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STRATEGIES FOR EXTUBATION OF THE DIFFICULT AIRWAY

STRATEGIES FOR EXTUBATION OF THE DIFFICULT AIRWAY. Pejakov Ljubica Medical faculty Podgorica, Montenegro Clinical Centre, Montenegro. DFFICULT AIRWAY-DEFINITION.

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STRATEGIES FOR EXTUBATION OF THE DIFFICULT AIRWAY

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  1. STRATEGIES FOR EXTUBATION OF THE DIFFICULT AIRWAY Pejakov Ljubica Medical faculty Podgorica, Montenegro Clinical Centre, Montenegro

  2. DFFICULT AIRWAY-DEFINITION • THE DIFFICULT AIRWAY IS CLINICAL SITUATION IN WHICH A CONVENTIONALLY TRAINED ANESTHETIST EXPERIENCES DIFFICULTY WITH MASK VENTILATION OF THE UPPER AIRWAY, TRACHEAL INTUBATION, OR BOTH.

  3. STRATEGIES FOR EXTUBATION OF THE DIFFICULT AIRWAY • The ASA Task Force on Difficult Airway Management:“PREFORMULATED PLAN” FOR EXTUBATING THE DIFFICULT AIRWAY SHOULD BE A STANDARD CONSIDERATION. Caplan RA, Benumof JL et al. Anesthesiology 2003 PLANDEPENDS ON: • INDIVIDUAL CONDITION OF THE PATIENT • SKILLS OF THE PRACTITIONER • EXPERIENCE OF THE PRACTITIONER • PREFERENCES OF THE PRACTITIONER • DEVICES AVAILABLE AT THE HOSPITAL

  4. STRATEGIES FOR EXTUBATION OF THE DA • THE GOAL: EXTUBATE IN A SECURE BUT REVERSIBLE FASHION • EFFECTIVE EXTUBATION STRATEGY: low reintubation rate, should not cause patient discomfort, should enable oxygenation and ventilation and facilitate reintubation, if necessary. • THE ART AND SCIENCE OF KNOWLEDGEABLE AND SAFE EXTUBATION PRACTICE IS IN INFANCY • …”EACH EXTUBATION IS A TRIAL-THERE IS NO GUARANTEE THAT IT WILL BE TOLERATED….” Mort CT, Hartford, Connecticut, 2008 • PREDICTION OF SUCCESSFUL OR FAILED EXTUBATION – IMPRECISE (rapidly changing clinical circumstances) Epstein SK Crit Care Med 2006 Esteban A et al,. N Engl J Med 2004

  5. REINTUBATION OF THE DA • TRACHEAL REINTUBATION MORE DIFFICULT THAN INITIALLY: - emergent nature, - accompanying hypoxemia, - cardiovascular instability, - limited access to the airway (e.g. cervical or intermaxillary fixation, lingual, pharyngeal and laryngeal edema, neck swelling…) - the lack of patient cooperation, • EXTUBATION OF THE DA SHOULD ALWAYS BE VIEWED AS A POTENTIALLY DIFFICULT REINTUBATION! • REPEATED INTUBATION ATTEMPTS…WORSE OUTCOME (DEATH, BRAIN DAMAGE) Peterson GN et al. Anesthesiology 2005

  6. REINTUBATION OF THE DA EPIDEMIOLOGY: • Reintubation rate IN THE OPERATING ROOM folowing elective surgery inceased in procedures performed in the proximity to the airway. Risk factors for failed extubation and difficult reintubation: difficult intubation, requirement for aditional airway devices during induction of anaesthesia, airway problems since intubation, obesity, history of obstructive sleep apnea. Peterson GN et al. Anesthesiology 2005

  7. REINTUBATION OF THE DA CRITICAL CARE UNIT: • UP TO 20% OF ALL CRITICAL INCIDENT REPORTS ARE AIRWAY RELATED • DA is commonly cause of adverse events (including airway injury, hypoxic brain injury, death) • In ICU reintubation within 12 h after extubation: up to 25% patients- alterations in the neurologic, cardiovascular, metabolic, psychological and nutritional status, fluid derangements; chronic dependence on mechanical ventilation, alterations in airway reflexes.

