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Extubation failure after general anesthesia

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Wayne Pearce
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 A Supplement to APRIL 2018

The Frost Series #337 Continuing Medical Education

Extubation Failure After General Anesthesia

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PHYSICIAN CONTINUING MEDICAL EDUCATION

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The Postgraduate Institute for Medicine designates this enduring material for a
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maximum of 1.0 AMA PRA Category 1 Credit™. Physicians should claim only the credit
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commensurate with the extent of their participation in the activity.

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CONTINUING NURSING EDUCATION

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The maximum number of hours awarded for this Continuing Nursing Education activ-
ity is 1 contact hour. It is designated for 0.3 contact hours of pharmaocotherapy credit for
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Advanced Practice Registered Nurses.

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DISCLOSURE OF CONFLICTS OF INTEREST

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Postgraduate Institute for Medicine (PIM) requires instructors, planners, managers, and
other individuals who are in a position to control the content of this activity to disclose
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any real or apparent conflict of interest (COI) they may have as related to the content of
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this activity. All identified COIs are thoroughly vetted and resolved according to PIM policy.
The existence or absence of COIs for everyone in a position to control content will be dis-
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RELEASE DATE: April 1, 2018 EXPIRATION DATE: March 31, 2019 closed to participants prior to the start of each activity.
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WRITTEN BY
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FACULTY DISCLOSURES
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Wayne Pearce, MB BCh Wayne Pearce, MB BCh, and Sonia J. Vaida, MD, have no relationships with commercial
Assistant Professor of Anesthesiology & Perioperative Medicine
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interests related to the content of this CME activity.

Director, ENT Anesthesia
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The planners and managers reported the following financial relationships or relationships
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Department of Anesthesiology and Perioperative Medicine

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to products or devices they or their spouse/life partner have with commercial interests
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Penn State Health Milton S. Hershey Medical Center

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Hershey, Pennsylvania related to the content of this CME activity:

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The following PIM planners and managers, Trace Hutchison, PharmD, Samantha Mattiucci,
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REVIEWED BY PharmD, CHCP, Judi Smelker-Mitchek, RN, BSN, and Jan Schultz, MSN, RN, CHCP, hereby
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Sonia Vaida, MD state that they or their spouse/life partner do not have any financial relationships or rela-
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Professor of Anesthesiology & Perioperative Medicine and Obstetrics and Gynecology tionships to products or devices with any commercial interest related to the content of this
Vice Chair for Research
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activity of any amount during the past 12 months.

Director of Obstetric Anesthesia
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The planners and managers from Penn State College of Medicine hereby state that they or
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Department of Anesthesiology and Perioperative Medicine

their spouse/life partner do not have any financial relationships or relationships to prod-
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Penn State Health Milton S. Hershey Medical Center

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ucts or devices with any commercial interest related to the content of this activity of any
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Hershey, Pennsylvania
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amount during the past 12 months.

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PROFESSIONAL GAPS
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SPONSORSHIP
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Complicated tracheal extubation is a significant cause of postoperative morbidity and

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mortality. Judicious planning significantly contributes to the safety and success of tracheal This activity is jointly provided by Postgraduate Institute for Medicine and Penn State
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extubation. This lesson focuses on failed extubation after general anesthesia in adult College of Medicine.
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patients.
INSTRUCTIONS FOR PARTICIPATION
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LEARNING OBJECTIVES Participants can download and print the course material in an easy to read printer-
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After completion of this activity, the reader should be able to: friendly format, available through the boxed link at the top of the page. Participants
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• Estimate the incidence of airway complications at extubation after general anesthesia. must reflect on the information presented, and then register to complete the exam and
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course evaluation online before the expiration date at CMEZone.com/TheFrostSeries.

• Recognize causes of failed extubation.
• Identify risk factors for failed extubation.
• Implement strategies to increase the probability of safe and successful extubation.
• Plan for failed extubation.
JOINT ACCREDITATION STATEMENT
In support of improving patient care, this activity has been planned and implemented by
the Postgraduate Institute for Medicine and Penn State College of Medicine. Postgraduate
Institute for Medicine is jointly accredited by the Accreditation Council for Continuing
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for the healthcare team.
Because there is no commercial support subsidizing this activity, the certification
fee for CME/CE credit is $25. During the period April 1, 2018 through March 31, 2019,
participants must read the learning objectives and faculty disclosures and study the
educational activity.
Upon registering and successfully completing the post-test with a score of 75% or better
and the activity evaluation, your certificate will be made available immediately.
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This educational activity might contain discussion of published and/or investigational uses
of agents that are not indicated by the FDA. The planners of this activity do not recom-
mend the use of any agent outside of the labeled indications. The opinions expressed in
2 I Anesthesiology News APRIL 2018

