Tracheal extubation is a high risk procedure in anaesthesia and critical care. Until now most guidelines have focused on intubation, with little to guide the process of extubation. Complications may relate to the following issues:
- Exaggerated reflexes – laryngospasm (which can lead to both hypoxia and negative pressure pulmonary oedema) and bronchospasm
- Reduced airway reflexes
- Dysfunctional laryngeal reflexes
- Depletion of oxygen stores at extubation
- Airway injury
- Physiological compromise in other systems
- Human factors
The goal is to ensure uninterrupted oxygen delivery to the patient’s lungs, avoid airway stimulation, and have a back-up plan, that would permit ventilation and re-intubation with minimum difficulty and delay should extubation fail.
The Difficult Airway Society has now published guidelines for the management of tracheal extubation, describing four steps:
Step 1: plan extubation.
Step 2: prepare for extubation.
Step 3: perform extubation.
Step 4: post-extubation care: recovery and follow-up.
During step 3, emphasis is on pre-oxygenation, positioning, and suction. This is followed by simultaneous deflation of the tracheal tube cuff and removal of the tube at the peak of a sustained inflation. This generates a passive exhalation, which may assist in the expulsion of secretions and possibly reduce the incidence of laryngospasm and breathholding.
The guideline refers to low-risk and at-risk extubations. ‘Low-risk’ (routine) extubation is characterised by the expectation that reintubation could be managed without difficulty, if required. ‘At-risk’ means the presence of general and/or airway risk factors that suggest that a patient may not be able to maintain his/her own airway after removal of the tracheal tube. ‘At-risk’ extubation is characterised by the concern that airway management may not be straightforward should reintubation be required.
These guidelines are written for the peri-operative patient but the text contains some interesting points that are pertinent to the ED or ICU patient. Some simple algorithms are presented: