Conference Lectures

BAILEY MANOEUVRE
Introduction
Tracheal extubation is a critical step during recovery from general anaesthesia, but has not received the same attention as intubation. It is not simply a reversal of the process of intubation. At extubation, there is a transition from a controlled to an uncontrolled situation.
The majority of problems that occur during extubation and emergence are of a minor nature, but a small and significant number may result in morbidity and mortality. The need for incorporating a plan for extubation is mentioned in several international airway management guidelines, but they speak only on extubation of the patient with a difficult airway. The Difficult Airway Society has developed guidelines for the safe management of tracheal extubation in adult peri-operative practice.

BAILEY MANOEUVRE (Laryngeal Mask Exchange) -
The Bailey method is described in an old study from 1998. The Bailey method is compared to the standard extubation-to-guedels method.
Paul Bailey, consultant anesthetist at the Royal National Throat, Nose and Ear Hospital in London, first recognized and described this exchange.
While awakeextubations 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.This technique allows extubation under deep anaesthesia by substituting an oral endotracheal tube for an LMA. Following oropharyngeal suction, the LMA is inserted over the ET tube, and the cuff is inflated (Fig 1). The cuff on the ET tube is then deflated and the tube is removed. The patient is ventilated through mask airway. The  mask airway is left in place until the patient regains consciousness and is able to remove the mask airway when prompted verbally. The manoeuvre allows the LMA to maintain the airway during emergence with minimal stimulation, avoiding the coughing and bucking .This method favours correct positioning of the LMA as the tracheal tube splints the epiglottis as it is inserted, preventing downfolding of the epiglottis. The step wise approach is given in table 1.
The method involves placing the LMA before removing the tube. This is because,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 and unstimulated while the patient sleeps through the remaining deep anesthesia.This technique of emergence is superior to either awake or deep extubation (3-6).  It may also benefit smokers, asthmatics and other patients with irritable airways. It is inappropriate in patients in whom re-intubation would be difficult or if there is a risk of regurgitation.
Difficult Airway Society Guidelines -
The Difficult Airway Societyare taking extubations seriously. They recently issued extubation guidelines. One of the advanced methods for extubation they mention is the Bailey Manoeuvre. 
The guidelines discuss the problems arising during extubation and recovery and they recommend that an extubation strategy should be planned before starting anaesthesia .They promote a strategic, stepwise approach to extubation. They emphasise the importance of planning and preparation, and include practical techniques for use in clinical practice and recommendations for post-extubationcare.The guidelines are applicable to adult peri-operative practice; they do not address paediatric or critical care patients.
Problems at extubation were more common in patients who were obese and in those with obstructive sleep apnoea. The problems related to extubation are not only technical and may be compounded by human factors .There is, however, a general agreement that good preparation is key to successful airway management and that an extubation strategy should be in place for every patient.
Extubation is an elective process, and it is important to plan and execute it well. The goal is to ensure uninterrupted oxygen delivery to the patient’s lungs, avoid airway stimulation, and have a back-up plan, that would permit ventilation and re-intubation with minimum difficulty and delay should extubation fail. The guidelines(7)describe the following four steps:
Step 1: plan extubation.
Step 2: prepare for extubation.
Step 3: perform extubation.
Step 4: post-extubation care: recovery and follow-up.

CONCLUSION
Extubation differs from intubation, in that it should always be an elective process with adequate time available to the anaesthetist for methodical management. Technical and non-technical factors can contribute to adverse events at extubation, but outcomes are improved by planning, organisation and communication.
References

  1. Laryngeal Mask Airway devices:Three manoeuvres for any clinical situation. Anesthesiology News Guide to Airway Management 2010:15-16.
  2. Koga K, Asai T, Vaughan RS, Latto IP. Respiratory complications associated with tracheal extubation. Timing of tracheal extubation and use of the laryngeal mask during emergence from anaesthesia. Anaesthesia 1998; 53:540-4.
  3. Stix MS, Borromeo CJ, Sciortino GJ, Teague PD. Learning to exchange an endotracheal tube for a laryngeal mask prior to emergence. Canadian Journal of Anesthesia 2001; 48: 795–9.
  4. Fujii Y, Toyooka H, Tanaka H. Cardiovascular responses to tracheal extubation or LMA removal in normotensive and hypertensive patients. Canadian Journal of Anesthesia 1997; 44: 1082–6.
  5. Costa e Silva L, Brimacombe JR. Tracheal tube/laryngeal mask exchange for emergence. Anesthesiology 1996; 85: 218.
  6. Difficult Airway Society Guidelines for the management of tracheal extubation. Anaesthesia Journal of the Association of Anaesthetists of Great Britain and Ireland.Volume 67, Issue 3, pages 318–340.

Fig 1

 

Table 1.Sequence for LMA exchange in ‘at-risk’ extubation.

  1. Administer 100% oxygen
  2. Avoid airwat stimulation: either deep anaesthesia or neuromuscular blockade is essential.
  3. Perform laryngoscopy and suction under direct vision.
  4. Insert deflated LMA behind the tracheal tube.
  5. Ensure LMA placement with the tip in its correct position.
  6. Inflate cuff of LMA.
  7. Deflate tracheal tube cuff and remove tube whilst maintaining positive pressure.
  8. Continue oxygen delivery via LMA.
  9. Insert a bite block.
  10. Sit the patient upright.
  11. Allow undisturbed emergence from anaesthesia.