Extubation of the Difficult Airway: An Algorithmic Approach

The difficult airway has been defined as a “clinical situation in which a conventionally trained anesthesiologist experiences difficulty with mask ventilation of the upper airway, tracheal intubation, or both.” Given the potentially lifethreatening consequences, the American Society of Anesthesiology has developed an airway algorithm that focuses on establishing an airway, generally for the induction of anesthesia. However, there is no algorithm on how to safely transition from an established airway back to the normal, natural airway. Up to 0.19 percent of patients can require reintubation in the post anesthesia recovery unit, with the known difficult airway at greater risk in these settings for failed reintubation. Because of this, there has been recognition of the need for guidelines in the form of an algorithm to deal with extubation in these patients. To fill this current need, we propose the following difficult to intubate patient extubation algorithm for use in the operating room setting.