The Frost Series #337

the educational activity are those of the faculty and do not necessarily represent the views
of the planners. Please refer to the official prescribing information for each product for
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DISCLAIMER
Participants have an implied responsibility to use the newly acquired information to enhance
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expressed or implied, with respect to the material contained herein.
CONTACT INFORMATION
Questions regarding course content may be directed to Dr. Sonia Vaida at svaida@
pennstatehealth.psu.edu. Questions regarding continuing education may be directed to
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activity is not meant to serve as a guideline for patient management. Any procedures, med- CALL FOR WRITERS
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ications, or other courses of diagnosis or treatment discussed or suggested in this activity If you would like to author a future installment of The Frost Series in Anesthesiology News,
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should not be used by clinicians without evaluation of their patients’ conditions and possi- please send an email to Sonia Vaida, MD, at svaida@pennstatehealth.psu.edu.
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ble contraindications and/or dangers in use, review of any applicable manufacturer’s product
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STATEMENT OF NEED
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information, and comparison with recommendations of other authorities.

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The content of this activity was developed by the faculty indicated herein under the supervi- Airway complications during extubation following general anesthesia occur about 15% of
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sion of Postgraduate Institute for Medicine and assistance from Penn State University. the time, meaning these complications are not rare events. The causes and risk factors for
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Applied Clinical Education (ACE) is responsible for graphic design and distribution of the failed extubation are reviewed in this review, as is how to strategically plan for extuba-
activity via Anesthesiology News and CMEZone.com. All information included in this activity tion, including strategies for high-risk extubation. Anesthesiologists responsible for airway
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is believed to be true and accurate at the date of publication. ACE makes no warranty, management must learn how to plan for failed extubations.
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Case Presentation
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A 68-year-old man, with a body mass index (BMI) of hypertension, type 2 diabetes mellitus, smoking, and obstructive
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41 kg/m2, was scheduled to undergo anterior cervical sleep apnea (OSA). The preoperative airway evaluation revealed
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discectomy and fusion (ACDF) because of cervical radiculopathy a Mallampati class II, thyromental distance of 6 cm, and a mouth
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at the C2-C4 levels. His past medical history was significant for opening of 4 cm, with limited neck flexion and extension.
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After induction of general anesthesia, endotracheal intubation with Introduction

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an 8-cm endotracheal tube (ETT) was successful using a GlideScope Tracheal extubation is an elective procedure performed during a highly
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video laryngoscope (Verathon Inc), after two failed attempts, first with vulnerable period in the perianesthetic process. Failure to successfully main-
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a Macintosh and then with a Miller direct laryngoscopy. Surgery was tain a patent airway after removing the ETT often necessitates reintubation
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uneventful and lasted 6.5 hours. Intraoperative blood loss was estimated followed by unplanned admission to intensive care. Furthermore, it can lead
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to be 400 mL. Appropriate reversal of the neuromuscular blockade was to important postoperative respiratory complications, such as hypoxia, pul-
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confirmed with a train of four (TOF) ratio of 0.9. An audible leak was monary aspiration of gastric contents and/or blood, or cardiac arrest.
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detected after deflating the ETT cuff.

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Incidence of Airway Complications at Extubation

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Oxygen was administered through a non-rebreathing mask. Oxygen

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saturation (SpO2) decreased to 86% and the respiratory rate increased to After General Anesthesia
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25 breaths per minute. Face mask manually assisted ventilation failed to The 4th National Audit Project of the Royal College of Anaesthetists
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improve the SpO2. Reintubation was attempted using a GlideScope video (NAP4) prospectively reviewed airway complications in the United King-
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laryngoscope. A Cormack-Lehane laryngeal view grade 2 was obtained; dom over a one-year period and analyzed 184 reported cases.1 Major air-
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however, the ETT could not be inserted into the trachea. The SpO2 con- way complications occurred in 16% of cases during emergence from
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tinued to decrease to 60%. anesthesia and 14% during recovery from anesthesia.1
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An LMA Fastrach (Teleflex) was inserted, and ventilation and oxygen-
ation were restored to normal values. A 7.0-mm ETT was inserted blindly
through the LMA. The patient was transferred to the ICU, sedated and ven-
tilated. After 24 hours, extubation was planned. The patient was positioned
in a head-up position; a 14-F Cook Airway Exchange Catheter (AEC) then
was inserted 22 cm through the ETT, and the ETT was removed. Correct
placement of the AEC was confirmed by end-tidal carbon dioxide (CO2)
monitoring and fiber-optic examination. The AEC was left in place for 60
minutes with concomitant oxygen administration through a nasal cannula
and successfully removed with no further complications.
Peterson et al analyzed the American Society of Anesthesiologists
(ASA) Closed Claims database for 1985 to 1999 for airway manage-
ment–related malpractice claims. The investigators found that 12%
of airway injuries occurred during extubation and 5% during postan-
esthesia recovery.2 In 2013, Cavallone and Vannucci reported that a
follow-up review for litigated malpractice claims, from 2000, identified
15 out of 16 cases of death and permanent brain damage that occurred
after failed extubation.3 An analysis of reintubations from a quality
assurance database of 152,000 cases found their incidence to range
from 0.09% to 0.19%.4
 APRIL 2018 Anesthesiology News I 3

