Extubation: Difference between revisions
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*Turn off sedatives | *Turn off sedatives | ||
*Leave opiods on at a low dose (e.g. fentanyl 50 mcg/hr) | *Leave opiods on at a low dose (e.g. fentanyl 50 mcg/hr) | ||
*Allow | *Allow patient to regain full mental status | ||
*If | *If patient shows signs of discomfort consider giving more pain medication | ||
*Pt should be able to understand respond to commands | *Pt should be able to understand respond to commands | ||
==Testing for Readiness== | ==Testing for Readiness== | ||
*Mental Status<ref>Weingart SD, Menaker J, et al. Trauma Patients Can Safely Be Extubated in the Emergency Department. J Emerg Med. 2009 Aug 22.</ref> | *Mental Status<ref>Weingart SD, Menaker J, et al. Trauma Patients Can Safely Be Extubated in the Emergency Department. J Emerg Med. 2009 Aug 22.</ref> | ||
**Ask | **Ask patient to raise arm and leave in air for 15s | ||
**Ask | **Ask patient to raise their head off the bed | ||
**Ask | **Ask patient to cough (they should be able to generate a strong cough) | ||
**Place on pressure support 5; sit | **Place on pressure support 5; sit patient up to at least 45 degrees | ||
**Observe for 15-30 | **Observe for 15-30 | ||
***If sat <90%, HR >140, SBP >200, severe anxiety or decreased LOC discontinue attempt | ***If sat <90%, HR >140, SBP >200, severe anxiety or decreased LOC discontinue attempt | ||
| Line 33: | Line 33: | ||
==Procedure<ref>Weingart SD, Menaker J, et al. Trauma Patients Can Safely Be Extubated in the Emergency Department. J Emerg Med. 2009 Aug 22.</ref>== | ==Procedure<ref>Weingart SD, Menaker J, et al. Trauma Patients Can Safely Be Extubated in the Emergency Department. J Emerg Med. 2009 Aug 22.</ref>== | ||
#Have nebulizer filled w/ NS attached to a mask | #Have nebulizer filled w/ NS attached to a mask | ||
#Sit | #Sit patient up to at least 45 degrees | ||
#Suction ETT w/ bronchial suction catheter | #Suction ETT w/ bronchial suction catheter | ||
#Suction oropharynx w/ Yankeur suction | #Suction oropharynx w/ Yankeur suction | ||
#Deflate ETT cuff | #Deflate ETT cuff | ||
#Have | #Have patient cough; pull the tube during the cough | ||
#Suction the oropharynx again | #Suction the oropharynx again | ||
#Encourage the | #Encourage the patient to keep coughing up any secretions | ||
#Place nebulizer on | #Place nebulizer on patient at 4-6 L/min | ||
==After Extubation== | ==After Extubation== | ||
*Monitor closely for at least 60min | *Monitor closely for at least 60min | ||
*If | *If patient develops resp distress, non-invasive ventilation will often be sufficient | ||
==See Also== | ==See Also== | ||
Revision as of 20:46, 1 July 2016
Algorithm is for patients who have only been intubated for a few hours
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
- 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 patient to regain full mental status
- If patient shows signs of discomfort consider giving more pain medication
- Pt 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 w/ sensitivity of 56-92%[3]
- 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[4]
- Have nebulizer filled w/ NS attached to a mask
- Sit patient up to at least 45 degrees
- Suction ETT w/ bronchial suction catheter
- Suction oropharynx w/ 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 resp distress, non-invasive ventilation will often be sufficient
See Also
Mechanical Ventilation Pages
- Noninvasive ventilation
- Intubation
- Mechanical ventilation (main)
- Miscellaneous
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.