Extubation

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 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
  • Patient 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 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]

  1. Have nebulizer filled with NS attached to a mask
  2. Sit patient up to at least 45 degrees
  3. Suction ETT with bronchial suction catheter
  4. Suction oropharynx with Yankeur suction
  5. Deflate ETT cuff
  6. Have patient cough; pull the tube during the cough
  7. Suction the oropharynx again
  8. Encourage the patient to keep coughing up any secretions
  9. 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

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.