•All ventilated patients should receive humidification (with HME (Heat and Moisture Exchanger) filter or using a heated humidifier circuit).

•ETT/TT suction should be done only when required and preferably using a closed suction system.

•Sedate patients well when they need to remain intubated. Do not allow them to get restless.

•Start weaning the patient off sedation, only in the daytime when ICU staff is in adequate strength.

•Do not leave the patient unattended when sedation has been turned off and the patient is just about waking up. Reassure patients as they wake up from sedation.

•Apply boxer gloves/bandages to those patients who appear agitated. Refrain from tying patient’s limbs.

•Report any airway accident as a “critical incident.”

Step 11: Extubation of the airway (refer to Chap. 7)

•Perform a good oral and endotracheal suction prior to extubation.

•Keep all equipment ready for reintubation/noninvasive ventilation if required.

•Do a cuff-leak test (especially after prolonged intubations)—deflate the ETT cuff and check for air leak around the cuff. If absent, suspect laryngeal edema. Consider the use of steroids and plan extubation at a later date over a tube exchanger.

•Intravenous methylprednisolone started 12 h before a planned extubation has been shown to substantially reduce the incidence of postextubation laryngeal edema and reintubation in patients intubated for more than 36 h and having absent cuff leak.

•In a patient with a difficult airway, ensure that expert airway help is available prior to extubation and extubate preferably over a tube exchanger. Oxygenate the patient through the exchanger and remove it only when you are sure that the airway is not compromised/obstructed. If in doubt, pass the ETT back inside over the tube exchanger and secure in place.

Step 12: Continue to watch for and treat complications of tracheal intubation (days to months after extubtion)

•Sore throat

•Airway edema

•Airway infections/pneumonia

•Laryngeal damage/granuloma

•Tracheal stenosis, tracheomalacia, trachea-esophageal fistula

Suggested Reading

1.American Society of Anesthesiologists. Practice guidelines for management of the difficult airway: an updated report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Anesthesiology. 2003;98:1269–77.

A comprehensive guideline that addresses the stepwise approach for difficult intubation in perioperative period. This guideline can be applicable in intensive care units if used and interpreted judiciously.

2.Berry JM. Conventional (laryngoscopic) Orotracheal and Nasotracheal Intubation (Single –Lumen Tube): chapter 16. In: Hagberg CA, editor. Benumof’s airway management. 2nd ed. Philadelphia: Elsevier Mosby; 2007.

This chapter gives a detailed description of the preparation, procedure and precautions during conventional orotracheal and nasotracheal intubation.

3.Jaber S, Jung B, Corne P, Sebbane M, Muller L, Chanques G, Verzilli D, Jonquet O, Eledjam JJ, Lefrant JY. An intervention to decrease complications related to endotracheal intubation in the intensive care unit: a prospective, multiple-center study. Intensive Care Med. 2010;36(2):248–55.

The implementation of an intubation management protocol can reduce immediate severe lifethreatening complications associated with intubation of ICU patients.

4.Sitzwohl C, Langheinrich A, Schober A, Krafft P, Sessler DI, Herkner H, Gonano C, Weinstabl C, Kettner SC. Endobronchial intubation detected by insertion depth of endotracheal tube, bilateral auscultation, or observation of chest movements: randomised trial. BMJ. 2010;341: c5943.

The highest sensitivity and specificity for ruling out endobronchial intubation, however, is achieved by combining tube depth, auscultation of the lungs, and observation of symmetrical chest movements.

5.François B, Bellissant E, Gissot V, Desachy A, Normand S, Boulain T, Brenet O, Preux PM, Vignon P, Association des Réanimateurs du Centre-Ouest (ARCO). 12-h pretreatment with methylprednisolone versus placebo for prevention of postextubation laryngeal oedema: a randomised double-blind trial. Lancet. 2007;369(9567):1083–9.

Methylprednisolone started 12 h before a planned extubation substantially reduced the incidence of postextubation laryngeal oedema and reintubation. Such pretreatment should be considered in adult patients before a planned extubation that follows a tracheal intubation of more than 36 h.

6.Kaufman D. Etomidate versus ketamine for sedation in acutely ill patients. Lancet. 2009; 374(9697):1240–1.

Ketamine is a safe and valuable alternative to etomidate for endotracheal intubation in critically ill patients and should be considered in those with sepsis.