Extubation Flashcards
(16 cards)
What airway problems may occur following the removal of a tracheal tube
Sore throat / Hoarseness
Foreign body causing obstruction e.g. teeth, throat pack blood clot
External compression of airway for example due to surgical site swelling or bleeding
Laryngospasm triggered by blood, secretions, or airway manipulation during light anaesthesia
Laryngeal oedema
Laryngeal trauma caused during intubation (for example while using a bougie) causing bleeding, swelling or tears
Vocal Cord Paralysis due to direct trauma or pressure
Vocal cord dysfunction
Tracheomalacia (erosion / softening) of the tracheal rings due to prolonged intubation, retrosternal thyroid, large thymus or tumour
Tracheal Stenosis after prolonged intubation
What respiratory complications might occur following the removal of a tracheal tube
Coughing
Mucociliary dysfunction
Diffusion Hypoxia
Basal Atelectasis causing ventilation/perfusion mismatch
Post-Obstructive Pulmonary Oedema
Bronchospasm
Pulmonary Aspiration
Respiratory failure due to any respiratory or airway complications
What cardiovascular complications might occur following the removal of a tracheal tube
Catecholamine release causing tachycardia and hypertension
Catecholamine release causing tachycardia and increased systemic vascular resistance, resulting in reduced ejection fraction, or even acute heart failure in a patient with coronary artery disease
Risk of silent or overt myocardial infarction due to increased myocardial oxygen demand, the effect of which is exacerbated if there is concurrent hypoxaemia due to other complications of extubation
What patient related factors or comorbidities pertaining to the airway might contribute to a high risk extubation
Airway pathology (e.g. tumour)
Obesity
“Dysmorphia”
What patient related factors or comorbidities pertaining to the respiratory system might contribute to a high risk extubation
Asthma
Obstructive sleep aponea
COPD
Recent upper respiratory tract infection
Smoking
What patient related factors or comorbidities pertaining to the cardiovascular system might contribute to a high risk extubation
Ischaemic Heart Disease
Unstable Angina
What patient related factors or comorbidities pertaining to the Neurological system might contribute to a high risk extubation
Posterior Fossa Tumour Surgery
Head Injury
Guillain Barre Syndrome
Myasthenia Gravis
Multiple Sclerosis
What patient related factors or comorbidities pertaining to the Gastrointestinal system might contribute to a high risk extubation
Full Stomach
Reflux
Hiatus Hernia
What patient related factors or comorbidities pertaining to the Musculoskeletal system might contribute to a high risk extubation
Muscular Dystrophies
Dystrophia Myotonica
Rheumatoid Arthritis / Ankylosing Spondylitis affecting neck movement
What surgical factors might contribute to a risk extubation
The site of the surgery
For example airway, head, neck, thorax, posterior fossa or cervical spine
Surgery requiring the use of a double lumen tube
Prolonged duration of surgery
Trendelenburg or Prone Positioning Risks the development of laryngeal oedema.
Intraoperative issues not directly related to the airway
For example, difficulty achieving adequate ventilation, hypothermia, significant blood loss, electrolyte imbalance, fluid shifts
What airway risk factors may predict a difficult extubation
Known difficult airway
Airway deterioration (e.g. trauma, oedema or bleeding)
Restricted Airway Access (e.g. mandibular wiring, halo brace)
Obesity or obstructive sleep aponea
Risk of aspiration
What “general” factors are there that may predict a difficult extubation
Cardiovascular Co-morbidities
E.g. coronary artery disease, or unstable arrhythmia
Respiratory Co-morbidities
E.g. asthma, COPD, Recent upper respiratory tract infection, smoking
Neurological Co-morbidities
E.g. Posterior fossa tumour surgery, head injury, Guillain-Barre, Myasthenia Gravis, Multiple Sclerosis
Metabolic disorder
Including complications from surgery or duration of anaesthesia such as fluid shifts, electrolyte imbalance, hypothermia, acid base disturbance.
Special Surgical Requirements e.g. need for smooth emergence following neurosurgery or flap surgery
What patient factors can be optimised prior to extubation
Respiratory:
Ensure ventilatory adequacy
Optimised gas exchange with supplementary oxygen to raise lung partial pressure of oxygen in case of difficulties at extubation
Cardiovascular:
Pharmacological correction of unstable blood pressure of rhythm
Adequate fluid replacement
Metabolic:
Optimise acid-base balance
Ensure coagulation status is acceptable
Ensure normothermia
Neuromuscular:
Ensure adequate reversal from neuromuscular blockade through accelerometer or train of four monitoring and reversal agent given in an appropriate dose
List what non patient factors can be optimised prior to extubation
Ensure that extubation occurs in an appropriate location
For example An operating theatre or ICU where there are appropriate numbers of staff and equipment
Presence of skilled assistant
Monitoring as for intubation
Availability of airway kit that was necessary for intubation and any further equipment that has become necessary as a consequence of changes in airway circumstances since intubation
What strategies could you employ to manage a high risk extubation
Laryngeal Mask Exchange
Remifentanil Technique
Airway exchange catheter
Postponement of extubation in order to achieve risk factor optimisation first
Tracheostomy
What possible indications are there for exchanging an endotracheal tube for a supraglottic airway device to aid extubation
Surgical requirement for minimising coughing and raised venous pressure at extubation
e.g. ocular surgery, neurosurgery, flap surgery
Avoidance of excessive catecholamine release at extubation resulting in risk of cerebrovascular consequences or myocardial ischaemia in patients in at risk groups e.g. severe coronary artery disease.
Reduction of airway stimulation in patients at risk of adverse respiratory consequences of extubation e.g. smokers and asthmatics
