Managing the difficult airway at extubation: Vices or devices

Francisca Llobell, M.D.1, Patricia Marzal, M.D.1, Maria Serna, M.D.1, Lauren K. Hoke, B.S.2, Yvon F. Bryan, M.D.2
1. Hospital G. U. Marina Alta, Denia (Alicante), Spain 2. Wake Forest University Baptist Medical Center, Winston-Salem, NC

Introduction Methods Discussion

Table 1: Extubation survey questions
•Devices used during intubation may not be •Our survey found a high incidence of
successful during extubation and/or re- problems occuring at extubation
intubation
•Anesthesiologist experience and familiarity
•Timing of extubation depends on patient with different airway devices may have
condition and practioner experience influenced choice of device
•We present the experience of •Further research is required in developing
anesthesiologists during extubation of protocols for use during extubation in
patients with DA’s in a region of Spain patients with DA’s

Abstract

Methods Results Title: Managing the difficult airway at extubation: Vices or devices
 
Francisca Llobell, M.D., Patricia Marzal, M.D., Maria Serna, M.D., Lauren K Hoke, B.S. and Yvon F
Bryan, M.D.. Department of Anesthesiology, Hospital G.U. Marina Alta, Denia, Alicante, Spain.
 
•Survey consisted of 10 questions regarding Introduction

management of DA during extubation Problems encountered during extubation of patients with difficult airways are prevalent though formal guidelines
seem to be lacking (1). This dichotomy of problems occurring at extubation and a lack of specific strategies may
be due to anesthesiologist experience and/or training with specialized airway devices required during the
management of the difficult airway (2). Certain airway devices may be best suited for rescue (oxygenation and
•Surveyed 38 anesthesiology departments in the ventilation) while others are better used to bridge (reintubation) and to delay the extubation. We surveyed
Spanish anesthesiologists about their clinical practice management for the extubation of patients with difficult

regions of Valenciana and Murciana in Spain airways.

Methods
A survey was sent to the anesthesiology departments of 38 hospitals in the provinces of the Comunidad
Valenciana (Castellon, Valencia, Alicante) and cities in the Comunidad Murciana (Murcia, Orihuela) of Spain. The
survey consisted of 10 questions pertaining to the clinical management at extubation of patients with difficult
airways (see Table 1). The surveys were completed anonymously and returned via self-return envelope to
Hospital G.U. Marina Alta in Denia (Alicante), Spain.
Results
A total of 10 out of 38 anesthesiology departments completed and returned the survey (as of March 1, 2008)
totaling 120 anesthesiologists. Problems at extubation were reported by 95% of respondents with only 12%
having a formal extubation protocol. 34% reported experiencing difficulty with reintubation and 23% reported
patients requiring surgical access for airway support. 7% reported a patient death or a severe brain injury as a
consequence of problems occurring at extubation. Of the airway devices used to rescue, 76% were
supralaryngeal devices (LMA, ILMA, Proseal LMA). To bridge the extubation, supralaryngeal devices and airway
exchange catheters were used 53% and 16% of the time, respectively. See Table 2.
 
Discussion
Our survey found a very high incidence of problems occurring at extubation in patients with difficult airways. A
lack of established extubation protocols and training with specialized airway devices may be the reason for the
problems. The devices used to rescue and bridge the extubation by the majority of respondents were
supralaryngeal in nature. This may have reflected the individuals training with these devices, the unavailability of
certain devices or not being familiar with other types of devices (ie, airway exchange catheters). Further research
is required in the management of the difficult airway to discern which devices are best suited for rescuing and/or
bridging during extubation.
 
References
1) Anesthesiology 2005:103(1);33-9.
2) Anesthesiology 2007:100;A934

ASA 2008