Extubation of the Difficult Airway and Extubation Failure

Copyright © 2013 International Anesthesia Research Society DOI: 10.1213/ANE.0b013e31827ab572 It is increasingly recognized that extubation of the difficult airway is a situation at risk of life-threatening complications, whereas criteria and guidelines to guide safe practices in airway management at extubation are still based on limited scientific evidence and of unproven effectiveness in improving outcomes.1,2 Several authors suggest that the dissemination of the difficult airway algorithm by the American Society of Anesthesiologists (ASA) in 1993 and 2003 and the increased availability of advanced airway management tools and techniques may have contributed to a reduction in the number of severe outcomes related to tracheal intubation.3 On the contrary, over the same period, the rate of severe airway-related adverse events occurring in the operating room (OR) or in the recovery area after tracheal extubation has not changed.1,2,4,5 The recently published Report of the Fourth National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society (NAP4) identified serious airway complications occurring during anesthesia, in the intensive care unit (ICU), and in the emergency department in the United Kingdom over a 1-year period, and pointed out that one-third of the events occurred at extubation or in the recovery room. Poor airway management strategies, inadequate assessment of risk factors for airway difficulty, and overall failure to plan were frequent contributing factors to adverse events.6,7,a These results confirm the importance of developing preplanned strategies for extubation of the difficult airway to improve patient safety and outcomes, as suggested by the ASA Task Force on Management of the Difficult Airway since 19938,9 and, more recently, by an updated analysis of the ASA Closed Claims database.5 Substantial lack of adequate scientific evidence has prevented the creation of evidence-based tracheal extubation guidelines. In January 2012, the Difficult Airway Society (DAS) in the United Kingdom, acknowledging the absence of any large randomized controlled trial of extubation practices, released a set of guidelines for the management of tracheal extubation, mainly based on expert opinions. The goal of the society is to provide clinicians with pragmatic guidelines Extubation of the Difficult Airway and Extubation Failure