Extubation

Algorithm is for patients who have only been intubated for a few hours

Inclusion

• Plan to extubate in ED after only few hrs
  • Resolution of clinical issue requiring intubation
  • Sat >95% on FiO2 40%, PEEP 5
  • RR <30, SBP >100, HR <130
  • Pt 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 pt to regain full mental status
• If pt shows signs of discomfort consider giving more pain medication
• Pt should be able to understand respond to commands

Testing for Readiness

• Mental Status
  • Ask pt to raise arm and leave in air for 15s
  • Ask pt to raise their head off the bed
  • Ask pt to cough (they should be able to generate a strong cough)
  • Place on pressure support 5; sit pt 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 w/ sensitivity of 56-92%
  • Cuff leak refers to airflow around ETT w/ deflated cuff
  • Qualatative measurement: deflate and listen for air w/ stethoscope
  • Quantative measurement: measure difference between inspired TV while on vent and expired TV w/ 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

1. Have nebulizer filled w/ NS attached to a mask
2. Sit pt up to at least 45 degrees
3. Suction ETT w/ bronchial suction catheter
4. Suction oropharynx w/ Yankeur suction
5. Deflate ETT cuff
6. Have pt cough; pull the tube during the cough
7. Suction the oropharynx again
8. Encourage the pt to keep coughing up any secretions
9. Place nebulizer on pt at 4-6 L/min

After Extubation

• Monitor closely for at least 60min
• If pt develops resp distress, non-invasive ventilation will often be sufficient

See Also

Mechanical Ventilation Pages

• Noninvasive ventilation
• Intubation
  • Intubation (peds)
• Mechanical ventilation (main)
  • Ventilation modes
  • Initial mechanical ventilation settings
    • Initial mechanical ventilation settings (peds)
  • Adjusting mechanical ventilation settings
    • Deterioration after intubation
    • Lung recruitment maneuver
    • Ventilator high pressures
    • Ventilator associated lung injury
  • Weaning mechanical ventilation
    • Extubation
• Miscellaneous
  • ARDS and EBQ:ARDSnet
  • Airway pressure release ventilation
  • Ideal Body Weight Estimation