Extubation in OR SHAJI SAINUDEEN RASHID HOSPITAL, DUBAI

1. Extubation in OR SHAJI SAINUDEEN RASHID HOSPITAL, DUBAI

2. Is tracheal extubation a problem ? NO Difficult extubation : 208 references Difficult intubation : 3022 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 : 1/145 500 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 N=1005 Asai et Col BJA 1998 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 % - - Airway Obstruction - 1.9 % 3.8 % • 1 compli- cation 4.6 % 12.5 % 9.5 %

8. An Analysis of Reintubations from a Quality Assurance Database of 152,000 patientsP Lee et al J clin Anesth 2000 N=191 (1/1000)OR PACU OR+PACU % Respiratory 48 64 112 58 complications Unintentional 25 0 25 13 Extubation Surg Compl. 10 6 16 8 Neurom. blocking 4 7 11 6 Opioïd residual 2 7 9 5 Upper airway obst. 8 0 8 4 Cardiac complications 2 0 2 1

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. 315 incidents or accidents (0,4%) 111 totally related to anesthesia 27 during recovery(oxygen desaturation, airway patency problem) and8 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 5 sec TOF ratio > 0.9 +++ 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. 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

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. 2005 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 > 3 ++++

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. VT expired = VT inspired Oedema LEAK = 0 Predicting difficult extubation.. Cuff-leak test VT expired < VT inspired Tracheal intubation > 48 h leak > 12-15 % OK leak < 12-15 % 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