1. Extubation Process Andy Higgs Warrington Hospitals Cheshire UK

2. Extubation Process Extubation is easy? Is it?

3. Extubation Process RCA: 4 th National Audit Project – NAP4 Major 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

4. Extubation Process Difficult extubation – WHY?

5. Extubation Process Difficult extubation – WHY? Initial cause of difficult intubation is still there You have traumatised / worsened the airway at intubation FRC ↓O 2 CVS ↑CO 2 Post GA ↓GCS ↓pH Pain Agitated New airway factors have developed: oedema, ↓access, bleeding... ‘The Scream.’ Edvard Munch

6. 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. 2 nd 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

7. 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

8. Extubation Process Training We emphasize take-off but ignore landing

9. Extubation Process Extubation plan – DAS guideline

10. Extubation Process Extubation plan – DAS guideline in CANADA Nov 2013

11. Extubation Process

14. Step 1: PLAN - assessment 1. 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

15. Extubation Process Step 1: PLAN - assess 1. 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

16. Extubation Process Step 1: PLAN - assess Assess glottis & sub-glottis This is difficult: anatomical & functional Laryngoscopy Cuff leak CT (limitations) A

17. Extubation Process Step 1; PLAN - assess Assess lower airway Consider: aspiration collapse (RMB intubation) gastric distension (?NGT) ? CXR pneumothorax surgical emphysema Airway trauma ETT position ? Fibrescopy Secretions Blood A

18. Extubation Process Step 1: PLAN - assessment 1. 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

19. Extubation Process

20. Step 2: PREPARE - Steroids > 12 hours Hydrocortisone 100mg 6 hourly

21. Extubation Process

25. Step 3: Leave the ETT in situ …for the medical SHO

26. 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

27. Airway Exchange Catheters Catheter CatheterCatheterETT FrLength /cm ID / mmID / 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