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Post by Andy Benson on Mar 30, 2017 10:51:19 GMT -5
Thanks Katya for recommending the article. 1. Like many of those who responded, I didn't realize the technique had a specific name nor do I ever remember using it. I will add this maneuver to the other options that I consider and use for extubating a difficult airway. Personally, I would be somewhat cautious to use it...I would be worried about complications or losing the airway. I think it would depend on the circumstance. It is also important to consider the ease or difficulty of mask ventilation in the beginning. If it was an easy mask in the beginning then hopefully it would be true at the end. 2. Preparation is the key. I always over prepare and am ready for reintubation at any time. I have never been mad at myself for being overly prepared. Can you be overly prepared? Is there a such thing?
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kty67
New Member
Posts: 22
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Post by kty67 on Mar 31, 2017 14:24:24 GMT -5
Thank you everybody for all your answers. I learned few new tricks. I liked the Ben's stile to insert exchanger before extubation.
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Post by krechti1 on Mar 31, 2017 16:19:18 GMT -5
1) I think the Bailey maneuver introduces an additional, unnecessary step of inserting an LMA. If I do not want the patient to cough and buck on wakeup, I do one of 2 things: First, and most commonly, I run a remifentanil and propofol infusion. After the drips have been turned off, and once the patient demonstates a regular respiratory rate and adequate tidal volume, I extubate. There is no stage 2 without the use of gas, so this is neither a deep or awake extubation, but rather somewhere between. I have never had a problem with this, and the patient usually opens their eyes very quickly, if not before, I pull the tube. The second way is a deep extubation, and insertion of either nasal or oral airway if needed until pt wakes up. I prefer the first method, because it is almost always a smooth extubation and pt is usually awake upon entering pacu. With either of these techniques, it is very important to suction the oropharynx before extubation, as any secretions can cause a laryngospasm
2) I think all the different types of difficult airway equipment have been mentioned above, but I wanted to emphasize the importance of remembering the LMA is a backup in an emergency, if you do have a truly difficult intubation. Also, with the advent of the C-Mac, glidescope, etc.. difficult intubations are not nearly as common as they used to be. One down side with that is that it is easy to lose your skills of fiberoptic intubation. Therefore, it may be helpful to do an elective fiberoptic on occasion so that when we do need to use this technique, we still have this skill.
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Post by Soo-Ok Kim on Mar 31, 2017 18:49:02 GMT -5
I am not sure Bailey maneuver is really useful for difficult airway since you might want to wake up pt fully for that. LMA is a fancy form of mask and doesn't protect airway, not different from extubating with oral airway, in my opinion. One of things I would emphasize is, in addition to necessary preparation, that the importance of clear communication between surgical team and anesthesia team. I have experienced twice so far the communication failure regarding the airway condition ended with emergent cricothyroidomy and unnecessary tracheostomy. I also would like to point out not to undermine the effective DL technique. I observed that Level 1 case with facial trauma in OR (assumed difficult airway due to trauma) was easily intubated with simple DL after multiple awake fibroptic intubation attempts. I understand technology is great thing if you can utilize it for the right moment. However, we also build our skills and confidence, not too depend on equipment.
Soo-Ok
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Post by belinda on Mar 31, 2017 18:51:43 GMT -5
We seem to use this approach in ENT fairly often after DL's/rigid pulmonary interventions when done with the rigid scope or ETT's and then we place an LMA for wake up. I have never heard the term so now I know The new C-mac towers with the FO option seem to work well and reduce the amount of "stuff" you need in the room for a difficult airway. Having ENT available may also be part of your plan in the case of a known difficult airway.
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Post by Rouchon on May 3, 2017 12:49:24 GMT -5
Good afternoon. A nice article, thank you. I have not employed the Bailey technique as described, especially to do a direct laryngoscopy, place a classic LMA behind an ETT, then remove the ETT to emerge on the LMA. I have seen deep extubation- after ensuring no response to ETT suctioning after the patient has been reversed from muscle relaxant- and placement of an LMA which the thought of a smoother wake up. In practice with a provider used to the Bailey technique and experience, it could be effective. I think the key was meticulous attention to detail in positioning of the LMA. Even with a deflated LMA cuff, good seal and placement, movement of soft tissue during extubation could loose the integrity of the LMA seal. Classic LMAs however are more compliant and more forgiving than the Unique LMA I found. So, in the event I wanted to employ this technique, I'd proceed as done before, ETT out, LMA in.
In prepping a difficult airway case, how to prepare would depend on the clinical scenario, as there's so many circumstances and limitations.
Plan A Awake FOB would be the go to with true difficult airway (scleroderma, head and neck radiation, unstable C/spine, longstanding RA, any condition where sedation would be concerning preop.) and IF secretions won't block view (i.e. blood in airway from trauma, NPO not confirmed- and sedation could lead to aspiration). Plan B, if no full stomach/GERD is controlled and awake FOB not necessary- but standard ETT still an issue-, could proceed with GA/LMA+aintree FOB, using aintree for ETT placement as exchange catheter. Plan C, if that fails, i.e. can't position an LMA because the pharnynx is too narrow, acutely angled, or full stomach concern and GA/LMA is contraindicated, could proceed with RSI+Bullard scope or RSI+C MAC D blade if the airway is anterior Plan D, if that fails can't intubate, can't ventilate- call for help, place every possible airway (double barrel nasal trumpet, oral airway- if can't use LMA, adding CPAP, Rxs ineffective? Assess, why? Wake up patient/trach, maybe?
Preparation: Depending on technique After equipment is collected, 1. an antisialogogue (if allowed) is helpful, 2. ensure functioning of the fiberoptic (light source works w/o using tape to hold it together), 3. correct length of the aintree (not too long for scope) is ascertained, 4. anti-fog is placed to scope, 5. airway prep is done for FOB (if topically done, should be done in the OR due to the rapid diminuition of lidocaine neb), 6. For Bullard scope, ensure all parts connected (especially the plastic triangular cover- has been found in the airway due to accidental detachment from the scope), lubricate the ETT well with the attached stylet, and ensure proper focus on handle, 7. For GA+LMA+aintree, it's helpful to cut off the plastic lined area at the opening of the LMA to allow easier passage with the fiberoptic; make sure you have the correct elbow for the LMA to circuit attachment to allow ventilation during FOB via the LMA. TIVA during airway placement is typically employed at this time
Most important, every scenario requires communication with the team, if it looks beyond my clinical experience/ability, immediately hand over to next provider before any airway trauma to make an optimal working environment for next attempt.
Lastly back to the article regarding extubation for difficult airways, optimal preparation can make it easier, i.e. correct neuromuscular reversal given, optimal analgesia given (if allowed, return to spont. ventilation and titrate to effect), suction for less laryngospasm risk, extubate in sitting position- if allowed- and apply CPAP until patient safe. If using deep extubation technique, apply all the above and once tidal volumes regular, deep (5ml/kg), remove ETT with suction, place airways and wake up patient; fingers crossed without issue.
It doesn't work for everyone, but there are some options.
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Post by oyoguhk on May 20, 2019 5:02:27 GMT -5
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Post by ivuucasi on May 20, 2019 6:39:50 GMT -5
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