CMEZone.com/TheFrostSeries

Causes of Failed Extubation Risk Factors for Failed Intubation

Upper airway obstruction is the most frequent cause of failed extuba- Risk factors for a difficult or failed extubation can be associated with
tion after general anesthesia. Other causes of failed extubation include anesthetic factors, surgical interventions, and patient comorbidities.
failure of ventilation or of pulmonary oxygenation, and ineffective clear-
ance of pulmonary secretions. Certain medical conditions are associated Obesity and Obstructive Sleep Apnea Syndrome
with extubation difficulties (eg, macroglossia and tracheomalacia). Upper airway tissue collapse and pharyngeal obstruction is frequent
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in obese patients and patients with OSA.3 Pharyngeal muscles are late to
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Laryngospasm recover from neuromuscular blockade. Reduction of the pharyngeal tone

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The most common cause of postextubation laryngeal obstruction is with pharyngeal obstruction occurs with a TOF less than 9, and is accen-
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laryngospasm. tuated in these patients.8,9 According to the NAP4, 42% of major airway
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Laryngospasm results from contraction of the laryngeal muscles due events occur in obese patients.1 Similarly, Peterson et al, in the ASA Closed
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to stimulation of the superior laryngeal nerve, causing partial or com- Claims analysis, reported 15 out of 26 postextubation major airway events
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plete sustained closure of the vocal cords. It is triggered by blood, saliva occurring in obese patients.2 Isoco suggested routine use of the sitting or
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or surgical debris entering the glottic space, mainly during light lev- lateral position at extubation and nasal CPAP in obese patients with OSA
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els of anesthesia. Untreated, laryngospasm can lead to severe compli- syndrome to prevent postoperative pharyngeal obstruction.10
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cations, such as hypoxia, postobstructive negative pressure pulmonary

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edema, and cardiac arrest. Laryngospasm occurs more frequently in chil- Airway Trauma
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dren, patients with upper respiratory tract infection, smokers, and obese Large or overinflated ETTs, especially if used for a prolonged time, can
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patients, and during surgical procedures involving the upper airway.3 cause edema and ulceration of the laryngeal mucosa. Repeated attempts
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Jaw thrust and continuous positive airway pressure (CPAP) with at laryngoscopy and ETT insertion can cause traumatic injuries to the
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100% oxygen can relieve laryngospasm, and administration of propofol oropharynx, larynx, or trachea. Use of adjunct airway management
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(1-2 mg/kg) and/or succinylcholine (1 mg/kg) may be necessary.5 devices (eg, ETT introducer) to facilitate intubation can cause or exacer-
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bate the airway injury. A recent Cochrane review of 64 randomized con-

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Laryngeal Edema
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trolled studies comparing video laryngoscopy with direct laryngoscopy

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Laryngoscopy, insertion of the ETT, and prolonged intubation can reported reduced airway trauma with video laryngoscopy.11
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damage the laryngeal mucosa, leading to laryngeal edema. Upper air- Surgical procedures in proximity to the airway increase the risk for
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way edema can be exacerbated by positioning the patient in a pro- difficult extubation. These procedures include but are not limited to
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longed prone or Trendelenburg position, or by fluid overload.5 As shown upper airway, head and neck, maxillofacial, carotid, and cervical spine
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by Tanaka et al, even routine, elective intubations in patients undergoing surgeries.

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general anesthesia with endotracheal intubation lead to increased laryn-

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geal resistance due to laryngeal swelling.6 Anterior Cervical Spine Surgery

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The value of the ETT “cuff leak” test in detecting laryngeal edema is Anterior cervical spine surgery requires prolonged periods of intraop-
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discussed below. erative tracheal retraction and can lead to postoperative airway obstruc-
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tion and/or vocal cord paralysis. Postoperative airway complications can

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Vocal Cord Dysfunction occur up to 48 hours after surgery. Radiographic evidence shows that
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Bilateral vocal cord paralysis can lead to stridor or complete airway upper cervical surgery, particularly at the C4 level, is associated with the
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highest degree of prevertebral soft tissue edema.12 In a retrospective

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obstruction and results from injury to the recurrent laryngeal nerve,

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mainly after cervical (eg, thyroidectomy) or intrathoracic surgery.3 Aryte- chart review of 311 patients having anterior cervical spine surgery, Sagi et
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noid cartilage dislocation is a rare complication caused most frequently al reported that 6.1% had airway complications, with 1.9% requiring rein-
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by traumatic intubation.7 tubation. In all but two patients the airway complications were attrib-
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uted to pharyngeal edema. Factors associated with postoperative airway

