Deep Extubation / Laryngospasm / No PPV

[Monty Python]

I received this Penned Post in today's email on the art of deep extubation. Was wondering what others think of "no PPV" for breaking larnygospasm. The article is a great read. I have used the Larson maneuver a few times, mentioned in the article with link provided.

The art of deep extubation

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[deleted162650]

While deep extubation can be pretty, it's primary use is as a crutch for those who haven't yet figured out how to wake someone up smoothly.

 

[deleted171991]

It's a really patronizing article. And she just couldn't miss pointing out her Ivy League roots, as if that gives her theories more credibility.

On topic, I seldom use PPV alone for laryngospasm. If painful jaw thrust doesn't break it, it's usually either propofol or sux. It's from my best teacher, Dr. Experience. I just don't like to sit around and pray while the sats are dropping.

 

[dhb]

While deep extubation can be pretty, it's primary use is as a crutch for those who haven't yet figured out how to wake someone up smoothly.

Another reminder that i suck at this
I should probably go to the hospital in a wheelchair since i haven't extubated a patient "awake" in years.

 

[deleted162650]

Another reminder that i suck at this
I should probably go to the hospital in a wheelchair since i haven't extubated a patient "awake" in years.

The question is why did you start extubating deep in the first place . Now (years later) I bet you don't suck anymore, you're just lazy.

 

[teeva]

Option 1 is for *****s and option 2 is a false dichotomy. The author has missed, ignored, or is ignorant of option 3. Extubate when the pt opens his/her eyes and is breathing comfortably with no gagging. No need for all those other steps -- giving more opiates, oral/nasal airways, chin lift or jaw thrust, or even touching the pt.

I don't do deep extubation much these days because I'm solo and want to make sure my pt is awake and stable before moving on to the next case asap.

 

[deleted171991]

Option 1 is for *****s and option 2 is a false dichotomy. The author has missed, ignored, or is ignorant of option 3. Extubate when the pt opens his/her eyes and is breathing comfortably with no gagging. No need for all those other steps -- giving more opiates, oral/nasal airways, chin lift or jaw thrust, or even touching the pt.

I don't do deep extubation much these days because I'm solo and want to make sure my pt is awake and stable before moving on to the next case asap.

That works only if you don't have wise people around who must either chat or touch the patient during emergence. It's all the external stimuli that agitate the patient, as in the ICU, not the tube.

 

[Spacedman]

actually thought it was a good read, though perhaps I'm influenced by the influx of dewy-eyed CA1s.

It gets at a few particular bits of dogma that were passed down to me as a resident and I still hear:

1. Stage 2.... was described for ether. Perhaps with pediatric wakeups using volatile you can see "stage 2-ey" behavior, but IMO the phenomenon is irrelevant for prop wakeups

2. PPV for laryngospasm (from the link):

Applying positive pressure will not relieve true laryngospasm, and may worsen it, because it will press the
aryepiglottic folds more firmly against each other and reinforce the closure.​

this is the anatomy, right? why tf do we persist in PPV? doesn't it make tons more sense to apply pressure from below the cords, i.e. a little gentle chest compression? I read about this as a resident, and like a dumba$$ actually tried it in the peds PACU. It worked pretty well actually....but the nurses thought I was coding a 5 yr old. that cost me several boxes of girl scout cookies.

 

[PainDrain]

While deep extubation can be pretty, it's primary use is as a crutch for those who haven't yet figured out how to wake someone up smoothly.

I use deep extubation frequently and it isn't because I am a lazy dunce. Deep extubation has a purpose and in the proper setting can be useful, while in the wrong hands or in the wrong setting it can be disastrous. I use it for thyroids/parathyroids, ACDFs, carotids, and mediastinoscopy. Why anyone would risk the potential for these patients to buck on a tube stressing a fresh suture line is beyond me. If you know WTF you are doing you don't need to wait for the patient to stand up and dance a jig prior to extubation; simply following a few basic rules allows for most patients to be extubated deep without trouble. 1. Never extubate a difficult airway or someone you cannot mask. 2. Patients must meet basic extubation criteria with regard to adequate TV/RR/reversal of relaxation/NIP/ect. 3. Understand the stages of anesthesia emergence and never extubate in stage 2 (a no brainer but you would be surprised).

 

[pgg]

doesn't it make tons more sense to apply pressure from below the cords, i.e. a little gentle chest compression? I read about this as a resident, and like a dumba$$ actually tried it in the peds PACU. It worked pretty well actually....but the nurses thought I was coding a 5 yr old. that cost me several boxes of girl scout cookies.

Interesting.

