14 June 2013

No 20

Postoperative Tracheal Extubation:
Current Controversies
SA Jara!h
Commentator: N. Mzoneli Moderator: R Samuel
"iscipline o# Anaesthetics
C$NTENTS
%NT&$"'CT%$N(((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((3
C$NS%"E&AT%$NS AT E)T'*AT%$N((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((3
Position o# Extubation(((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((3
A+a,e versus "eep Extubation((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((4
Pre-ox.enation(((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((/
Ti0in. o# extubation((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((/
C$1P2%CAT%$NS $3 T&AC4EA2 E)T'*AT%$N((((((((((((((((((((((((((((((((((((((((((((((((/
'pper air+a obstruction((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((5
2arn.ospas0((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((5
4poventilation((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((6
Cou.hin.(((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((6
4ae0o7na0ic co0plications((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((8
9'%"E2%NES $N E)T'*AT%$N((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((8
A0erican Societ o# Anesthesiolo.ists :ASA;((((((((((((((((((((((((((((((((((((((((((((((((8
"i##icult Air+a Societ 9ui7elines :"AS;(((((((((((((((((((((((((((((((((((((((((((((((((((((((<
C$NC2'S%$N((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((14
&E3E&ENCES((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((1/
Page 2 of 16
Current Controversies &e.ar7in. Tracheal Extubation
%NT&$"'CT%$N
All anaesthetists will at some point eperien!e diffi!ult"# pro$lems with or after
tra!heal etu$ation
1
. %hilst tra!heal intu$ation has $een etensi&el" studied'
in!luding the predi!tion' me!hanism and in!iden!e of diffi!ult tra!heal intu$ation
2
!oupled with esta$lished guidelines' tra!heal etu$ation has re!ei&ed little
attention. (espite tra!heal etu$ation $eing re!ognised as a situation that !an $e
potentiall" life threatening' there is little literature and guidelines are $ased on
limited s!ientifi! e&iden!e and mainl" epert opinion
)
.
A stud" $" Peterson et al used the Ameri!an So!iet" of Anesthesiologist *ASA+
Closed Claims data$ase to loo, at 1-. !laims for diffi!ult airwa" management
$etween 1./011...
2
. 3wo groups where identified' one $efore the implementation
of the diffi!ult airwa" guidelines *1./011..2+ and the other after its implementation
*1..)11...+.
3he findings showed that the in!iden!e of (eath# 4rain damage during indu!tion
of anaesthesia de!reased from 625 during the 1./011..2 period to )05 during
the 1..)11... period
2
. 3his de!rease was not noted with the other phases of
anaesthesia' in!luding maintenan!e' etu$ation and re!o&er" phase. 6t has $een
suggested that the implementation of the ASA diffi!ult airwa" guidelines along with
ad&an!ed airwa" tools and te!hni7ues ha&e helped to redu!e the num$er of
se&ere e&ents related to tra!heal intu$ation
)
. 4ased on this' it would seem
reasona$le to suggest that the implementation of similar guidelines for etu$ation
is ne!essar".
C$NS%"E&AT%$NS AT E)T'*AT%$N
3ra!heal etu$ation must $e !onsidered an important step during emergen!e from
anaesthesia and it is not 8ust the re&ersal of the pro!ess of intu$ation
0
.

9tu$ation
represents a !hange from a !ontrolled to an un!ontrolled situation
0
.
Position o# Extubation:
3raditionall" patients ha&e $een etu$ated in the left lateral head down position
with the aim to de!rease the ris, of aspiration
6
and o$stru!tion. 6n a stud" $"
Mehta et al different endotra!heal etu$ation te!hni7ues were !ompared
6'-
. 6t was
found that a left lateral position with a 1: degree head down tilt and gentle
su!tioning through the endotra!heal tu$e pre&ented aspiration of 2:mls of
!ontrast medium
6'-
.
