A prospective study of the safety of tracheal extubation using a pediatric airway exchange catheter for patients with a known difficult airway.
STUDY OBJECTIVE: To determine the usefulness of routinely inserting a hollow airway exchange catheter (jet stylet) prior to tracheal extubation of adult patients with risk factors for difficult tracheal intubation. DESIGN: Prospective, 1-year study of 40 consecutive patients undergoing mechanical ventilation who had one or more risk factors for difficult tracheal reintubation. SETTING: Surgical ICU of a tertiary university medical center. INTERVENTIONS: Study patients at risk for difficult tracheal reintubation were extubated using a No. 11 Cook airway exchange catheter (CAEC). Following tracheal extubation, the CAEC was secured, and humidified oxygen was insufflated through the central lumen (2 to 8 L/min) for a minimum of 4 h, during which oxyhemoglobin saturation (SpO2) and respiratory frequency were monitored. Stridor or other signs of respiratory difficulty were also assessed. The CAEC was removed when it became clinically apparent that the need for tracheal reintubation was unlikely. When patients failed to respond to tracheal extubation, the CAEC was used to facilitate reintubation of these difficult airways. RESULTS: Respiratory distress necessitating tracheal reintubation occurred in 3 of 40 patients (8%). One patient failed to respond to tracheal extubation twice. None of the patients developed oxyhemoglobin desaturation (SpO2 <90%) before or during tracheal reintubation. All four reintubations were accomplished during the first attempt using the CAEC as a stylet. The CAEC was kept in the trachea for a mean duration of 9.4 h. There were no adverse events documented. CONCLUSIONS: The No. 11 CAEC is a useful and effective tool for giving patients a trial of extubation. Administration of oxygen through the CAEC diminishes the potential for hypoxia while maintaining the ability to reintubate the trachea, especially when reintubation might prove challenging. Previous data suggest that the CAEC is rigid enough to facilitate tracheal reintubation in adults; this was confirmed in the three patients in our study who required tracheal reintubation. The risk of aspiration, barotrauma, or other airway trauma during prolonged placement of the CAEC appears to be low (zero incidence in 40 patients in this study), and use of the No. 11 CAEC appeared to be safe. Since oxygen can be delivered through the CAEC, it may provide a means to safely evaluate an airway during a trial of extubation, ie, a reversible extubation. Finally, oxygen administration through the CAEC may obviate the need for facemask or nasal cannula following tracheal extubation.