Bonus points for freaking out some nurses in the process.

 

[WholeLottaGame7]

I tuned out as soon as she outed herself as a hack by describing the only 2 ways she knows how to extubate a patient...

Also, never seen an (actually) awake patient laryngospasm.

Also also, stage 2 is real (and it is spectacular).

Also also also, I wouldn't preferentially use PPV to break laryngospasm if I had an IV, either, but that's not always an option in kids. PPV is your friend.

 

[Ronin786]

I tuned out as soon as she outed herself as a hack by describing the only 2 ways she knows how to extubate a patient...

Also, never seen an (actually) awake patient laryngospasm.

Also also, stage 2 is real (and it is spectacular).

Also also also, I wouldn't preferentially use PPV to break laryngospasm if I had an IV, either, but that's not always an option in kids. PPV is your friend.

Agreed. Terrible false equivalency suggesting that an awake patient is "flailing like a fish line". My patient's frequently open their eyes to command right as the drapes are coming down and the tube comes out without issue. Lots of ways to do that: lidocaine, propofol, narcotics and proper timing.

I'm interested in that talk about the true cause of laryngospasm, but there's no reason to suggest that a deep extubation is the only way.

 

[anbuitachi]

The stage 2 is weird.
and I feel like deep extubation needs help from nurses so you need nurses who know how to care for patients who were deep extubated. like dont start turning the patient and shaking the patient as soon as patient gets to the pacu

 

[fakin' the funk]

While deep extubation can be pretty, it's primary use is as a crutch for those who haven't yet figured out how to wake someone up smoothly.

Playing Devil's advocate here:

You intubate everyone deep, it's usually pretty and it's a helluva lot smoother than doing it awake. Is that because you're weak or lazy?

 

[deleted162650]

Playing Devil's advocate here:

You intubate everyone deep, it's usually pretty and it's a helluva lot smoother than doing it awake. Is that because you're weak or lazy?

A is not like B

 

[fakin' the funk]

A is not like B

They are literally inverse/reverse/mirror processes!

 

[deleted162650]

They are literally inverse/reverse/mirror processes!

Really G?? You can't think of a t least a few reason prop/roc/tube is not quite the same as pulling the tube with a large degree of anesthesia on board and then waiting around for them wake up??

 

[divinemsm]

The utility of deep extubtion in appropriate patients is huge ! I don't and never will understand the thought process of a patient being on the vent still when the drapes are down-remember APPROPRIATE patient-no trauma/ full stomach / difficult airway and it's equivalent / etc etc

It requires more work -yes-but really, its minimal. The surgeons appreciate it when they see you are ready to roll to the PACU when they take down the drapes , because a properly executed deep extubation has established :
1. Hemodynamically stable patient
With
2. Appropriate minute ventilation-without any airway interventions
With
3. Adequate pain management
With
4. Calm affect.

Maybe this is my bias having been in private practice for 6 years doing my own cases -where we more often than not stay with the same surgeon all day case after case.

 

[Noyac]

Don't worry about people criticizing deep extubations. There is a time and place for it. Probably not every case and also probably not never. Somewhere in between.

Personally, I like it in pts that may wake up wild or confused. They area risk to themselves and the staff. They seem to wake up smoother with a deep extubation when appropriate.

 

[Hoya11]

Don't worry about people criticizing deep extubations. There is a time and place for it. Probably not every case and also probably not never. Somewhere in between.

Personally, I like it in pts that may wake up wild or confused. They area risk to themselves and the staff. They seem to wake up smoother with a deep extubation when appropriate.

Try precedex for the same purpose and wake up - its great.. but i agree with you

 

[fakin' the funk]

Really G?? You can't think of a t least a few reason prop/roc/tube is not quite the same as pulling the tube with a large degree of anesthesia on board and then waiting around for them wake up??

Continuing to play devil's advocate:

- You needn't use NMB to intubate someone; so you use NMB because you're weak/lazy?
- A deep extubation with Des and a reasonable MV is usually awake by the time I'm in PACU, sometimes before moving to gurney, so not sure about the "waiting around" part
- even so, you don't need "a large degree of anesthesia" bc if you topicalize the cords, you can basically pull the tube anytime you want, if you so choose

 

[deleted171991]

Also, never seen an (actually) awake patient laryngospasm.

I have seen one, as I hit the PACU with one of my LMA patients, years ago. She simply could not breathe, and the panic just made it worse. It got better with 10 of sux, but it was extremely scary for the patient (despite our reassurances). She was 100% awake, sitting on the stretcher and gasping for air.

