Difference between revisions of "Extubation"

Line 2: Line 2:
  
 
==Inclusion==
 
==Inclusion==
#Resolution of clinical issue requiring intubation
+
*Plan to extubate in ED after only few hrs
#Sat >95% on FiO2 40%, PEEP 5
+
**Resolution of clinical issue requiring intubation
#RR <30, SBP >100, HR <130
+
**Sat >95% on FiO2 40%, PEEP 5
#Pt not known to be a difficult intubation
+
**RR <30, SBP >100, HR <130
 +
**Pt not known to be a difficult intubation
  
 
==Preparation==
 
==Preparation==
#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 pt to regain full mental status
+
*Allow pt to regain full mental status
#If pt shows signs of discomfort consider giving more pain medication
+
*If pt 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==
#Ask pt to raise arm and leave in air for 15s
+
*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 pt to raise their head off the bed
+
**Ask pt to raise arm and leave in air for 15s
#Ask pt to cough (they should be able to generate a strong cough)
+
**Ask pt to raise their head off the bed
#Place on pressure support 5; sit pt up to at least 45 degrees
+
**Ask pt to cough (they should be able to generate a strong cough)
#Observe for 15-30
+
**Place on pressure support 5; sit pt up to at least 45 degrees
##If sat <90%, HR >140, SBP >200, severe anxiety or decreased LOC discontinue attempt
+
**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
 +
**Predicts post-intubation stridor w/ 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 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==
+
==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 pt up to at least 45 degrees
 
#Sit pt up to at least 45 degrees
Line 29: Line 38:
 
#Deflate ETT cuff
 
#Deflate ETT cuff
 
#Have pt cough; pull the tube during the cough
 
#Have pt cough; pull the tube during the cough
#Suctio nthe oropharynx again
+
#Suction the oropharynx again
 
#Encourage the pt to keep coughing up any secretions
 
#Encourage the pt to keep coughing up any secretions
 
#Place nebulizer on pt at 4-6 L/min
 
#Place nebulizer on pt at 4-6 L/min
  
 
==After Extubation==
 
==After Extubation==
#Monitor closely for at least 60min
+
*Monitor closely for at least 60min
#If pt develops resp distress, non-invasive ventilation will often be sufficient
+
*If pt develops resp distress, non-invasive ventilation will often be sufficient
  
 
==See Also==
 
==See Also==
Line 42: Line 51:
  
 
==References==
 
==References==
 +
<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.
  
 
[[Category:Critical Care]]
 
[[Category:Critical Care]]
 
[[Category:Procedures]]
 
[[Category:Procedures]]

Revision as of 21:19, 13 December 2015

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[1]
    • 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
    • Predicts post-intubation stridor w/ sensitivity of 56-92%[2]
    • 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[3]

  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

References

  1. Weingart SD, Menaker J, et al. Trauma Patients Can Safely Be Extubated in the Emergency Department. J Emerg Med. 2009 Aug 22.
  2. 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.
  3. 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.