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Residual Neuromuscular Block complications were surgery lasting more than 5 hours, blood loss greater
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Residual neuromuscular block defined as a TOF ratio less than 0.9, as than 300 mL, and exposure of more than three vertebral bodies (partic-
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measured by quantitative monitoring, can cause weakness of the upper
airway muscles, potentially leading to significant respiratory muscle dys-
function.8 In a recent review article, Murphy emphasized the importance
of using quantitative neuromuscular monitoring to reliably identify full
recovery from neuromuscular blockade. Quantitative neuromuscular
monitoring techniques measuring the muscle strength (mechanomyog-
raphy, electromyography, acceleromyography, kineograph, and phono-
myography), are superior to qualitative techniques (peripheral nerve
stimulators) in assessing the accuracy and reversal of the neuromuscu-
lar blockade.9
ularly when including C2, C3, or C4)13
In a retrospective cohort study, Kim et al compared airway complica-
tions—defined as unplanned postoperative reintubation or tracheostomy
following anterior cervical spine surgery, before and after implement-
ing a protocol for postoperative airway management. The postopera-
tive airway complication rate was significantly decreased after applying
the protocol (0.76%) compared with the non-protocol approach (3.64%).
Predictors of airway complications were a history of comorbidities, com-
bined anterior and posterior cervical spine surgery, patients operated on
for trauma, and surgery time longer than 5 hours.14
4 I Anesthesiology News APRIL 2018

The Frost Series #337

Strategic Planning for Extubation
Airway changes can occur during surgery, such as laryngeal edema
after prolonged intubation, surgical bleeding or pressure from hema-
toma, even in patients in whom tracheal intubation was easy. The ASA
practice guidelines for management of the difficult airway emphasize
the importance of a “pre-formulated extubation strategy.” The recom-
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not be able to maintain his ⁄ her own airway after removal of the tracheal
tube.”5
Assessing Laryngeal Edema
If laryngeal edema is suspected, the cuff leak test is a simple, nonin-
vasive technique to detect a leak around the ETT due to the decreased

mended strategy includes considering the benefits of “awake extuba- caliber of the airway lumen. The cuff leak test is performed by deflat-
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tion” versus “extubation before the return of consciousness,” having a ing the ETT cuff and listening for an audible leak during exhalation with
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detailed reintubation plan, and the possible use of airway devices capa- a stethoscope placed over the neck. Quantitative cuff leak test is per-
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ble of serving as guides for expedited reintubation.15 formed with the ETT cuff deflated, by calculating the difference between
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In 2012, the Difficult Airway Society (DAS) in the United Kingdom inspired and expired tidal volumes averaging 3 to 5 ventilator-delivered
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published guidelines for the management of tracheal extubation, high- respiratory cycles.
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lighting the importance of a stepwise approach to planning, preparing, The diagnostic value and accuracy of the cuff leak test in predict-
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executing the tracheal extubation, and postextubation follow-up.5 ing postoperative airway obstruction are controversial. Miller and Colle
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found that a leak volume less than 110 mL is indicative of a high risk for
Planning and Preparing
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postextubation stridor.16 De Basty et al suggested that less than 15.5%

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Planning for extubation should start early during the anesthetic pro- change in tidal volumes is associated with laryngeal edema.17 A meta-
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cess, preferably before endotracheal intubation. It is crucial to optimize analysis of 11 studies, including 2,303 patients, found only a moderate
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the conditions for extubation and identify risk factors for failure to main- predictive value for the cuff leak test.18 Recently, Schenell et al, in a pro-
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tain airway patency after removal of the ETT (Figures 1 and 2). Plans for spective multicenter cohort study, described a high rate of false-positive
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extubation and a back-up plan for reintubation need to be prepared, quantitative cuff leak tests.19 Evaluating the laryngeal air column width
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and the necessary airway equipment and adequately trained person- with ultrasonography has been described as a valuable tool to assess the
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nel should be made immediately available. The cricothyroid mem- severity of laryngeal edema.20
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brane should be identified and marked to facilitate front-of-neck access,

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should that become necessary. Ultrasonographic identification of the cri- Preoxygenation Before Extubation
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cothyroid membrane can be considered. General clinical factors such as Administering high oxygen concentration before extubation was
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shown to induce postoperative atelectasis.21 However, as emphasized by

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cardiorespiratory parameters, acid–base data, and body temperature

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should be evaluated and optimized before proceeding with extubation. Popat et al in the DAS recommendations for management of tracheal
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DAS suggests two separate algorithms for patients at “low risk” or “at- extubation, “pre-oxygenation before extubation is vital” because the
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risk” extubation. The “at-risk” definition refers to a patient who “may “priority is to maximize oxygen stores.”5
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Plan for Extubation Prepare for Extubation

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Adequate equipment and personnel +

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Assess airway and general risk factors

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communication with surgeons and nursing

for difficult/failed extubation
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Airway Optimization of
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general conditions
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Preexisting Restricted Perioperative

Evaluate airway changes developed Neuromuscular blockade
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airway airway airway

difficulties access deterioration during the procedure reversal adequacy
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Identify conditions interfering with Hemodynamic parameters

Yes No Yes No Yes No bag mask ventilation
Respiratory status
Cuff leak test
Acid–base balance
Identify/mark the cricothyroid
High risk membrane Temperature

Figure 1. Plan for extubation. Figure 2. Prepare for extubation.

