Developing an Extubation strategy for the difficult pediatric airway—Who, when, why, where, and how?

Abstract

Comprehensive airway management of the pediatric patient with a difficult airway requires a plan for the transition back to a patent and protected airway. Multiple techniques are available to manage the periextubation period. Equally important is performing a comprehensive risk assessment and developing 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. This review summarizes extubation of pediatric patients with difficult airways along with one suggested framework to manage this challenging period.

Recommendations from the Brazilian Society of Anesthesiology (SBA) for difficult airway management in pediatric care

“…Children with difficult airways are at high risk of extubation failure; thus, the anesthesiologist must be ready to respond and optimize oxygenation or ventilation. 58 Children presenting a difficult airway should be extubated awake. Observation of at least three of the following signs suggests awake extubation will be safe: contraction of facial muscles (grimacing), spontaneous movement (not to be confused with reflex cough), spontaneous eye opening, spontaneous breathing showing tidal volume > 5 mL.kg −1 and conjugate gaze.…”

“…The equipment required for extubation and the strategy for reintubation must be prepared, including anesthesia equipment or a bag-valve-mask device, oropharyngeal and nasopharyngeal cannulas, material for epinephrine nebulization for post-extubation stridor treatment and oxygenation equipment for post-extubation support, such as noninvasive ventilation devices or high-flow catheters. 58 …”

Trygg ekstubasjon av barn

“…Mye fokus og energi går med til planlegging av intubasjoner, og vi har et bredt utvalg teknikker og hjelpemidler for å overta luftvei og etablere trygg ventilasjon av pasienter i generell anestesi. Mindre oppmerksomhet er viet ekstuba sjon, og den kritiske overgangen fra sikret luftvei til spontan respirasjon uten assist anse (2).…”

“…Tidligere definisjoner har tradisjonelt tatt utgangspunkt i pasienter som er eller har vaert vanskelige å intubere. Weatherall et al (2) foreslår følgende i sin publikasjon:…”

Pediatric difficult extubation: The end of the movie matters!

“…In addition, many algorithms and clinical studies examine difficult tracheal intubation and its consequences, while few focus on extubation 1 . In the current issue of pediatric anesthesia, Weatherall et al 2 . published an educational review on "Developing an extubation strategy for the difficult pediatric airway".…”