Tracheal extubation: Landing the plane is as important as takeoff
Myron Yaster MD, Melissa Brooks Peterson MD, and Lynne G. Maxwell MD
I’ve always appreciated the comparison of anesthetic practice to flying a plane. My good friend and colleague Dr. Rob Greenberg, who is a pilot and flying enthusiast, loves to point out: yes, there are many parallels between aviation and anesthesia but there are also important differences. Accidents occur most frequently during takeoff and ascent as well as during descent and landing. These accidents are related to common risk factors: pilot or mechanical errors, poor communication and cognitive errors, failure of crew resource management, etc. But he also points that unlike aviation, when anesthesiologists fail to prepare or fail to remain vigilant, the patient dies and when a pilot errs, he/she dies along with the passengers. And for those of you don’t know, Rob created and runs the website and forum www.PedsAnesthesia.net, which I’d urge you to check out…it is an unbelievably valuable resource to all who practice pediatric anesthesiology.
When we plan our anesthetic management, particularly when dealing with a difficult airway, and make plans A/B/C, we devote most of our time and effort on the induction of anesthesia and intubation, with little time or thought spent on emergence and extubation. Today’s PAAD focuses on emergence and tracheal extubation. I’ve also included one of my favorite articles written a couple of years ago by one of the most important leaders in pediatric anesthesia in Europe, Dr. Francis Veyckemans. Another valuable recent article by Templeton et al. focused on criteria for safe awake extubation in infants and young children in general, not limited to those with difficult airways.1 These articles are “MUST reads” and should be part of your journal clubs and referenced routinely in your M&Ms. Pediatric airway issues were a long-term focus of Ron Litman’s research, including pediatric airway anatomy and patency under various anesthetic agents. One study germane to today’s PAAD focused on airway morphology in children during emergence from propofol anesthesia.2 Myron Yaster MD
Original article:
Andrew D Weatherall, Renee D Burton, Michael G Cooper, Susan R Humphreys. Developing an Extubation strategy for the difficult pediatric airway-Who, when, why, where, and how? Paediatr Anaesth. 2022 May;32(5):592-599. PMID: 35150181
Editorial:
Disma N, Fiadjoe J. Pediatric difficult extubation: The end of the movie matters! Paediatr Anaesth. 2022 May;32(5):590-591. PMID: 35460161
An additional critical article:
Veyckemans F. Tracheal extubation in children: Planning, technique, and complications. Paediatr Anaesth. 2020 Mar;30(3):331-338. PMID: 31769576
“Comprehensive airway management of the pediatric patient with a difficult airway requires a plan for the transition back to a patent and unprotected airway.”3 Planning for anesthetic management should include considerations for emergence and extubation. It is essential to perform a comprehensive risk assessment and develop a strategy that “optimizes the likelihood of safe extubation. This includes team-focused communication of the desired goals, critical steps in the process, and potential responses in the case of failed extubation.”3 Today’s primary article “summarizes extubation of pediatric patients with difficult airways along with one suggested framework to manage this challenging period”.3
In the accompanying editorial, Disma and Fiadjoe suggest that “This article is timely and highlights the critical importance of extubation planning. Extubation can be even more complicated than intubation and is associated with more adverse events”.4 They restate a common theme that we’ve talked about a lot in the PAAD, namely the importance of developing evidence-based pediatric-specific extubation strategies, which currently do not exist.4
As described by Weatherall et al., the adult extubation guidelines promulgated by the Difficult Airway Society “stress the importance of planning, preparation, performance, and post-extubation care”.5 The authors review these adult guidelines, outline the considerations specific to pediatric patients, and present a simple approach with four steps: Risk, Ready, Do, Discharge or R2D2.
“Risk: What risk factors were already present? What are new risk factors since admission? Would more information help? Are there reversible factors (Cardiovascular, Respiratory, Airway, Sedation Level, Strength)?”
“Ready: Who is needed? When should it happen? Where should it happen? With what equipment? Reintubation plan”.
“Do: Any other procedures as part of the extubation? What are the Go/No Go points? Is the first step in respiratory support ready? What are your targets after extubation?”
“Discharge: Who will be looking after the patient? Where will the patient be? With what ongoing respiratory support? Is the plan documented and directly handed over? Are other parts of the plan wrapped up (e.g. analgesia)?”
OK, what are some of the highlights/insights of these steps?
