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Extubation Process
Andy Higgs
Warrington Hospitals
Cheshire
UK
Extubation Process
Extubation is easy?
Is it?
Extubation Process
RCA: 4th National Audit Project – NAP4Major complications airway management in UK
• Deaths• Brain damage• Sub-glottic access• Unplanned ICU
• 138 anaesthesia cases• 38 extubation (28%)
•Major Complications of Airway Management in the UK•1/9/08 – 31/8/09
•Major Complications of Airway Management in the UK•1/9/08 – 31/8/09
•March 2011•March 2011
Extubation Process
Difficult extubation – WHY?
Extubation Process
Difficult extubation – WHY?• Initial cause of difficult intubation is still there• You have traumatised / worsened the airway at intubation
• FRC ↓O2
• CVS ↑CO2
• Post GA ↓GCS ↓pH• Pain Agitated• New airway factors have developed:
oedema, ↓access, bleeding...
‘The Scream.’ Edvard Munch
Extubation Process
Difficult extubation – WHO?• History difficult intubation / extubation KNOW• Impending airway obstruction / oedema pre-op• Difficult intubation at induction - multiple ≥3 attempts
- alternative techniques FIND
- traumatic intubation• Intra-op airway events inc. 2nd airway device• Airway surgery / trauma • Poor post-op access to or immobility of airway MAKE • Category of surgery – thoracic, neck surgery• Burns FILL• Massive fluid resuscitation• Obesity – OSA BIG
Extubation Process
Training
Basic Level Training: - explain how to remove tracheal tube and
- describe the associated problems and
- complications
- demonstrate assessment of reflexes
- describe adequate ventilation
• Intermediate Level: NIL• Advanced Level: NIL
• We emphasize intubation but ignore extubation
E Sans-Solachi & J Hadlow. 2010
Extubation Process
Training
• We emphasize take-off but ignore landing
Extubation Process
Extubation plan – DAS guideline
Extubation Process
Extubation plan – DAS guideline in CANADA Nov 2013
Extubation Process
Extubation Process
Extubation Process
Extubation Process
Step 1: PLAN - assessment1. Assess general condition
2. Assess airway
1. ‘General airway’factors
2. Supra-glottis
3. Glottis and sub-glottis
4. Lower airway
5. Emergency sub-glottic access!
A
Extubation Process
Step 1: PLAN - assess1. Assess airway – general airway risk factors
2. Supra-glottis – Direct or VL / FO laryngoscopy
Don’t be fooled!
ETTs tell you where larynx is
ETTs stent airway - elevate supra-glottis
Molding
Expect minor oedema to progress
Infection spreads
Ask the surgeon
A
Extubation Process
Step 1: PLAN - assessAssess glottis & sub-glottis
This is difficult: anatomical & functional
Laryngoscopy Cuff leak
CT
(limitations)
A
Extubation Process
Step 1; PLAN - assessAssess lower airway
Consider: aspiration
collapse (RMB intubation)
gastric distension (?NGT) ? CXR
pneumothorax
surgical emphysema
Airway trauma
ETT position ? Fibrescopy
Secretions
Blood
A
Extubation Process
Step 1: PLAN - assessment1. Assess general condition
2. Assess airway
1. General airway factors
2. Supra-glottis
3. Glottis and sub-glottis
4. Lower airway
5. Emergency sub-glottic access!
A
Extubation Process
Extubation Process
Step 2: PREPARE - Steroids
• > 12 hours• Hydrocortisone 100mg 6 hourly
Extubation Process
Extubation Process
Extubation Process
Extubation Process
Extubation Process
Step 3: Leave the ETT in situ
…for the medical SHO
Extubation Process
AECs: If patient deteriorates
Railroading the ETT• Any railroading procedure• ‘Mind the gap’ between ETT & stylet
# 11 COOK AEC
Aintree Catheter
# 7.0mm ETT
Higgs et al 2010
Airway Exchange Catheters
Catheter Catheter Catheter ETT
Fr Length /cm ID / mm ID / mm
8 45 1.6 ≥ 3
11 83 2.3 ≥ 4
14 83 3.0 ≥ 5
19 83 3.4 ≥ 7
Extra Firm Soft Tipped
11 100 2.3 ≥ 4
14 100 3.0 ≥ 5