 

[deleted171991]

The utility of deep extubtion in appropriate patients is huge ! I don't and never will understand the thought process of a patient being on the vent still when the drapes are down-remember APPROPRIATE patient-no trauma/ full stomach / difficult airway and it's equivalent / etc etc

It requires more work -yes-but really, its minimal. The surgeons appreciate it when they see you are ready to roll to the PACU when they take down the drapes , because a properly executed deep extubation has established :
1. Hemodynamically stable patient
With
2. Appropriate minute ventilation-without any airway interventions
With
3. Adequate pain management
With
4. Calm affect.

Maybe this is my bias having been in private practice for 6 years doing my own cases -where we more often than not stay with the same surgeon all day case after case.

And that's why one should just use a good LMA for all these cases. So instead of thinking about deep extubations and what drugs can one use to help emergence, one should think (out of the box) whether the case cannot be done with an LMA.

95+% of my LMA cases are drapes down, patient moved to stretcher, LMA out. Or LMA out as/before the drapes are coming down, patient moved/moving herself to stretcher. By the time we hit the PACU, the patient is awake and chatting.

In my book, there is no way a post-ETT patient is more awake (hence safer) at the time of extubation than a post-LMA patient, even/especially in expert hands. Plus the vocal cords are much less irritated than those of a patient who had them abducted by an ETT.

I am a minimalist. The fewer drugs I have to use to make the patient tolerate the airway and the surgery, the better for the patient. And nothing beats an LMA at that (especially when combined with nitrous).

 

[deleted162650]

- You needn't use NMB to intubate someone; so you use NMB because you're weak/lazy?

Yes, anyone here who routinely uses an NMB to intubate is a weak, lazy f*cker!

Seriously though, NMB's are a part of a balanced induction/anesthetic - sure you could intubate off just PPF or gas or whatever, but it's gonna take a lot to get there which they pt may or may not be able to tolerate, and you still have no guarantee the pt is not gonna gag and aspirate. Not really germane to discussion about deep extubation though.

even so, you don't need "a large degree of anesthesia" bc if you topicalize the cords, you can basically pull the tube anytime you want, if you so choose

Well now maybe we're playing a semantics game, but extubating a light pt with a numb trachea is not really a deep extubation now is it .

When I refer to a deep extubation, it's in the classical sense of pulling the tube on someone who still a MAC + of anesthetic on board.

My initial comment was based off my own experience. As a junior resident, I had a hard on for deep extubations 'cuz they were "prettier" since I hadn't yet dialed in my wake-ups. Once you figure out how to wake someone up with a tube in without having them cough/buck/sputter/repeat, the allure of deep extubations kinda falls by the wayside - at least it did for me.

I'll also throw in that extubating deep is no guarantee that the pt will not cough/buck. All it takes is for a few drops of saliva to hit those cords at the wrong time or rolling over that bump on the way to PACU (right during Stage 2 which is real) and you can have an agitated, bucking pt only now there's no airway in place.

I'm not totally against deep extubations, I just think that if that's your default strategy for every pt it stems from a place of either being a) lazy, or b) insecure in your wake-up technique.

 

[deleted162650]

Curious: Is there a video recording of the larynx during a laryngospasm anywhere? Now that would be cool to see. I think it would also shed some light on whether PPV is helpful or not. I can see how it would not be helpful in a full blown severe spasm with all the components described in the article, but I think there are a lot of partial/mild spasms where PPV is probably helpful.

 

[Noyac]

Try precedex for the same purpose and wake up - its great.. but i agree with you

Too expensive.
Too much work.

 

[Hoya11]

Too expensive.
Too much work.

Takes less than 5 mins to set it up and I dont pay for it ...

 

[deleted171991]

Try precedex for the same purpose and wake up - its great.. but i agree with you

+1, if cost is not an issue. Great for awake intubations, too.

 

[Pooh & Annie]

You can look like the greatest anesthesiologist in history getting all your tubes out deep or a little deep or awake without the patient budging, protecting their "fresh suture line" or big hernia repair or whatever. Then at some point in the next 1-2 days most of them will have a big coughing or retching fit that no one will see to make sure the suture line/hernia repair is sound. Only a very small fraction have to come back because of it.

Not that I want people coughing when I extubate. But my eyes will aggressively roll when I'm asked "please don't let them cough." You wanna make sure they don't cough with a fresh surgery? Keep them tubed and sedated for a couple weeks.

 

[pastafan]

Years ago working with slow ortho surgeon. When he got to closure he started talking and came to an absolute crawl. I extubted patient deep, he had never seen this, no I told him we need to get finished. He panicked a bit, stopped talking, and closed in record time.