INDIAN JOURNAL OF ANAESTHESIA, DECEMBER 2006 430 Indian J. Anaesth. 2006; 50 (6) : 430 - 434 1. M.D.,FAMS. Hony.

Consultant Anaesthesiologist, Apollo Gleneagles Hospital, Kolkata. 2. M.D., Asst. Prof., Calcutta Medical College & Hospital; Kolkata. Correspond to : Dr. Suman Chatterjee BC - 103, Salt Lake, Kolkata 700064. E-mail : sumanchatterji@hotmail.com (Accepted for publication on 20 - 10 - 2006 ) REVIEW ARTICLE TRACHEAL EXTUBATION IN THE DIFFICULT AIRWAY Dr. A. Rudra1 Dr. S. Chatterjee2 Management of the difficult airway does not end with the placement of an endotracheal tube. The anaesthesia practitioner is faced daily with the extubation of patients in the operating room, the postanaesthesia care unit, or in the intensive care unit. On occasion one is faced with extubation of a difficult airway. For most operating room patients, the likelihood of a patient requiring tracheal reintubation is in the order of 0.1 to 0.2 percent. 1,2 In patients undergoing diagnostic panendoscopy, particularly if a biopsy is obtained, this increase to 1 to 3 percent. 3-7 For

intensive care unit patients, tracheal reintubation is required between 6 to 25 percent depending upon extubation criteria and case mix. 8 The ASA Task Force9 regards the concept of an extubation strategy as a logical extension of intubation strategy which is strongly supported by consultants opinion. ASA9 and Canadian Airway Focus Group10 recommends the preformulated strategy for extubation of the difficult airway would depend in part on the surgery, the condition of the patient, and the skills and preferences of the anasethesia practitioner. They further recommended that the preformulated strategy should include : 1. Consideration of relative merits of awake intubation versus extubation before the return of consciousness. 2. An evaluation of factors that may impair ventilation after extubation. 3. Formulation of an airway management plan that can be implemented if the patient is not able to maintain adequate ventilation after extubation. 4. Consideration of the short term use of a hollow device that can serve as a guide for reintubation and ventilation, or both, if extubation is not successful. This article reviews to identify patients at high risk at the time of extubation and strategies to minimize such

risk, and also potential complications associated with extubation. The difficult airway A difficult airway, as defined by the ASA Task Force, is the clinial situation in which a conventionally trained anaesthesia practitioner experiences difficulty with mask ventilation, difficulty with tracheal intubation, or both. 11 Obviously, if one had difficulty with ventilation or initial endotracheal intubation, particular caution should be exercised at the time of extubation. Usually this scenario is seen due to airway trauma leading to oedema and trauma following multiple attempts at securing the airway. Risk factors for difficult tracheal reintubation include a history of previous difficult intubation, airway oedema secondary to surgical manipulation or volume resuscitation, morbid obesity, inexperienced personnel, airway injury, burns or smoke inhalation, limited access or anatomical derangement, and an immobilized or unstable cervcal spine. 12 Reestablishing and securing the airway in these patient can be extremely challenging, often resulting in considerable morbidity and mortality. 13,14 Indeed, adverse outcomes constituted the single largest class of injury in the American

Society of Anesthesiologists Closed Claims Study (34%), with death or brain damage occuring in 85% of these cases. 15 The main goal of extubating the difficult airway, as with any airway, is to avoid reintubation if at all possible. Otherwise, that may lead to a less than desirable outcome. The extubation in a difficult airway depend on both airway and nonairway issues. The usual criteria should be met, for example, haemodynamic stability, a satisfactory oxygen-carrying capacity, normothermia, an adequate respiratory rate and tidal volume, good oxygen saturation, and a conscious alert patient who is able to clear secretions and protect the airway. Patients at high risk for failed extubation are those with any potential for hypoventilation, a ventilation pefusion mismatch, a failure of the pulmonary toilet, or airway obstruction. One should also take into cosideration the patients future operative schedule. It makes no sense to extubate a patient with a difficult airway and later find out that the patient will be returning the next morning for follow-up surgery. 15 Commonly practiced maneuvers to determine the feasibility of extubation are direct laryngoscopy and cuff leak before extubation to detect oedema around the airway. Direct laryngosopy in this scinerio has a limited value, as

