Correspondence

Anaesthesia 2013, 68, 206217

Reference
1. Greenberg M. Mislabeling of Miller 1.5
laryngoscope blade complicating tracheal Intubation. Anesthesia and Analgesia 2006; 103: 5045.
doi:10.1111/anae.12131

Difficult Airway Society

guidelines for the
management of tracheal
extubation
We read with concern the letter
from Ms Ogilvie [1] in reaction to
the recently published extubation
guidelines by the Difcult Airway
Society (DAS) [2]. Ogilvie, representing Cook Medical (Limerick,
Ireland), manufacturers of the Cook
Airway Exchange Catheter (AEC),
indicated that this device is not
intended to remain in the airway
for an extended period of time
following extubation of a difcult
airway. One of us (RMC) was
involved in the development of the
AEC, and this is precisely how he
had intended that it be used. Our
ability to predict successfully those
patients who will tolerate extubation
is far from perfect. Comparing
patients with difcult airways whose
tracheas were re-intubated with or
without an AEC, Mort demonstrated that the AEC was associated
with a very signicant improvement
in the rst attempt success rate, the
time required to complete re-intubation, and a reduction in severe
hypoxia as well as bradycardia [3].
Only 21/51 (41%) of the re-intubations involving an AEC took place
within 2 h of extubation while
30/51 (59%) occurred between 2 h

and 10 h. Thus, the major safety

advantages of extubation over a
tube exchanger are likely to be
missed if the device is used exclusively to perform an exchange or if
it is removed shortly following extubation of the difcult airway. The
undersigned, representing DAS and
the Society for Airway Management, strongly reafrm the recommendations of the DAS guidelines
and discourage the premature
removal of tube exchangers until
the probability of a required
re-intubation seems very remote.
R. M. Cooper
President
Society for Airway Management
Email: richard.cooper@uhn.ca
E. OSullivan
President
Difcult Airway Society
M. Popat
Chairman
Difcult Airway Society Extubation
Group
E. Behringer
Past President
C. A. Hagberg
Executive Director
Society for Airway Management

No external funding or competing

interests declared. Previously posted
on the Anaesthesia Correspondence
website:
http://www.anaesthesia
correspondence.com.

References
1. Ogilve L. Difficult Airway Society guidelines for the management of tracheal
extubation. Anaesthesia 2012; 67:
12778.
2. Popat M, Mitchell V, Dravid R, Patel A,
Swampillai C, Higgs A. Difficult Airway
Society Guidelines for the management of tracheal extubation. Anaesthesia 2012; 67: 31840.

Anaesthesia 2013 The Association of Anaesthetists of Great Britain and Ireland

3. Mort TC. Continuous airway access for

the difficult extubation: the efficacy of
the airway exchange catheter. Anesthesia and Analgesia 2007; 105: 1357
62.
doi:10.1111/anae.12139

Algorithm for
management of
tracheostomy emergencies
on intensive care
We congratulate McGrath and colleagues on producing the multidisciplinary
guidelines
for
the
management of tracheostomy and
laryngectomy airway emergencies
[1]. An enormous amount of time
and effort has clearly gone into producing these; bringing together so
many different parties and producing a unied set of guidelines is
extremely impressive. Use of these
guidelines can be expected to
improve signicantly the safety of
patients with a tracheostomy on
our wards. We support the use of
signs to indicate the type of tracheostomy, are currently introducing
the green (potentially patent upper
airway) and red (neck breather)
bed-head signs on our intensive
care unit (ICU), and our ENT colleagues are currently introducing
these guidelines, in full, on our
wards.
However, whilst we feel that
these guidelines will be extremely
useful for ward patients, we do have
some reservations about using the
algorithms for tracheostomy emergencies in our ICU. Tracheostomy
emergencies in ward patients are
usually related to blockage of a tra217