Module 12
The American Society of Anesthesiologists'
Management
of the Difficult Airway Algorithm
and Explanation-Analysis of the Algorithm
The ASA Algorithm on the
Management of the Difficult Airway
TRACHEAL EXTUBATION OF A PATIENT WITH A
DIFFICULT AIRWAY
Extubation of the patient with a difficult
airway should be carefully assessed and performed and the
anesthesiologist should develop a strategy for safe extubation
of these patients. The Task Force regards the concept of
an extubation strategy as a logical extension of the intubation
strategy. This strategy will depend upon the surgery, the
condition of the patient, and the skills and preferences of the
anesthesiologist. The preformulated extubation strategy
should include a consideration of the relative merits of awake
extubation versus extubation before the return of consciousness;
an evaluation for general clinical factors that may produce an
adverse impact on ventilation after the patient has been
extubated; (e.g., abnormal mental status or gas exchange, airway
edema, inability to clear secretions, inadequate return of
neuromuscular functions) the formulation of an airway management
plan that can be implemented if the patient is not able to
maintain adequate ventilation after extubation; and
consideration of the short-term use of a device that can serve
as a guide for expedited reintubation. This type of device is
usually inserted through the lumen of the tracheal tube and into
the trachea before the tracheal tube is removed. The device may
be rigid to facilitate intubation and/or hollow to facilitate
ventilation.
If tracheal extubation of a patient with a
known difficult airway is followed by respiratory distress, then
reintubation and ventilation may be difficult or impossible.
Thus, the ideal method of extubation is one that permits a
withdrawal from the airway that is controlled, gradual,
step-by-step, and reversible at any time. Extubation over
a jet stylet closely approximates this ideal.
A jet stylet is a small inside diameter
(ID), hollow, semirigid catheter that is inserted into an in
situ ET prior to extubation. After the ET is withdrawn
over the jet stylet, the small-ID hollow catheter may then be
used as a means of ventilation (i.e., the jet function) and/or
as an intratracheal guide for reintubation (i.e., the stylet
function). The jet function may safely allow additional
time to assess the need for the reintubation stylet function
(see Chapter 47).
Miller et al44
formulated an algorithm for intubation of the difficult airway
that incorporates the use of a ventilating tube exchanger and is
suggested as one of several step-wise approaches to difficult
airway management after extubation. The actual and optimal
maneuvers involved in extubation may vary depending on patient
conditions and the skills of the practitioners delivering care.
The necessary equipment that should be immediately available
prior to extubating the difficult airway includes the same
equipment that should be contained in a portable storage unit or
cart for intubation of the difficult airway
(see Chapter 47),
as previously discussed.
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