because, the endotracheal tube blocks the operators view of the laryngeal inlet. Moreover, the endotracheal tube in situ will deform the anatomy, leading to an underestimation of 430RUDRA, CHATTERJEE : TRACHEAL EXTUBATION IN DIFFICULT AIRWAY 431 the difficulty of reintubation. The second maneuver commonly performed is testing for a cuff leak. 16 This is accomplished in a spontaneously ventilating patient by removing the patient from the ventilation circuit and occluding the end of the endotracheal tube with a finger while simultaneously deflating the cuff. If no significant oedema is present, the patient will be able to breathe around the endotracheal tube. A cuff leak test should be performed on any patient who it is felt may demonstrate obstruction after extubation. The incidence of reintubation and the need for tracheostomy is greater in the absence of a cuff leak. 17,18 Strategies for exutubation Since the majority of patients, even those at high risk, will be tracheally extubated with success, it is essential that any proposed strategy entails less risks than simply removing the tracheal tube and hoping for the best. A safe tracheal extubation strategy should also involve minimal discomfort, at acceptable costs, and facilitate oxygenation, ventilation in a failing pateint even while the airway is

being reestablished; and tracheal reintubation, if necessary. 14 These strategies are not evidence-based; most are derived from case reports or small series. Therefore, the anaesthesia practitioner must understand the various options for extubation and formulate a plan of action to regain control of the airway if extubation fails. Benumof considers a controlled, gradual, step-by-step, reversible withdrawal of airway support as the optional approach to the difficult airway extubation. 19 There are basically three approaches to extubation of the difficult airway: 20,21 a) extubate conventionally with the patient awake, b) extubate in a deep plane of anaesthesia followed by the placement of a laryngeal mask airway to decrease the risk of laryngospasm or bronchospasm, c) extubate with the patient awake with a bridge to full extubation. In a spontaneously breathing patient, extubation over a fibreoptic bronchoscope offers the possibility of visually assessing vocal cord function. This can be very helpful for the patient suspected of having a vocal cord palsy. It also permits an assessment of anatomic injury to the trachea, glottis, or supraglottic structures. When significant abnormalities are noted, a decision must be

made whether to immediately reinsert the tracheal tube or withdraw the bronchoscope and manage the patient with agents such as racemic epinephrine and helium/oxygen. 22 Other than bronchoscope many devices have been used in the extubation of the difficult airway. These are long hollow catheters which may include connections for jet and/or manual ventilation; most have distance and radiopaque markers. They also have end and/or distal side holes, though these differ in number. Oxygen insufflation or jet ventilaition can be provided through the lumen of catheter. Respiratory monitoring can also be achieved by connecting to a capnograph. Spontaneous breathing may take place around the device. In most reports, tracheal tube exchange catheters have been tolerated well enough that they can be left in place until it is probable that tracheal ventilation will not be required. 23,24 Properly securing the airway exchange (and ventilation) catheters at the same depth as the previously replaced endotracheal tube prevents it from coming out even if the patient coughs. Clarifying to the nursing staff and labeling these catheters as an airway device will avert a potent disaster if mistaken for a feeding tube. Even with the catheter in the trachea, most patients will be able to talk or cough. If tracheal

reintubation or a tracheal tube exchange is required, this can be facilitated with gentle direct laryngoscopy, not necessarily to reveal the glottis but to retract the tongue and to detect any airway pathology. These devices are consistent with the recommendation of the American Society of Anesthesiologists Task Force on Management of Difficult Airway9 and the Canadian Airway Focus Group10 regarding tracheal extubation of the difficult airway. The device will provide a means whereby oxygen by insufflation or ventilation, if necessary, can be accomplished while altenative techniques are explored. This may be thought of as a reversible tracheal extubation. With the device in place, other option can be persued, including an evaluation of the benefits of helium/oxygen or the inhalation of racemic epinephrine. Knowing that the patient is satisfactorily oxygenated (and ventilated), additional information, equipment, or expertise can be recruited. There are numerous manufacturers for these types of catheters, but all basically work on the same principle. Table - 1 : Endotracheal ventilation & exchange catheters. Bedger jet stylet METTRO (Mizus Endotracheal Tube Replacement Obturator) Airway exchange catheter (Cook) Patil two-part intubation catheter (Cook) Tracheal Tube Exchanger (TTX, Sheridan)

