title: Tracheal extubation in children with difficult airways: a descriptive cohort analysis.
abstract: BACKGROUND
  Tracheal extubation in children with difficult airways may be associated with an increased risk of perioperative adverse events.
  
  
  OBJECTIVE
  The aim of this study was to describe the exubation techniques used/ success rates/ adverse events related to tracheal extubation practices in children with difficult airways.
  
  
  METHODS
  A retrospective analysis of tracheal extubation practices in the difficult airway population over a 78-month period was performed. Difficult airway was defined as a Cormack and Lehane Grade 3 view or greater, and/or tracheal intubation requiring ≥ 3 attempts, and/or the need for an alternate device to direct laryngoscopy for successful tracheal intubation, and/or difficult mask ventilation. Reasons for difficult airway, demographic/surgical data, technique(s) for tracheal extubation, success/failure of tracheal extubation, and adverse events were recorded. A failed tracheal extubation was defined as any adverse event related to the airway occurring within 6 h of extubation requiring reintubation.
  
  
  RESULTS
  A total of 519 patients were reported to have a difficult airway during this study period in a tertiary care pediatric center. Of these, 137 patients (26%) met inclusion criteria. Tracheal extubation was successfully performed in 130 patients (95%). The majority of tracheal exubations were performed without the use of additional airway adjuncts straight onto anesthesia face mask (121/137; 88%). Extubation failure occurred in seven cases (5%). Among the failed extubations, 6/7 children (85%) had evidence of severe upper airway obstruction and were <10 kg in weight. Of these children, one child required emergency tracheostomy, and two children (one with tracheal stenosis and other with spinal muscular atrophy) suffered from hypoxemic cardiac arrest and anoxic brain damage, respectively, and eventually died.
  
  
  CONCLUSIONS
  In the studied population of children with difficult airways handled in a tertiary center environment, the majority of tracheal extubations could be performed without the use of airway adjuncts. In a minority of patients, tracheal extubation was associated with severe adverse outcomes.
authors.affiliation: Department of Pediatric Anesthesia, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA.|Department of Anesthesiology, Northwestern University's Feinberg School of Medicine, Chicago, IL, USA.
authors.forename: Narasimhan
authors.initials: N
authors.lastname: Jagannathan
authors.affiliation: Department of Pediatric Anesthesia, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA.|Department of Anesthesiology, Northwestern University's Feinberg School of Medicine, Chicago, IL, USA.
authors.forename: Armin
authors.initials: A
authors.lastname: Shivazad
authors.affiliation: Department of Pediatric Anesthesia, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA.|Department of Anesthesiology, Northwestern University's Feinberg School of Medicine, Chicago, IL, USA.
authors.forename: Michael
authors.initials: M
authors.lastname: Kolan
mesh_terms: D000293:Adolescent; D060666:Airway Extubation / Q000009:adverse effects / Q000379:methods*; D058109:Airway Management / Q000009:adverse effects / Q000379:methods*; D002648:Child; D002675:Child, Preschool; D015331:Cohort Studies; D005260:Female; D006323:Heart Arrest / Q000209:etiology; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D007442:Intubation, Intratracheal; D007828:Laryngoscopy; D008297:Male; D012121:Respiration, Artificial; D012189:Retrospective Studies; D063128:Tertiary Health Care; D014139:Tracheostomy; D017211:Treatment Failure; D055815:Young Adult
keywords: complications; difficult airway; techniques; tracheal extubation