EXTUBATION AFTER DIFFICULT

INTUBATION
 Difficult airway represents a complex interaction between patient factors, the
clinical setting and the skills of practitioner. The same principles also applicable
in the management of extubation of difficult airway following intubation the
airway may occlude when the tracheal tube is removed.
 Reintubation may be much more difficult than before due to
• Airway bruising and swelling
• Airway contamination with clot, regurgitated material
• Laryngospasm due to laryngeal or recurrent laryngeal N damage.
• New impairment of airway access (cervical fusion, external
factors, dental wiring)

Approach to the difficult extubation:

 The patient should always be wide awake, cooperative and able to maintain their
airway and ventilation before extubation. if there are any doubts about the airway
the safest way to perform extubation is to insert a boogie or guide wire through
endotracheal tube, and extubate over this. The ET tube may be re introduced over
the catheter/boogie of patient requires re intubation
 . An important consideration during extubation is negative pressure pulmonary
edema result from any airway obstruction in a patient who continues to have a
voluntary respiratory effort.

Criteria for routine ‘AWAKE’ extubation:

Subjective clinical criteria:

• Follows commands.
• Intact gag reflex.
• Clear oropharynx / hypopharyns ( No active bleeding, secretions cleared)
• Sustained head lift for 5 sec, sustained hand grip.
• Adequate pain control.
• Minimal end expiratory concentration of inhaled anaesthetics.

Objective criteria:

• VC ≥ 10 ml / kg
• Peak voluntary negative inspiratory pressure > 20cm H20
• TV > 6 ml/kg
 • Sustained tetanic contraction (5 sec)
• T1/TA ratio >0.7
• Alveolar arterial Pao2 gradient (on Fio2 of 1.0) < 350 mmHg
• Dead space to TV ratio ≤ 0.6

Last two are used for weaning in ICU

Leak Test: A popular test to predict airway patency after extubation is the detection of a
leak upon deflation of ET tube cuff. If there is no leak around ETT cuff, patient it at risk
of respiratory problems after extubation.

Extubation over catheter / bougie:

• Cook airway exchange catheter one example available in diameter of 2.7, 3.7,
4.7, and 6.33 mm. smaller diameter catheters is 45 cm long, others are 83 cm.
they all have central lumen and rounded a traumatic ends. Patient can be
oxygenated or jet ventilated in case of failed extubation/Reintubation.
• The other is PATIL two-part Intubation catheter and cardio med endotracheal
ventilation catheter

Strategy for extubation of difficult airway:

• The strategy is slightly different from intubation, and will depend in part on
nature of surgery, condition of Patient, and the skills and preferences of
anaesthesiologist.
• Extubation at peak of inspiration

The recommended strategy should include.

1. Consideration of relative merits of awake extubation versus extubation before the

return of consciousness
2. Evaluation for general clinical factors that may produce an adverse impact on
ventilation after the patient has been extubated.
3. formulation of an airway management plan that can be implemented if patient is
not able to maintain adequate ventilation after extubation
4. Consideration of short term use of a device is usually inserted through the lumen
of ET tube, and in to trachea before tracheal tube is removed .Device may be rigid
to facilitate re intubation and / or hollow to facilitate ventilation.

Extubation must be planned:

• Prepare and check the same equipment and personnel as for a difficult intubation
• Have a plan and backup plan.
• Corticosteroid therapy for 24 hrs before extubation to reduce edema
• Elective tracheotomy.
• Delaying extubation and ventilating in ICU reassess later.
 • Extubation over Cook airway exchange catheter in the trachea before extubation,
which allows apneic oxygenation and jet ventilation.

Recommended Technique by the ASA for extubation in difficult airway:

1. Administer 100% oxygen

2. Suction the oropharynx.
3. Deflate the cuff of endotracheal tube for cuff leakage check
4. Insert an airway exchange catheter through the endotracheal tube to a
predetermined depth
5. Extubate the patient over a jet ventilation catheter
6. Apply oxygen by 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 30-60 minutes if no obstruction appears.