Airway management relates to the period of tracheal intubation, maintenance of endotracheal tube in situ, and finally extubation. Problems related to difficult extubation still pose significant challenge for both anesthesiologists and intensivists. This article reviews current approach to extubation strategy following difficult intubation. Guidelines and algorithm may be helpful in order to ensure safe management of the patient during this delicate period of airway management.Osiguravanje dišnog puta odnosi se na razdoblje intubacije, održavanje endotrahealnog tubusa in situ i konačno na razdoblje ekstubacije. Problemi u vezi s otežanom ekstubacijom još uvijek predstavljaju značajan izazov za anesteziologe i intenziviste. Ovaj članak prikazuje suvremeni strateški pristup ekstubaciji nakon otežane intubacije. Smjernice i algoritmi mogu biti korisni za održavanje sigurnosti bolesnika u tom osjetljivom razdoblju osiguravanja dišnog puta

Ana Markić

Branka Maldini

Jadranka Skurić

Morena Milić

Tatjana Goranović

English

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Acta Clin Croat,  Vol. 51,  No. 3,  2012 499Acta Clin Croat 2012; 51:499-503 Conference PaperExtubAtion strAtEgy following diffiCult intubAtiontatjana goranović1, branka Maldini2, Ana Markić1, Morena Milić3 and Jadranka skurić1 1department of Anesthesiology and intensive Care unit, sveti duh university Hospital; 2department of Anesthesiology, resuscitation and intensive Medicine, sestre milosrdnice university Hospital Center; 3department of Anesthesiology and intensive Care unit, dubrava university Hospital, Zagreb, Croatia suMMAry – Airway management relates to the period of tracheal intubation, maintenance of endotracheal tube in situ, and finally extubation. Problems related to difficult extubation still pose significant challenge for both anesthesiologists and intensivists. This article reviews current approa-ch to extubation strategy following difficult intubation. guidelines and algorithm may be helpful in order to ensure safe management of the patient during this delicate period of airway management. Key words: Airway management; Difficult intubation; ExtubationCorrespondence to: Tatjana Goranović, MD, department of Ane-sthesiology and intensive Care unit, sveti duh university Hospi-tal, sveti duh 64, Hr-10000 Zagreb, CroatiaE-mail: tanjagoranovic@hotmail.comreceived July 8, 2012, accepted August 23, 2012IntroductionAirway management focuses on the period of tra-cheal intubation, maintenance of the endotracheal tube in situ, and extubation including continuous control of the airway in the post-extubation period1. A large number of published papers and current guidelines on airway management focus on the pe-riod of induction of anesthesia and difficult tracheal intubation2. by following these guidelines, we nowa-days witness their positive results. An analysis of the proportion of closed malpractice claims for death or brain damage performed by the American society of Anesthesiologists has shown a significant decrease in death or brain damage with induction of anesthesia from 62% in the period between 1985 and 1992 to 35% between 1993 and 19993.on the contrary, the number of published articles and guidelines focusing on the period of extubation following difficult intubation is much lower, although the risk of complications in this period seems to be relevant. respiratory complications following tra-cheal extubation are three times more often compared to those during induction of anesthesia (12.6% vs. 4.6%)3. Accordingly, the proportion of malpractice claims for death or brain damage related to mainte-nance of anesthesia, extubation and post-anesthesia recovery did not change during the last ten years2. Therefore, problems related to difficult extubation still pose a significant challenge for both anesthesiologists and intensivists. Extubation Strategy The American society of Anesthesiologists task force on Management of the difficult Airway states that the use of an extubation strategy is a logical exten-sion of the intubation process4. As it is often stressed in the literature, in a patient at a high risk of difficult airway it is essential to reformulate the extubation strategy. since there is no single strategy for difficult intubation and the practitioner chooses between dif-ferent options according to the clinical situation, there is also the need for specific extubation strategies, de-pending on the medical and surgical conditions of the patient, previous procedures on the airway, current airway status, as well as the skills and preferences of the anesthesiologist. 