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The Role of ECMO in the “At-Risk” Tracheal Extubation: A Case Report

Phipps, Sarah J. MBChB, FANZCA*; Meisner, Jason G. MD, PhD*; Watton, David E. MD*; Malpas, Gemma A. MBChB, FANZCA*; Hung, Orlando R. MD, FRCPC

doi: 10.1213/XAA.0000000000000838
Case Reports

Tracheal extubation requires careful planning and preparation. We present the extubation of a patient with severe ankylosing spondylitis after cervical spine surgery. We discuss the use of extracorporeal membrane oxygenation (ECMO) in this “at-risk” extubation, where our ability to oxygenate was uncertain and reintubation was predicted to be difficult. To our knowledge, ECMO has not previously been used in this context. We suggest preparing ECMO for rescue oxygenation when all other fundamental oxygenation techniques are predicted to be difficult or impossible. ECMO could be included in airway management and extubation guidelines.

From the Departments of *Anesthesiology

Anesthesiology, Surgery, and Pharmacology, Dalhousie University, Halifax, Nova Scotia, Canada.

Accepted for publication May 31, 2018.

Funding: None.

The authors declare no conflicts of interest.

Address correspondence to Sarah J. Phipps, MBChB, FANZCA, Department of Anesthesia, Queen Elizabeth II Health Sciences Center, 1276 S Park St, Halifax, NS B3H 2Y9, Canada. Address e-mail to

The Difficult Airway Society proposes 4 steps for safe extubation: Plan, Prepare, Perform, and Post-Extubation Care.1 We present an “at-risk” extubation (one in which the ability to oxygenate the patient is uncertain, reintubation is potentially difficult, and/or general risk factors are present1) and our approach to preparing and planning for a favorable outcome. We discuss the role of extracorporeal membrane oxygenation (ECMO) when difficulty is anticipated with all 4 fundamental methods of oxygenation (bag-mask ventilation [BMV], supraglottic airway [SGA], tracheal intubation [TI], and front-of-neck airway [FONA]). To our knowledge, ECMO has not previously been used to facilitate postsurgical extubation in the patient with a difficult airway.

Written consent has been obtained from the patient for this publication.

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A 74-year-old man with ankylosing spondylitis presented with neck pain after a fall. He had chronic obstructive pulmonary disease and was in stable health. He previously underwent C2-T12 fusion. He had no neurologic deficit. Computerized tomography scan revealed a C4/5 Chance fracture (Figure 1). Neurosurgeons planned stabilization surgery.

Figure 1.

Figure 1.

Preoperative assessment revealed a severe, fixed kyphosis such that the patient’s chin approximated his chest. Thyromental distance was difficult to assess, mouth opening was 2 cm, Mallampati score was IV, mandibular protrusion was good, and dentition was intact.

Difficulty was anticipated with BMV, SGA, TI, and FONA. Awake orotracheal intubation using a flexible bronchoscope was successful but was challenging. Surgery took place in the prone position without complication and the patient was transferred to the intensive care unit (ICU) with extubation deferred pending resolution of airway edema. On postoperative day 1, ICU requested assistance from anesthesia for extubation. Postoperative x-rays were evaluated (Figure 2).

Figure 2.

Figure 2.

If extubation failed, BMV, placement of a SGA, and TI via direct laryngoscopy or video laryngoscopy would all likely be difficult or impossible due to limited mouth opening and inability to extend the neck. A FONA would be impossible because anterior neck landmarks could not be palpated. An otolaryngologist and a cardiac surgeon were consulted: if tracheotomy was necessary, it would require sternotomy. Extubation over an Airway Exchange Catheter (AEC; Cook Medical, Bloomington, IN) was planned; however, the severe kyphosis could impede reintubation. The final plan was to extubate over an AEC, with ECMO cannulae inserted beforehand and an ECMO circuit immediately available for rescue oxygenation if airway access via sternotomy was needed.

The patient was brought to the operating room (OR) for extubation. Staff from anesthesia, otolaryngology, cardiovascular surgery, nursing, and perfusion were present. The patient was positioned supine and sedated with remifentanil and propofol. The right femoral vein and artery were cannulated for veno-arterial ECMO.

The patient was repositioned semireclined and the oropharynx was suctioned. The presence of a cuff-leak was confirmed. Nasopharyngoscopy showed no airway edema. Bronchoscopy confirmed that the endotracheal tube tip was above the carina for optimal AEC positioning.

Sedation was weaned and appropriate spontaneous ventilation was confirmed. After placement of a 19F AEC coated with 5% lidocaine ointment (AstraZeneca Canada, Mississauga, ON, Canada), the endotracheal tube was removed and facemask oxygen was provided. After coughing briefly, the patient settled and was observed in the OR for approximately 30 minutes. He was breathing comfortably and oxygenating well. The AEC was removed and he was returned to the ICU. ECMO cannulae were left in place overnight and removed the following day.

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Extubation after surgery is an elective procedure and conditions should be optimized.1 However, a prolonged period of intubation is not without risk,2 and extubation should not be deferred unnecessarily. The fourth National Audit Project recommends “patients at high-risk of airway problems at emergence require a specific extubation and reintubation plan.”3 Our patient was an “at-risk” extubation: the ability to oxygenate was uncertain and difficult reintubation was anticipated.1

We decided the optimal location to perform this extubation was the OR, in keeping with published recommendations.1,3 ECMO was available at our hospital, but elsewhere the use of ECMO might require an interhospital transfer.

