Use of the flexible intubating fibrescope for tracheal re-intubation in a patient with difficult extubation

Difficulty in tracheal extubation was experienced in a patient following major maxillofacial surgery for reconstruction of the maxilla using bone grafts and a microvascular free flap. With the aid of an intubating flexible fibrescope, the cause of the difficulty was identified as a stitch accidentally transfixed through the tracheal tube. Tracheal re-intubation was required to facilitate surgical exploration to remove the stitch and the proximal end of the tube. The tip of an Olympus LF-2 intubating fibrescope was successfully negotiated in the trachea alongside the original tube with its cuff deflated. This allowed safe and speedy railroading of a new tube immediately after the distal end of the original tube was removed.     

Tracheal extubation of the adult intensive care patient with a predicted difficult airway – a narrative review

Management of the difficult airway is an important, but as yet poorly‐studied, component of intensive care management. Although there has been a strong emphasis on prediction and intubation of the difficult airway, safe extubation of the patient with a potentially difficult airway has not received the same attention. Extubation is a particularly vulnerable time for the critically ill patient and, because of the risks involved and the consequences of failure, it warrants specific consideration. The Royal College of Anaesthetists 4th National Audit Project highlighted differences in the incidence and consequences of major complications during airway management between the operating room and the critical care environment. The findings in the section on Intensive Care and Emergency Medicine reinforce the importance of good airway management in the critical care environment and, in particular, the need for appropriate guidelines to improve patient safety. This narrative review focuses on strategies for safe extubation of the trachea for patients with potentially difficult upper airway problems in the intensive care unit.     

Postoperative sore throat: topical hydrocortisone

Forty patients undergoing tracheal intubation and controlled ventilation of the lungs for elective surgical procedures were studied. They were allocated randomly into one of two groups. The tracheal tubes used for group A patients were lubricated before insertion with water-soluble 1% hydrocortisone cream. Those for group B patients were lubricated with KY jelly. The incidence of postoperative sore throat was found to be significantly greater in group A. Topical 1% hydrocortisone cream is therefore ineffective in the prevention of postoperative sore throat.     

A boy with an anterior mediastinal mass

A 12-year-old boy presented for biopsy of a large mediastinal mass. General anaesthesia precipitated immediate severe airway obstruction. This was overcome by the insertion of two microlaryngeal tubes, one into each main bronchus. The anaesthetic management of patients with an anterior mediastinal mass is discussed and the importance of pre-operative assessment stressed.     

Tissue expander causing iatrogenic difficult intubation

Difficulty during tracheal intubation may occur due to a number of anatomical factors and pathological conditions. These factors may be influenced by earlier surgical manoeuvres, so that dificulty may occasionally be encountered at subsequent operation. One such case of'iatrogenic'dificulty, where a tissue expander beneath the anterolateral skin of the neck caused transient intubation problems, is reported.     

An unusual complication of tracheal intubation

We report a previously undescribed complication of tracheal intubation. The complication arose as a result of tracheal intubation performed as an emergency procedure in a patient with an abnormal anteriorly placed larynx. Subsequent corrective laryngeal surgery was required after a temporary tracheostomy had been performed.     

Postoperative tracheal extubation after orthotopic liver transplantation

BACKGROUND: The duration of postoperative mechanical ventilation and its influence on pulmonary function in liver transplant recipients is still debated controversially. METHODS: We retrospectively analyzed the incidence of immediate tracheal extubation, prolonged mechanical ventilation (>24 h following surgery), and episodes of reintubation in 546 patients who underwent orthotopic liver transplantation (OLT) at our institution. RESULTS: Immediate tracheal extubation in the operating theater was achieved in 18.7% of patients, and prolonged mechanical ventilation was required by 11.2% of patients. In these, median time of extubation was 49.5 h, whereas the remaining 70.1% of patients required ventilation support for a median 5 h after OLT. As risk factors for prolonged mechanical ventilation we identified the indications of acute liver failure and retransplantation, as well as factors such as mechanical ventilation prior to OLT, massive intraoperative bleeding, and severe reperfusion injury of the liver graft. The incidence of reintubation was 8.8% in patients who were immediately extubated following surgery, and 13.1% in patients who underwent extubation within 24 h. The incidence was significantly increased in patients requiring prolonged mechanical ventilation (36.1%). CONCLUSIONS: Immediate tracheal extubation was safe and well tolerated. The incidence of reintubation was not increased when compared to patients in whom extubation succeeded later. However, special attention should be given to transplant recipients presenting in reduced clinical condition at the time of OLT, undergoing complicated surgery, or receiving liver allografts with severe reperfusion injury because of an increased risk for prolonged mechanical ventilation.     

