DIFFICULT EXTUBATION PROTOCOL - Updated (1).pptx

DIFFICULT EXTUBATION PROTOCOL

1. DIFFICULT EXTUBATION MODERATED BY : DR.SALONY AGARWAL MA’AM PRESENTED BY : DR.R.DHIVYAPRIYA

2. EXTUBATION

3. DIFFICULT EXTUBATION Difficult extubation refers to anticipated or unanticipated difficulties with breathing and oxygenation after extubation . It is the loss of airway patency and adequate ventilation after removal of a tracheal tube or supraglottic airway from a patient with a known or suspected difficult airway

4. Definition Extubation failure Early reintubation – few mins up to 6 hours after extubation Resp. Insufficiency, airway obstruction (laryngeal edema ), bronchospasm, prolonged neuromuscular blockade, side effects of opioids Late reintubation – events occurring between 6 and 72 hours after extubation

5. DIFFICULT AIRWAY SOCIETY GUIDELINES (UK)

6. Extubation is an elective procedure, and hence, strategies need to be planned based on the individual patient condition. It is prudent to assess medical or surgical factors that have impact on the plan for extubation . The common causes for reintubation include : Bronchospasm Poor respiratory efforts Airway obstruction Residual neuromuscular blockade or residual effects of drugs such as sedatives/opioids (delayed recovery).

7. AIDAA 2016 Guidelines for the Management of Anticipated Difficult Extubation NORMAL AIRWAY AWAKE EXTUBATION DEEP EXTUBATION

8. Patients requiring extubation may be broadly categorised to fit into one of three strategies (labelled as limbs).

9. POST‑EXTUBATION CARE After extubation , patient needed to be given supplemental oxygen and monitored for any airway compromise in a controlled and monitored environment. The NAP4 report revealed adverse outcomes after extubation in the absence of appropriate monitoring. Wherever required, appropriate suctioning, heads-up positioning and bronchodilators should be continued as per patient’s requirement. Difficulties experienced during extubation , management strategies used and adverse events if any need to be documented in the case notes and the airway alert form.

10. At increased risk for extubation failure Obesity/OSA BMI >30kg/m 2 (34% of population) ↑incidence of difficult mask ventilation ↑risk of pulmonary aspiration ↑airway obstruction ↑rapid oxygen desaturation Postop concerns: Opioids vs. resp. depression, hypoxia, patient positioning, adequate monitoring ↑major airway complications

11. At increased risk for extubation failure Head and neck pathology/surgery Reintubation rate 0.7-11.1% Obstetrics – edema of the airway, obesity Obese patients

12. Causes and mechanisms of extubation failure

13. Options?

14. 11.0 Fr; L = 100 cm; ID = 2.3 mm 14.0 Fr; L = 100 cm; ID =3.0 mm 19.0 Fr; L= 56 cm; ID = 4.7 mm

15. Use AEC for re-intubation L Duggan, Can J Anesth /J Can Anesth (2011) 58:560–568

16. Specialty guidelines?

17. Obese, Head and neck surgery

18. Name: Mr.Thomas Age: 52 years Weight: 120 kg (BMI: 38.6, Obese Class II) Medical History: Obstructive sleep apnea (OSA), hypertension, t Procedure: mandible osteomyelitis debridement with resection of infected tissue Anesthesia: General anesthesia with endotracheal intubation Duration of Surgery: 3 hours

19. Obesity and Extubation : Key Considerations Airway management concerns : Difficult intubation due to excess tissue Increased risk of airway obstruction post- extubation Challenges during extubation : Obstructive sleep apnea (OSA) Reduced pulmonary function Airway edema post-surgery

20. Pre- extubation Checklist : Evaluate depth of anesthesia: Ensure the patient is awake and able to follow commands Airway assessment: Check for signs of airway edema Respiratory function: Assess oxygen saturation, CO2 levels, and respiratory rate Neurological status: GCS (Glasgow Coma Scale) score

21. Step 1: Optimize Oxygenation and Ventilation : Pre-oxygenation with 100% oxygen Consider CPAP/BiPAP post- extubation if OSA is present Step 2: Extubation Criteria : Spontaneous respiratory efforts Adequate tidal volume and respiratory rate Stable hemodynamics No significant airway edema

22. Post- extubation Monitoring : Monitor for signs of airway obstruction (stridor, desaturation) Post- extubation sedation with caution Close monitoring for respiratory distress

23. obstructive Sleep Apnea (OSA) : Increased risk of airway collapse during sleep post- extubation Ensure continuous positive airway pressure (CPAP) or Bi-level positive airway pressure (BiPAP) Post- Extubation Management : Oxygen therapy with a nasal cannula or non-invasive ventilation (NIV) Close monitoring for respiratory failure or airway obstruction Pain Management : Avoid opioids if possible (due to respiratory depression risk) Consider regional anesthesia or non-opioid analgesics

24. THANK YOU!