Reference 5. Reference 5.
 APRIL 2018 Anesthesiology News I 5

CMEZone.com/TheFrostSeries

Administration of IV Steroids Before Extubation
The benefits of administering prophylactic intravenous steroids in
preventing postextubation laryngeal edema are controversial.5,22 In a
meta-analysis of 6 studies that included 1,923 adult patients, Fan et
al found a 62% reduction in the incidence of laryngeal edema after
extubation in patients receiving prophylactic IV steroids. Multiple-dose
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extubation should be considered in instances where it is important to
avoid hemodynamic changes, coughing, and straining (eg, in patients
with increased intracranial or intraocular pressure). The main concern
with deep extubation is maintaining airway patency in a patient with
decreased airway reflexes; therefore, it is best avoided in patients who
have difficult mask ventilation or difficult intubation, or are at increased

administration was more efficient in preventing postoperative laryngeal risk for aspiration.
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edema than single-dose administration.23

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Pharmacologic Agents to Attenuate Hemodynamic

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One of the techniques to minimize tracheal stimulation at extubation

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Responses and Coughing at Extubation during emergence from general anesthesia is to switch the ETT with a
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Lidocaine laryngeal mask airway (LMA) or another supraglottic airway device while
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Lidocaine can be administered intravenously, topically, or instilled the patient is under deep anesthesia. Using a supraglottic airway device
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in the ETT to significantly blunt hemodynamic responses and cough at as a bridge to extubation allows removal of the ETT under deep anes-
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extubation.5,23 Spraying the trachea before tracheal intubation with 160 thesia (deep extubation), while maintaining airway control. LMA and the
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mg of 4% lidocaine HCl solution significantly reduced the incidence of LMA variants (eg, Pro-Seal LMA) are less stimulating and thus induce
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coughing during extubation in procedures lasting less than 2 hours.24 less systemic hemodynamic and cerebral changes, as well as decrease
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Nath et al recently reported a significantly reduced incidence of the incidence of coughing and straining during emergence, compared
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coughing at extubation (12%) in patients intubated with an ETT with with an ETT.32,33
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a cuff preloaded with alkalinized lidocaine compared with placebo The maneuver described in 1995 by Bailey consists of inserting the
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(22%).25 deflated LMA in the hypopharynx behind the larynx, inflating the LMA,
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and then removing the ETT.34 It also allows the LMA to be used as a con-
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Dexmedetomidine
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duit for examination of the glottis for swelling, edema, or injury, or para-
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Dexmedetomidine is a potent alpha agonist with sedative and doxical movement of the vocal cords.
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antihypertensive properties. Guler et al reported that administration

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of single-dose dexmedetomidine (0.5 mcg/kg) 5 minutes before Airway Exchange Catheters

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extubation significantly reduced systolic blood pressure, diastolic blood ASA practice guidelines for management of the difficult airway
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pressure, heart rate, and coughing at extubation, with no effect on suggest considering “short-term use of a device that can serve as
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recovery time.26 a guide for expedited reintubation” as part of a safe extubation

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strategy.15 Airway exchange catheters (AECs) are hollow, polyvinyl

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Remifentanil
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Remifentanil is a potent suppressor of the cough reflex. Its

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administration has found a place among techniques aiming to foster a

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beneficial situation before extubation, in which a patient both tolerates Perform Extubation
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an ETT and is able to obey commands.27,28 If an ultra short-acting agent

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such as remifentanil is used (eg, a balanced anesthetic combining Preoxygenation with FiO2
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propofol and remifentanil), then return of spontaneous respiration Optimize the patient’s position
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may occur at the same time as consciousness. This not only allows for
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Adequate suctioning of the oropharynx and lower airway.

extubation to be performed at the onset of spontaneous respiration, it
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avoids undesirable cardiovascular responses.29,30 A low-dose remifentanil

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infusion maintained during extubation reduces coughing on the ETT,

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nonpurposeful movement, and tachycardia without interfering with Low risk High risk
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recovery from anesthesia.31 When using a remifentanil extubation

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technique, it is important to not rush or stimulate the patient.5 Wait until Awake vs deep extubation Airway exchange device
the patient opens her eyes, or even better, her mouth on command, and
Supraglottic device as bridge
furthermore takes a deep breath on cue. to extubation

Performing Tracheal Extubation Remifentanil extubation

Front-of-neck access
There are several techniques for extubation (Figure 3).

Awake Versus Deep Extubation Figure 3. Perform extubation.

