Extubating the difficult airway: formulating the management strategy; use of accessory airway devices and alternative techniques may be key

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Author: Thomas C. Mort
Date: May 2003
From: The Journal of Critical Illness(Vol. 18, Issue 5)
Publisher: CMP Medica, LLC
Document Type: Article
Length: 4,123 words

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ABSTRACT: Since any extubation potentially is a reintubation, the critical care operator should be prepared with an extubation strategy formulated to provide continuous oxygenation and ventilation, minimize complications, and establish a means to ease airway reestablishment. Physical examination of the airway via direct laryngoscopy and/or fiberoptic visualization is necessary to identify the difficult airway and gauge the potential for successful extubation. Fiberoptic evaluation may permit assessment of vocal cord patency and function and observation of the subglottic region, the supraglottic structures, and the surrounding pharyngeal tissues; however, this procedure may not yield useful information consistently. A laryngeal mask airway (LMA), an airway exchange catheter (ABC), and a combination of an ABC within an LMA are available options for airway control. Any patient who has fever, severe dysphagia, hoarseness, or progressive clinical deterioration after airway management, especially with difficult or repetitive attempts, should be watched closely for signs and symptoms of undiagnosed airway trauma and its sequelae. (J Crit Illness. 2003:18(5):210-217)

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The American Society of Anesthesiologists Task Force on the Management of the Difficult Airway regards the extubation strategy as a logical extension of the intubation strategy and recommends that the airway manager be prepared with a strategy for extubation of the difficult airway (DA). This strategy depends on the surgery and the condition of the patient as well as the skills and preferences of the physician. (1)

In the April 2003 issue of The Journal of Critical Illness, I reviewed the physical findings and clinical conditions that are associated with high-risk extubation. In this article, I will describe extubation strategies and airway interventions for the patient with a known or suspected DA. The extubation strategy is rounded out by observation of the patient in a monitored environment by experienced personnel who have immediate access to DA equipment.

Readiness is essential

Evaluation and preparation of the patient at high risk for extubation failure should be methodical and comprehensive. Patient preparation consists of 3 phases:

* General assessment of past and current medical and surgical conditions and how these conditions relate specifically to the airway and respiratory system.

* Physical assessment of the airway itself with either direct laryngoscopy or fiberoptic visualization, or both.

* Coordination of the first 2 phases to formulate an extubation strategy that specifically focuses on providing continuous oxygenation and ventilation and establishes a means to facilitate the reestablishment of the airway--a "reversible extubation. " (1-4)

Because accurate prediction of extubation success is less than reliable, any extubation is potentially a reintubation. A cautious extubation strategy should be seriously considered in the patient who has a known or suspected problematic airway with or without underlying pulmonary limitations. Table 1 lists the options for management of the high-risk extubaton, which may include:

* Standard extubation (observation)

* Extubation that is guided by a fiberoptic bronchoscope (FOB).

* Extubation with placement of a laryngeal mask airway (LMA).

* Extubation that is guided by an airway exchange catheter (AEC). (3)

A plan that ensures accessibility of the airway and provides a continuous state of reversible extubation is imperative...

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Gale Document Number: GALE|A102540057