The Difficult Airway Society are taking extubations seriously. They recently issued extubation guidelines. One of the advanced methods for extubation they mention is the Bailey Manoeuvre. While not exactly news, it is something I will consider incorporating into my own anaesthetic bushido. (Finally got to use that word in natural, casual way.)
The Bailey Manoeuvre
It is recommended as a method for extubating patients deep. While awake extubations are generally considered the safest, there are situations where you want the controlled gradual awakening without the sometime violent agitation of an awake extubation. This agitation is obviously the consequence of the ETT moving against the vocal chords.
This stimuli can result in coughing, tachycardia and hypertension that can be deleterious for patients with ENT-surgery, ischaemic heart disease, aortic surgery or other pressure sensitive conditions. The Bailey method does away with this stage by extubating the patient deep and allowing him/her to wake up quietly on a LMA.
The method involves placing the LMA before removing the tube. Sometimes an LMA pushes down on the epiglottis and occludes the airway when placed. If the LMA is placed before pulling out the tube then the ETT splints the epiglottis until the LMA slides down into the correct position behind the epiglottis without closing it.
When the tube is out and the LMA is in place the airway will stay patent while the patient sleeps through the remaining deep anesthesia with it’s remaining airway collapsibility.
The Bailey method is described in an old study from 1998, back when studies were allowed to be four pages long and only have three references. The Bailey method is compared to the standard extubation-to-guedels method. Guess what works best?
It’s available full and free here. Abstract below.
What does it do for me?
It makes sense in the patients who need a quiet awakening without the violent coughing and catecholamine surge an awake intubation gives us.
For me it could provide a safer way of extubating my patients deep. I prefer deep extubations. I find that the awake extubations get me into more trouble than the deep ones. It is contrary to current opinion and a subject for a whole future post in itself, so suffice to say it works for me.
I could use the Bailey-method to bridge the patients until they are awake. A lot of hospitals do entire tonsillectomies with LMAs so why not? It could also reduce theatre times if we move the spontaneously breathing patient, with the LMA, into the PACU instead of waiting for the patient to wake up, go into a fit and extubate himself.
As always, someone out there is doing it already.