Rassam et al in their sur&e" of pra!ti!e in the ;nited <ingdom and 6reland' found
that although this positioning was fa&oured in the emergen!" operations' the
supine position was fa&oured after ele!ti&e operations and the head up#sitting
position followed $" the left lateral position post etu$ation in o$ese patients
/
.
Page ) of 16
3his !hange in trend of pra!ti!e with regard to patient positioning at etu$ation
that was noted !ould $e due to a num$er of reasons:
Supine
1 9le!ti&e surger" patients are generall" well prepared prior to surger" $" $eing
star&ed in order to fa!ilitate an empt" stoma!h at indu!tion.
1 3he in!reased use of supraglotti! airwa"s' whi!h are $etter tolerated $"
patients on emergen!e allows for the patient to $e more awa,e $efore
remo&ing these de&i!es
.
.
1 3he in!reased usage of short a!ting anaestheti! drugs' well e7uipped re!o&er"
rooms and well trained staff ha&e also !ontri$uted to this !hange in pra!ti!e
/
.
Sitting/Head up
1 3he in!reased pre&alen!e of o$esit" and !hroni! lung disease !aused $"
smo,ing also in!reases the ris, of respirator" and airwa" !ompli!ation
.
.
=u$$ et al in their s"stemati! re&iew found no trial e&iden!e to pro&e one
te!hni7ue to $e safer than the other. 3he" re!ommend that the left lateral head
down position $e used for patients for emergen!" surger" and the sitting#head up
position $e used with ele!ti&e patients or o$ese patients and those with pre1
eisting respirator" !ompli!ations
6
.
A+a,e versus "eep Extubation:
3ra!heal etu$ation !an $e performed either when the patient is still deepl"
anaesthetised *deep+ or when the" ha&e regained !ons!iousness *awa,e+
1:
.
3here are ad&antages and disad&antages to $oth te!hni7ues. %ith etu$ation
under deep anaesthesia the patients eperien!e less !oughing and
haemod"nami! !hanges howe&er the" ha&e a greater potential ris, of airwa"
o$stru!tion and gastri! aspiration due to their prote!ti&e airwa" reflees $eing
o$tunded
)'6'11
.
%ith awa,e etu$ation' patients ha&e full re!o&er" of the airwa" reflees and
spontaneous $reathing
)
. >owe&er the" are at ris, of !oughing' straining' $u!,ing
during emergen!e whi!h are asso!iated with raised intra!ranial' intrao!ular' intra1
a$dominal pressures and haemod"nami! !hanges and this ma" $e undesira$le
with !ertain t"pes of surger" and in patients with pre1eisting patholog". Most of
the a&aila$le literature does not pro&ide a definition for awa,e or deep etu$ation.
Patel et al defined wa,efulness as the return of lar"ngeal and phar"ngeal reflees'
e"e opening' grima!ing' !oughing and purposeful mo&ements
12
.
3here seems to $e no definiti&e !onsensus with regards to timing of etu$ation.
Asai et al in a prospe!ti&e sur&e" on the in!iden!e of respirator" !ompli!ations
asso!iated with tra!heal intu$ation and etu$ation' found that the danger of
respirator" pro$lems was greater in patients etu$ated under deep anaesthesia
irrespe!ti&e of the t"pe of operation
2'11
. <armar,ar et al also suggest as a rule that
patients should $e etu$ated awa,e
11
.
Page 2 of 16
A few studies in&ol&ing !hildren ha&e demonstrated a greater o!!urren!e of
desaturation with awa,e etu$ation' although there was no differen!e in in!iden!e
of other respirator" !ompli!ations
2'11'12
. 3he de!ision to etu$ate a patient awa,e
or deep needs to $e guided $" the !ondition of the patient' the pro!edure $eing
performed and eperien!e of the anaesthetist.
Pre-ox.enation:
Preo"genation prior to etu$ation is !ontro&ersial. =u$$ et al in their s"stemati!
re&iew re!ommend pre1o"genation with 1::5 o"gen prior to etu$ation
6
. 6f the
situation o!!urs where a patient has airwa" o$stru!tion post etu$ation' this pre1
o"genation allows for more time and higher o"gen reser&es' than with a
miture' $efore h"poaemia o!!urs
-
.
