Question
What about a cuff leak?
Answer
Kuriyama & Kamei (2020) concluded laryngeal edema and airway obstruction following extubation is a major cause of extubation failure. Post-extubation stridor, its clinical sign, has a reported incidence of 2–26% and frequently results in reintubation. Reintubation is associated with an increase in morbidity, duration of mechanical ventilation, and ICU stay. The cuff leak test has excellent specificity but low to moderate sensitivity for post-extubation airway obstruction. Your input and the Intensivist both decide the patient is ready, but the nurse says there is no cuff leak.
What are your thoughts? Should you hold off? Well, honestly, opinions vary on this topic. Most evidence suggests that the cuff leak test has excellent specificity but low to moderate sensitivity for post-extubation airway obstruction. It can be a valuable tool in deciding whether or not to extubate a patient, but the low sensitivity suggests that a negative test, meaning the presence of a leak, cannot wholly exclude post-extubation airway obstruction.
Therefore, this test should not be the sole variable in deciding to extubate if all other factors suggest you should. The team and their collaborative efforts should decide if it is safe and factor in other things such as, was the patient a difficult airway upon initial intubation? Does there continue to be airway swelling? Do you think there may be encrusted secretions accounting for no-leak rather than upper airway swelling? My point is here, what your team deems the higher-risk patient, it is probably safer to give steroids and wait, but if they are not, it might be perfectly acceptable to extubate. The global picture and context of your patient's history and condition should be factored in as well
This Ask the Expert is an edited excerpt from the course, What’s Anesthesia Got To Do With It? presented by Steven Vela, MSNA, CRNA.