Airway control is best maintained in spontaneously breathing patients Reference 5.
who are extubated after regaining consciousness. However, deep
6 I Anesthesiology News APRIL 2018

The Frost Series #337

chloride ventilating catheters with a well-established role in staged
extubation. Typically, AECs have depth marks and Luer lock connectors
for CO2 monitoring and jet ventilation.
AECs are well tolerated by awake and spontaneously breathing
patients. An AEC is inserted through an ETT, above the carina, to a
depth of 20 to 22 cm and left in place after extubation to provide
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Let us apply this approach to the case.
The patient presented the anesthesiologist with mixed conditions: high
BMI, OSA, and limited flexion and extension of the neck. These were noted,
however, in the presence of ample oropharyngeal and mandibular spaces.
This type of gestalt suggests a difficult intubation, but not necessarily a
higher risk for reintubation. Adding two factors—the type of surgery (ACDF,

oxygenation and guidance for reintubation. The maximum allowed 3 levels) and a rather lengthy operating time with blood loss exceeding
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depth of insertion is 25 cm.5 Gentle rotation of the ETT under direct 300 mL)—could sway clinical judgment toward the possibility of an
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or video laryngoscopy can facilitate passing the ETT over an AEC. Jet intermediate extubation risk.
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ventilation through the AEC can be considered with extreme caution, After induction, intubation was not easy and required considerable
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to avoid severe complications such as barotrauma. Mort analyzed the instrumentation. This implies a very high likelihood of a difficult
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efficacy of an AEC as a device to provide continuous access to the reintubation and that different equipment and technique from those used
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airway in ICU patients with a known or suspected difficult airway, at intubation may be required. Indeed, reintubation required the initial
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reporting an 87% first-attempt success rate passing an ETT. The AEC use of a supraglottic airway device after unsuccessful attempts with video
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was left in place for a mean duration of 3.9 hours. Migration of the AEC laryngoscopy.
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occurred in 6% of cases and the author recommended securing the This case illustrates that despite all convincing, reassuring signs
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proximal tip to the patient’s clothing.35 at emergence (the patient was alert, followed commands, breathed
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spontaneously with a good tidal volume and rate, and had an audible cuff
Postextubation Care
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leak), which are in the vast majority of cases associated with extubation
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Postextubation monitoring of end-tidal CO2 can help early detection success, one should always be alert to, and prepared for, the need for
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of airway obstruction. Heliox and CPAP ventilation at the bedside reintubation. Extubation is an elective procedure and as such requires
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may sometimes be useful (eg, for patients with paradoxical vocal proper preparation (Figure 2).
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cord movement). Pulse oximetry is not a good monitor for airway

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Management of High-Risk Extubation

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obstruction when the patient is breathing oxygen-enriched air.

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Good communication with the staff who are caring for the patient Strategies when faced with a high-risk extubation (Figure 3)
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in the postoperative period is crucial. The gathering of equipment should include:

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and expertise needs to occur expeditiously in the case of airway • Intubating over an AEC (as was done in the case discussed after
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obstruction. reintubation).
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Conclusion: Revisiting the Case • Exchanging the ETT for a supraglottic airway device, which promotes
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The prediction of successful extubation is an inexact science. It a smoother awakening and allows for fiber-optic examination of the
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requires judgment that is informed by both experience and deliberate glottis for edema or injury, or paradoxical motion of the vocal cords.
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practice. Could the case presented here have been judged as • An awake or “dissociated” extubation employing a remifentanil
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representing a high-risk extubation postoperatively? A glib and easy or dexmedetomidine infusion, or both, for ETT tolerance in a
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answer, not necessarily correct and heavily influenced by outcome bias cooperative patient.
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and hindsight, would be yes. On closer examination, however, a more

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• Front-of-neck (infraglottic) surgical access in circumstances when

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nuanced response would be appropriate.

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this is the safest strategy.

Labeling a case as a high-risk extubation requires affirmative
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answers to two questions36: Is there an increased likelihood of required In any event, postponement of extubation is always better than rapid
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reintubation? Is there a risk for difficult reintubation (Figure 1)? reintubation.

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 APRIL 2018 Anesthesiology News I 7

CMEZone.com/TheFrostSeries

References
1. Cook TM, Woodall N, Frerk C. Fourth National Audit Project. Major complications of 20. Mikaeili H, Yazdchi M, Tarzamni MK, et al. Laryngeal ultrasonography versus cuff leak
airway management in the UK: Results of the Fourth National Audit Project of the test in predicting postextubation stridor. J Cardiovasc Thoracic Res. 2014;6(1):25-28.
Royal College of Anaesthetists and the Difficult Airway Society. Part 1: Anaesthesia.
Br J Anaesth. 2011;106(5):617-631. 21. Benoit Z, Wicky S, Fischer JF, et al. The effect of increased FIO(2) before tracheal
extubation on postoperative atelectasis. Anesth Analg. 2002;95(6):1777-1781.
2. Peterson GN, Domino KB, Caplan RA, et al. Management of the difficult airway:
A

22. Khemani RG, Randolph A, Markovitz B. Corticosteroids for the prevention and treat-
ll

A closed claims analysis. Anesthesiology. 2005;103(1):33-39.