500 Acta Clin Croat,  Vol. 51,   No. 2,  2012tatjana goranović et al. Extubation strategybefore choosing a specific strategy, it is assumed that the routine procedures of an extubation plan have been performed, including:•	 deciding	when,	where	and	in	which	position	to	ex-tubate the patient;•	 recognizing	and	managing	problems	related	to	ex-tubation; and•	 recognizing	patients	at	a	high	risk	of	difficult	extu-bation and reintubation.As a general rule, patients should be extubated awake3. Extubation in the state of deep anesthesia re-duces cardiovascular stimulation and the incidence of coughing and straining, while increasing the incidence of respiratory complications regardless of the type of surgical procedure3. traditional extubation practice in the left lateral recumbent position with a lowered head keeps the airway open, detaches the tongue from the posterior pharyngeal wall, and protects the airway from aspiration. There is no scientific evidence that extubation in supine semi-sitting position is as safe as the traditional one, but it is applicable in previously fasted patients in whom short-acting neuromuscular blocking agents (nMbA) were used3. supine semi-sitting position facilitates reintubation and is recom-mended in patients at a high risk of difficult intubation and in obese patients. in these patients, as well as in those with chronic obstructive pulmonary disease or previous surgical procedures on upper airways, the su-pine half-sitting position facilitates spontaneous res-piration and diaphragmatic expansion, assists cough-reflex effectiveness, increases functional residual capacity, helps lymph drainage and decreases airway edema3. Extubation in prone position is occasionally used after spinal surgery3,5.Extubation is usually performed at the end of in-spiration, with the glottis completely open, in order to reduce trauma and prevent laryngospasm. Extubation is primarily performed in the operating theater as well as in recovery room and intensive care unit (iCu). since there is evidence that extubated patients trans-ported to the recovery unit arrive there with a lower oxygen saturation, it is recommended that 100% ox-ygen is administered before leaving the theater and high inspired oxygen given during transfer3,5.Problems related to extubation can be mechanical or result from a pathophysiological reaction (cardio-vascular response, respiratory complications, airway obstruction, postoperative lung edema, tracheotomy, pulmonary aspiration)3.Patients at a risk of difficult extubation and reintu-bation are those who underwent multiple intubation attempts, patients with severe cardiovascular diseases, congenital or acquired airway pathology, morbidly obese, patients with obstructive sleep apnea syndrome and severe gastroesophageal reflux3. Additional surgi-cal factors include recurrent laryngeal nerve damage (10.6% in malignant thyroids); hematoma (0.1%-1.1% in larynx or thyroid surgery); edema and distortion of anatomy following head and neck surgery6; posterior cranial fossa surgery; intermaxillary fixation and deep neck and dental abscess drainage3.Difficult extubation strategiesMany strategies for at risk extubation have been addressed in the literature: exchanging the tracheal tube for laryngeal mask airway (lMA) before emer-gence, extubation over a flexible bronchoscope, airway exchange catheter-assisted extubation, and extubation in the iCu.Substituting a laryngeal mask for a tracheal tubeA laryngeal mask airway (lMA) exchange is performed	while	the	patient	is	still	anesthetized	and	paralyzed.	LMA	is	inserted	following	tracheal	extu-bation with the patient in a deeper plane of anesthe-sia.	Muscle	relaxation	is	then	antagonized	and,	when	spontaneous breathing resumes, the airway patency and adequacy of breathing are reconfirmed and the patient is compliant, the lMA is removed. This ma-neuver avoids coughing and pressure rise during extu-bation and at the same time involves less airway ma-nipulation compared with deep anesthesia extubation with guedel’s oropharyngeal airway insertion3. Extubation over a flexible bronchoscope This approach can be considered in patients with suspected laryngeal paralysis, tracheomalacia7, or tube entrapment3. An lMA is inserted to substitute endo-tracheal tube in the aforementioned way and the patient is then allowed to resume spontaneous ventilation while still	anaesthetized.	