1. Extubation in OR
SHAJI SAINUDEEN
RASHID HOSPITAL, DUBAI

2. NO YES Is tracheal extubation a problem ?
Difficult extubation : 208 references
Difficult intubation : references (x 14.5)
YES
Morbidity factor related to anesthesia

3. Incidence of death, brain damage, and nerve injury as a percentage of total claims
Cheney FW Anesthesiology 1999

4. Incidence of respiratory, cardiovascular, and equipment-related damaging events as a percentage of the total claims for death and brain damage
Cheney FW Anesthesiology 1999

5. T : 1/
P : 1/21 200

6. Management of the Difficult Airway A Closed Claims Analysis
Peterson GNet al. Anesthesiology 2005

7. Respiratory complications associated with tracheal intubation or extubation
Asai et Col BJA 1998
Induction Extubation OR Extubation PACU
Cough % % %
SpO2< % 2.4 % %
Laryngo-
Spasm % % %
DV %
DI %
Airway
Obstruction % %
1 compli-
cation % % %

8. 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
complications
Unintentional
Extubation
Surg Compl
Neurom. blocking
Opioïd residual
Upper airway obst
Cardiac complications

9. 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

10. All problems related to anesthesia were considered preventable
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 bronchospasm
aspiration
All problems related to anesthesia were considered preventable

11. Analysis of reintubations
Respiratory complications were the most common cause of reintubation in the perioperative period.
More reintubations occured in the immediate post extubation phase.
Muscle relaxant effect and opioid effect are rare causes of respiratory failure in the anaesthetized patient in the immediate postoperative period.
Anaesthesia related problems in immediate post extubation phase is preventable

12. 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.

13. 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

14. Management of extubation
Extubation criteria
Appropriate technique
Anticipate difficult extubation(DE)
Management of DE

15. Tracheal Extubation criteria
No residual neuromuscular blockade
Respiratory Criteria
Cardiovascular Criteria
General criteria
Level of conciousness

16. Tracheal Extubation criteria
No residual neuromuscular blockade
Head lift sec
TOF ratio >
DBS 2

17. Residual Paralysis in the PACU after a Single Intubating
Dose of Nondepolarizing Muscle Relaxant with an
Intermediate Duration of Action
Residual paralysis rate 37
Debaene B et Col Anesthesiology 2003

18. Murphy G S et al. Anesth Analg 2005;100:1840-1845
Train-of-four (TOF) ratios measured immediately before tracheal extubation and again on admission to the postanesthesia care unit (PACU).
Figure 1. Train-of-four (TOF) ratios measured immediately before tracheal extubation and again on admission to the postanesthesia care unit (PACU). The graphs illustrate the number of patients (of a total of 120) with TOF ratios <0.7, 0.8, and 0.9 at each measurement interval.
Murphy G S et al. Anesth Analg 2005;100:
©2005 by Lippincott Williams & Wilkins

19. 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 Jun;100(6):1840-5

20. 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)

21. 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…)

22. 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

24. 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+++)

25. How to anticipate a difficult tracheal extubation?
Complications related to the patient and/or surgery
Difficult Intubation - Anticipate Difficult Extubation

26. Risk factors of difficult tracheal extubation
Related to the patient
Difficult mask ventilation during induction
Difficult Intubation
Traumatic Intubation
Upper airway oedema or tumor
Increased risk number of attempts >

27. Risk factors of difficult tracheal extubation
Related to the surgery (ENT, head and face )
Local : oedema, hematoma, VC paralysis
Expected difficulties : jaw immobilisation

28. Predicting difficult extubation..
LEAK = 0
Oedema
VT expired =
VT inspired
Cuff-leak test
VT expired <
VT inspired
Tracheal intubation > 48 h
leak > % OK
leak < % increased risk of stridor and/or reintubation
Leak with
deflated cuff
Jaber S et Col Intensive Care Med 2003

29. 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

30. Laryngeal ultrasound: a useful method in predicting post-extubation stridor
Ding LW Eur Respir J .2006

31. Laryngeal ultrasound- no oedema

32. Laryngeal ultrasound- with oedema
Inflated cuff
Deflated cuff

33. Predicting difficult extubation..
Spontaneous Breathing trial
T piece
30 – 45 minutes

34. 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 the
WOB performed after extubation

35. Strategies for difficult extubation
Tracheal tube exchange catheter/gum elastic bougie
Extubation over flexible bronchoscope through an LMA

36. Anticipated difficult extubation
Cook ® airway exchanger

39. 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.

40. Safe landing is equally important