Management
of
the Post Extub)ation Airway
in Patients with Intermaxillary Fixation Willeam A. Choby DMD* Kwong Ann Ung MD** Adel R. Abadir MD***
Duiring emergence from general anesthesia, a primaiy concern is the assuri-ance of adequate ventilation.
This can be compromised by a variety of situiations, suich as 1) the depression of the respiratory center by anesthetic agents, 2) the residuial effect of muiscle relaxants, 3) laiyngeal spasm or edema, 4) enlargement of the tonguie, pharynx or laiynx secondaiy to surigical or anesthetic manipuilation, 5) obstruiction by a posteriorly displaced tonguie, foreign bodies, vomitus, blood clot or secretions. The uise of intermaxillary fixation in olal and maxillofacial surigery makes nasotracheal intuibation mandatory. However, the presence of the fixation complicates the problems of extuibation becauise immediate access to the airway is not readily available. Attempts to suction or re-intuibate these patients is essentially a blind techniquie, the hazards of which are well uinderstood. An excessive amouint of time may be requiired to remove the fixation for direct visualization of the laiynx for emergency activity. This may prove to be costly in terms of hypoxia. A relatively safe techniquie for extuibation in the presence of intermaxillary fixation is as follows: After the uisual inhalation of 100% oxygen prior to extubation and while the nasotracheal tuibe is still in position an appropriately sized French catheter is introduced into the Ilumen of the tube for suctioning of secretions. (figuire 1) Once clear of secretions, the suiction is replaced by the insufflation of oxygen throuigh the catheter. The catheter is then advanced juist beyond the bevel of the tuibe. The ciff is deflated and the tube is slowly withdrawn from the trachea over the remaining catheter. The tuibe is retained in the nasophaiynx to
serve as an airway. (figure 2) At this time, the patency of the airway and the adequiacy of ventilation can be assessed. If difficuilty is not encountered and the patient is breathing adequiately, the catheter can also be removed. When, however, the patient is not breathing sufficiently or is obstruieted the catheter inside the trachea serves to 1) oxygenate by continuiouisly instifflating oxygen throuigh the catheter 2) to serve as a guiide for re-intuibation withouit removing the dental fixation.
*Former Chief Resident, Dept of Dental and Oral Stirgery, **Attending Anesthesiologist
***Director,
Dept of Anesthesiology
Brookdale Hospital Medical Center Linden Blvd and Rockaway Pkwy Br-ooklyn, New Yor-k 11212
124
Fig 1. Catheter introduced through endotracheal tube for suctioning airway at end of procedure. ANESTHESIA PROGRESS
With the preliminary inhalation of puire oxygen before extuibation and the continuiouis administration of oxygen via the catheter, there is little difficulty in maintaining an adequiate arterial 02 level. This techniquie has its own limitation in that where exchange is impossible, total gaseous retention will cauise the arterial C02 to rise within the ranges of 3 to 6 torr/min.1 However, the anesthesiologist or oral suirgeon has uip to a ten minuite safety period with apneic mass movement oxygenation before the arterial C02 begins to cause significant respiratory acidosis. This time is usuially more than adequate to assess the adequacy of ventilation and to institute appropriate measuires, incluiding the removal ofthe fixation. In the event that re-intuibation is necessary, the catheter will serve to guiide the nasotracheal tuibe back into the trachea in most instances. SUMMARY: A techniquie has been presented which provides an added margin of safety in managing the extubation of patients with intermaxillary fixation. An indwelling catheter inside the trachea with continuious insufflation of oxygen can maintain adequiate arterial 02 levels if obstruiction occuirs and it concuirrently provides a guide for re-intuibation, shouild this be deemed necessary.
Fig 2. With cuff deflated, the endotracheal tube is removed leaving the catheter in place for oxygen insufflation and as a guide should reintubation become necessary.
REFERENCE:
Nuinn JF Applied Respiratory Physiology 2nd Ed (1977) Buitterworths p. 358.
ANNOUNCEMENT International Symposium on Sedation and Anesthesia in Dentistry March 30-April 4, 1980 Sponsored by the N. B. Jorgensen Memorial Library Loma Linda University Place: San Diego Hilton Hotel For further information, write: Gerald D. Allen, M.D. Department of Anesthesiology UCLA School of Medicine Los Angeles, California 90024
SEPTEMBER-OCTOBER 1979
125
of
the Post Extub)ation Airway
in Patients with Intermaxillary Fixation Willeam A. Choby DMD* Kwong Ann Ung MD** Adel R. Abadir MD***
Duiring emergence from general anesthesia, a primaiy concern is the assuri-ance of adequate ventilation.
