Author: Thomas Rosenthal
Placement of an airway exchange catheter (AEC) in ICU patients at high risk for extubation failure facilitates safe and rapid replacement of an endotracheal tube, research concluded.
From a small series of medical ICU patients, researchers found that “placement of an airway exchange catheter in patients at high risk of extubation failure is feasible in that it was well tolerated and facilitated safe and rapid replacement of an endotracheal tube when needed,” said lead author J. Michael Brewer, MD, a pulmonary and critical care medicine specialist at the University of Mississippi Medical Center, in Jackson.
The study, presented at the 2018 annual meeting of the Society of Critical Care Medicine (abstract 305), involved adult ICU patients at risk for extubation failure due to morbid obesity (four of eight [50%]), prior extubation failure (four of eight [50%]), chronic respiratory failure (three of eight [37.5%]), and difficult initial intubation (one of eight [12.5%]). Patients underwent eight placements of a Cook AEC (Cook Medical) after planned extubation, they said.
Reintubation was required in five of eight (62.5%) of the AEC placements and successful on the first attempt in all cases, Dr. Brewer said. Reintubation in four of five (80%) of the cases incorporated use of a GlideScope video laryngoscope (Verathon), and three of those cases also incorporated the use of an Aintree intubation catheter (Cook Medical). “All patients tolerated the AEC well, and there were no complications directly related to the AEC,” the report noted.
Hazards of Reintubation
“Reintubation is associated with increased mortality and morbidity, in part due to clinical deterioration resulting from extubation failure and the scenario of reintubation, which can be difficult due to anatomical or physiological abnormalities,” the authors said.
Extubation failure occurs in up to 20% of ICU patients, Dr. Brewer added. “I think extubation failure occurs so frequently because of the pressure to extubate patients as quickly as possible in order to potentially avoid the known complications of mechanical ventilation.
“Guidelines from the American Thoracic Society and the American College of Chest Physicians place a high value on avoiding ventilator-associated complications,” Dr. Brewer said. “The criteria for extubation include successful completion of a spontaneous breathing trial, resolution of the primary indication for intubation, adequate oxygenation, and hemodynamic stability.”
However, Dr. Brewer added, “these criteria do not take into account patient comorbidities and are unable to predict airway failure following removal of the endotracheal tube, all of which may lead to eventual failure. The ultimate decision to extubate a patient is primarily by the physician’s gestalt and is not an exact science.”
Dr. Brewer noted that the Difficult Airway Society published “Guidelines for the Management of Tracheal Intubation in Critically Ill Adults” in the British Journal of Anaesthesia (2018;120:323). “The guidelines include a section titled Planned Extubation, and recommend use of airway exchange catheters for known difficult airways,” he said. “Our criteria for placement of airway exchange catheters is a bit more broad in that we use them for patients at high risk for failure due to a variety of causes and not just a known difficult airway.”
Joseph Shiber, MD, an associate professor in the Departments of Emergency Medicine, Surgery and Neurology at the University of Florida College of Medicine, in Jacksonville, said he applauded “the presenter and his colleagues for bringing attention to this important issue and their possible intervention to make the periextubation period safer for these patients.”
Dr. Shiber said ICU providers can assess a patient’s airway “while still intubated by checking for a cuff leak by deflating the endotracheal tube balloon and observing for air movement around the tube—hearing air escape the mouth, seeing a difference in inspiratory and expiratory volume delivered by the ventilator.”