Tracheal ExtubationDiscussion

Abstract

Tracheal extubation in both the critical care and anesthesia setting is not only an important milestone for patient recovery, but also a procedure that carries a considerable risk of complication or failure. Mechanical ventilation is associated with significant complications that are time-dependent in nature, with a longer duration of intubation resulting in a higher incidence of complications, including ventilator-associated pneumonia, and increased mortality. Extubation failure and subsequent re-intubation are associated with an overall increase in the duration of mechanical ventilation, increased mortality, a greater need for tracheostomy, and higher medical costs. These risks demand that the process of extubation be managed by practitioners with a detailed understanding of the causes of extubation failure and the potential complications. A pre-established extubation plan with considerations made for the possible need for re-intubation is of the utmost importance.

All India Difficult Airway Association 2016 guidelines for the management of anticipated difficult extubation

“…The common causes for reintubation include bronchospasm, poor respiratory efforts, airway obstruction, residual neuromuscular blockade or residual effects of drugs such as sedatives/opioids (delayed recovery). [9] Pre-existing airway concerns such as difficult mask ventilation, intubation, obesity and obstructive sleep apnoea (OSA) mandate vigilant extubation. The airway may become compromised due to perioperative manipulations (surgical procedure, oedema, collapse, multiple airway management attempts).…”

“…These patients could be extubated in an awake state or under deep inhalational anaesthesia. [9] The trachea could be extubated in awake state by suppression of the responses using pharmacological agents such as topical lignocaine 10%, intravenous β-blockers (intravenous esmolol 1.5 mg/kg, 2–5 min before extubation), lignocaine 1 mg/kg over 2 min or fentanyl 0.5–1 μg/kg, dexmedetomidine 0.75 μg/kg administered 15 min before extubation. [21112] The other option could be to replace the ETT with a supraglottic airway device (SAD) (preferably a second generation) under deep anaesthesia.…”

“…This technique should be avoided in cases of full stomach (obese, pregnant, recent ingestion of food or raised intra-abdominal pressure). [29] Exchange with SAD avoids any reflex response due to tracheal tube intolerance or its removal at emergence from anaesthesia. [15161718] Bailey's manoeuvre has been reported to be useful for effective exchange of ETT with laryngeal mask airway.…”

Comparison of Proportional Assist Ventilation Plus, T-Tube Ventilation, and Pressure Support Ventilation as Spontaneous Breathing Trials for Extubation: A Randomized Study

“…Thus, updating the weaning protocol to prevent such failures is important. [2][3][4][5][6][7] Even when weaning criteria are met and a successful spontaneous breathing trial (SBT) is conducted, a planned extubation may fail in ϳ10 -20% of cases. 8 Several authors have pointed out that the SBT protocols and screening conducted by physiotherapists yield good results and have proven effectiveness and are therefore highly recommended.…”

“…The most commonly used techniques are the T-tube and pressure support ventilation (PSV) of up to 7 cm H 2 O. 7 New modes are being studied, such as proportional assist ventilation plus (PAVϩ), which is a spontaneous mode of mechanical ventilation designed primarily to respond to changes in a patient's ventilator demand. It provides patients with synchronized support, where assistance is instantaneous in response to the patients' respiratory efforts.…”