extubation process andy higgs warrington hospitals cheshire uk
TRANSCRIPT
![Page 1: Extubation Process Andy Higgs Warrington Hospitals Cheshire UK](https://reader036.vdocuments.mx/reader036/viewer/2022062421/56649e455503460f94b3abdb/html5/thumbnails/1.jpg)
Extubation Process
Andy Higgs
Warrington Hospitals
Cheshire
UK
![Page 2: Extubation Process Andy Higgs Warrington Hospitals Cheshire UK](https://reader036.vdocuments.mx/reader036/viewer/2022062421/56649e455503460f94b3abdb/html5/thumbnails/2.jpg)
Extubation Process
Extubation is easy?
Is it?
![Page 3: Extubation Process Andy Higgs Warrington Hospitals Cheshire UK](https://reader036.vdocuments.mx/reader036/viewer/2022062421/56649e455503460f94b3abdb/html5/thumbnails/3.jpg)
Extubation Process
RCA: 4th National Audit Project – NAP4Major complications airway management in UK
• Deaths• Brain damage• Sub-glottic access• Unplanned ICU
• 138 anaesthesia cases• 38 extubation (28%)
•Major Complications of Airway Management in the UK•1/9/08 – 31/8/09
•Major Complications of Airway Management in the UK•1/9/08 – 31/8/09
•March 2011•March 2011
![Page 4: Extubation Process Andy Higgs Warrington Hospitals Cheshire UK](https://reader036.vdocuments.mx/reader036/viewer/2022062421/56649e455503460f94b3abdb/html5/thumbnails/4.jpg)
Extubation Process
Difficult extubation – WHY?
![Page 5: Extubation Process Andy Higgs Warrington Hospitals Cheshire UK](https://reader036.vdocuments.mx/reader036/viewer/2022062421/56649e455503460f94b3abdb/html5/thumbnails/5.jpg)
Extubation Process
Difficult extubation – WHY?• Initial cause of difficult intubation is still there• You have traumatised / worsened the airway at intubation
• FRC ↓O2
• CVS ↑CO2
• Post GA ↓GCS ↓pH• Pain Agitated• New airway factors have developed:
oedema, ↓access, bleeding...
‘The Scream.’ Edvard Munch
![Page 6: Extubation Process Andy Higgs Warrington Hospitals Cheshire UK](https://reader036.vdocuments.mx/reader036/viewer/2022062421/56649e455503460f94b3abdb/html5/thumbnails/6.jpg)
Extubation Process
Difficult extubation – WHO?• History difficult intubation / extubation KNOW• Impending airway obstruction / oedema pre-op• Difficult intubation at induction - multiple ≥3 attempts
- alternative techniques FIND
- traumatic intubation• Intra-op airway events inc. 2nd airway device• Airway surgery / trauma • Poor post-op access to or immobility of airway MAKE • Category of surgery – thoracic, neck surgery• Burns FILL• Massive fluid resuscitation• Obesity – OSA BIG
![Page 7: Extubation Process Andy Higgs Warrington Hospitals Cheshire UK](https://reader036.vdocuments.mx/reader036/viewer/2022062421/56649e455503460f94b3abdb/html5/thumbnails/7.jpg)
Extubation Process
Training
Basic Level Training: - explain how to remove tracheal tube and
- describe the associated problems and
- complications
- demonstrate assessment of reflexes
- describe adequate ventilation
• Intermediate Level: NIL• Advanced Level: NIL
• We emphasize intubation but ignore extubation
E Sans-Solachi & J Hadlow. 2010
![Page 8: Extubation Process Andy Higgs Warrington Hospitals Cheshire UK](https://reader036.vdocuments.mx/reader036/viewer/2022062421/56649e455503460f94b3abdb/html5/thumbnails/8.jpg)
Extubation Process
Training
• We emphasize take-off but ignore landing
![Page 9: Extubation Process Andy Higgs Warrington Hospitals Cheshire UK](https://reader036.vdocuments.mx/reader036/viewer/2022062421/56649e455503460f94b3abdb/html5/thumbnails/9.jpg)
Extubation Process
Extubation plan – DAS guideline
![Page 10: Extubation Process Andy Higgs Warrington Hospitals Cheshire UK](https://reader036.vdocuments.mx/reader036/viewer/2022062421/56649e455503460f94b3abdb/html5/thumbnails/10.jpg)
Extubation Process
Extubation plan – DAS guideline in CANADA Nov 2013
![Page 11: Extubation Process Andy Higgs Warrington Hospitals Cheshire UK](https://reader036.vdocuments.mx/reader036/viewer/2022062421/56649e455503460f94b3abdb/html5/thumbnails/11.jpg)
Extubation Process
![Page 12: Extubation Process Andy Higgs Warrington Hospitals Cheshire UK](https://reader036.vdocuments.mx/reader036/viewer/2022062421/56649e455503460f94b3abdb/html5/thumbnails/12.jpg)
Extubation Process
![Page 13: Extubation Process Andy Higgs Warrington Hospitals Cheshire UK](https://reader036.vdocuments.mx/reader036/viewer/2022062421/56649e455503460f94b3abdb/html5/thumbnails/13.jpg)
Extubation Process
![Page 14: Extubation Process Andy Higgs Warrington Hospitals Cheshire UK](https://reader036.vdocuments.mx/reader036/viewer/2022062421/56649e455503460f94b3abdb/html5/thumbnails/14.jpg)
Extubation Process
Step 1: PLAN - assessment1. Assess general condition
2. Assess airway
1. ‘General airway’factors
2. Supra-glottis
3. Glottis and sub-glottis
4. Lower airway
5. Emergency sub-glottic access!
A
![Page 15: Extubation Process Andy Higgs Warrington Hospitals Cheshire UK](https://reader036.vdocuments.mx/reader036/viewer/2022062421/56649e455503460f94b3abdb/html5/thumbnails/15.jpg)
Extubation Process
Step 1: PLAN - assess1. Assess airway – general airway risk factors
2. Supra-glottis – Direct or VL / FO laryngoscopy
Don’t be fooled!