  8. EXTUBATION COMPLICATIONS • Laryngospasm (upper airway obstructionnegative pressure pulmonary edema!), hipoxemia, hypercarbia • Hemodynamic alterations (hypertension, tachycardia, bradicardia, dysrhythmias, myocardial injury) • Glottic incompetence (aspiration, ineffective cough, phonation difficulties) • Periglottic injury (supraglottic edema, vocal cord edema and paralysis-paresis, subglottic narrowing, cartilaginous dislocation) • Coughing, breathe holding, aspiration of gastric contents • Unintentional or self-extubation

  9. EXTUBATION STRATEGY • STRATEGY SHOULD INCLUDE: A) MERITS OF EXTUBATION IN THE AWAKE VERSUS UNCOSCIOUS STATE B) CONSIDERATION OF CLINICAL FACTORS THAT MAY IMPAIR RESPIRATION AFTER EXTUBATION C) PREFORMULATED PLAN IN CASE THE PATIENT IS UNABLE TO TOLERATE EXTUBATION D) CONSIDERATION OF THE USE OF A DEVICE THAT CAN FACILITATE REINTUBATION

  10. EXTUBATION STRATEGY • PATIENTS AT HIGH RISK FOR EXTUBATION FAILURE- METHODICAL PREPARATION. • Preparation phases 1. General and specific assessment of past and current medical and surgical pathophysiologic factors related to the airway or respiratory system 2. Physical assessment of the airway 3. Formulation of an extubation strategy with the goal of providing a “reversible extubation”

  11. EXTUBATION STRATEGY • Phase 1: GENERAL ASSESSMENT - Review of the patients medical records for previous airway instrumentation, condition and extubation failures; - Elective/emergent airway interventions, extubations - Surgical /medical factors affecting the airways - Postoperative/miscellaneous conditions (massive fluid resuscitation, burns, inhalational injuries, subglottic stenosis, laringo/tracheo/bronchitis, cervical spine injury, halo traction vert) - Current and past medical illnesses affecting extubation tolerance (CVS, pulmonary, renal, hepatic, coagulopathy, sepsis, etc) - Review of current ventilatory requirements (FiO2, PEEP, MV, secretions, ETT tolerance during awake state) - Current vital signs, mental and neurologic status

  12. EXTUBATION STRATEGY CATEGORIZATION PATIENTS POSSIBLY AT HIGH RISK FOR EXTUBATION FAILURE • Those with significant cardiopulmonary or related dieases-but are not expected to have a DA; • Those with a known or suspected DA; • Patient in both categories would be at greater risk for extubation; • Risk rises sharply when experienced personnel with advanced intubation skills and equipment are not available (Cooper RM. Anesthesiol Clin North America, 1995)

  13. EXTUBATION STRATEGY • Phase 2: COMPREHENSIVE AIRWAY EVALUATION Assessment of ability to ventilate, oxygenate and reintubate the patient, if required. - Discussion with care providers (physicians, nurses, respiratory therapists, midlevel parctitioners) - External evaluation, direct or indirect airway assessment - Discussion of plan with patient (and family, if appropriate) - Acquisition of basic/advanced airway equipment at bedside, experienced personnel. Previous easy with mask ventilation, supraglottic airway placement or tracheal intubation, does not guarantee the same during the next airway management!

  14. EXTUBATION STRATEGY • Phase 3: DEVELOPMENT OF A STRATEGY • Cuff Leak? No - In case of: excessive hydration, airway trauma (intubation related?), poor positioning, generalized edema, systemic reactions, sepsis, angioedema, infections, compromised head and neck venous drainage, oversized ETT. No Cuff LeakDELAY IN EXTUBATION OR TRACHEOSTOMY Cuff Leak Test (no standardized): quantitative (volume of the leak) non quantitative (audible) No Cuff Leak: higher likelihood of post-extubation stridor, reintubation, tracheostomy. Steroids pre-extubation –lower stridor. Direct or indirect visualization of the airway (airflow obstruction)