>owe&er in a stud" $" 4enoit et al' it was found that the administration of 1::5
o"gen at the end of a general anaesthesia promotes postoperati&e atele!tasis
regardless of whether a &ital !apa!it" manoeu&re is performed
1)
. A ?ital !apa!it"
manoeu&re was defined as the inflation of intu$ated patients@ lungs to 2:!m >2A
for 10 se!onds
1)
.
3here is also some e&iden!e to suggest that a miture of o"gen and nitrogen
ma" help to a&oid a$sorption atele!tasis
6
.

A safet" margin with regards to
o"genation during etu$ation is important and further studies are needed to
e&aluate whether atele!tasis !an $e pre&ented despite the use of 1::5 o"gen
1)
.
Ti0in. o# extubation :
9tu$ation !an o!!ur during either inspiration or epiration. (uring inspiration
there is an in!rease firing threshold of the neurones to the &o!al !ords
6
. 6t has
therefore $een re!ommended that to de!rease the in!iden!e of lar"ngospasm'
etu$ation should ta,e pla!e at the end of inspiration a!!ompanied $" a positi&e
pressure $reath
6
. 3his results in a !ough as the first post etu$ation respirator"
$reath whi!h in theor" will !lear the airwa"s of an" se!retions
-
. No !ontrolled
studies or s!ientifi! e&iden!e !ould $e found to support these re!ommendation
-
.
C$1P2%CAT%$NS $3 T&AC4EA2 E)T'*AT%$N
Ad&erse respirator" e&ents are more !ommon with etu$ation and the immediate
post etu$ation period then with indu!tion and intu$ation.
2'/'11

Some of the !ommon !ompli!ations of etu$ation in!lude:
1. ;pper Airwa" o$stru!tion
2. Bar"ngospasm
). >"po&entilation*(ue to residual neuromus!ular $lo!,ade or anaestheti!
drug effe!t+
2. Coughing
0. Pulmonar" aspiration#impaired lar"ngeal !ompeten!e
6. >aemod"nami! distur$an!es *h"pertension' ta!h"!ardia' M6+
Page 0 of 16
'pper air+a obstruction :'A$;
3he ta$le $elow lists some of the !auses of ;AA:
2arn.ospas0
Air+a 1uscle &elaxation
o &esi7ual 0uscle relaxants
o &esi7ual Anaesthetics
So#t tissue oe7e0a
Cervical 4ae0ato0a
=ocal cor7 paralsis
3orei.n bo7 aspiration
Table 1: (ifferential (iagnosis of Postoperati&e Airwa" A$stru!tion
-
2arn.ospas0
Bar"ngospasm is a !ommon !ompli!ation of etu$ation whi!h results from the
prolonged addu!tion of the &o!al !ords mediated $" the superior lar"ngeal ner&e'
a $ran!h of the &agus ner&e
6'-
. 6t is a result of irritation of the glottis $" $lood'
sali&a or foreign material during the light phase of anaesthesia
11
. Nasal' $u!!al'
phar"ngeal or lar"ngeal irritation' upper a$dominal stimulation or manipulation and
smell ha&e all $een impli!ated in the aetiolog" of lar"ngospasm
0
.
3reatment in&ol&es:
6dentif"ing and remo&ing the pre!ipitating !ause
1
(eepen patients anaesthesia either &ia 6? or inhalation agents
1

Continuous positi&e airwa" pressure and administering 1::5 o"gen
0
Barsons@s manoeu&re ma" $e used1 the middle finger of ea!h hand is pla!ed
in the Clar"ngospasm not!h@ *$etween the posterior $order of the mandi$le
and the mastoid pro!ess+. Pressure to this point ma" help relie&e
lar"ngospasm
0
6t ma" $e ne!essar" to use suamethonium.
6? ligno!aine' magnesium and doapram ha&e also $een used.