ETTs tell you where larynx is
ETTs stent airway - elevate supra-glottis
Molding
Expect minor oedema to progress
Infection spreads
Ask the surgeon
A
![Page 16: Extubation Process Andy Higgs Warrington Hospitals Cheshire UK](https://reader036.vdocuments.mx/reader036/viewer/2022062421/56649e455503460f94b3abdb/html5/thumbnails/16.jpg)
Extubation Process
Step 1: PLAN - assessAssess glottis & sub-glottis
This is difficult: anatomical & functional
Laryngoscopy Cuff leak
CT
(limitations)
A
![Page 17: Extubation Process Andy Higgs Warrington Hospitals Cheshire UK](https://reader036.vdocuments.mx/reader036/viewer/2022062421/56649e455503460f94b3abdb/html5/thumbnails/17.jpg)
Extubation Process
Step 1; PLAN - assessAssess lower airway
Consider: aspiration
collapse (RMB intubation)
gastric distension (?NGT) ? CXR
pneumothorax
surgical emphysema
Airway trauma
ETT position ? Fibrescopy
Secretions
Blood
A
![Page 18: Extubation Process Andy Higgs Warrington Hospitals Cheshire UK](https://reader036.vdocuments.mx/reader036/viewer/2022062421/56649e455503460f94b3abdb/html5/thumbnails/18.jpg)
Extubation Process
Step 1: PLAN - assessment1. Assess general condition
2. Assess airway
1. General airway factors
2. Supra-glottis
3. Glottis and sub-glottis
4. Lower airway
5. Emergency sub-glottic access!
A
![Page 19: Extubation Process Andy Higgs Warrington Hospitals Cheshire UK](https://reader036.vdocuments.mx/reader036/viewer/2022062421/56649e455503460f94b3abdb/html5/thumbnails/19.jpg)
Extubation Process
![Page 20: Extubation Process Andy Higgs Warrington Hospitals Cheshire UK](https://reader036.vdocuments.mx/reader036/viewer/2022062421/56649e455503460f94b3abdb/html5/thumbnails/20.jpg)
Extubation Process
Step 2: PREPARE - Steroids
• > 12 hours• Hydrocortisone 100mg 6 hourly
![Page 21: Extubation Process Andy Higgs Warrington Hospitals Cheshire UK](https://reader036.vdocuments.mx/reader036/viewer/2022062421/56649e455503460f94b3abdb/html5/thumbnails/21.jpg)
Extubation Process
![Page 22: Extubation Process Andy Higgs Warrington Hospitals Cheshire UK](https://reader036.vdocuments.mx/reader036/viewer/2022062421/56649e455503460f94b3abdb/html5/thumbnails/22.jpg)
Extubation Process
![Page 23: Extubation Process Andy Higgs Warrington Hospitals Cheshire UK](https://reader036.vdocuments.mx/reader036/viewer/2022062421/56649e455503460f94b3abdb/html5/thumbnails/23.jpg)
Extubation Process
![Page 24: Extubation Process Andy Higgs Warrington Hospitals Cheshire UK](https://reader036.vdocuments.mx/reader036/viewer/2022062421/56649e455503460f94b3abdb/html5/thumbnails/24.jpg)
Extubation Process
![Page 25: Extubation Process Andy Higgs Warrington Hospitals Cheshire UK](https://reader036.vdocuments.mx/reader036/viewer/2022062421/56649e455503460f94b3abdb/html5/thumbnails/25.jpg)
Extubation Process
Step 3: Leave the ETT in situ
…for the medical SHO
![Page 26: Extubation Process Andy Higgs Warrington Hospitals Cheshire UK](https://reader036.vdocuments.mx/reader036/viewer/2022062421/56649e455503460f94b3abdb/html5/thumbnails/26.jpg)
Extubation Process
AECs: If patient deteriorates
Railroading the ETT• Any railroading procedure• ‘Mind the gap’ between ETT & stylet
# 11 COOK AEC
Aintree Catheter
# 7.0mm ETT
Higgs et al 2010
![Page 27: Extubation Process Andy Higgs Warrington Hospitals Cheshire UK](https://reader036.vdocuments.mx/reader036/viewer/2022062421/56649e455503460f94b3abdb/html5/thumbnails/27.jpg)
Airway Exchange Catheters
Catheter Catheter Catheter ETT
Fr Length /cm ID / mm ID / mm
8 45 1.6 ≥ 3
11 83 2.3 ≥ 4
14 83 3.0 ≥ 5
19 83 3.4 ≥ 7
Extra Firm Soft Tipped
11 100 2.3 ≥ 4
14 100 3.0 ≥ 5
![Page 28: Extubation Process Andy Higgs Warrington Hospitals Cheshire UK](https://reader036.vdocuments.mx/reader036/viewer/2022062421/56649e455503460f94b3abdb/html5/thumbnails/28.jpg)