Tracheal Extubation of the Difficult Airway
The provision of tracheal extubation srategies for patients with a difficult airway (DA), experienced or developing during the surgical procedure performed, is a recommended safety measure (2, 22, 43). For example, the short-term use of a ventilating airway exchange catheter (AEC) as continuous airway access may allow oxygenation, rescue ventilation, and reversible tracheal extubation when necessary and should be considered particularly in high-risk tracheal extubations (21, 37). The catheter is introduced through the tracheal tube (TT) and left in place in a midtracheal position until the time when tracheal reintubation danger is minimized or eliminated. This procedure may occasionally fail due catheter dislodgement or the inability to advance the TT in a completely blinded fashion over the catheter through the laryngeal aperture into the trachea; therefore, adequate equipment for resecuring the airway should be prepared.
Tracheal extubation over a flexible bronchoscope (FB) is another proposed technique with the option of airway evaluation and immediate flexible bronchoscopy-assisted tracheal reintubation when necessary; this technique is limited in time, prone to failures and damages to the FB, and requires an experienced operator and a qualified assistance. Video laryngoscopes (VLs) with image magnification probably provide the best airway evaluation and allow tracheal reintubation under visual control.
Recommendations of the Austrian Working Group for Airway Management
We recommend the staged strategy for tracheal extubation using a ventilating AEC in patients with a DA, particularly in expected high-risk situations, with adequate equipment for resecuring the airway prepared in the case of failed tracheal reintubation. We also recommend the use of a VL allowing airway evaluation and tracheal reintubation under visual control.
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