Extubation in Children with Difficult Airways

Airway Management

“…Planning for extubation requires consideration of neuromuscular blockade, analgesics, and other sedation medications. 40 Positioning, temperature, hemodynamic stability, and metabolic state should all be optimized to facilitate successful extubation. 40 Readiness of extubation can be assessed by confirmation of strength verified by objective means (e.g., train-of-four monitoring), a return of regular spontaneous ventilation and respiratory efforts, adequacy of tidal volumes, a return of protective airway reflexes, a capacity to manage secretions, and the ability to maintain oxygenation.…”

“…40 Positioning, temperature, hemodynamic stability, and metabolic state should all be optimized to facilitate successful extubation. 40 Readiness of extubation can be assessed by confirmation of strength verified by objective means (e.g., train-of-four monitoring), a return of regular spontaneous ventilation and respiratory efforts, adequacy of tidal volumes, a return of protective airway reflexes, a capacity to manage secretions, and the ability to maintain oxygenation. Following antagonism of neuromuscular blockade, strength can be demonstrated by cough and achieving acceptable tidal volumes.…”

“…3 In infants, strength can be confirmed by hip flexion. 40 Brow furrowing and nonauditory crying both also express a readiness to extubate. The anesthesia provider should be aware that airway dynamics may be altered postprocedure due to possible trauma from airway instrumentation, secretions, fluid shifts, and potential for respiratory compromise related to anesthesia medications.…”

“…When preparing to extubate the child with a difficult airway, it is important to follow the same basic principles of positioning, neuromuscular blockade reversal, pain control, maintenance of normothermia, and optimization of cardiovascular, neurological and metabolic status that are routinely followed for the patient with a nondifficult airway. 40 Additionally, alveolar recruitment maneuvers may be helpful as well as continuous oxygenation via nasal cannula or HFNC placed prior to extubation or immediately after extubation. 40 Prior to an extubation attempt, the entire surgical care team should be aware of the plan of action if extubation is not successful.…”

“…40 Additionally, alveolar recruitment maneuvers may be helpful as well as continuous oxygenation via nasal cannula or HFNC placed prior to extubation or immediately after extubation. 40 Prior to an extubation attempt, the entire surgical care team should be aware of the plan of action if extubation is not successful.…”