Considerations for difficult extubation in non-hospital facilities

The unanticipated difficult airway is a very stressful event. When it goes well, everyone involved should be thanked, and in the best of medical worlds, there would be a debrief and discussion as to what went well and what could be done better next time. What perhaps is not paid enough attention to is the extubation plan, following either an anticipated or unanticipated difficult airway. This is despite the mounting evidence that the peri-extubation period is a high-risk time that requires planning with appropriate monitoring, good communication and skilled staff. 

A recent case reviewed by the Non-Hospital Medical and Surgical Facilities Accreditation Program Patient Safety Incident Review Panel highlighted the need to have extubation protocols at non-hospital facilities. 

Extubation is an elective procedure, and following an unanticipated difficult intubation there are several factors one must consider prior to extubating the patient, other than ensuring a patient can protect their airway and has reasonable ventilation parameters. Questions to consider: Did airway trauma occur during the intubation attempts? Was the surgical procedure long and associated with significant fluid shifts? Is there facial edema following use of prone or steep Trendelenberg position? Was bag-mask ventilation challenging? Is the patient at high risk for oxygenation challenges?  

An extubation plan should include at a minimum:

  1. An assessment of the internal airway (e.g. laryngeal area)—supraglottic edema is a risk factor for post-extubation respiratory distress. This can be done with a videolaryngoscope (VL) prior to awakening the patient; the VLs such as the Glidescope and C-Max have a large field of view providing visual assessment of potential airway trauma. The presence of an endotracheal cuff leak is not a guarantee of a successful extubation, as edema is typically supraglottic in these scenarios (known tracheal stenosis/small trachea suspected being the exceptions).
  2. Having a fully awake and cooperative patient—this may take time, and one has to consider the process for supported ventilation outside of the OR in the facility—transfer to a hospital may be required. Good communication with the surgeon and facility staff is a priority.
  3. Consideration of the use of
    1. an extubation catheter—these are purpose built and well tolerated in the awake patient; providing the security of an ‘easy’ reintubation, or
    2. extubating to a supraglottic device if that was a successful oxygenation strategy during the difficult intubation and the concern is not airway edema.
  4. Have available a temporizing medication such as nebulized racemic epinephrine, as it may be sufficient to manage supraglottic airway edema that is symptomatic but not severe or worsening. 

The presence of risk factors such that extubation may well fail is best managed by keeping the patient intubated and sedated, with transfer emergently to a hospital.

A set of extubation algorithms is freely available online from the Difficult Airway Society. 

References:

  1. Quinn A, Woodall N. Chapter 8, The end of anaesthesia and recovery. In: Cook T, Woodall N, Frerk C, editors.4th national audit project of the Royal College of Anaesthetists and the Difficult Airway Society: major complications of airway management in the United Kingdom: report and findings [Internet]. London: Royal College of Anaesthetists and the Difficult Airway Society; 2011. [cited 2018 Dec 5]; p. 62-71. Available from: https://www.rcoa.ac.uk/system/files/CSQ-NAP4-Full.pdf 
  2. Kluger MT, Bullock MRM. Recovery room incidents: a review of 419 reports from the Anaesthetic Incident Monitoring Study (AIMS). Anaesthesia 2002;57:1060-1066.