47 Tracheal extubation in children: Planning, technique, and complications

Question 1

Principal músculo que mantem o tonus das VAS

Answer 1

Genioglosso

Question 2

Recomendacoes de posicionamento ao extubar a crianca:

Answer 2

1. coxim atras dos ombros (propicia abertura faringea e extensão da cabeca)
2. Posicao lateral apos extubacao (estabiliza a VA e reduz forca gravitacional da ligua, epiglote e palato mole)

Question 3

O que deve ser feito antes de iniciar o processo de extubacao?

Answer 3

• Manobra de recrutamento pulmonar suave
• succao de orofaringe

Question 4

Indicacoes de extubacao acordado:

Answer 4

• difficult intubation to avoid to reintubate the child in emergency because of upper airway obstruction
• full stomach situation (emergency) in order to protect the air- way from aspiration: The later occurred in 1.8 vs 0.7/1000 of the emergency and elective cases, respectively, in APRICOT
• and if the practitioner feels uncomfortable with deep extubation.

Question 5

Principais indicacoes de extubacao em plano: (2)

Answer 5

• in the presence of a reactive airway (eg, asthma and recent upper airway infection) to avoid inducing a bronchospasm
• when coughing or bucking should be avoided.

They increase intra- cranial or intraocular pressure (eg, following open eye surgery) but also venous pressure in the head and neck and could favor bleed- ing (eg, following adenotonsillectomy and cleft palate repair). It should also be kept in mind that they are potential causes of la- ryngotracheal damage and bronchospasm and that they increase intrathoracic pressure with a risk of acute right to left shunting in case of intracardiac defect.20 Last but not least, coughing results in apnea at the end of a forced expiration and thus reduces the pulmonary O2 reserve before extubation.

Question 6

Etapas do processo de extubacao “just in time”:

Answer 6

Question 7

Principais causas de apneia central em criancas apos extubacao

Answer 7

• Prematuridade
• laringoespasmo sem esforço respiratorio
• opioide residual
• relaxante muscular

Question 8

Conduta se crianca tosse no TOT durante a extubacao:

Answer 8

Lidocaina

A meta-analysis recently confirmed that IV lidocaine prevents coughing after extubation with a risk ratio of 0.44 (95% CI 0.28- 0.70, P = .0005).32 Although the curative effect of lidocaine in case of coughing bouts has not been studied, in the author’s ex- perience administering 1.5 mg/kg IV lidocaine in a child cough- ing while still intubated reliably provides an 1 to 3 minutes safety window during which coughing is stopped and extubation can be performed with a minimal risk of hypoxemia, laryngospasm, or bucking provided all the conditions mentioned above (full recov- ery of muscle strength and respiratory drive, conjugate gaze) are also present.

Question 9

Imediatamente apos a extubacao, a crianca para de respirar. Qual a pp hipotese e conduta?

Answer 9

Laringoespasmo silencioso

• Ventilacao BVM suave - em neonatos pode ser o suficiente para deflagrar o reflexo de Head e prevenir des-recrutamento pulmonar
• Se ventilacao dificil, iniciar tratamento completo para laringoespasmo (Manobra de Larson, Propofol, Succinilcolina+Atropina)

Question 10

Durante extubacao, bebê encontra-se acordado, mas nao respira. Sao excluídos overdose de opioide e bloqueio neuromuscular. Qual a conduta?

Answer 10

Reflexo paradoxal de Head

This reflex seems to be present only in early life and is the reverse of the Hering-Breuer reflex. In other words, a slow deep inspiration with positive pressure applied to the lungs initiates spontaneous breathing. This has sometimes to be repeated a few times to produce sustained spontaneous ventilation and allow safe extubation.