Managing the difficult airway at extubation: Vices or devices

Francisca Llobell, M.D.1, Patricia Marzal, M.D.1, Maria Serna, M.D.1, Lauren K Hoke B.S.2, Yvon F. Bryan, M.D.2
1. Hospital G. U. Marina Alta, Denia (Alicante), Spain 2. Wake Forest University Baptist Medical Center, Winston-Salem, NC

Introduction Methods Discussion

Table 1: Extubation survey questions
•Problems occur during extubation in •High incidence of problems occured at
patients with difficult airways (DA’s) extubation
•Different airway devices may be used at •Anesthesiologist experience and familiarity
extubation or for re-intubation with different airway devices may have
•[Timing of extubation depends on operator influenced choice of device
decision] •Further research required in developing
•We present experience of protocols for use during extubation in
anesthesiologists in a region of Spain patients with DA’s
during extubation of patients with DA’s
Abstract

Methods Results Title: Managing the difficult airway at extubation: Vices or devices
 
Francisca Llobell, M.D., Patricia Marzal, M.D., Maria Serna, M.D., Lauren K Hoke, B.S. and Yvon F
Bryan, M.D.. Department of Anesthesiology, Hospital G.U. Marina Alta, Denia, Alicante, Spain.

•Survey consisted of 10 questions regarding  

Introduction

management of DA during extubation Problems encountered during extubation of patients with difficult airways are prevalent though
formal guidelines seem to be lacking (1). This dichotomy of problems occurring at extubation and a
lack of specific strategies may be due to anesthesiologist experience and/or training with

•Surveyed 38 anesthesiology departments in

specialized airway devices required during the management of the difficult airway (2). Certain
airway devices may be best suited for rescue (oxygenation and ventilation) while others are better
used to bridge (reintubation) and to delay the extubation. We surveyed Spanish anesthesiologists
Communities of Valenciana and Murciana in Spain about their clinical practice management for the extubation of patients with difficult airways.
Methods
A survey was sent to the anesthesiology departments of 38 hospitals in the provinces of the
Comunidad Valenciana (Castellon, Valencia, Alicante) and cities in the Comunidad Murciana
(Murcia, Orihuela) of Spain. The survey consisted of 10 questions pertaining to the clinical
management at extubation of patients with difficult airways (see Table 1). The surveys were
completed anonymously and returned via self-return envelope to Hospital G.U. Marina Alta in Denia
(Alicante), Spain.
Results
A total of 10 out of 38 anesthesiology departments completed and returned the survey (as of
March 1, 2008) totaling 120 anesthesiologists. Problems at extubation were reported by 95% of
respondents with only 12% having a formal extubation protocol. 34% reported experiencing
difficulty with reintubation and 23% reported patients requiring surgical access for airway support.
7% reported a patient death or a severe brain injury as a consequence of problems occurring at
extubation. Of the airway devices used to rescue, 76% were supralaryngeal devices (LMA, ILMA,
Proseal LMA). To bridge the extubation, supralaryngeal devices and airway exchange catheters
were used 53% and 16% of the time, respectively. See Table 2.
 
Discussion
Our survey found a very high incidence of problems occurring at extubation in patients with
difficult airways. A lack of established extubation protocols and training with specialized airway
devices may be the reason for the problems. The devices used to rescue and bridge the extubation
by the majority of respondents were supralaryngeal in nature. This may have reflected the
individuals training with these devices, the unavailability of certain devices or not being familiar
with other types of devices (ie, airway exchange catheters). Further research is required in the
management of the difficult airway to discern which devices are best suited for rescuing and/or
bridging during extubation.
 
References
1) Anesthesiology 2005:103(1);33-9.
2) Anesthesiology 2007:100;A934