Tracheal Extubation of the Difficult Airway
The provision of preformulated tracheal extubation strategies for patients with a difficult airway (DA), experienced or developing during the surgical procedure, and continued control of the airway after tracheal extubation should constitute part of overall DA management (11, 19, 22).
Delayed Tracheal Extubation
Severe laryngeal edema formation justifies a delayed tracheal extubation strategy as it requires some time to resolve; a trial of tracheal extubation may be considered for the following day after repeated airway evaluation.
Staged Tracheal Extubation Using an Airway Exchange Catheter
The American Society of Anesthesiologists Task Force on the Management of the Difficult Airway (1-3), the Canadian Airway Focus Group (12), the Italian expert working group (24) and the Difficult Airway Society Extubation Guidelines Group (19) recommend the short-term use of a ventilating airway exchange catheter (AEC) or a similar device for high-risk tracheal extubations as continuous airway access allowing oxygenation, rescue ventilation, and reversible tracheal extubation when necessary. The catheter is introduced through the existing tracheal tube (TT) and left in place in a midtracheal position until the time when tracheal reintubation danger is minimized or eliminated. When placed in a midtracheal position, the catheters are well tolerated with less patient discomfort. There are several case series confirming the effectiveness and safety of reversible tracheal extubation over an AEC (13, 18, 21).
We also recommend the staged tracheal extubation technique using an AEC for high-risk tracheal extubations (28); however, tracheal reintubation may occasionally fail (7). Therefore, adequate equipment for resecuring the airway should be provided. The main causes for failure are dislodgement of the catheter and inability to advance the TT in a completely blinded fashion over the catheter through the laryngeal aperture into the trachea. The difficulties with TT advancement over an AEC are comparable with those associated with flexible-bronchoscopy assisted (FBA) tracheal intubation; the TT may impinge on the epiglottis or laryngeal structures, preferably on arytenoid cartilages or the interarytenoid area. Jaw thrust or retraction of the tongue and elevation of the epiglottis with a conventional laryngoscope, rotational maneuvers of the TT, and/or change to a smaller-sized TT may overcome these problems (5).
Tracheal Extubation Using a Flexible Bronchoscope
Tracheal extubation over a flexible bronchoscope (FB) is another proposed technique with the option of FBA tracheal reintubation (22). This technique is limited in time, prone to failures and damages to the FB, and requires an experienced operator and a qualified assistance.
Tracheal Extubation Using a Video Laryngoscope
The laryngeal views provided by videolaryngoscopy are usually superior compared to those obtained with direct laryngoscopy (27). This feature may make video laryngoscopes suitable for high-risk extubation allowing tracheal reintubation under visual control (14). The additional use of an AEC before videolaryngoscopic tracheal extubation may provide more safety in high-risk extubations and may enhance the success of resecuring the airway.
Tracheal Tube Change to a Laryngeal Mask Airway
TT change to a suitable laryngeal mask airway (LMA) may provide access to the airway after tracheal extubation providing rescue ventilation and serving as conduit for tracheal reintubation (3, 19). Alternatively, the LMA may be inserted into the hypopharynx before removal of the TT (16). When the LMA is properly aligned with the larynx, tracheal reintubation may be easy to perform by the two-stage technique of FBA tracheal intubation over an Aintree intubating catheter for guidance of the TT into the trachea (9, 15).
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