Extubation in OR
SHAJI SAINUDEEN
RASHID HOSPITAL, DUBAI
Difficult extubation : 208 references
Difficult intubation : 3022 references (x 14.5)
Is tracheal extubation a problem ?
NO
Morbidity factor related to anesthesia
YES
Incidence of death, brain damage, and nerve injury as a percentage of total claims
Cheney FW Anesthesiology 1999
Cheney FW Anesthesiology 1999
Incidence of respiratory, cardiovascular, and equipment-related damaging events as a percentage of the total
claims for death and brain damage
T : 1/145 500 P : 1/21 200
Peterson GNet al. Anesthesiology 2005
Management of the Difficult AirwayA Closed Claims Analysis
Respiratory complications associated with tracheal intubation or extubation
Induction Extubation OR Extubation PACU
Cough 1.5 % 6.6 % 3.1 % SpO2< 90 1.1 % 2.4 % 2.2 %Laryngo-Spasm 0.4 % 1.7 % 0.8 %DV 1.4 % - -DI 0.8 % - -AirwayObstruction - 1.9 % 3.8 %
Asai et Col BJA 1998
1 compli-cation 4.6 % 12.5 % 9.5 %
N=1005
An Analysis of Reintubations from a Quality Assurance Database of 152,000 patients
P Lee et al J clin Anesth 2000
N=191 (1/1000) OR PACU OR+PACU %
Respiratory 48 64 112 58complications
Unintentional 25 0 25 13ExtubationSurg Compl. 10 6 16 8Neurom. blocking 4 7 11 6Opioïd residual 2 7 9 5Upper airway obst. 8 0 8 4
Cardiac complications 2 0 2 1
EMERGENCY TRACHEAL INTUBATION IN PACU
• 13593 admission to PACU from October 1986-Oct 1988.
• 26(0.19%) required reintubation in PACU. 20/26 (77%) within 1hr of extubation and/or admission to PACU.
Reintubation was common in extremes of age. 54% more than 60yrs, 19% less than 3yrs.
23% of the reintubated underwent ENT procedures.
18/26 (69%) were directly related to anaesthetic management.
Mathew, Anesth Analg. 1990
315 incidents or accidents (0,4%) 111 totally related to anesthesia
27 during recovery (oxygen desaturation, airway patency problem) and 8 totally due to anesthesia
Inappropriate extubation : residual effect of muscular relaxant or anesthetetic agents (misjudgment), laryngospasm or bronchospasmaspiration
All problems related to anesthesia were considered preventable
Analysis of reintubations
1. Respiratory complications were the most common cause of reintubation in the perioperative period.
2. More reintubations occured in the immediate post extubation phase.
3. Muscle relaxant effect and opioid effect are rare causes of respiratory failure in the anaesthetized patient in the immediate postoperative period.
4. Anaesthesia related problems in immediate post extubation phase is preventable
CAUSES OF FAILED EXTUBATION
• Several attempts for difficult intubation.
• Traumatic intubation.
• Large diameter,overinflation,malposition of endotracheal tube.
• Prolonged surgery( more than 4hrs).
• Emergency surgery.
• Cervicomaxillofacial surgery.
• Prolonged trendelenberg position
• Radiotherapy and neck dissection.
EXTUBATION FAILURE
• Prevention better than treatment.
Be aware of the factors that predict extubation outcome to improve clinical decision making.
• Rapid reinstitution of ventilatory support in patients who fail extubation may improve outcome.
Rothar and Epstein- current opinion in crit care, 2003
Management of extubation
• Extubation criteria
• Appropriate technique
• Anticipate difficult extubation(DE)
• Management of DE
Tracheal Extubation criteria
• No residual neuromuscular blockade
• Respiratory Criteria
• Cardiovascular Criteria
• General criteria
• Level of conciousness
Tracheal Extubation criteria
• No residual neuromuscular blockade
Head lift 5 sec
TOF ratio > 0.9 +++
DBS 2
Debaene B et Col Anesthesiology 2003
37
Residual Paralysis in the PACU after a Single IntubatingDose of Nondepolarizing Muscle Relaxant with an
Intermediate Duration of Action
Residual paralysis rate
Train-of-four (TOF) ratios measured immediately before tracheal extubation and again on admission to the postanesthesia care unit (PACU).