  15. EXTUBATION STRATEGY • Phase 3: DEVELOPMENT OF A STRATEGY Therapeutic options for high risk patients a) standard extubation b) extubation and evaluation via a FOB c) extubation followed by placement of supraglottic airway (SGA) for airway patency, oxygenation, ventilation and pathway for potential reintubation d) extubation over an airway excange catheter (AEC)

  16. EXTUBATION STRATEGY Extubation and evaluation with the FOB - brief evaluation of the airway - provides vital airway information to the clinician (obstruction from redundant pharyngeal tissues, traumatized supraglottic structures, arytenoid dislocation, vocal cord alterations, swelling or laryngeal dysfunction) Decision: maintain current status extubate reintubate obtain ENT consultation schedule elective surgical airway Requires skill of practitioner!

  17. EXTUBATION STRATEGY • Extubation with a supraglottic airway (SGA) Airway evaluation with FOB via SGA (not supraglottic and pharyngeal structures) Needs patient to be extubated: risk safety/clinical information provided Periglottic obstruction- no benefit

  18. EXTUBATION STRATEGY • Extubation over AEC • First Bedger and Chang- passing “jet stylet” Bedger RC, Chang JL. Anesthesiology; 1987 • Seldinger technique; intubation conduits • AEC is integral component of the DA cart and any extubation strategy Cooper RC, Chohen DR. Can J Anesth; 1994 • Catheter size (adult): small (ED 3,7-4 mm)- phonation, good tolerance medium (4,7 mm)- for taller patients

  19. AEC in patient with “hallo traction” of cervical spine

  20. AIRWAY EXCANGE CATHETERS The “Ideal” Airway Excange Catheter • Appropriate rigidity • Atraumatic distal tip • Central lumen for suctioning, O2 delivery, CO2 measurement • Distal side ports, radiographically distinct • Readible depth markings, minimal termal lability • Multiple lengths and diameters available • Reasonable cost

  21. AIRWAY EXCANGE CATHETERS POTENTIAL BENEFITS OF AEC • Access for tracheal suctioning • Continuous access to the airway • Portal for administration of medication - local anesthetics, racemic epinephrine nebulization • Portal for end-tidal CO2 monitoring • Portal for ventilation (via adapters) • Jet ventilation portal (skilled and knowledgable practitioners) • Reintubation guide • Oxygen delivery portal (preparation for reintubation)

  22. AIRWAY EXCANGE CATHETERS DYSADVANTAGES OF AEC Prolonged use: - airway trauma - aspiration (glottal functional incompetence) - retention of tracheal secretions- impaired coughing - the tip of the ETT may impact on the epiglottis during advancement over the AEC - lung laceration if inappropriate use during tracheal extubation Biro P. Anaesthesia & Analgesia, 2007

  23. EXTUBATION STRATEGY The ASA Task Force on Management of the Difficult Airway Practice guidelines Controlled, gradual and reversible withdrawal of airway support Approaches to extubation of the DA: • Extubate in a deep plane of anaesthesia • Extubate awake conventionally and hope for the best • Extubate awake with a “bridge” to full extubation Awake extubation is the most appropriate method of removing the ET in most patients with a difficult airway

  24. CONCLUSION • THE HIGH RISK PATIENTS SHOULD BE IDENTIFIED IF AT ALL POSSIBLE • BEFORE DECISION FOR EXTUBATION, OPTIMIZE MEDICAL CONDITION OF THE PATIENT • APPROPRIATE”KNOW-HOW” AND EQUIPMENT SHOULD BE AVAILABLE AT THE TIME OF EXTUBATION, AND IMMEDIATELY AFTER • BE PREPARED FOR EXTUBATION FAILURE • SENIOR ANAESTHESIOLOGIST WITH EXPERIENCE IN DIFFICULT AIRWAY (AND TRAINED NURSE) SHOULD BE PRESENT ALONGSIDE THE AIRWAY MANAGER WHICH MAY IMPROVE PATIENT SAFETY

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