This can be compromised by a variety of situiations, suich as 1) the depression of the respiratory center by anesthetic agents, 2) the residuial effect of muiscle relaxants, 3) laiyngeal spasm or edema, 4) enlargement of the tonguie, pharynx or laiynx secondaiy to surigical or anesthetic manipuilation, 5) obstruiction by a posteriorly displaced tonguie, foreign bodies, vomitus, blood clot or secretions. The uise of intermaxillary fixation in olal and maxillofacial surigery makes nasotracheal intuibation mandatory. However, the presence of the fixation complicates the problems of extuibation becauise immediate access to the airway is not readily available. Attempts to suction or re-intuibate these patients is essentially a blind techniquie, the hazards of which are well uinderstood. An excessive amouint of time may be requiired to remove the fixation for direct visualization of the laiynx for emergency activity. This may prove to be costly in terms of hypoxia. A relatively safe techniquie for extuibation in the presence of intermaxillary fixation is as follows: After the uisual inhalation of 100% oxygen prior to extubation and while the nasotracheal tuibe is still in position an appropriately sized French catheter is introduced into the Ilumen of the tube for suctioning of secretions. (figuire 1) Once clear of secretions, the suiction is replaced by the insufflation of oxygen throuigh the catheter. The catheter is then advanced juist beyond the bevel of the tuibe. The ciff is deflated and the tube is slowly withdrawn from the trachea over the remaining catheter. The tuibe is retained in the nasophaiynx to
serve as an airway. (figure 2) At this time, the patency of the airway and the adequiacy of ventilation can be assessed. If difficuilty is not encountered and the patient is breathing adequiately, the catheter can also be removed. When, however, the patient is not breathing sufficiently or is obstruieted the catheter inside the trachea serves to 1) oxygenate by continuiouisly instifflating oxygen throuigh the catheter 2) to serve as a guiide for re-intuibation withouit removing the dental fixation.
*Former Chief Resident, Dept of Dental and Oral Stirgery, **Attending Anesthesiologist
***Director,
Dept of Anesthesiology
Brookdale Hospital Medical Center Linden Blvd and Rockaway Pkwy Br-ooklyn, New Yor-k 11212
124
Fig 1. Catheter introduced through endotracheal tube for suctioning airway at end of procedure. ANESTHESIA PROGRESS
With the preliminary inhalation of puire oxygen before extuibation and the continuiouis administration of oxygen via the catheter, there is little difficulty in maintaining an adequiate arterial 02 level. This techniquie has its own limitation in that where exchange is impossible, total gaseous retention will cauise the arterial C02 to rise within the ranges of 3 to 6 torr/min.1 However, the anesthesiologist or oral suirgeon has uip to a ten minuite safety period with apneic mass movement oxygenation before the arterial C02 begins to cause significant respiratory acidosis. This time is usuially more than adequate to assess the adequacy of ventilation and to institute appropriate measuires, incluiding the removal ofthe fixation. In the event that re-intuibation is necessary, the catheter will serve to guiide the nasotracheal tuibe back into the trachea in most instances. SUMMARY: A techniquie has been presented which provides an added margin of safety in managing the extubation of patients with intermaxillary fixation. An indwelling catheter inside the trachea with continuious insufflation of oxygen can maintain adequiate arterial 02 levels if obstruiction occuirs and it concuirrently provides a guide for re-intuibation, shouild this be deemed necessary.
Fig 2. With cuff deflated, the endotracheal tube is removed leaving the catheter in place for oxygen insufflation and as a guide should reintubation become necessary.
REFERENCE:
Nuinn JF Applied Respiratory Physiology 2nd Ed (1977) Buitterworths p. 358.
ANNOUNCEMENT International Symposium on Sedation and Anesthesia in Dentistry March 30-April 4, 1980 Sponsored by the N. B. Jorgensen Memorial Library Loma Linda University Place: San Diego Hilton Hotel For further information, write: Gerald D. Allen, M.D. Department of Anesthesiology UCLA School of Medicine Los Angeles, California 90024
SEPTEMBER-OCTOBER 1979
125
