Extubation of the Difficult Airway

It is well known that induction and intubation are periods associated with patient risk. Especially in the case of patients with known or suspected difficult airways, extubation may be associated with similar risk. Therefore, attempts at extubation must be well planned, and preparations for urgent or emergent intubation must be in order prior to removal of an endotracheal tube. Preparations should be made on a case-by-case basis with consideration given to that specific patient’s indications for difficult airway management. Patients at risk for airway obstruction from edema require different techniques and preparations compared with those patients at risk for intracranial hypertension. Advanced preparations should include consideration of the best location for extubation (ie, OR, PACU, ICU), required tools (ie, airway exchange catheter, videolaryngoscope, fiberoptic bronchoscope supraglottic device), and personnel. A thorough plan for emergent reintubation should be considered taking into account the patient’s baseline airway anatomy, previous difficulty of intubation, subsequent airway edema, hemodynamics, and other complicating factors (ie, patient now in a Halo device, jaw wiring). This review contains 5 figures, 6 tables, and 45 references. keywords: airway edema, airway exchange catheter, cricothyrotomy, difficult airway, difficult intubation, extubation, fiberoptic bronchoscopy, retrograde intubation