Remembering the classics : The Art of Extubation
Francis Veyckemans MD
We’ve all been there…you are sitting in an M&M conference in which one of your colleagues or students presents a complication following extubation. You ask yourself (usually under your breath) “what were they thinking”? As we’ve discussed in previous PAADs, “landing the plane is as important as taking off”. One of my personal favorite articles on this topic and one that I consider a MUST read for all of you and your trainees is by Dr. Francis Veykemans.1 I asked him to review the article for the PAAD and to give us the historical context of how he came to write it. Myron Yaster MD
Original review article
Veyckemans F. Tracheal extubation in children: Planning, technique, and complications. Paediatr Anaesth. 2020 Mar;30(3):331-338. PMID: 31769576
It all started with the 9th International Symposium on the Pediatric Airway (ISPA), organized by Walid Habre and David Polaner in Geneva in June 2019. Many of the biggest names in pediatric anesthesia were part of the Faculty, including, to name only a few, Viviane Nasr, David Polaner, Tom Engelhardt, John Fiadjoe, Tino Greif, Nicola Disma, Patrick Schoettker, and me. Indeed, I was surprised to have been invited to contribute. The subject was: “Critical assessment of extubation criteria/extubation failure”.
I confess that this theme looked very complex to me and I therefore choose to rather focus on extubation itself because it is not described in detail in most textbooks, it is rarely presented in meetings and, except for laryngospasm which is one of its possible complications, it is almost impossible to include in a simulation scenario. Moreover, this is one of my preferred topics of staff meetings and bedside teaching for trainees. Finally, as always when preparing a lecture on a clinical topic, this was a good opportunity to re-check the scientific evidence supporting habits generally acquired during the clinical training.
In my review, it became clear that extubation is a dangerous part of anesthesia and is similar to aviation where most incidents occur during landing. For example, in the European APRICOT study, the incidence of laryngospasm, bronchospasm and aspiration was greater during extubation and awakening than during induction.2 From a physiologic point of view, the lecture was a good opportunity to remind:
- 1) the differential effects of all general anesthetics, whether inhalational or IV, on the tone of the airway muscles: the diaphragm is the most resistant and the genioglossus is the most sensitive,3-6 explaining why upper airway obstruction can still occur when thoracic movements are back to normal;
- 2) the importance of the glottic brake in neonates and infants and why some CPAP should be applied by mask to act as a pneumatic stent immediately after extubation in this population as well as in any child at risk for obstructive apnea (midface hypoplasia, micrognathia, OSAS)
Moreover, awake and deep extubation were compared, and whether extubation should be performed in the OR or PACU was briefly discussed. Other aspects were solely based on clinical experience such as the way to transition from controlled to spontaneous ventilation or the best time for tracheal tube removal during the respiratory cycle, ie the end of inspiration without applying any suction. Some tricky situations, their diagnosis and treatment were also described such as using Head’s paradoxical reflex (the reverse of the Hering-Breuer reflex during a few weeks after birth)7 to restart spontaneous breathing in a neonate who becomes apneic after extubation or the use of IV lidocaine in case of cough. Finally, the successful use of the Cook airway exchange catheter in case of possible difficult reintubation was also described.8
Because of the high scientific level of the meeting, some participants who were part of the Editorial Board of the journal Pediatric Anesthesia suggested to its Editor in Chief, Andrew Davidson, to invite the presenters to make a paper out of their oral presentation. Most accepted with enthusiasm. This is how a presentation ended up as a publication.
References :
1. Veyckemans F. Tracheal extubation in children: Planning, technique, and complications. Paediatric anaesthesia. Mar 2020;30(3):331-338. doi:10.1111/pan.13774
2. Habre W, Disma N, Virag K, et al. Incidence of severe critical events in paediatric anaesthesia (APRICOT): a prospective multicentre observational study in 261 hospitals in Europe. Lancet Respir Med. May 2017;5(5):412-425. doi:10.1016/s2213-2600(17)30116-9
3. Ochiai R, Guthrie RD, Motoyama EK. Effects of varying concentrations of halothane on the activity of the genioglossus, intercostals, and diaphragm in cats: an electromyographic study. Anesthesiology. 1989 1989;70(5):812-816. Not in File.
4. Crawford MW, Arrica M, Macgowan CK, Yoo SJ. Extent and localization of changes in upper airway caliber with varying concentrations of sevoflurane in children. Anesthesiology. Dec 2006;105(6):1147-52; discussion 5A. doi:10.1097/00000542-200612000-00014
5. Litman RS, Weissend EE, Shrier DA, Ward DS. Morphologic changes in the upper airway of children during awakening from propofol administration. Anesthesiology. 3/2002 2002;96(3):607-611. Not in File.
6. Mahmoud M, Radhakrishman R, Gunter J, et al. Effect of increasing depth of dexmedetomidine anesthesia on upper airway morphology in children. Paediatric anaesthesia. Jun 2010;20(6):506-15. doi:10.1111/j.1460-9592.2010.03311.x
7. Widdicombe J. Henry Head and his paradoxical reflex. J Physiol. Aug 15 2004;559(Pt 1):1-2. doi:10.1113/jphysiol.2004.065367
8. Wise-Faberowski L, Nargozian C. Utility of airway exchange catheters in pediatric patients with a known difficult airway. Pediatric critical care medicine : a journal of the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies. Jul 2005;6(4):454-6. doi:10.1097/01.Pcc.0000163739.82584.C6