ment of post-extubation stridor in neonates, children and adults. Cochrane Database
rig

Co

3. Cavallone LF, Vannucci A. Extubation of the difficult airway and extubation failure. Syst Rev. 2009;3:CD001000.
ht

Anesth Analg. 2013;116(2):368-383.

py
s

23. Fan T, Wang G, Mao B, et al. Prophylactic administration of parenteral steroids for pre-
rig ed.

4. Lee PJ, MacLennan A, Naughton NN, et al. An analysis of reintubations from a quality
re

venting airway complications after extubation in adults: meta-analysis of randomized

assurance database of 152,000 cases. J Clin Anesth. 2003;15(8):575-581.
ht
se

placebo controlled trials. BMJ. 2008;337:a1841.

5. Difficult Airway Society Extubation Guidelines Group, Popat M, Mitchell V, et al.
rv

Difficult Airway Society guidelines for the management of tracheal extubation. 24. Minogue SC, Ralph J, Lampa MJ. Laryngotracheal topicalization with lidocaine before
20

Anaesthesia. 2012;67(3):318-340. intubation decreases the incidence of coughing on emergence from general anesthe-
sia. Anesth Analg. 2004;99(4):1253-1257.
18
Re

6. Tanaka A, Isono S, Ishikawa T, et al. Laryngeal resistance before and after minor
25. Nath P, Williams S, Herrera Méndez LF, et al. Alkalinized lidocaine preloaded endotra-
M
pr

surgery: Endotracheal tube versus laryngeal mask airway. Anesthesiology.

cheal tube cuffs reduce emergence cough after brief surgery: A prospective random-
cM

2003;99(8):252-258.
od

ized trial. Anesth Analg. 2018;126(2):615-620.

uc

7. Oppenheimer AG, Gulati V, Kirsch J, et al. Case 223: arytenoid dislocation. Radiology.
ah in w

2015;277(2):607-611. 26. Guler G, Akin A, Tosun Z, et al. Single-dose dexmedetomidine attenuates air-
tio

on

8. Murphy GS, Brull SJ. Residual neuromuscular block: lessons unlearned. Part I: defi- way and circulatory reflexes during extubation. Acta Anaesthesiol Scand.
n

2005;49(8):1088-1091.
Pu

nitions, incidence, and adverse physiologic effects of residual neuromuscular block.

bl

Anesth Analg. 2010;111(1):120-128. 27. Aouad MT, Al-Alami AA, Nasr VG, et al. The effect of low-dose remifentanil on
is

9. Murphy GS. Neuromuscular monitoring in the perioperative period. Anesth Analg. responses to the endotracheal tube during emergence from general anesthesia.
ho

hi

2018;126(2):464-468. Anesth Analg. 2009;108(4):1157-1160.

ng
le

10. Isono S. Obstructive sleep apnea of obese adults: pathophysiology and perioperative 28. Lee B, Lee JR, Na S. Targeting smooth emergence: the effect site concentration of
or

airway management. Anesthesiology. 2009;110(4):908-921. remifentanil for preventing cough during emergence during propofol-remifentanil
ro
in

anaesthesia for thyroid surgery. Br J Anaesth. 2009;102(6):775-778.

11. Lewis SR, Butler AR, Parker J, et al. Videolaryngoscopy versus direct laryngoscopy for
up
pa

adult patients requiring tracheal intubation: a Cochrane systematic review. 29. Nho JS, Lee SY, Kang JM, et al. Effects of maintaining a remifentanil infusion on the
un ou
rt

Br J Anaesth. 2017;119(5):369-383. recovery profiles during emergence from anaesthesia and tracheal extubation.
w

le

12. Andrew SA, Sidhu KS. Airway changes after anterior cervical discectomy and fusion. Br J Anaesth. 2009;103(6):817-821.
ith

ss

J Spinal Disord Tech. 2007;20(8):577-581. 30. Shajar MA, Thompson JP, Hall AP, et al. Effect of a remifentanil bolus dose on the car-
ot

13. Sagi HC, Beutler W, Carroll E, et al. Airway complications associated with surgery on diovascular response to emergence from anaesthesia and tracheal extubation.
he

Br J Anaesth. 1999;83(4):654-656.
tp

the anterior cervical spine. Spine. 2002;27(9):949-953.

rw
er

14. Kim M, Choi I, Park JH, et al. Airway management protocol after anterior cervical 31. Lee JH, Koo BN, Jeong JJ, et al. Differential effects of lidocaine and remifentanil on
is

spine surgery: Analysis of the results of risk factors associated with airway complica-
m

response to the tracheal tube during emergence from general anaesthesia.

e

tion. Spine (Phila Pa 1976). 2017;42(18):E1058-E1066.