Extubation was deferred to allow time for resolution of airway edema that can occur after prone positioning for C-spine surgery and that can cause airway obstruction.4 Additionally, the initial consult for extubation was requested in the evening; however, it was deemed too risky to extubate this patient late in the day with limited resources and personnel, so extubation was deferred until the following morning.

Equipment for extubation should be considered, including a rescue oxygenation strategy in case of extubation failure. AECs have an 87% first-pass success for reintubation after failed extubation.5 The chance of first-pass success is increased when intubation over an AEC is done under laryngoscopic guidance.6 It was felt that reintubation over the AEC would be very difficult or impossible due to the extreme C-spine flexion-deformity and predicted difficulty with performing direct laryngoscopy or video laryngoscopy. Mort5 demonstrated the failure of reintubation over an AEC in 8% of cases, and failures were associated with severe hypoxemia, bradycardia, and hypotension. Rescue oxygenation via an AEC is described but is associated with significant complications.3,7 ECMO was prepared in case of failure with both extubation and reintubation over the AEC.

Optimizing personnel for extubation is essential. This case illustrates the necessary multidisciplinary approach to a complex extubation and the importance of team communication must be emphasized.

The semiupright position is suggested for extubation of patients with difficult airways, who are obese or have chronic respiratory disease.8 This position improves diaphragmatic expansion, effective coughing, and functional residual capacity while reducing airway edema8; however, it will likely impede ECMO cannulae insertion and compromise femoral blood flow. Our patient was positioned supine for cannulae insertion, then semiupright for extubation. If oxygenation with ECMO was needed, the plan was to rapidly reposition him supine.

Failed extubation is defined as the need for reintubation within 24–72 hours of extubation and is associated with increase in length of ICU and hospital stay, morbidity, and mortality.2 A prolonged time to reintubation after extubation failure has been shown to independently predict mortality2 and could reasonably be anticipated in this patient with a difficult airway. We aimed to reduce the risks of morbidity and mortality by having ECMO prepared for rescue oxygenation.

Reliable diagnostic and predictive tests for extubation failure are lacking, and extubation failure should be distinguished from failure to wean from mechanical ventilation.9 A range of patient and surgical factors are independently predictive for postoperative extubation failure.9,10,11 Those factors relevant to our case were chronic obstructive pulmonary disease and C-spine surgery. Graboyes et al11 showed that 27% patients who failed extubation after head and neck surgery required an emergency surgical airway, which, in this patient would require sternotomy. Inappropriate clinical judgment and inadequate planning can also contribute to extubation failure,3,9 and we aimed to mitigate this with careful planning and multidisciplinary preparation.

ECMO can provide respiratory or cardiorespiratory support.12 Usually, venovenous ECMO would be used in patients with isolated respiratory failure.12 However, veno-arterial ECMO, which is commonly used for cardiorespiratory support,12 was chosen by our cardiovascular surgeon due to technical and equipment factors. Complications of ECMO include thrombosis, coagulopathy, bleeding, limb ischemia, infection, renal failure, neurological and musculoskeletal complications, hyperbilirubinemia, and risk of technical problems or equipment failure,12 and the benefits must be weighed against these risks. Complications associated with short-term ECMO are rare.13

The recent case report and systematic review by Malpas et al13 describe ECMO use for the anticipated difficult airway, also in the setting where the other 4 fundamental techniques of tissue oxygenation are likely to fail. We are not aware of any previous reports describing the use of ECMO in the “at-risk” postsurgical extubation. In the present case, ECMO was not ultimately needed for oxygenation but was “on standby” in case of extubation failure. The use of ECMO as an additional fundamental oxygenation strategy could be included in future airway management and extubation guidelines. This strategy would reinforce recommendations from the Canadian Airway Focus Group to prioritize oxygenation rather than TI in managing the difficult airway.14

In conclusion, there are currently 4 fundamental methods of oxygenation: BMV, SGA, TI, or FONA. For this “at-risk” extubation, ECMO was prepared for rescue oxygenation due to anticipated difficulty or failure with all of the 4 other methods. When planning and preparing for extubation, we highlight the importance of optimizing timing, location, equipment, personnel, and patient positioning, in addition to ensuring clear team communication. We propose that ECMO should be considered for an “at-risk” extubation and that ECMO could be incorporated into future airway management and extubation guidelines as a fifth fundamental oxygenation technique.

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Name: Sarah J. Phipps, MBChB, FANZCA.

Contribution: This author helped search the literature and prepare the manuscript.

Name: Jason G. Meisner, MD, PhD.

Contribution: This author helped supply case details and prepare the manuscript.

Name: David E. Watton, MD.

Contribution: This author helped supply case details and prepare the manuscript.

Name: Gemma A. Malpas, MBChB, FANZCA.

Contribution: This author helped prepare the manuscript.

Name: Orlando R. Hung, MD, FRCPC.

Contribution: This author helped search the literature and prepare the manuscript.

This manuscript was handled by: BobbieJean Sweitzer, MD, FACP.

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