Intubation and extubation

Intubation is a standard part of airway management in the O.R., ICU and other settings. At some point, every intubation will be followed by an extubation. But what if the extubation has complications? Few anesthesiologists think about strategies for reintubation until problems have already begun to escalate. “Extubation has percolated into most airway guidelines at least as far as a consideration given to strategies for reintubating a patient with a difficult airway,” said Richard Cooper, M.D., FRCP, Professor of Anesthesia and Pain Management at the University of Toronto. “But for most people, reintubation ends up being an afterthought when things go badly. And when things go badly after an extubation, they can go very badly very quickly.” Richard Cooper, M.D., FRCP, will share strategies for reintubating a patient with a difficult airway. Dr. Cooper will discuss the practical aspects of strategizing for reintubation during Sunday’s Society for Airway Management Ovassapian Lecture “Extubation and Re-Intubation of the Difficult Airway.” Preparing for the possibility of reintubation is vital. “The initial intubation, at least for elective anesthesia, is performed at a time when conditions are optimized for success,” Dr. Cooper said. “A need for reintubation means conditions are anything but optimized and the situation is deteriorating rapidly. Time may be very critical, and the patient’s physiological state may be severely compromised.” Reintubation is required relatively infrequently for most adult patients. However, certain surgical procedures and medical conditions can significantly increase the probability of reintubation. Complications following extubation account for about a quarter of all serious adverse respiratory events in anesthesia. Anesthesiologists can stratify patients by the potential risks of extubation and the potential difficulty of reintubating without further harm. The risk for reintubation increases almost ten-fold for patients undergoing head and neck procedures. Morbidly obese patients, especially those with obstructive sleep apnea or hypoventilation syndrome, are more likely to require reintubation, as are ICU patients. Airway obstruction requiring reintubation can occur for any number of reasons. Laryngospasm is the most common problem, because patients emerging from anesthesia are particularly sensitive to noxious stimulus. Other common problems include hypoxia or inadequate breathing. “Sometimes patients have inadequate pulmonary toilet or inadequate respiratory reserve,” Dr. Cooper said. “They are unable to clear secretions or unable to breathe adequately due to splinting because of pain, incomplete reversal of neuromuscular blockade, respiratory depression from narcotics and residual effects of volatile agents. They can often be managed conservatively without reintubation, but sometimes reintubation is required. The key is to identify situations that may put patients at increased risk, identify the particular patient who may be at special risk, then develop strategies that are appropriate to that particular patient.” Identifying patients at increased risk is just the beginning. It is equally important to implement those strategies and reduce the potential for reintubation. Also, it is important to communicate the risk to be sure the problem does not recur with another clinician or in another setting. Patients who have been successfully reintubated are often transferred to the ICU for follow-up care, Dr. Cooper said. Failing to properly inform the ICU of the airway problem and its successful resolution simply sets the patient up for later difficulties. “Failure to manage a critical airway even after successful intubation, failure to successfully manage an extubation, can have devastating consequences,” he said.