DIFFCULT EXTUBATION Dr K.

Krishnan MD DA(India) DA(UK) FRCA(Ireland) M Med Sci (Leeds) Honorary Lecturer Hull and York Medical school, Critical Care Consultant Scunthorpe General Hospital, UK Extubation of the airway may prove as challenging as its intubation. Difficult airway is a clinical situation in which a conventionally trained anaesthetist experiences difficulty with mask ventilation of upper airway, tracheal intubation or both. 0.2 % of patients require reintubation and rising to higher rates in high risk populations. Up to 25% of patients in critical care unit require reintubation. The process of extubation should be reversible withdrawal of the airway, which is elective, controlled, gradual and step-by-step. The aim should include minimal discomfort and maintain oxygenation, ventilation and if needed reintubation. Difficult extubation represents a complex interaction between patient factors, the clinical settings and skills of practitioner. Reintubation may be much more difficult than before due to airway bruising, swelling, airway contamination with clot and regurgitation of material. Laryngospasm can occur due to damage of the laryngeal or recurrent laryngeal nerve along with new impairment of airway access (cervical fusions, dental wiring, and external factors).

SYSTEMATIC APPORACH FOR ROUTINE EXTUBATION: For normal cases without difficult intubation the following steps will give algorithmic extubation process, where if required reintubation could be managed without difficulty. Patient should be able to respond to commands, have an intact gag reflex along with clear oropharynx/hypo pharynx, sustained head lift for 5 sec, sustained leg lift, sticking out tongue, eye opening, and adequate pain control. The following parameters can be used to assess the patients ability to protect the airway against obstruction. To test for a good cough reflex, hold a white paper 3-5 cm away from the airway and ask the patient to cough: in a good cough reflex there will be visible secretions or movement of the paper, if on the other hand the patient is unable to moisten the paper this indicates the patient is more likely to fail extubation. Further test include spirometer which can be used to measure the vital capacity (> 15ml/kg), voluntary negative inspiratory pressure (>20 cm of water) and tidal volume (>6 ml/kg). By using peripheral nerve stimulator T1/T4 ratio (>0.7) could be measured and to ensure there are sustained tetanic contractions.

COMPLICATIONS OF ROUTINE EXTUBATION Immediate post extubation period where patients are vulnerable to laryngospasm (upper airway obstruction, negative pressure pulmonary edema), hypoxemia, hypercarbia, haemodynamic alterations (hypertension, tachycardia, bradycardia, 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 and unintentional or self-extubation. The following table column shows the factors contributing laryngeal injuries.

Table 1: FACTORS CONTRIBUTING TO LARYNGOTRACHEAL INJURY Big size ETT Double lumen tube Excessive cuff pressure Long duration of intubation Prone position and abnormal positions Head /neck infections Airway surgery Tumor and heamorrhage Trumatic intubation- multiple attempts,reintubation Bucking, coughing on the tube Drug or systemic reactions Angioedema Anaphylaxis Sepsis Excessive volume infusion Smoke inhaltion, burn inury

TRACHEAL REINTUBATION ON MORE DIFFICULT THAN INITIALLY: Many extubations are relatively benign and transient complications. In certain cases the tracheal reintubation are increased. It depends on the extent of the airway compromise and duration at the end of surgery and ability to rescue the airway. It is associated with agitations, emergent nature, accompanying hypoxemia, cardiovascular instability; limited access to the airway (e.g. cervical or intermaxillary fixation, lingual, pharyngeal and laryngeal edema, neck swelling) and the lack of patients cooperation and extubation of difficult airway should be viewed as a potentially difficult intubation. Repeated intubation attempts can lead worse out come like death or brain damage. The aim of this topic to extubate in a secure controlled way, mean time it should be reversible fashion. It is always to have effective extubation strategy which should not cause patient discomfort, should enable to oxygenate and ventilate and facilitate reintubation if necessary. American Society of Anaesthesiologists and Canadian Airway Society and Difficult airway society and UK recommend that an anaesthetist should have a preformulated strategy for extubation of the difficult airway situation. Any proposed strategy needs to be modified according to the local culture of practice and available materials and clinical situation. The strategy should include the merits of awake extubation, considering the clinical factors that impair respiration after extubation, make a plan in case the patient unable to maintain airway and consider to use airway adjutants that can facilitate reintubation.

