Difficult Airway Society guidelines for the management of tracheal extubation


We read with concern the letter from Ms Ogilvie [1] in reaction to the recently published extubation guidelines by the Difficult Airway Society (DAS) [2]. Ogilvie, representing Cook Medical (Limerick, Ireland), manufacturers of the Cook Airway Exchange Catheter (AEC), indicated that this device “is not intended to remain in the airway…for an extended period of time…” following extubation of a difficult airway. One of us (RMC) was involved in the development of the AEC, and this is precisely how he had intended that it be used. Our ability to predict successfully those patients who will tolerate extubation is far from perfect. Comparing patients with difficult airways whose tracheas were re-intubated with or without an AEC, Mort demonstrated that the AEC was associated with a very significant improvement in the first attempt success rate, the time required to complete re-intubation, and a reduction in severe hypoxia as well as bradycardia [3]. Only 21/51 (41%) of the re-intubations involving an AEC took place within 2 h of extubation while 30/51 (59%) occurred between 2 h and 10 h. Thus, the major safety advantages of extubation over a tube exchanger are likely to be missed if the device is used exclusively to perform an exchange or if it is removed shortly following extubation of the difficult airway. The undersigned, representing DAS and the Society for Airway Management, strongly reaffirm the recommendations of the DAS guidelines and discourage the premature removal of tube exchangers until the probability of a required re-intubation seems very remote.