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Chapter: Clinical Anesthesiology: Anesthetic Management: Airway Management

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Techniques of Extubation

Most often, extubation should be performed when a patient is either deeply anesthetized or awake.

TECHNIQUES OF EXTUBATION

Most often, extubation should be performed when a patient is either deeply anesthetized or awake. In either case, adequate recovery from neuromus-cular blocking agents should be established prior to extubation. If neuromuscular blocking agents are used, the patient has at least a period of controlled mechanical ventilation and likely must be weaned from the ventilator before extubation can occur.

Extubation during a light plane of anesthe-sia (ie, a state between deep and awake) is avoided because of an increased risk of laryngospasm. The distinction between deep and light anesthesia is usually apparent during pharyngeal suctioning: any reaction to suctioning (eg, breath holding, cough-ing) signals a light plane of anesthesia, whereas no reaction is characteristic of a deep plane. Similarly, eye opening or purposeful movements imply that the patient is sufficiently awake for extubation.

Extubating an awake patient is usually asso-ciated with coughing (bucking) on the TT. This reaction increases the heart rate, central venous pressure, arterial blood pressure, intracranial pres-sure, intraabdominal pressure, and intraocular pressure. It may also cause wound dehiscence and increased bleeding. The presence of a TT in an awake asthmatic patient may trigger bronchospasm. Some practitioners attempt to decrease the likeli-hood of these effects by administering 1.5 mg/kg of intravenous lidocaine 1–2 min before suctioning and extubation; however, extubation during deep anesthesia may be preferable in patients who cannot tolerate these effects (provided such patients are not at risk of aspiration and/or do not have airways that may be difficult to control after removal of the TT).

Regardless of whether the tube is removed when the patient is deeply anesthetized or awake, the patient’s pharynx should be thoroughly suc-tioned before extubation to decrease the potential for aspiration of blood and secretions. In addition, patients should be ventilated with 100% oxygen in case it becomes difficult to establish an airway after the TT is removed. Just prior to extubation, the TT is untaped or untied and its cuff is deflated. The tube is withdrawn in a single smooth motion, and a face mask is applied to deliver oxygen. Oxygen delivery by face mask is maintained during the period of transportation to the postanesthesia care area.

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