TRACHEAL EXTUBATION AFTER
COMPROMISE OF THE AIRWAY
Protection of the airway with potential encroachment by hemorrhage,
edema, infection, or tumor using an endotracheal tube often engenders uncertainty
at the time of extubation (see Chapter
74
and Chapter 75
).
Airway patency after extubation may not be ensured, and sudden loss of airway may
occur. Reintubation may then be difficult or impossible.
Useful measures that can be taken at the time of extubation include
inspection of the upper airway, directly or with a fiberoptic instrument to detect
residual swelling of the oropharynx or nasopharynx, and occlusion of the endotracheal
tube with cuff deflated. If the patient is able to breathe around the tube in this
way, it is less likely that critical airway compromise will occur after extubation.
If the endotracheal tube is large with respect to the patient's airway, the patient
may not be able to breathe around it, even in the setting of a normal airway. Replacement
of the tube with a smaller one may be accomplished over a rigid introducer. Extubation
over a rigid introducer allows abrupt loss of the airway to be treated immediately
with reinsertion. A nasogastric tube with the bulbous end cut off may be used, but
a more rigid plastic introducer is preferable. Alternatively, a fiberoptic bronchoscope
may be introduced into the endotracheal tube. If the patient is able to breathe
after removal of the tube from the larynx and lower pharynx, direct inspection of
the airway may be accomplished during removal of the fiberoptic instrument.
These measures should be undertaken while someone with the necessary
skills to perform an emergency tracheotomy is available. Before removal of the endotracheal
tube, the patient should be oxygenated with 100% O2
, providing a margin
of safety in the event of loss of airway patency.
