CASE REPORT: The unrecognised difficult extubation: a call for vigilance

Abstract

SummaryTracheal extubation remains a critical and often overlooked period of difficult airway management. A 66-year-old man, scheduled for C5-C7 anterior fusion, with an easy view of the vocal cords, presented with a sublaryngeal obstruction that required a reduced tracheal tube size. Despite correct tube placement, intra-operative ventilation remained difficult. At the end of surgery a pulsatile tracheal compression was fibreopticially observed above the carina. After discussion with the attending otolaryngologist, neuromuscular blockade was antagonised and the patient was able to maintain normal minute volumes while spontaneously ventilating. With the otolaryngologist present, and with the patient conscious, the trachea was successfully extubated over an airway exchange catheter. A subsequent CT scan revealed an impingement of the trachea by the innominate artery and a mildly ectatic ascending and descending aorta that, in conjunction with tracheomalacia and neuromuscular blockade, could explain the observed signs and symptoms.

Extubation of the Difficult Airway: An Algorithmic Approach

“…Current prediction models for difficult airways have proven useful for the management of the difficult intubation, however, there is no evidence that they are useful for the prediction of difficult extubation. Given the numerous challenges regarding difficult extubation, a recent case report (with several additional supporting case reports) has specifically recognized the need for guidelines and recommendations in the form of an algorithm to deal with extubation in these patients [1][2][3][4][6][7][8][9].…”