Extubation

Revision as of 21:55, 27 December 2015 by Neil.m.young (talk | contribs)

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 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[2]
    • 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%[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]

  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

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