 Endotracheal ventilation catheter ( ETVC, CardioMed) Jet Tracheal Tube Exchanger (JETTX) E.T.X. catheter for double lumen endotracheal tube exchange (Sheridan ) Endotracheal exchangers should be handled with caution: the rate of failures seems to be higher than expected depending on the type of airway exchange catheter, technique and experience of the operator. The user should be aware that endotracheal tube exchange can lead to major complications that include laceration of the lateral wall, bronchial perforation with pneumothorax, loss of airway with hypoxaemia and/or bradycardia, potential need of aINDIAN JOURNAL OF ANAESTHESIA, DECEMBER 2006 432 surgical airway, cardiac arrest or death. A clear algorithm and equipment for alternative ways to control the airway should be readily available before an endotracheal tube exchange is performed. There are differences between these commercial products and such differences may be important. Essential points for consideration include the security of the connection and the number of distal side ports (if jet ventilation is to be used) and the length and diameter of the device (particularly if a tracheal tube exchange is contemplated or a double-lumen tracheal tube is involved). In general, the greater the diameter, the more alike is the device to a long tracheal tube but the simpler it is to perform a tracheal tube exchange. Long devices with narrow inner diameter

allow for positive pressure ventilation but offer high resistance. While such ventilation may be life-saving, it may not be adequate for severely compromised patients. This may necessitate jet ventilation. When jet ventilating through a tracheal tube exchange catheter, it is important to ensure the device is proximal to the carina, to reduce the driving pressure and inspiratory time to that required to expand the lungs, and to provide a sufficiently time to allow for complete exhalation. A device with multiple endholes results in lower injection pressure and reduces catheter whip. The objective of jet ventilation is to provide lifesaving oxygenation rather than normal blood gases. Such an objective will reduce the likelihood of barotrauma. 25 However, till today fibreoptic endoscopy has been suggested as a better and safer option to exchange endotracheal tubes. 26,27 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 excange catheter through the endotracheal tube to a predetermined depth.

5. Extubate the patient over a jet ventilation catheter. 6. Apply oxygen by face mask 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. Complications associated with extubation Rarely, attempts to remove a tracheal tube cannot be achieved due to entrapment by fixation devices or sutures, cuffs that cannot be deflated, or a barb resulting from a partly severed tracheal tube. 28 Haemodynamic changes Extubation is accompanied by transient hypertension and tachycardia in most adults. Catecholamine release due to endotracheal tube stimulation is thought to be responsible for the change in haeodynamics. The clinical importance and optimal management of these problems will depend upon the context in which the event occurs. Patients with cardiac disease, pregnancy - induced hypertensions, 12 and raised intracranial pressure29 may be at particular risk for adverse consequences. Patients with cardiac disease have shown decreased ejection fractions at the time of

extubation. 30 Strategies to attenuate such responses include the use of intratracheal lignocaine or intravenous lignocaine, nitrates, beta-blockers, and extubation while in a surgical anaesthetic plane. Extubation in the deeper plane is inappropriate for those with a difficult airway, those with a high risk for aspiration, and those in whom airway access is reduced. Laryngospasm Laryngospasm is a common cause of upper airway obstruction particularly when stimuli are encountered during emergence. A variety of triggers are recognized including vagal, trigeminal, auditory, phrenic, sciatic and splanchnic nerve stimulation. Cervical flexion or extension with an indwelling tracheal tube, and vocal cord irritation from blood, vomitus or oral secretions cause laryngospasm. Various techniques have been used in attempt to decrease the incidence of this event. Management consists of suctioning the oropharynx before extubation, disconnection of painful stimulation, and administering 100% oxygen with sustained positive pressure at the time of extubation. Severe cases may require a small does of suxamethouicum to break the spasm along with reintubation. 31,32 Glottic oedema

Tracheal and laryngeal trauma may result in glottic oedema, which is an important cause of postextubation obstruction. Glottic oedema has been subsclassified as supraglottic, retroarytenoidal, and subglottic. 33 Supraglottic oedema results in posterior displacement of the epiglottis reducing the laryngeal inlet and causing inspiratory obstruction. Retroarytenoidal oedema restricts movement of the arytenoid cartilages, limiting vocal cord abduction on inspiration. Subglottic oedema, a particular problem in neonates and infants results in swelling of the loose submucosal connective tissue and is confined by the nonexpandable cricoid cartilage. In neonates, this is the narrowest part of the upper airway, and small reductions in diameter results in a significant increase in airway resistance. Management of laryngeal oedema depends upon its severity. Treatment options range from head-up positioning, supplemental humidified oxygen, racemic epinephrine, helium-oxygen administration and reintubationRUDRA, CHATTERJEE : TRACHEAL EXTUBATION IN DIFFICULT AIRWAY 433 with a smaller endotrachel tube. The practice of administering systemic steroids in the hopes of reducing oedema is controversial, and studies are divided on their efficiency. 34 Vocal cord malfunctions

