Some patients are extubated on the table, others in recovery
and still others in the intensive care unit, sometimes even
after several days. If you expect that a prolonged period of
intubation will follow postoperatively, select a suitable non-irritant
tube for starting the case.
In general, it is better to extubate the patient yourself at
the end of surgery, on the table when he or she is fully awake,
with good suction and oxygenation and under controlled conditions.
You can also monitor the airway, breathing and vital reflexes
in the immediate post-extubation period. If you have a pulse
oximeter connected, it must not be removed until the patient
has been extubated and remains well oxygenated on room air.
Self extubation by the patient might cause some damage to the
larynx as the cuff will not be deflated and there may also
be secretions in the pharynx that normally would have been
sucked away. However, self extubation is usually a harmless
event and shows at least that the patient is awake and has
good muscle power. The LMA is sometimes taken out in theatre
with suction or sometimes left for the patient himself to pull
out when fully awake.
When to leave the endotracheal tube in place
Always bear in mind that an tracheal tube left in place for
several hours has the potential to become blocked. This will
happen more quickly if the tube is small, there are secretions,
pus or blood in the lungs or if nursing care is inadequate.
As a general rule, you can expect any tracheal tube to become blocked
within 24 hours.
A blocked tracheal tube = a dead patient.
Situations when you should leave the tracheal tube in place
or delay extubation include:
with potential airway problems such as major maxillofacial
surgery or trauma, large thyroidectomies or other
swelling in the airway may sometimes be left intubated
for the first overnight period in case there is
swelling that might cause airway obstruction
in advance whether to leave the tube in and give
a sedative and opiate analgesic so that it is tolerated
otherwise the patient’s coughing or attempts
to self-extubate will cause more difficulties
than intubation solves
unstable patients: very sick patients from haemorrhage
or sepsis who:
not fully recover
cardiovascular collapse in the postoperative period
patients who might need ventilation
who do not wake up as planned:
general, do not extubate an unconscious patient
after surgery or
one who shows no cough reflex when moving the tube in the trachea
until the patient is breathing (not breath-holding
the tube) and shows a gag reflex and, ideally, opens his or her eyes.
All emergency cases have potentially full stomachs. At the end of surgery,
there should be a nasogastric tube in place; the stomach may, in any case,
have been emptied during the operation. An orogastric tube is very easy to
pass under anaesthesia, but further intestinal contents reflux into the stomach and
may regurgitate at extubation.
Neonates are at special risk for apnoeic attacks in the hours
and days postoperation. A neonatal ventilator and the necessary
postoperative care are unlikely to be available. The anaesthetist
may choose to leave the neonate intubated so that the nursing
staff can hand ventilate when required. On the other hand,
it is common in a neonatal emergency for there to be secretions
in the chest which will thicken in the postoperative period
and block a size 3 tube very easily. The choice is not easy.