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Extubation
From WikEM
Algorithm is for patients who have only been intubated for a few hours
Contents
Inclusion
- Plan to extubate in ED after only few hrs[1]
- Resolution of clinical issue requiring intubation
- Sat >95% on FiO2 40%, PEEP 5
- RR <30, SBP >100, HR <130
- Patient not known to be a difficult intubation
Preparation
- Turn off sedatives
- Leave opiods on at a low dose (e.g. fentanyl 50 mcg/hr)
- Allow patient to regain full mental status
- If patient shows signs of discomfort consider giving more pain medication
- Patient should be able to understand respond to commands
Testing for Readiness
- Mental Status[2]
- Ask patient to raise arm and leave in air for 15s
- Ask patient to raise their head off the bed
- Ask patient to cough (they should be able to generate a strong cough)
- Place on pressure support 5; sit patient up to at least 45 degrees
- Observe for 15-30
- If sat <90%, HR >140, SBP >200, severe anxiety or decreased LOC discontinue attempt
- Perform cuff leak test to assess airway patency (not needed for ED extubation for only few hrs per Weingart article)
- Predicts post-intubation stridor with sensitivity of 56-92%[3]
- Cuff leak refers to airflow around ETT with deflated cuff
- Qualatative measurement: deflate and listen for air with stethoscope
- Quantative measurement: measure difference between inspired TV while on ventilator and expired TV with deflated cuff (avg lowest 3 expired breaths over 6 cycles)
- Positive cuff leak = volumes <110 mL or <12-24% of TV. This indicates decreased space between ETT and airway (laryngeal edema)
- If positive test, consider course of steroids and delay extubation
Procedure[4]
- Have nebulizer filled with NS attached to a mask
- Sit patient up to at least 45 degrees
- Suction ETT with bronchial suction catheter
- Suction oropharynx with Yankeur suction
- Deflate ETT cuff
- Have patient cough; pull the tube during the cough
- Suction the oropharynx again
- Encourage the patient to keep coughing up any secretions
- Place nebulizer on patient at 4-6 L/min
After Extubation
- Monitor closely for at least 60min
- If patient develops respiratory distress, non-invasive ventilation will often be sufficient
See Also
Mechanical Ventilation Pages
- Noninvasive ventilation
- Intubation
- Deterioration after intubation
- Ventilation settings
- Ventilation modes
- Ventilator high pressures
- Ventilator associated lung injury (VALI)
- Recruitment maneuver
- Ventilation weaning
- Extubation
References
- ↑ Weingart SD, Menaker J, et al. Trauma Patients Can Safely Be Extubated in the Emergency Department. J Emerg Med. 2009 Aug 22.
- ↑ Weingart SD, Menaker J, et al. Trauma Patients Can Safely Be Extubated in the Emergency Department. J Emerg Med. 2009 Aug 22.
- ↑ Ochoa ME, Marín Mdel C, Frutos-Vivar F, Gordo F, Latour-Pérez J, Calvo E, Esteban A. Cuff-leak test for the diagnosis of upper airway obstruction in adults: a systematic review and meta-analysis. Intensive Care Med. 2009 Jul;35(7):1171-9.
- ↑ Weingart SD, Menaker J, et al. Trauma Patients Can Safely Be Extubated in the Emergency Department. J Emerg Med. 2009 Aug 22.
