Extubation of the Difficult Airway: An Algorithmic Approach

C Voscopoulos,F L Kirk,C Apfel,A Saxena,L Jalota,J Antoine,M Lema

doi:10.2174/1874321801206010001

Abstract

The difficult airway has been defined as a “clinical situation in which a conventionally trained anesthesiologist experiences difficulty with mask ventilation of the upper airway, tracheal intubation, or both.” Given the potentially lifethreatening consequences, the American Society of Anesthesiology has developed an airway algorithm that focuses on establishing an airway, generally for the induction of anesthesia. However, there is no algorithm on how to safely transition from an established airway back to the normal, natural airway. Up to 0.19 percent of patients can require reintubation in the post anesthesia recovery unit, with the known difficult airway at greater risk in these settings for failed reintubation. Because of this, there has been recognition of the need for guidelines in the form of an algorithm to deal with extubation in these patients. To fill this current need, we propose the following difficult to intubate patient extubation algorithm for use in the operating room setting.

Highlights

Numerous papers and current guidelines regarding difficult airway management have focused on difficult tracheal intubation
Death/brain death claims from difficult airway management associated with induction of anesthesia decreased in 1993-1999 (35%, n= 86) compared with 1985-1992 (67%, n=93), but not from other phases of anesthesia [1].This fall in claims for adverse events related to the induction of anesthesia may be attributable, in part, to the creation of algorithms and guidelines related to intubation [1,2,3]
To address the other phases of anesthesia related to difficult airway management, it is recognized that there is a need for the development of additional management strategies encountered during maintenance, emergence, and recovery

Summary

INTRODUCTION

Numerous papers and current guidelines regarding difficult airway management have focused on difficult tracheal intubation. As highlighted in a recent review article, the recommended technique by the ASA for extubation of the difficult airway utilizes an AEC [33] This device is a hollow catheter that can be used for removal and replacement of tracheal tubes without the need for laryngoscopy (though concomitant use of laryngoscopy may increase the chances of a successful reintubation over such a device). A GEB is a 60 cm long tracheal tube introducer that is a helpful tool for intubation, but it can be used for extubation of the difficult airway, as it can serve as a reintubation guide [35] It does not serve the functions of an AEC which allows for oxygen insufflation, jet ventilation, or positive pressure ventilation, the GEB is an option in settings where an AEC may not be available, or when the anesthesiologist is inexperienced with its use [35].

13. Consider the use of peri‐operative corticosteroids

Findings

EXTUBATION PROCEDURE