EXTUBATION OF HIGH RISK PATIENTS High risk means the presence of general or airway risk factors that suggest that a patient may not able to maintain their own airway after removal of the tracheal tube. Risk extubation is characterised by the concern that airway management may not be straight forward should reintubation be required. In a high risk patients, a strategy towards extubation of the difficult airway should include a plan that can be implemented if the patient is unable to maintain adequate oxygentaion after extubation, and the plan should include the short term use of device which can guide to revesible extubation or reintubation. 1.Plan extubation 2.Prepare extubation 3.Perform extubation 4.Post extubation PLAN EXTUBATION: Review the patients medical notes for airway problem and general risks factors and surgical conditions,previeous extubation problems should be reviewed.The problems of postoperative miscellaneous conditions can occur(massive fluid resuscitation, burns, inhalational injuries, subglottic stenosis, laryngo/tracheo/bronchitis, cervical spine injury, halo traction vert) The patients current and past medical illnesses can affect the extubation tolerance (CVS, pulmonary, renal, hepatic, coagulopathy, sepsis, etc). Same time review of current ventilatory requirements (FiO2, PEEP, MV, secretions, ETT tolerance during awake state) and vital signs, mental and neurologic status before extubation. The following table shows in these conditoins extubations may be risky.

Table 2: HIGH RISK EXTUBATIONS Airway Obstructions o Post cervical spine surgery o Maxillfacial injury o Tracheomalacia o Cervical cord compression Pulmonary Causes o Depressed neurological status o Neuromuscular impairment, malnutrition o Central sleep aponea o Diapharmatic dysfunction Inability to protect airway o Laryngeal incompetence due to injury o Neurological depression o Neuromuscular weakness Difficult aiway o Previous airway history o Damage to airway o Rheumatiod arthritis o Cricoarytenoid arthritis Access to airway o Oromaxillofacial fixation o Limited cervical spine mobility (halo fixation,cervical collar,cervical fusion,ankylosing spondlyosis) o Smoke ,chemical inhalation o Burns

PREPARE EXTUBATION Optimise the cardiovascular, respiratory,metabolic, temparture and neuromusclar block. Plan to extubate in the theatre or other location where all the monitoring and equipement available. Decide to extubate by the systemtic apporach. a) standard extubation b) extubation and evaluation via a Fibreoptic Bronchoscope (FOB) c) extubation by placement of supraglottic airway (SGA) for airway patency, oxygenation, ventilation and pathway for potential reintubation d) extubation over an airway excange catheter (AEC) e) postpond extubation or surgical airway

STANDARD EXTUBATION: the following sequence gives logical apporach to the process of extubation.

EXTUBATION OVER THE FOB In a spontanously breathing patient extubation over a fibreoptic bronchoscope is a useful to brief evaluation of the airway,observe the periglottic functions,injury,mucosal intergrity and surrounding pharyngeal tissues. When a sigificant abnormalities are noted, a decision can be made to maintain the current situation,extubate or elective surgical way. The down side of the FOB needs skill,can not leave in the airway for long because heaviness of the equipment, not effective oxygen supply because of the narrow diameter and does not have distance marker. If required ,reintubation can be facilited using an Aintree intubation catheter which jackets the flexiable bronchoscope.

