We read with interest the Difficult Airway Society (DAS) guidelines for the management of tracheal extubation [1] and we congratulate the authors on their work.

We conducted a survey of anaesthetists in our department to ascertain the experience and level of confidence in using each of the five extubation techniques described and asked which technique or techniques they would choose to manage an ‘at-risk’ extubation.

Fifty-one anaesthetists responded, a response rate of 68% (Table 1). Twenty-seven (53%) had more than 10 years’ experience and 13 (25%) had less than five years’ experience in anaesthesia. Seven anaesthetists (14%) had two preferred techniques for the ‘at-risk’ extubation and two (4%) would use all five techniques depending on the clinical situation. Twelve (24%) had not performed any of the advanced extubation techniques in the last five years and 14 (27%) did not feel confident with any of the techniques. Only 11 (22%) felt confident to use techniques that they had not used within the last five years.

Table 1.   Survey results. Values are numbers of anaesthetists responding for each category (proportion of those who provided answer).
 Awake extubationAwake extubation with remifentanilDeep extubationTracheal tube exchange for laryngeal mask airwayAirway exchange catheter
Number of times each technique performed in the last five years
0 times022 (43%)4 (8%)17 (33%)34 (67%)
1–5 times1 (2%)8 (16%)8 (16%)14 (27%)11 (21%)
5–10 times2 (4%)2 (4%)7 (14%)7 (14%)5 (10%)
>10 times48 (94%)19 (37%)32 (62%)13 (26%)1 (2%)
Level of confidence with technique
Confident51 (100%)27 (53%)41 (80%)32 (64%)11 (22%)
Can do, but would like more experience/training0 (0%)9 (18%)8 (16%)15 (30%)19 (38%)
Not confident0 (0%)15 (29%)2 (4%)3 (6%)20 (40%)
Preferred technique for ‘at-risk’ extubation
 41 (84%)12 (24%)8 (16%)9 (18%)5 (10%)

These results raise several potential issues. Each technique requires a different skill set and the clinical situations in which each is likely to be most useful are not necessarily interchangeable. We do not know the learning curve and numbers required for the acquisition or retention of these skills. Furthermore, the numbers of procedures performed do not always correlate with an individual’s confidence and competence. Within our institution some techniques are used more frequently than others, and gaining department-wide experience and confidence in them all may not be possible. Simulation and workshops are potential solutions but we feel that these skills will be difficult to teach in this format only. Within the CCT in Anaesthetics 2010 curriculum [2], airway management has become increasingly prominent, but extubation training is only mentioned in the Basic Level Training document. With increasing evidence of extubation-related morbidity and mortality [3], we suggest that publication of the DAS guidelines provides a strong impetus to improve extubation training and technique.


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