Immediate extubation and epidural analgesia allow safe management in a high-dependency unit after two-stage oesophagectomy. Results of eight years of experience in a specialized upper gastrointestinal unit in a district general hospital

Background. The perioperative management of two-stage oesophagectomyhas not been standardized and the prevailing practice regardingthe timing of extubation after the procedure varies. This audithas evaluated the outcome, in particular the respiratory morbidityand mortality, after immediate extubation in patients who havehad thoracic epidural analgesia. Methods. All the patients who underwent two-stage oesophagectomyby a single specialist upper gastrointestinal surgeon were recordedboth retrospectively (1993–1999) and prospectively (1999–2001).Physical characteristics, comorbid factors, anaesthetic managementand postoperative events were recorded on a computer database.Analysis was undertaken to evaluate the morbidity and mortality,in particular the need for reventilation and transfer to theITU. Results. Seventy-six patients underwent two-stage oesophagectomybetween 1993 and 2001. Seventy-three (96%) patients were extubatedin theatre and transferred to a high-dependency bed. Three wereventilated electively and extubated within 36 h and madean uncomplicated recovery. Seven (10%) of the immediately extubatedpatients subsequently needed admission to the ICU and reventilation.Sixty-seven patients had effective epidural analgesia and nineneeded i.v. morphine by patient-controlled analgesia. The 30-dayor in-hospital mortality was 2.6% (2 of 76). A further two patientsdied within 90 days, but after discharge. Respiratory complicationswere responsible for half of the overall morbidity (44.7%).Respiratory failure occurred in 6.5% (5 of 76) and acute respiratorydistress syndrome in 2.6% (2 of 76). Both the in-hospital deathsoccurred in patients requiring reventilation and resulted fromrespiratory complications. The following factors were foundto be significant in the reventilated patients: duration ofone-lung ventilation; forced expiratory volume in the firstsecond; and ratio of forced expiratory volume in the first second/forcedvital capacity. Conclusions. Immediate extubation after two-stage oesophagectomyin patients with thoracic epidural analgesia is safe and associatedwith low morbidity and mortality. Patients can be managed ina high-dependency unit, thus avoiding the need for intensivecare. This has cost-saving and logistical implications. Br J Anaesth 2003; 90: 474–9     

Tracheal extubation in children: Planning,technique, and complications

Although poorly described in textbooks and rarely a topic of lecture, tracheal extubation is a critical phase of anesthetic care. It should therefore be carefully planned taking into account simple physiology‐based principles to maintain the upper airway patent and avoid lung de‐recruitment, but also the pharmacology of all anesthetic agents used. Although the management of most of its complications can be learned in a clinical simulation environment, the basic techniques can so far only be taught at the bedside, in the operating room. In this paper, the process of extubation is described in successive steps: preparation, return to adequate spontaneous ventilation, awake versus deep extubation, timing according to the child's breathing cycle, extubation in the operating room or in the Postanesthesia Care unit, child's management immediately after extubation, diagnosis and treatment of the early complications, and finally, how to prepare for a difficult reintubation.     

Hoarseness after tracheal intubation

The reported incidence of hoarseness following short-term tracheal intubation varies widely. It has been reported as being permanent in 3%. This suggests that an enormous problem exists considering the numbers of patients intubated daily in the United Kingdom. A prospective study of 235 adult patients undergoing general anaesthesia in a district general hospital included 167 patients whose tracheas were intubated. Of these 167, 54 (32%) complained of hoarseness postoperatively. All but five returned to normal within 7 days. The others were hoarse for 9, 10, 12, 54 and 99 days. Those who were hoarse for 54 and 99 days had vocal cord granulomata. Regression analyses showed that certain patient and anaesthetic factors had a significant effect on the hoarseness. This study confirms a low incidence of prolonged or permanent hoarseness following short-term tracheal intubation.     

Beclomethasone prevents postoperative sore throat

The effects of a dose of beclomethasone inhaler (50 μg) or lidocaine 10% spray on postoperative sore throat were studied in 120 patients undergoing tracheal intubation for elective surgical procedures. Fifty-four patients (90%) in the beclomethasone group scored no postoperative sore throat compared with 27 (45%) in the lidocaine group (P<0.00l). Beclomethasone inhaler seems to be highly effective in the prevention of postoperative sore throat and is therefore to be recommended before tracheal intubation for general anaesthesia.     

Neonatal tracheal perforation

Tracheal perforation following intubation in the neonatal period is rarely reported but is a serious complication that should be considered whenever difficulty in ventilation, surgical emphysema or pneumothoraces appear following intubation. Management includes the immediate and skilled replacement of the tube within the tracheal lumen and control of the air leak. Factors which increase the likelihood of occurrence of perforation are discussed.     