Page 6 of 16
3i.ure1. Barson@s manoeu&re in&ol&es firm $ilateral'medial
and !ephalad pressure with either the inde
or middle finger in theClar"ngospasm not!h
6
4poventilation
3his !an $e due to residual anaestheti! or mus!le relaant effe!ts.
6t is re!ommended to use a peripheral ner&e stimulator to ensure ade7uate
re&ersal of neuromus!ular $lo!,ade
6
. A 3rain of Dour *3AD+ ratio as high as :..
has $een suggested as ade7uate prior to etu$ation. 3AD E:.. is asso!iated with
impaired phar"ngeal !oordination' in!reased ris, of aspiration' upper airwa"
o$stru!tion
)
.
Cou.hin.
Coughing is a fre7uent o!!urren!e at etu$ation. 6t is !onsidered a !ompli!ation
when it is asso!iated with a desaturation' lar"ngospasm or upper airwa"
o$stru!tion
2
. Coughing is also undesira$le as it !auses an in!rease in intrao!ular'
intrathora!i! and intra!ranial pressures as well as !auses an in!rease in heart rate
and $lood pressure.
Apioids and ligno!aine ha&e $een used to suppress the !ough refle.
Aouad et al in a prospe!ti&e dou$le $lind Randomised !ontrol trial' showed that
low dose remifentanil gi&en during emergen!e from anaesthesia de!reased the
in!iden!e and se&erit" of !oughing $ut did not dela" wa,e up time
12
.
Page - of 16
4ae0o7na0ic co0plications
An in!rease of 1:1):5 in $lood pressure and heart rate lasting 0110 minutes after
etu$ation has $een found in man" studies
-
. %hilst these !hanges are generall"
well tolerated $" most patients' there are some patients in whom it will $e poorl"
tolerated
1
. Parti!ularl" those with pre1eisting !ardio&as!ular pro$lems' the
haemod"nami! !hanges due to etu$ation ma" !ause a disruption to the suppl"1
demand $alan!e of the m"o!ardium resulting in m"o!ardial is!haemia
1
.
Bigno!aine has $een used to suppress $oth !ough and haemod"nami!
responses
6
.

3opi!al ligno!aine instilled down the 933 has $een shown to $e more
effe!ti&e than intra&enous or intra1!uff ligno!aine in suppressing the !ough and
haemod"nami! effe!ts of etu$ation
6'10
.
?erapamil' esmolol#la$etolol and opioids su!h as remifentanil ha&e $een used to
suppress the haemod"nami! effe!ts of etu$ation
6
.
9'%"E2%NES $N E)T'*AT%$N
Compli!ations during etu$ation are !ommon howe&er most airwa" management
guideline do not dedi!ate as mu!h attention to it as intu$ation
0
. (ue to a la!, of
e&iden!e to support a single etu$ation strateg" for all patients' it is important to
ha&e an ade7uatel" prepared etu$ation strateg" for ea!h patient
0
.
A0erican Societ o# Anesthesiolo.ists :ASA; 9ui7elines:
3he ASA in their guidelines for the management of a diffi!ult airwa"' re!ommends
that a preformulated strateg" for etu$ation should eist whi!h is $ased on the
t"pe of surger" performed' the patient@s !ondition' and the s,ills of the
anaesthetist
16
.
3his strateg" should in!lude:
A !onsideration of the relati&e merits of awa,e etu$ation
&ersus etu$ation $efore the return of
!ons!iousness.
An e&aluation for general !lini!al fa!tors that ma"
produ!e an ad&erse impa!t on &entilation after the
patient has $een etu$ated
3he formulation of an airwa" management plan that
!an $e implemented if the patient is not a$le to
maintain ade7uate &entilation after etu$ation
A !onsideration of the short1term use of a de&i!e that
!an ser&e as a guide for epedited reintu$ation.
Table 2: ASA Re!ommendation for 9tu$ation Strateg"
16
Page / of 16
"i##icult Air+a Societ 9ui7elines :"AS;:
3he (AS re!entl" pu$lished a four step guideline for the management of the adult
perioperati&e tra!heal etu$ation.
