Airway management before, during and after extubation: a survey of practice in the United Kingdom and Ireland

Abstract

SummaryComplications at extubation remain an important risk factor in anaesthesia. A postal survey was conducted on extubation practice amongst consultant anaesthetists in the United Kingdom and Ireland. The use of short acting drugs encourages anaesthetists to extubate the trachea at lighter levels of anaesthesia. The results show that oxygen (100%) is not routinely administered either before extubation or en route to the recovery area. A trend towards a head up or sitting position at extubation is emerging. However, further research into the use of these positions is required. Airway related complications at extubation are relatively frequent but are usually dealt with by simple basic measures. The role of drugs such as propofol in decreasing the incidence of these complications needs further evaluation. Some of these results give concern for patient safety and for training. The importance of teaching and adherence to continued oxygenation until complete recovery is strongly emphasised. Nerve stimulators should be used continually as standard monitoring throughout the anaesthetic period when muscle-relaxing drugs are part of the anaesthetic technique. It has been shown that there are more adverse incidents associated with extubation than intubation and these are occurring not only during extubation itself, but also during the time spent in the recovery room [1][2][3][4][5]. The increased incidence of complications has been correlated with the pre-operative physical status, depth of anaesthesia at extubation, increasing age and gender with a male preponderance [2,6]. These complications remain consistent regardless of the type of operation [1].The problems associated with extubation may be broadly categorised into cardiovascular and respiratory complications. Cardiovascular complications include tachycardia, hypotensive and hypertensive episodes [7][8][9][10], which may be significant in patients with pre-existing ischaemic heart disease [11,12], pre-eclampsia [13] and in those undergoing neurological procedures [14]. Respiratory complications include local trauma, coughing, desaturation, breath-holding, masseter-spasm, laryngospasm, airway obstruction and aspiration [7,[15][16][17][18]].An on-line journal search revealed a lack of recent investigations or statistical data in these areas. This survey was performed with this in mind. The main aims of the survey were twofold. The first was to ascertain extubation practices with regard to the type of surgery, timing, position and techniques. The second was to estimate the incidence of problems associated with extubation and how these were treated. MethodsA postal survey was conducted in May 2004. A total of 845 Consultant Anaesthetists were randomly selected from the membership database of the Association of Anaesthetists of Great Britain and Ireland (AAGBI). These anaesthetists were sent the questionnaire, which they were asked to complete and return anonymously in the stamped, addressed envelope provided. The questionnaire (Fig. 1) was a structured document with...

A discrete event simulation model of clinical and operating room efficiency outcomes of sugammadex versus neostigmine for neuromuscular block reversal in Canada

“…Uncomplicated aspiration, occurring to the level of, or above, the vocal cords has been reported in volunteer studies with TOF ratios < 0.9, but not below the vocal cords. Due to the rare documentation of aspiration during the post-extubation and recovery periods in general anesthetic settings, [25–27] and likely silent nature of events with lack of clinical management, aspiration was not modeled within the DES.…”

Increasing positive end expiratory pressure at extubation reduces subglottic secretion aspiration in a bench-top model

“…The secretions in the oropharynx can then be removed from the oral cavity with a Yankeur oral suction catheter. Another technique is commonly used by anaesthetists in the operating theatre, who close the adjustable pressure limiting valve and squeeze the reservoir bag in the breathing circuit just prior to cuff deflation and extubation (Rassam et al , 2005).…”

Extubation of Pediatric Patients: Can Nurses Safely Pull the Tube?

“…2 A high incidence of laryngospasm was reported (20%), but desaturation (22%), coughing (18%), breath holding (13%), and airway obstruction (5.5%) were also reported as complications of extubation. 2 Similar airway complications have been identified by Asai et al in adult patients. 7 Nineteen percent of their subjects had some extubation complications; 12.6% of these occurred immediately after extubation and 9.5% during the recovery period.…”

“…Adverse events may occur during the extubation procedure, but also during the immediate recovery period. 1,2 Respiratory adverse events related to general anesthesia, although not abundant, are not rare in pediatric patients.…”