Re: Risk factors: If airway management was unexpectedly difficult on induction, then it may be on emergence and extubation, or to quote Homer Simpson, “DUH”! If airway edema is likely from surgery or initial intubation, consider a leak test with the cuff deflated. Despite decades of folklore, acute steroid administration after intubation may be ineffective for the extubation time period. To be effective, steroids are best given 12-24 hours beforehand, so for most of our patients that would be preoperative administration. Further, the minimal effective dose of dexamethasone may be as low as 0.25 mg/kg rather than 0.5 or higher that is usually used or demanded by ENT surgeons.6,7
Re: Ready: Extra educated hands are necessary, and “experience matters”. This is true not only for the anesthesiologist but for a standby ENT surgeon. Other essential consideration include where to extubate (OR,PACU, or PICU?) and what specialized equipment to have on hand. And, as we’ve discussed previously for the intubation time period, there should be a focus and specific plan for supplemental oxygenation (high flow nasal cannulae) and prevention of atelectasis (extubate from a positive pressure breath or CPAP). Finally, (and similar to preparation on the front end) what is the reintubation plan?
Re: Do: Awake or deep extubation? “Go/No Go”? The whole team should confirm before progressing to extubation. Is there a place for the Cook airway exchange catheter (CAEC)? Surprisingly, although this is commonly used in adult patients, there is little pediatric data supporting its use. One of the few pediatric studies of this subject was written by Lisa Wise-Faberowski (of blessed memory), although the focus of that study was the use of the CAEC for planned extubation of known pediatric difficult airway patients in the PICU.8 This is an obvious area of future research.
Re: Discharge: Of the many issues discussed in these articles, Discharge may be amongst the most obvious targets for formal checklists especially during peer-to peer handover of care. Once the location of discharge is identified. (home, floor, or PICU) safe transfer and handover is an essential communication issue. Handoffs for this type of patient must include emphasis on ongoing oxygenation and ventilation needs, pearls for intervention for supporting oxygenation and ventilation, and a plan for reintubation. A sign out for successful reintubation of a “difficult airway” patient should include what to do as first steps if reintubation is required, who to call and with what urgency, equipment to keep at the bedside 24/7, equipment to gather should reintubation be required, and personnel immediately or less immediately available. This is an obvious task for the SPA’s Quality and Safety Committee, SPA’s checklist gurus and the PediCrisis workgroup. In fact, we noticed when checking the PediCrisis event tab for difficult airway, a pre- or post-extubation checklist is absent. This is a “low hanging fruit” in quality improvement speak, and we urge its development ASAP. Perhaps R2D2 format may be a good basis from which to start, or perhaps another format would be better. What do you think?
Myron Yaster MD, Melissa Brooks Peterson MD, and Lynne G. Maxwell MD
References
1. Templeton TW, Goenaga-Díaz EJ, Downard MG, McLouth CJ, Smith TE, Templeton LB, Pecorella SH, Hammon DE, O'Brien JJ, McLaughlin DH, Lawrence AE, Tennant PR, Ririe DG: Assessment of Common Criteria for Awake Extubation in Infants and Young Children. Anesthesiology 2019; 131: 801-808
2. Litman RS, Weissend EE, Shrier DA, Ward DS: Morphologic changes in the upper airway of children during awakening from propofol administration. Anesthesiology 2002; 96: 607-611
3. Weatherall AD, Burton RD, Cooper MG, Humphreys SR: Developing an Extubation strategy for the difficult pediatric airway-Who, when, why, where, and how? Paediatr Anaesth 2022; 32: 592-599
4. Disma N, Fiadjoe J: Pediatric difficult extubation: The end of the movie matters! Paediatr Anaesth 2022; 32: 590-591
5. Law JA, Duggan LV, Asselin M, Baker P, Crosby E, Downey A, Hung OR, Kovacs G, Lemay F, Noppens R, Parotto M, Preston R, Sowers N, Sparrow K, Turkstra TP, Wong DT, Jones PM: Canadian Airway Focus Group updated consensus-based recommendations for management of the difficult airway: part 2. Planning and implementing safe management of the patient with an anticipated difficult airway. Can J Anaesth 2021; 68: 1405-1436
6. Fiadjoe JE, Nishisaki A, Jagannathan N, Hunyady AI, Greenberg RS, Reynolds PI, Matuszczak ME, Rehman MA, Polaner DM, Szmuk P, Nadkarni VM, McGowan FX, Jr., Litman RS, Kovatsis PG: Airway management complications in children with difficult tracheal intubation from the Pediatric Difficult Intubation (PeDI) registry: a prospective cohort analysis. Lancet Respir Med 2016; 4: 37-48
7. McCaffrey J, Farrell C, Whiting P, Dan A, Bagshaw SM, Delaney AP: Corticosteroids to prevent extubation failure: a systematic review and meta-analysis. Intensive Care Med 2009; 35: 977-86
8. Wise-Faberowski L, Nargozian C: Utility of airway exchange catheters in pediatric patients with a known difficult airway. Pediatr Crit Care Med 2005; 6: 454-6
5. Wise-Faberowski L, Nargozian C. Utility of airway exchange catheters in pediatric patients with a known difficult airway. Pediatr Crit Care Med. 2005; 6:454-6