in patients with myasthenic crisis. Neurocrit Care. 2005;3:213-5.
24. Gupta RM, Parvizi J, Hanssen AD, Gay PC. Postoperative complications in patients with obstructive sleep apnea syndrome undergoing hip or knee replacement: A case-control study. Mayo Clin Proc. 2001;76:897-905.
25. Biro P, Priebe HJ. Staged extubation strategy: Is an airway exchange catheter the answer? Anesth Analg. 2007;105:1182-5.
26. Hickey RF, Cason BA. Timing of tracheal extubation in adult cardiac surgery patients. J Card Surg. 1995;10 4 Pt 1:340-8.
27. Ferrario L. Extubation catheters. En: Hagberg CA, Artime CA, Daily WH, editores. The Difficult Airway: A Practical Guide. New York: Oxford University Press; 2013. p. 136.
28. Finucane BT, Tsui BC-H, Santora AH. Principles of Airway Management. 4th ed New York: Springer; 2011.
29. Fisher MM, Raper RF. The 'cuff-leak' test for extubation. Anaesthesia. 1992;47:10-2.
30. Maury E, Guglielminotti J, Alzieu M, Qureshi T, Guidet B, Offenstadt G. How to identify patients with no risk for postextubation stridor? J Crit Care. 2004;19:23-8.
31. Eng MR, Wu TT, Brock-Utne JG. An adjuvant of the cuff leak test. Anaesthesia. 2009;64:452.
32. De Bast Y, de Backer D, Moraine JJ, Lemaire M, Vandenborght C, Vincent JL. The cuff leak test to predict failure of tracheal extubation for laryngeal edema. Intensive Care Med. 2002;28:1267-72.
33. Engoren M. Evaluation of the cuff-leak test in a cardiac surgery population. Chest. 1999;116:1029-31.
34. Miller RL, Cole RP. Association between reduced cuff leak volume and postextubation stridor. Chest. 1996;110:1035-40.
35. Ochoa ME, Marín Mdel C, Frutos-Vivar F, Gordo F, Latour-Pérez J, Calvo E, et al. Cuff-leak test for the diagnosis of upper airway obstruction in adults: A systematic review and meta-analysis. Intensive Care Med. 2009;35:1171-9.
36. Jaber S, Jung B, Chanques G, Bonnet F, Marret E. Effects of steroids on reintubation and post-extubation stridor in adults: Meta-analysis of randomised controlled trials. Crit Care. 2009;13:R49.
37. Krohner RG. Anesthetic considerations and techniques for oral and maxillofacial surgery. Int Anesthesiol Clin. 2003;41:67-89.
38. Benumof JL. Management of the difficult adult airway. With special emphasis on awake tracheal intubation. Anesthesiology. 1991;75:1087-110.
39. Koga K, Asai T, Vaughan RS, Latto IP. Respiratory complications associated with tracheal extubation. Timing of tracheal extubation and use of the laryngeal mask during emergence from anaesthesia. Anaesthesia. 1998;53:540-4.
40. Daley MD, Norman PH, Coveler LA. Tracheal extubation of adult surgical patients while deeply anesthetized: A survey of United States anesthesiologists. J Clin Anesth. 1999;11:445-52.
41. Robles B, Hester J, Brock-Utne JG. Remember the gum-elastic bougie at extubation. J Clin Anesth. 1993;5:329-31.
42. Loudermilk EP, Hartmannsgruber M, Stoltzfus DP, Langevin PB. A prospective study of the safety of tracheal extubation using a pediatric airway exchange catheter for patients with a known difficult airway. Chest. 1997;111:1660-5.
43. Moyers G, McDougle L. Use of the Cook airway exchange catheter in "bridging" the potentially difficult extubation: A case report. AANA J. 2002;70:275-8.
44. Mort TC. Continuous airway access for the difficult extubation: The efficacy of the airway exchange catheter. Anesth Analg. 2007;105:1357-62.
45. Benumof JL. Airway exchange catheters for safe extubation: The clinical and scientific details that make the concept work. Chest. 1997;111:1483-6.
46. McLean S, Lanam CR, Benedict W, Kirkpatrick N, Kheterpal S, Ramachandran SK. Airway exchange failure and complications with the use of the Cook Airway Exchange Catheter®: A single center cohort study of 1177 patients. Anesth Analg. 2013;117:1325-7.
47. Baraka AS. Tension pneumothorax complicating jet ventilation via a cook airway exchange catheter. Anesthesiology. 1999;91:557-8.
48. Benumof JL. Airway exchange catheters: Simple concept, potentially great danger. Anesthesiology. 1999;91:342-4.
49. Mort TC. Tracheal tube exchange: Feasibility of continuous glottic viewing with advanced laryngoscopy assistance. Anesth Analg. 2009;108:1228-31.
50. Higgs A, Swampillai C, Dravid R, Mitchell V, Patel A, Popat M. Re-intubation over airway exchange catheters - mind the gap. Anaesthesia. 2010;65:859-60.
51. Kitagawa H, Imashuku Y, Yamazaki T. The Parker Flex-Tip tube is useful in a bougie-assisted endotracheal tube exchange after lung lavage. J Cardiothorac Vasc Anesth. 2010;24:901.
How to Cite
1.
Hagberg CA, Artime CA. Extubation of the perioperative patient with a difficult airway. Colomb. J. Anesthesiol. [Internet]. 2014Oct.1 [cited 2021Dec.5];42(4):295-01. Available from: https://www.revcolanest.com.co/index.php/rca/article/view/245

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Published
2014-10-01
How to Cite
1.
Hagberg CA, Artime CA. Extubation of the perioperative patient with a difficult airway. Colomb. J. Anesthesiol. [Internet]. 2014Oct.1 [cited 2021Dec.5];42(4):295-01. Available from: https://www.revcolanest.com.co/index.php/rca/article/view/245
Section
Narrative review

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