3i.ure2. (AS 9tu$ation Fuidelines: 4asi! Algorithm
0
3he first step in the (AS guidelines' in&ol&es the planning of etu$ation prior to
indu!tion. 3his is aided $" assessing the airwa"s and general ris, fa!tors of the
patient.
3he se!ond step is preparing for etu$ation and in&ol&es optimising airwa"'
general and logisti!al fa!tors to allow for the $est possi$le etu$ation !onditions
0
.
Step 1 and 2 will ena$le for the stratifi!ation of patients into a Clow ris,@ or Cat ris,@
!ategor".
Page . of 16
Low Risk Category:
6n this group of patients' the etu$ation is epe!ted to $e un!ompli!ated as the
airwa" was normal at indu!tion and has not !hanged $" the end of surger" and no
general ris, fa!tors are present
0
.
At Risk Category:
3hese patients are at ris, of !ompli!ation at etu$ation either due to airwa" or
general ris, fa!tor
0
.
Step ) in&ol&es performing the etu$ation.
Low Risk Extubation:
9&er" etu$ation has a ris, asso!iated with it $ut it is !onsidered that patients in
this group will $e a$le to $e re1intu$ated without mu!h diffi!ult"
0
Patients !an $e either etu$ated awa,e or deep and the steps re!ommended for
the pro!ess of etu$ation in ea!h situation is gi&en in the ta$les $elow.
1( (eli&er 1::5 A"gen through the $reathing s"stem
2( Remo&e orophar"ngeal se!retions using a su!tion de&i!e' ideall" under dire!t &ision
3( 6nsert a $ite $lo!, to pre&ent o!!lusion of the tu$e
4( Position the patient appropriatel"
/( Anatgonise residual neuromus!ular $lo!,ade
5( 9sta$lish regular $reathing and an ade7uate spontaneous minute &entilation
6( Allow emergen!e to an awa,e state of e"e opening and o$e"ing !ommands
8( Minimise head and ne!, mo&ements
<( Appl" positi&e pressure' deflate the !uff and remo&e the tu$e while the lung is near
&ital !apa!it"
10( Pro&ide 1::5 o"gen with the anaestheti! $reathing s"stem and !onfirm airwa"
paten!" and ade7ua!" of $reathing
11( Continue deli&ering o"gen $" mas, until re!o&er" is !omplete
Table 3: Se7uen!e for low ris, etu$ation in an awa,e patient
0
1. 9nsure that there is no further surgi!al stimulation
2. 4alan!e ade7uate analgesia against inhi$ition of respirator" dri&e
). (eli&er 1::5 o"gen through the $reathing s"stem
2. 9nsure ade7uate depth of anaesthesia with &olatile agent or 36?A as appropriate
0. Position the patient appropriatel"
6. Remo&e orophar"ngeal se!retions using a su!tion de&i!e' ideall" under dire!t &ision
Page 1: of 16
-. (eflate the tra!heal tu$e !uff. Airwa" responses su!h as !ough' gag or a !hange in
$reathing pattern indi!ate an inade7uate depth and the need to deepen anaesthesia
/. Appl" positi&e pressure &ia the $reathing !ir!uit and remo&e the tra!heal tu$e
.. Re!onfirm airwa" paten!" and ade7ua!" of $reathing
1:.Maintain airwa" paten!" with simple airwa" manoeu&res or oro#nasophar"ngeal airwa"
until the patient is full" awa,e
11. Continue deli&ering o"gen $" mas, until re!o&er" is !omplete
12.Anaestheti! super&ision is needed until the patient is awa,e and maintaining their own
airwa"
Table 4: Se7uen!e of low ris, deep etu$ation
0
At Risk Extubation:
Patient who ha&e general and#or airwa" ris, fa!tors that ma" results in them $eing
una$le to maintain their own airwa" after etu$ation and who are !onsidered to $e
a potentiall" diffi!ult reintu$ation fall into this group. A de!ision needs to $e made
if the patient should $e etu$ated or if its safer to ,eep the patient intu$ated. 6f
etu$ation is !onsidered safe' then an awa,e etu$ation or the use of an
ad&an!ed te!hni7ue of etu$ation !an $e used.
