Extubation: Difference between revisions
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==Inclusion== | ==Inclusion== | ||
*Plan to extubate in ED after only few hrs | *Plan to extubate in ED after only few hrs<ref>Weingart SD, Menaker J, et al. Trauma Patients Can Safely Be Extubated in the Emergency Department. J Emerg Med. 2009 Aug 22.</ref> | ||
**Resolution of clinical issue requiring intubation | **Resolution of clinical issue requiring intubation | ||
**Sat >95% on FiO2 40%, PEEP 5 | **Sat >95% on FiO2 40%, PEEP 5 | ||
**RR <30, SBP >100, HR <130 | **RR <30, SBP >100, HR <130 | ||
** | **Patient not known to be a difficult intubation | ||
==Preparation== | ==Preparation== | ||
*Turn off sedatives | *Turn off sedatives | ||
*Leave | *Leave [[opioids]] 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 | ||
* | *Patient should be able to understand and 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 | ||
*Perform cuff leak test to assess airway patency | *Perform cuff leak test to assess airway patency (not needed for ED extubation for only few hours per Weingart article) | ||
**Predicts post-intubation stridor | **Predicts post-intubation stridor with sensitivity of 56-92%<ref>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.</ref> | ||
**Cuff leak refers to airflow around ETT | **Cuff leak refers to airflow around ETT with deflated cuff | ||
**Qualatative measurement: deflate and listen for air | **Qualatative measurement: deflate and listen for air with stethoscope | ||
**Quantative measurement: measure difference between inspired TV while on | **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) | **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 | **If positive test, consider course of steroids and delay extubation | ||
==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 | #Have nebulizer filled with NS attached to a mask | ||
#Sit | #Sit patient up to at least 45 degrees | ||
#Suction ETT | #Suction ETT with bronchial suction catheter | ||
#Suction oropharynx | #Suction oropharynx with Yankauer 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 respiratory distress, non-invasive ventilation will often be sufficient | ||
==See Also== | ==See Also== | ||
{{Mechanical ventilation pages}} | |||
==References== | ==References== | ||
<references/> | <references/> | ||
[[Category:Critical Care]] | [[Category:Critical Care]] | ||
[[Category:Procedures]] | [[Category:Procedures]] |
Revision as of 19:53, 23 February 2021
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
- Patient not known to be a difficult intubation
Preparation
- Turn off sedatives
- Leave opioids 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 and 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 hours 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 Yankauer 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
- 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.