is

Br J Anaesth. 2011;106(3):410415.
no
si

15. Apfelbaum JL, Hagberg CA, Caplan RA, et al. Practice guidelines for manage-
on

32. Perelló-Cerdà L, Fàbregas N, López AM, et al. ProSeal Laryngeal Mask Airway attenu-
te

ment of the difficult airway: An updated report by the American Society of Anes- ates systemic and cerebral hemodynamic response during awakening of neurosurgi-
d.
is

thesiologists task force on management of the difficult airway. Anesthesiology. cal patients: A randomized clinical trial. J Neurosurg Anesthesiol. 2015;27(3):194-202.
2013;118(2):251-270.
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33. Koga K, Asai T, Vaughan RS, et al. Respiratory complications associated with tracheal
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16. Miller RL, Cole RP. Association between reduced cuff leak volume and postextubation
extubation. Timing of tracheal extubation and use of the laryngeal mask during emer-
stridor. Chest. 1996;110(4):1035.
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gence from anaesthesia. Anesthesia. 1998;53(6):540-544.

ite

17. De Bast Y, De Backer D, Moraine JJ, et al. The cuff leak test to predict failure of tra-
cheal extubation for laryngeal edema. Intensive Care Med. 2002;28(9):1267-1272. 34. Nair I, Bailey PM. Use of the laryngeal mask for airway maintenance following tracheal
d.

extubation. Anaesthesia. 1995;50(2):174-175.

18. Ochoa ME, Marin Mdel C, Frutos-Vivar F, et al. Cuff-leak test for the diagnosis of upper
airway obstruction in adults: a systematic review and meta-analysis. Intensive Care 35. Mort TC. Continuous airway access for the difficult extubation: the efficacy of the air-
Med. 2009;35(7):1171-1117. way exchange catheter. Anesth Analg. 2007;105(5):1357-1362.

19. Schnell D, Planquette B, Berger A, et al. Cuff leak test for the diagnosis of post- 36. Ellard L, Cooper RM. Extubation of the difficult airway. In: Glick DB, Cooper RM, Ovas-
extubation stridor: A multicenter evaluation study. J Intensive Care Med. 2017 Jan sapian A, eds. The Difficult Airway: An Atlas of Tools and Techniques for Clinical Man-
1:885066617700095. doi: 10.1177/0885066617700095. [Epub ahead of print] agement. New York, NY: Springer Science; 2013:271-287.
8 I Anesthesiology News APRIL 2018

The Frost Series #337

Post-test
Select the single best answer:

1. The incidence of airway complications at extubation is: 6. The quantitative cuff leak test is performed:
a. Lower than 4% a. With the ETT partly inflated, by calculating the difference between
b. Lower than 8% inspired and expired tidal volumes averaging 3 to 5 ventilator-
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c. Approximately 5% delivered respiratory cycles

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d. Higher than 10% b. With ETT deflated, by calculating the difference between inspired and
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expired tidal volumes averaging 3 to 5 ventilator-delivered respiratory

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2. The most common cause of postextubation laryngeal obstruction is: cycles

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a. Laryngospasm c. With ETT inflated, by calculating the difference between inspired and
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b. Vocal cord paralysis expired tidal volumes averaging 3 to 5 ventilator-delivered respiratory

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c. Arytenoid cartilage dislocation cycles

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d. Endotracheal intubation for more than 3 hours d. With ETT deflated, by calculating the difference between inspired and
20

expired tidal volumes averaging 2 ventilator-delivered respiratory

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3. Quantitative neuromuscular monitors include all the following except: cycles

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a. Electromyography
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7. Administering low-dose remifentanil before extubation:

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b. Acceleromyography
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c. Peripheral nerve stimulator a. Increases the incidence of cough

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d. Kineograph b. Can interfere with recovery from anesthesia

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c. Delays the return of spontaneous respiration

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4. Laryngospasm results from contraction of the laryngeal muscles due to d. Avoids undesirable cardiovascular responses
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stimulation of:
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a. Recurrent laryngeal nerve 8. Bailey maneuver is performed by:

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b. Superior laryngeal nerve a. Inserting the laryngeal mask airway in the hypopharynx, followed by
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c. Internal laryngeal nerve removal of the ETT

d. External laryngeal nerve b. Introducing an airway exchange catheter through a laryngeal mask
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airway
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5. Factors associated with postoperative airway complication in anterior c. Removal of the ETT, followed by placement of a laryngeal mask airway
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cervical spine surgery are: d. Fiber-optic examination of the laryngeal edema

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a. Surgery lasting more than 2 hours

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9. Depth of insertion of an AEC should not exceed:

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b. Exposure of 3 or more vertebral bodies

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c. Blood loss greater than 100 mL a. 10 cm

b. 16 cm
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d. Age over 60 years

c. 25 cm
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d. 27 cm
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10. An AEC inserted through an ETT:

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a. Is not well tolerated by spontaneously breathing patients

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b. Is not well tolerated by awake patients

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c. Allows continuous carbon dioxide monitoring

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d. Can be left in place for a maximum of 10 minutes

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d.

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