Murphy G S et al. Anesth Analg 2005;100:1840-1845©2005 by Lippincott Williams & Wilkins
Residual paralysis at the time of tracheal extubation.Murphy G.S
Complete recovery from neuromuscular blockade is rarely present at the time of tracheal extubation.
Respiratory and pharyngeal function do not normalize until TOF ratios of 0.8–1.0 are obtained.
Anesth Analg. 2005 Jun;100(6):1840-5
Tracheal Extubation criteria
Respiratory Criteria - steady spontaneous breathing without difficulty
- VT > 6 ml.kg-1
- respiratory rate 12 to 25 c/min-1
- negative inspiratory pressure < -20 à -30 cmH2O
- SpO2 >95 % (air)
Tracheal Extubation criteria
Cardiovascular Criteria HR and arterial pressure ± 20 % of baseline values
No vasopressor or inotropic drug
• General criteria temperature > 36° C pain control no surgical complications (bleeding, hematoma…)
Tracheal Extubation criteria
Level of conciousness Fully awake vs deep extubation
• Considerations – Any difficulty in controlling airway– Any risk of aspiration
• Awake – Incidence of respiratory complication less
• Deep – Sympathetic response less– Increased airway complications
Tracheal Extubation Appropriate Technique
Extubation manoeuvre •
Position ???.....Oxygénation FiO2 =1 during few minutes
buccal, pharyngeal and tracheal suctions 3 periods :
• 2 to 3 deep inspirations (recruiting manœuvre)
• deflate cuff of ET
• take off the ET at the end of inspiration to minimize the risk of laryngospasm (without suction+++)
How to anticipate a difficult tracheal extubation?
Difficult Intubation - Anticipate Difficult Extubation
Complications related to the patient and/or surgery
Related to the patient
Difficult mask ventilation during induction
Difficult Intubation
Traumatic Intubation
Upper airway oedema or tumor
Risk factors of difficult tracheal extubation
Increased risk number of attempts > 3 ++++
Related to the surgery (ENT, head and face )
Local : oedema, hematoma, VC paralysis
Expected difficulties : jaw immobilisation
Risk factors of difficult tracheal extubation
Predicting difficult extubation..
VT expired < VT inspired
Leak with deflated cuff
LEAK = 0
Oedema
VT expired = VT inspired
Tracheal intubation > 48 h
leak > 12-15 % OK
leak < 12-15 % increased risk of stridor and/or reintubation
Jaber S et Col Intensive Care Med 2003
Cuff-leak test
Predicting difficult extubation..
Cuff-leak test
Cuff-leak test for the diagnosis of upper airway obstruction in adults: a systematic review and meta-analysis.
A positive cuff-leak test (absence of leak) should alert the clinician of a high risk of upper airway obstruction.
Intensive Care Med ,2009
Laryngeal ultrasound: a useful method in predicting post-extubation stridor
•Ding LW Eur Respir J .2006
Laryngeal ultrasound- no oedema
Laryngeal ultrasound- with oedema
•Inflated cuff •Deflated cuff
Predicting difficult extubation..
• Spontaneous Breathing trial
– T piece
– 30 – 45 minutes
Contribution of the Endotracheal Tube and the Upper Airway to Breathing Workload
STRAUS C et al. AM J RESPIR CRIT CARE MED 1998
Total WOB
A 2-h trial of spontaneous breathing through an ETT tube well mimics theWOB performed after extubation
Strategies for difficult extubation
• Tracheal tube exchange catheter/gum elastic bougie
• Extubation over flexible bronchoscope through an LMA
Cook ® airway exchanger
Anticipated difficult extubation
Conclusion
Respiratory adverse events are more frequent during tracheal extubation than during anesthesia induction.
Tracheal extubation is a routine manœuvre but required full attention to prevent respiratory complications.
Difficult intubation = anticipate difficult extubation
Difficult extubation should be anticipated with a predefined strategy.
Safe landing is equally important