6f etu$ation is !onsidered to $e unsafe then a de!ision needs to $e made on
whether to postpone etu$ation or perform a tra!heostom"
0
. Dor an awa,e
etu$ation' the se7uen!e re!ommended is the same as that for the low ris, group.
Some patient howe&er ma" re7uire the use of an ad&an!ed te!hni7ue. 3hese
in!lude: Bar"ngeal mas, eh!hange *4aile" manoeu&re+' Remifenatnil etu$ation
te!hni7ue and Airwa" e!hange !atheters.
Page 11 of 16
3i.ure 3: (AS 9tu$ation Fuidelines: CAt Ris,@ Algorithm
0
Laryngeal mask exchange:
3his te!hni7ue ma" $e $enefi!ial in smo,ers' asthmati! and patients with irrita$le
airwa"s' and in&ol&es the e!hange of the tra!heal tu$e for an BMA in order to
pro&ide a patent airwa"
0
. 6t is not re!ommended in patients who are at ris, of
regurgitation and are !onsidered a diffi!ult reintu$ation
0
.
Page 12 of 16
1. Administer 1::5 o"gen
2. A&oid airwa" stimulation: either deep anaesthesia or neuromus!ular $lo!,ade is essential
). Perform lar"ngos!op" and su!tion under dire!t &ision
2. 6nsert deflated BMA $ehind the tra!heal tu$e
0. 9nsure BMA pla!ement with the tip in its !orre!t position
6. 6nflate !uff of BMA
-. (eflate tra!heal tu$e !uff and remo&e tu$e whilst maintaining positi&e pressure
/. Continue o"gen deli&er" &ia BMA
.. 6nsert $ite $lo!,
1:. Sit the patient upright
11. Allow undistur$ed emergen!e from anaesthesia
Table /: Se7uen!e for BMA e!hange in Cat ris,@ etu$ation
0
Remifentanil Extubation:
Remifentanil infusion is used to supress !oughing' agitation and haemod"nami!
distur$an!es during the emergen!e from anaesthesia
0
.
1. Consider postoperati&e analgesia. 6f appropriate' administer intra&enous morphine $efore
the end of the operation
2. 4efore the end of the pro!edure' set the remifentanil infusion at the desired rate
). Antagonise neuromus!ular $lo!,ade at an appropriate phase of surger" and emergen!e
2. (is!ontinue anaestheti! agent *inhalational agent or propofol+
0. 6f using inhalational agent' use high flow o"gen1 enri!hed gas miture to aid full
elimination and monitor its end tidal !on!entration
6. Continue &entilation
-. Bar"ngos!op" and su!tion should $e performed under dire!t &ision if appropriate
/. Sit the patient in the upright position
.. (o not rush' do not stimulate' wait until the patient opens their e"es to !ommand
1:. (is!ontinue positi&e pressure &entilation
11. 6f spontaneous respiration is ade7uate' remo&e the tra!heal tu$e and stop the infusion
12. 6f spontaneous respiration is inade7uate' en!ourage the patient to ta,e deep $reaths and
redu!e the infusion rate
1). %hen respiration is ade7uate' remo&e the tra!heal tu$e and dis!ontinue the remifentanil
infusion' ta,ing !are to flush residual drug from the !annula
12. After etu$ation' there is a ris, of respirator" depression and it is essential that the patient
is !losel" monitored until full re!o&er"
10. Remem$er that remifentanil has no long term analgesi! effe!ts
16. Remem$er that remifentanil !an $e antagonised $" naloone
Table 5: Se7uen!e for use of remifentanil infusion
0
Airway exchange catheter (AEC):
3hese are used in patients in whom re1intu$ation ma" $e diffi!ult and are used as
a guide o&er whi!h an 933 !an $e passed during re1intu$ation
0
.