Failed intubation and emergency percutaneous tracheostomy

Failed intubation associated with difficulty with ventilation is rare. Cricothyrotomy may provide a means of oxygenating the patient, but in practice it may be difficult to perform and does not establish a definitive airway. We report two patients in whom percutaneous tracheostomy was used as an emergency procedure. In both cases placement was extremely rapid and salvaged the situation, leaving a definitive airway.     

Detection of accidental oesophageal intubation Role of the anaesthetic assistant

Three situations in which an anaesthetic assistant might be able to detect accidental oesophageal intubation during or immediately after intubation were assessed. These were: firstly, whilst applying cricoid pressure, secondly, whilst applying gentle palpation over the trachea just above the suprasternal notch and, thirdly, after intubation by means of a 'roll test'. During cricoid pressure, tracheal intubation was correctly diagnosed in all of 10 cases. However, deliberate oesophageal intubation was only detected in six out of 10 cases. During suprasternal palpation, three cases out of 10 oesophageal and three cases out of 10 tracheal intubation were misdiagnosed. In the 'roll test', two out of 10 tracheal and five out of 10 oesophageal intubations were misdiagnosed. In conclusion, no method could be relied on entirely and may indeed give false reassurance. Nonetheless, any doubt expressed about the tracheal tube position by the assistant should be taken seriously and a careful check made.     

Single-dose dexmedetomidine attenuates airway and circulatory reflexes during extubation

BACKGROUND: The alpha agonist dexmedetomidine, a sedative and analgesic, reduces heart rate and blood pressure dose-dependently. We investigated whether it also has the ability to attenuate airway and circulatory reflexes during emergence from anaesthesia. METHODS: Sixty ASA I-III patients received a standard anaesthetic. Five minutes before the end of surgery, they were randomly allocated to receive either dexmedetomidine 0.5 microg/kg (Group D) (n=30) or saline placebo (Group P) (n=30) intravenously (i.v.) over 60 s in a double-blind design. The blinded anaesthetist awoke all the patients, and the number of coughs per patient was continuously monitored for 15 min after extubation; coughing was evaluated on a 4-point scale. Any laryngospasm, bronchospasm or desaturation was recorded. Heart rate (HR) and systolic and diastolic blood pressure (SAP, DAP) were measured before, during and after tracheal extubation. The time from tracheal extubation and emergence from anaesthesia were recorded. RESULTS: Median coughing scores were 1 (1-3) in Group D and 2 (1-4) in Group P (P<0.05), but there were no differences between the groups in the incidence of breath holding or desaturation. HR, SAP and DAP increased at extubation in both groups (P<0.05), but the increase was less significant with dexmedetomidine. The time from tracheal extubation and emergence from anaesthesia were similar in both groups. CONCLUSION: These findings suggest that a single-dose bolus injection of dexmedetomidine before tracheal extubation attenuates airway-circulatory reflexes during extubation.     

Minimum alveolar concentration of sevoflurane for tracheal extubation in children

Background: One advantage of tracheal extubation during deep anaesthesia is that respiratory complications are reduced. Sevoflurane is a suitable anaesthetic agent for children. This study was conducted to determine the minimum alveolar concentration of sevoflurane required to prevent cough or movement during and after tracheal extubation (MAC_extubation).
Methods: We studied 30 nonpremedicated children, aged 2–10 yr, undergoing plastic surgery. They were allocated randomly to five groups (end-tidal sevoflurane concentrations: 2.0, 2.5, 3.0, 3.5, 4.0%). After surgery, 60% nitrous oxide was discontinued and the target concentration of sevoflurane was maintained for at least 10 min in 100% oxygen, then the trachea was extubated to determine MAC_extubation. Logistic regression was used to estimate MAC_extubation. of sevoflurane.
Results: MAC_extubation. was 2.3 (0.2; standard error)% (95% confidence limits: 1.2% and 2.7%).
Conclusions: Tracheal extubation in 50% of anaesthetized children age 2–10 yr may be accomplished without coughing or moving at 2.3% end-tidal concentration of sevoflurane.     

Accidental bronchial intubation with RAE tubes

Performed tracheal tubes are used frequently in paediatric anaesthesia. A feature which contributes to their popularity is the belief that they can be positioned more reliably than conventional tracheal tubes because of their design. We studied a group of 40 patients in whom the incidence of bronchial intubation was 20%. The tube was too long in 32% of patients, although the tube size was appropriate for the child's age in all patients. The consequences and outcome of this complication are discussed.