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A 75-year-old man with ankylosing spondylitis and previous C2–T12 spinal fusion presented with a C4–C5 chance fracture after a fall (Figure 31.1). While neurologically intact, this unstable fracture required emergency fixation. He had a predicted difficult airway due to severe fixed kyphosis with his chin approximating his chest and was Mallampati IV on inspection. Awake orotracheal intubation using flexible bronchoscope was performed with difficulty due to marked cervical kyphosis but was successful after several attempts. Spinal stabilization surgery in prone position was uneventful. Postoperatively, he was transferred to the intensive care unit (ICU), intubated and sedated, to permit careful extubation planning.


This computed tomography image of the patient shows a chance fracture at C4–C5 (arrow) and the anatomic distortion of the patient’s spine due to ankylosing spondylitis and previous spinal fusion. The fixed position between the patient’s jaw and chest can be seen here as a radiologic predictor of difficult airway.


What Are the General Strategies for Optimizing Successful Extubation?

Because extubation failure is increasingly recognized as a cause of airway management-related morbidity and mortality, contemporary guidelines now address this critical component of airway management.1–3 In general, tracheal extubation should be performed thoughtfully, intentionally, and electively, allowing for sufficient time to identify patients at risk of extubation failure and to make contingency plans accordingly. It is important to remember that the overarching goal during extubation is to ensure adequate oxygenation by any means necessary.

General strategies for approaching tracheal extubation are as follows:

  • 1) Determining appropriateness for low-risk extubation. The degree of mechanical ventilatory support should be weaned as early as possible after the initial indication for intubation has resolved, when the patient is hemodynamically stable with metabolic derangements addressed. Oxygenation should be adequate with a minimized fraction of inspired oxygen. Additionally, the patient should be awake, cooperative, and have adequate return of strength with full reversal of neuromuscular blockade;

  • 2) Denitrogenation for 3 to 5 minutes to optimize physiologic reserve and apnea tolerance;

  • 3) Placements of a bite block to prevent occlusion of endotracheal tube (ETT) and possible resultant negative pressure pulmonary edema;

  • 4) Suctioning of the oropharynx, ideally under direct visualization to minimize risk of trauma and exacerbation of airway edema; and,

  • 5) Mitigating the risk of exaggerated laryngeal reflexes. Breath holding, coughing, bucking, and laryngospasm are all possible consequences of stimulating the airways during tracheal extubation. They all have the potential to exacerbate physiologic compromise from increased arterial blood pressure, bleeding from surgical sites, or obstruction of the airway. Strategies to minimize these reflexes should be considered, including the use of opioids, dexmedetomidine, and topical lidocaine via the ETT.3,4

What Is Failed Extubation?

Extubation failure occurs when the patient ...

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