A stud" $" 3.C Mort showed that the A9C in!reased the su!!ess rate of first
attempt to re1intu$ate and de!reased the in!iden!e of !ompli!ations in patients
with failed etu$ations
1-
.
Page 1) of 16
1. (e!ide how far to insert the A9C. 6t is essential that the distal tip remain a$o&e the
!arina. 6f there is an" un!ertaint" a$out the position of the tra!heal tu$e tip' its position
relati&e to the !arina should $e !he!,ed with a fi$reopti! $ron!hos!ope $efore A9C
insertion. An A9C should ne&er $e inserted $e"ond 20!m in an adult patient
2. %hen the patient is read" for etu$ation' insert the lu$ri!ated A9C through the tra!heal
tu$e to the predetermined depth. Ne&er ad&an!e an A9C against resistan!e
). 9mplo" phar"ngeal su!tion $efore remo&al of the tra!heal tu$e
2. Remo&e the tra!heal tu$e o&er the A9C' while maintaining the A9C position *do no
ad&an!e the A9C+
0. Se!ure A9C to the !hee, or forehead with tape
6. Re!ord the depth at the teeth#lips#nose in the patients notes
-. Che!, that there is a lea, around the A9C using an anaestheti! !ir!uit
/. Clearl" la$el the A9C to pre&ent !onfusion with a nasogastri! tu$e
.. 3he patient should $e nursed in a high dependen!" or !riti!al !are unit
1:. Supplemental o"gen !an $e gi&en &ia fa!emas,' nasal !annula or CPAP mas,
11. 3he patient should remain nil per mouth until the A9C is remo&ed
12. 6f the presen!e of the A9C !auses !oughing' !he!, that the tip is a$o&e the !arina and
in8e!t lido!aine &ia the A9C
1). Most patients remain a$le to !ough and &o!alise
12. Remo&e the A9C when the airwa" is no longer at ris,. 3he" !an $e tolerated for up to -2
hours
Table 6: Se7uen!e for use of an Airwa" e!hange !atheter for Cat ris,@ etu$ation
0
3he Dinal step in&ol&es the post etu$ation !are of patient in the re!o&er" room. 6t
$egins with the safe transfer of the patient from the operating room *on o"gen+ to
the re!o&er" room' !lear instru!tions on !on!erns and management to re!o&er"
room staff on hando&er' Close o$ser&ation of the patient for !ompli!ations and
treatment of them.
C$NC2'S%$N
9tu$ation is an ele!ti&e pro!edure and should $e performed in a se!ure and
re&ersi$le fashion. Although it is re!ognised that etu$ation !an $e a life
threatening situation' it is not afforded the same !onsideration and attention as
intu$ation. ?er" limited literature is a&aila$le to guide etu$ation pra!ti!e' most of
these re!ommendations are $ased largel" on epert opinion
0
and there is a need
for more e&iden!e $ased re!ommendations. 3he (AS etu$ation guidelines
promotes the !on!ept of an etu$ation strateg" in&ol&ing a Stepwise approa!h to
planning' preparation and ris, stratifi!ation aimed at !lear identifi!ation and
management of patients at ris, during etu$ation
0
. 6t should $e remem$ered
though that these are 8ust guidelines and should not su$stitute for good !lini!al
8udgement
0
.
Page 12 of 16
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Anaesthesia 2::.G 20: ):1)6
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.0:
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lar"ngeal mas, during emergen!e from anaesthesia. Anaesthesia 1../G 0):
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2
$efore tra!heal etu$ation on
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on responses to endotra!heal tu$e during emergen!e from general
anaesthesia. Anesthesia and Analgesia 2::.G .6: 1)2:11)22
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airwa"1!ir!ulator" reflees $" lo!al anaesthesia during emergen!e and
etu$ation. Anaesthesia and Analgesia 2::)G .6: 2.)12.-
16. Ameri!an So!iet" of Anesthesiologists 3as, Dor!e on Management of the
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th
9dition 2:1:
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Page 16 of 16