A	flexible	bronchoscope	is	advanced	through	the	LMA	to	enable	visualization	of	the	anat-omy and assessment of laryngeal function. if required, reintubation can be assisted using an intubation cath-Acta Clin Croat,  Vol. 51,  No. 2,  2012 501tatjana goranović et al. Extubation strategyeter (Aintree) which jackets the flexible bronchoscope8. The bronchoscope and the lMA are then removed and the patient is reintubated over the catheter.Use of a tracheal tube exchange catheter (reversible tracheal extubation)This strategy is especially useful for adult9 and pe-diatric patients10 expected to be difficult to reintubate. tracheal tube exchangers (e.g., Cook) are long hollow catheters with connectors for jet and/or manual venti-lation and respiratory monitoring, which continuously maintain the airway2. Most of them have depth-mark-ers and radio opaque markers, and end or distal side apertures. They can be introduced through a tracheal tube, thus permitting extubation. Catheters allow spontaneous breathing, talking and coughing, and are well tolerated (up to 72 h)2. These devices are a valuable option considering that reintubation occurs in 0.4%-25% of cases in different surgical population groups1. There are currently no clear recommendations on the optimal duration for continuous airway main-tenance using these catheters after extubation. Ex-perts recommend a minimum of 30 to 60 minutes, or vaguely speaking, until the possibility of reintubation is lower1. in case of a periglottic edema, it is recom-mended to leave the catheter in place for 60 to 120 minutes1. it is known that periglottic edema most commonly develops in 10 to 45 minutes after extuba-tion, while symptomatic laryngeal edema may appear even up to 8 hours after extubation1. when dealing with patients with a cardiovascular disease or other systemic disorder, it is sensible to prolong the con-tinuous maintenance of the airway11. in patients with difficult airways who had passed unsuccessful extuba-tion, it is wise to plan the timing for the next attempt of extubation by multiplying the previous extubation period by two or three times, to ensure the next suc-cessful extubation. in case of compromised mental or neurological status of the patient, especially as a result of cardiopulmonary constraints, prolongation of con-tinuous airway maintenance to up to 12 to 24 hours may ensure safe management of the patient1. Extubation in the Intensive Care UnitAfter anesthesia, the extubation risk patient can be transported to the iCu for extubation. Extuba-tion at iCu can then be either protocol directed or unplanned3. Current figures say that we are not very good in predicting extubation in iCu. successful ex-tubation after planned extubation occurs in 80% of patients, while reintubation after planned extubation occurs in up to 20% of patients within 24 to 72 hours of extubation3. in addition, most unplanned extuba-tions do not require reintubation3. However, since successfully extubated patients have lower mortality (2.5-10 times)3, it is important to make extubation at-tempt successful.DAS Difficult Extubation Algorithm in 2011, the british difficult Airway society (dAs) suggested creation of extubation guidelines. The guidelines are now available at: http://www.das.uk.com/content/extubation-guidelines12. The guidelines consist of three algorithms: basic, low risk, and at-risk algorithm. Each of these algo-rithms has 4 steps: 1) plan extubation; 2) prepare for extubation; 3) perform extubation; and 4) post-extu-bation care. strategies for difficult extubation are in-cluded in the at-risk algorithm12. The first step of the basic algorithm (plan extu-bation) involves assessment of the airway and general risk factors. Airway risk factors are known difficult airway, airway deterioration due to trauma, edema or bleeding, restricted airway access, obesity, and aspi-ration risk. general risk factors include cardiovascu-lar, respiratory, neurological, metabolic, and special medical conditions as well as special surgical require-ments12. The second step of the basic algorithm (preparation) is	aimed	at	optimization	of	the	patient	(cardiovascu-lar, metabolic, respiratory, neurological, temperature, neuromuscular) and other factors (location, finding skilled help/assistance, monitoring, equipment), and the patient is stratified into low-risk (fasted, uncom-plicated airway, no general risks) or at-risk (ability to oxygenate uncertain, reintubation potentially difficult and/or general risk factors present)12.If	the	patient	is	characterized	as	low-risk,	the	low	risk algorithm is followed. one chooses between extu-bation in deep anesthesia and awake extubation. deep extubation requires advanced technique, experience of the practitioner, and vigilance until the patient is fully 502 Acta Clin Croat,  Vol. 51,   No. 2,  2012tatjana goranović et al. Extubation strategyawake. Awake extubation includes preoxygenation with 100% oxygen, suctioning as appropriate, inser-tion	