Department of Anesthesiology, Washington University in St. Louis, Campus Box 8054, 660 South Euclid Ave, St. Louis, MO 63110, USA.
Anesth Analg. 2013 Feb;116(2):368-83. doi: 10.1213/ANE.0b013e31827ab572. Epub 2013 Jan 9.
Respiratory complications after tracheal extubation are associated with significant morbidity and mortality, suggesting that process improvements in this clinical area are needed. The decreased rate of respiratory adverse events occurring during tracheal intubation since the implementation of guidelines for difficult airway management supports the value of education and guidelines in advancing clinical practice. Accurate use of terms in defining concepts and describing distinct clinical conditions is paramount to facilitating understanding and fostering education in the treatment of tracheal extubation-related complications. As an example, understanding the distinction between extubation failure and weaning failure allows one to appreciate the need for pre-extubation tests that focus on assessing airway patency in addition to evaluating the ability to breathe spontaneously. Tracheal reintubation after planned extubation is a relatively rare event in the postoperative period of elective surgeries, with reported rates of reintubation in the operating room and postanesthesia care unit between 0.1% and 0.45%, but is a fairly common event in critically ill patients (0.4%-25%). Conditions such as obesity, obstructive sleep apnea, major head/neck and upper airway surgery, and obstetric and cervical spine procedures carry significantly increased risks of extubation failure and are frequently associated with difficult airway management. Extubation failure follows loss of upper airway patency. Edema, soft tissue collapse, and laryngospasm are among the most frequent mechanisms of upper airway obstruction. Planning for tracheal extubation is a critical component of a successful airway management strategy, particularly when dealing with situations at increased risk for extubation failure and in patients with difficult airways. Adequate planning requires identification of patients who have or may develop a difficult airway, recognition of situations at increased risk of postextubation airway compromise, and understanding the causes and underlying mechanisms of extubation failure. An effective strategy to minimize postextubation airway complications should include preemptive optimization of patients' conditions, careful timing of extubation, the presence of experienced personnel trained in advanced airway management, and the availability of the necessary equipment and appropriate postextubation monitoring.
气管插管拔管后发生的呼吸系统并发症与较高的发病率和死亡率相关，这表明需要改进这一临床领域的流程。自困难气道管理指南实施以来，气管插管期间发生呼吸不良事件的发生率降低，这支持了教育和指南在推进临床实践方面的价值。准确使用术语来定义概念和描述不同的临床情况，对于促进对气管拔管相关并发症治疗的理解和教育至关重要。例如，理解拔管失败和撤机失败之间的区别，可以使人认识到需要进行预拔管测试，这些测试不仅要评估自主呼吸能力，还要评估气道通畅性。计划性拔管后再次气管插管在择期手术的术后期间是一种相对罕见的事件，据报道，在手术室和麻醉后护理单元再次插管的发生率在 0.1%至 0.45%之间，但在危重病患者中较为常见（0.4%-25%）。肥胖、阻塞性睡眠呼吸暂停、头颈部和上呼吸道大手术以及产科和颈椎手术等情况会显著增加拔管失败的风险，并且经常与困难气道管理相关。拔管失败紧随上呼吸道通畅性丧失之后。水肿、软组织塌陷和喉痉挛是上气道阻塞最常见的机制之一。气管拔管的计划是成功气道管理策略的关键组成部分，尤其是在处理拔管失败风险增加的情况和具有困难气道的患者时。充分的计划需要识别出可能或已经存在困难气道的患者，识别出增加拔管后气道损伤风险的情况，以及了解拔管失败的原因和潜在机制。最大限度减少拔管后气道并发症的有效策略应包括患者情况的预先优化、拔管时机的谨慎把握、受过高级气道管理培训的有经验人员的存在，以及必要设备和适当的拔管后监测的可用性。
