Extubation: Difference between revisions
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==Inclusion== | ==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== | ==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== | ==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> | |||
**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%<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 | ||
# | #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 | |||
*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]
- Have nebulizer filled w/ NS attached to a mask
- Sit pt up to at least 45 degrees
- Suction ETT w/ bronchial suction catheter
- Suction oropharynx w/ Yankeur suction
- Deflate ETT cuff
- Have pt cough; pull the tube during the cough
- Suction the oropharynx again
- Encourage the pt to keep coughing up any secretions
- 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
- ↑ 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.
- Weingart SD, Menaker J, et al. Trauma Patients Can Safely Be Extubated in the Emergency Department. J Emerg Med. 2009 Aug 22.