of	a	bite	block	(e.g.,	rolled	gauze),	positioning	the	patient	 appropriately,	 antagonizing	 neuromuscular	blockade, establishing regular breathing, ensuring ad-equate	spontaneous	ventilation,	minimizing	head	and	neck movements, waiting until awake (eye opening/obeying commands), applying positive pressure, de-flating the cuff and removing tube, providing 100% oxygen, checking airway patency and adequacy of breathing, and continuing oxygen supplementation12.in case the risk stratification has identified the pa-tient to be at risk, the at-risk algorithm is followed. The key question is: is it safe to remove the tube? if the answer is “yes”, one of the possible strategies is chosen: awake extubation, laryngeal mask exchange, remifen-tanil technique, or airway exchange catheter. Patients are transferred to the recovery unit, high dependency unit	 (HDU)	or	ICU	for	 further	optimization	of	pa-tient related factors (safe transport, handover/com-munication, oxygenation and airway management, observation and monitoring, general medical and surgical management) as well as general ones (analge-sia, staffing, documentation and equipment). Patients with airway exchange catheters are transferred to the Hdu or iCu.if the answer to the key question is “no”, the extu-bation is postponed or tracheotomy is performed and the patient is transferred to the Hdu or iCu for fur-ther	optimization12.ConclusionThe period of extubation is very delicate and re-lated to possible complications, especially if following difficult intubation. in order to avoid complications, it is wise to plan safe way of extubation in advance. Algorithms may help. Therefore, we encourage anes-thesiologists and intensivists to use the existing extu-bation algorithms or to develop their own. References  1. Mort tC. Continuous airway access for the difficult extu-bation: the efficacy of the airway exchange catheter. Anesth Analg 2007;105:1357-62.  2. AntoinE J, HussAin Z, El-sAyEd i, APfEl CC. The unrecognised difficult extubation: a call for vigilance. Anaesthesia 2010;65:946-8.  3. KArMArKAr s, VArsHnEy s. tracheal extubation. Cont Educ Anaesth Crit Care Pain 2008;8:214-20.  4. American society of Anesthesiologists task force of the dif-ficult Airway practice guidelines for the management of the difficult airway; an updated report by the American society of Anesthesiologists task force on Management of the dif-ficult Airway. Anesthesiology 2003;98:1269-77.  5. Jubb A, ford P. Extubation after anaesthesia: a system-atic review. update in Anaesthesia 2009;25:30-5.  6. lEE C, CooPEr rM, goldstEin d. Management of a patient with tracheomalacia and supraglottic obstruction after thyroid surgery. Can J Anaesth 2011;58:1029-33.   7. EllArd l, brown dH, wong dt. Extubation of a difficult airway after thyroidectomy: use of a flexible broncho-scope via the lMA-Classic™. Can J Anaesth 2012;59:53-7.  8. fArAg E, bHAndAry s, dEungriA M, ZurA A, sEif J, borKowsKi r, doylE dJ. successful emergent reintubation using the Aintree intubation catheter and a la-ryngeal mask airway. Minerva Anestesiol 2010;76:148-50.  9. Higgs A, swAMPillAi C, drAVid r, MitCHEll V, PAtEl A, PoPAt M; difficult Airway society Clinical Extubation guidelines group. re-intubation over airway ex-change catheters – mind the gap. Anaesthesia 2010;65:859-60.10. wisE-fAbErowsKi l, nArgoZiAn C. utility of air-way exchange catheters in pediatric patients with a known difficult airway. Pediatr Crit Care Med 2005;6:454-6.11. russo sg, bräuEr A. difficult extubation in a patient with terminal ischemic heart failure and an accompanying difficult airway. J Cardiothorac Vasc Anesth 2011 Jul 13. [Epub ahead of print]12. difficult Airway society (dAs) Extubation guidelines. Available at: http://www.das.uk.com/content/extubation-guidelines. Acta Clin Croat,  Vol. 51,  No. 2,  2012 503tatjana goranović et al. Extubation strategysažetakstrAtEŠKi PristuP EKstubACiJi nAKon otEŽAnE intubACiJET. Goranović, B. Maldini, A. Markić, M. Milić i J. Skurić Osiguravanje	dišnog	puta	odnosi	se	na	razdoblje	 intubacije,	održavanje	endotrahealnog	tubusa	 in situ i konačno na razdoblje	ekstubacije.	Problemi	u	vezi	s	otežanom	ekstubacijom	još	uvijek	predstavljaju	značajan	izazov	za	anesteziologe	i	intenziviste.	Ovaj	članak	prikazuje	suvremeni	strateški	pristup	ekstubaciji	nakon	otežane	intubacije.	Smjernice	i	algoritmi	mogu	biti	korisni	za	održavanje	sigurnosti	bolesnika	u	tom	osjetljivom	razdoblju	osiguravanja	dišnog	puta.Ključne riječi: Osiguravanje dišnog puta; Otežana intubacija; Ekstubacija

Strateški pristup ekstubaciji nakon otežane intubacije

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