Vocal cord malfunctions from injury to the vagus or one of its branches (the recurrent laryngeal nerve or the external division of the superior laryngeal nerve) is a relatively rare complication associated mostly with head and neck, thyroid, or thoracic surgery. 12 Vocal cord malfunction can also be caused by cuff pressure from the endotracheal tube near the anterior division of the recurrent laryngeal nerve. 35 Unilateral vocal cord paralysis generally produces little other than hoarseness and usually improves without treatment. Bilateral vocal cord paralysis can cause airway obstruction requiring immediate reintubation and subsequent tracheostomy. Diagnosis can be confirmed by fibreoptic evaluation. Acute pulmonary oedema Acute pulmonary ordema may complicate tracheal extubation when significant airway obstruction occurs. 36-39 Generally, it occurs in adults following severe laryngospasm. However, in children, acute pulmonary oedema occurs following croup or epiglottitis. 38 This occurs when a forceful inspiratory effort is made against a closed glottis, generating

high intrapleural pressures promoting venous return. It may also result in a rightward shift of interatrial and interventricular septums, raising left atrial and ventricular pressures. This condition is seen within minutes after extubation and usually presents with pink frothy sputum and a decrease in oxygen saturation (SpO2). Management involves removing the obstruction, oxygen support, close monitoring, and afterload reduction with frusemide or morphine, or both. Reintubation is rarely needed and most cases resolve without complications. Airway compression External compression of the airway after extubation may lead to obstruction. An excessively tight postsurgical neck dressing cause external compression that can be easily resolved. A rapidly expanding haematoma in proximity to the airway. Situation may be seen after certain surgeries (e.g. carotid endarterectomy, thyroidectomy). Condition must be quickly diagnosed and properly treated before total airway obstruction occur. 40 Tracheomalacia, may occur for a number of reasons including prolonged compression from a goiter. 41 This condition is usually seen after the removal of the

goiter. Airway obstruction becomes apparent soon after extubation and management includes reintubation, surgical tracheal support, or tracheostomy below the obstruction. Aspiration Alteration in laryngeal function, along with residual anaesthesia, may make the patient more vulnerable to aspiration at the time of extubation. Management consists of supportive measures and depending on the extent of aspiration may include reintubation and ventilation with positive end-expiratory pressure. Macroglossia It may complicate prolonged posterior fossa surgery performed in the sitting, prone, or park-bench position. 42 Tongue enlargement may also be traumatic, haemorrhagic, vascular, or inflammatory. It may worsen after tracheal tube removal, leading to partial or complete airway obstruction. 43 Tracheal reintubation may prove difficult or impossible. Conclusion Many tracheal extubations are accompanied by relatively benign, transient complications. In certain settings, the risk of the patient requiring tracheal reintubation are

increased. Tracheal reintubation are generally more complex because of associated hypoxia, hypercarbia, haemodynamic problems, agitation, and airway obstruction. Tracheal reintubation over tube changers is neither without complications nor 100% successful; therefore, who use these devices should be familiar with the equipment and techniques, their potential complications, and alternatives in case of reintubation failure. Finally, the high risk patients should be identified if at all possible. Moreover, a senior anaesthesiologist with experience in difficult airway and a trained nurse should always be present alongside the airway manager, which may improve patient safety. References 1. Emery SE, Smith MD, Bohlman HH. Upper-airway obstruction after multilevel cevical corpectomy for myelopathy. J Bone Joint Surg Am 1991; 73: 544-511. 2. Hill RS, Koltai PJ, Parnes SM. Airway complications from laryngoscopy and panendoscopy. Ann Otol Rhinol Laryngol 1987; 96: 691-694. 3. Lacoste L, Gineste D, Karayan J, Mortaz N, Lehuede MS, Girault M et al. Airway complications in thyroid surgery. Ann Otol Rhinol Laryngol 1993; 102: 441-446. 4. Marini JJ, Wheeler AP. Weaning from mechanical ventilation. In : Marini JJ, Wheeler AP (eds) Critical care medicine : the essentials. Baltimore, Williams Wilkins 1997: 173-195.

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