A pilot study assessing the Cook Staged Extubation Set for endotracheal tube insertion in simulated difficult airway in patients undergoing routine intubation for elective surgery

In place of immediately introducing an ETT into the trachea, the guidewire from the Cook Staged Extubation Kit will, under direct laryngoscopy, be inserted into the trachea. The guidewire will be left in the trachea, the laryngoscope removed and the external part of the guidewire kept to the right side of the patient’s head. The purpose of the intervention up to this point is to have the patient with a guidewire in place, in order to simulate a staged extubation. The procedure up to this stage is estimated to take 30 seconds. Face mask ventilation will be resumed for a few breaths to ensure adequate anaesthesia and oxygenation. The face mask will be removed and laryngoscopy performed. Pressure will be decreased and the laryngoscope may be withdrawn slightly to simulate a Cormack and Lehane grade 3 view. The Cook staged extubation kit will be used in the prescribed way for reintubation from this point onwards. This requires the soft tipped catheter to be introduced into the trachea over the guidewire, followed by the endotracheal tube introduced into the trachea over the soft tipped catheter. Introduction of the catheter and endotracheal tube will be achieved without direct vision of the vocal cords, as the laryngoscope will be manipulated in such a way as to maintain a C&L grade 3 view. The soft tipped catheter as well as the guidewire will now be withdrawn and completely removed, with the endotracheal tube left in situ. The intubation will be timed from second face mask removal and is expected to take less than 60 seconds.