EXTUBATION OVER SUPRAGLOTTIC AIRWAY This techenique is considered in suspected pharyngeal paralysis or tube entrappment. Adequate depth of anaesthesia is very important to avoid laryngeal spasm in patients with irritable airways,smokers and asthmatics. Not useful with periglottic injury, risk of regurgitation and in whom reintubation would be difficult. The following sequence for LMA exchange extubation Administer 100% oxygen Maintain deep plane or neuromuscular blockade Laryngoscopy and do suction under direct vision Insert deflated Intubating LMA or LMA behind the tracheal tube and confirm the position Deflate tracheal tube and remove tube with maintaining the positive pressure. Administer oxygen through the LMA and emergence from anaesthesia

EXTUBATION OVER THE TRACHEAL TUBE EXCHANGE CATHERTER: ( REVERISBLE TRACHEAL INTUBATION) This strategy is very useful for patients expected to be diffcult to reintubate. Cook airway exchange catheter are 85cm long,hollow catheter with 15 mm connector for jet or manual ventilation and respiratory monitoring. It s also have depth marker and radio opaque. This device is inserted into tracheal tube before extubation. Catheters external diameter of 3.7 and 4.7 mm comaptiable with 4 and 5 mm of ETT. The following ASA flow chart gives systemic apporach for difficult extubation situations.

Recommended Technique by the ASA for Extubation of the Difficult Airway 1. Administer 100% oxygen. 2. Suction the oropharynx. 3. Deflate cuff of the endotracheal tube for cuff leakage check. 4. Insert an airway exchange catheter through the endotracheal tube to a predetermined depth. 5. Extubate the patient over a jet ventilation catheter. 6. Apply oxygen by facemask or insufflation through a jet ventilation catheter. 7. Tape the proximal end to the patients shoulder to stabilize it. 8. Remove the jet ventilation catheter after 30 to 60 minutes if no obstruction appears. Stimulation and administering 100% oxygen with sustained positive pressure at the time of extubation. Severe cases may require a small dose of muscle relaxant to break the spasm along with reintubation. AEC can be used as aguide overwhich trcheal tube can be passed for reintubation situation.They are high success rate 85-90% for reintubation. Most of the morbidity releated to inapporiate positions and oxygenation. It should be always above carina. Oxygenation insufflation and high pressure jet ventilation should only be undertaken with caution in exerem cases, because barotruma and death have been reported. Flow of oxygen should not exceed 1-2 litres /minutes. If it is more ,reintubation will usually be required. Reintubation using a AEC full monitoring, skilled assistant and equipment should be available. High jet ventilation is used to avoid life threatening hypoxia.High pressure upto 10 cm of H20 to reduce barotrauma by using minimal insufflation pessure. It can cause direct perforation of tracheal mucosa,interstitial pulmonary emphysema and dislodgement.

Table 4: REINTUBATION OVER AIRWAY EXCHANGE CATHETER Maintain optimal positioning Oxygen by mask ( AEC to corner of mouth) Choose smaller tube Maintain AEC in secure position Use induction agents if needed Open the mouth or insert laryngoscope to open the airway Pass ETT over the AEC advance into airway,if resistance turn counterclockwise and advance the ETT Confirm placement with endtidal carbondioxide monitor

Postpond extubation : At any time ,airway threat is so severe ,the extubation should be postponded for few hours or few days is most appropriate course of action. Time delay reduces the airway oedema and need to take consideration of future operative schedule as well. Transfer the patient to a critical care unit and write clear instruction of the reintubation plan. Elective Tracheostomy: trachesotomy gives rapid postoperative emergence without fear of extubation failure or failure to intubate. The anaesthetist and surgeon should discuss these problems in patients with preexisting airway problems,extented tumors, swelling and oedema. The surgical trachesotomy indicated if there is anticipated postoperative airway deteriortion, problem in resuce the airway and longer duration of airway compromise. Conclusions: Extubation should always be an elective process with methodical apporach. Many extubations are releatively benign and transient complications. Awake extubation is the best for most of the high risk patients. However some clinical situations laryngeal mask exchange and use of airway exchange catheters will be useful. Tracheal reintubation over the tube changer is neither without complications nor 100% successful. Therefore who use these devices should be familiar with equipements and techniques. Delaying extubation or elective tracheostomy should be considered when unsafe to extubate situations.