Extubation Guidelines

EXTUBATION: GUIDELINES AND PROCEDURE
by
Kevin T. Martin BVE, RRT, RCP
RC Educational Consulting Services, Inc. 16781 Van Buren Blvd, Suite B, Riverside, CA 92504-5798 (800) 441-LUNG / (877) 367-NURS www.RCECS.com

BEHAVIORAL OBJECTIVES UPON COMPLETION OF THE READING MATERIAL, THE PRACTITIONER WILL BE ABLE TO: 1. List the five general indications for intubation. 2. List the complications of extubation. 3. Give four examples of how to prevent the complications associated with extubation. 4. List the parameters to be measured prior to weaning from mechanical ventilation and subsequent extubation. 5. Define each of the above noted parameters and give the acceptable values for extubation. 6. List the measures that should be taken to prevent accidental extubation. 7. List the high-risk for reintubation conditions and parameters. 8. Outline the procedure for planned extubation. COPYRIGHT OCTOBER, 1985 BY RC Educational Consulting Services, Inc. COPYRIGHT April, 2000 By RC Educational Consulting Services, Inc (# TX 1 762 726)
AUTHORED BY KEVIN T. MARTIN, BVE, RRT, RCP REVISED BY KEVIN T. MARTIN, BVE, RRT, RCP 1987, 1991, 1993, 1996 REVISED BY SUSAN JETT LAWSON, RCP, RRT-NPS 2001 REVISED BY MICHAEL R. CARR, BA, RRT, RCP 2004 REVISED BY SUSAN JETT LAWSON, RCP, RRT-NPS 2008
ALL RIGHTS RESERVED
This course is for reference and education only. Every effort is made to ensure that the clinical principles, procedures and practices are based on current knowledge and state of the art information from acknowledged authorities, texts and journals. This information is not intended as a substitution for a diagnosis or treatment given in consultation with a qualified health care professional.
This material is copyrighted by RC Educational Consulting Services, Inc. Unauthorized duplication is prohibited by law.

TABLE OF CONTENTS INTRODUCTION .............................................................................................................. 5 INDICATIONS FOR INTUBATION. ............................................................................... 5 UPPER AIRWAY OBSTRUCTION............................................................................. 5 PREVENT ASPIRATION..............................................................................................6 SECRETION REMOVAL............................................................................................. 6 MECHANICAL VENTILATION ..................................................................................6 POSITIVE PRESSURE VENTILATION ......................................................................6 COMPLICATIONS OF EXTUBATION ............................................................................6 LARYNGOSPASM .......................................................................................................7 STRIDOR ......................................................................................................................7 GLOTTIC EDEMA .......................................................................................................7 VOCAL CORD DAMAGE ........................................................................................... 7 EVALUATION PARAMETERS ....................................................................................... 9 FORCED VITAL CAPACITY...................................................................................... 9 PEAK EXPIRATORY FLOW RATE ........................................................................... 9 FIO2 .............................................................................................................................. 10 SECRETIONS ............................................................................................................. 10 WORK OF BREATHING ........................................................................................... 10 CARDIOVASCULAR STATUS................................................................................. 10 ACCIDENTAL EXTUBATION ...................................................................................... 12 LEAK TEST PROCEDURE............................................................................................. 13 EXTUBATION PROCEDURE ........................................................................................ 14

CLINICAL PRACTICE EXERCISE ............................................................................... 17 SUMMARY...................................................................................................................... 18 PRACTICE EXERCISE DISCUSSION .......................................................................... 18 SUGGESTED READING AND REFERENCES ............................................................ 19

INTRODUCTION
he decision to extubate is not to be undertaken lightly. From the moment an artificial airway is placed, every effort should be made to have it removed as soon as possible. This does not mean that one should extubate prematurely. Reintubation is more difficult and traumatic than the initial intubation. Therefore, one should be secure in the knowledge the patient wont need the artificial airway in the immediate future. There are specific criteria for extubation. These not only include respiratory parameters but also neurological, circulatory, and metabolic parameters. Following an assessment of these parameters, the practitioner is reasonably secure the patient will tolerate extubation. This paper explains the parameters to be evaluated and provides a general procedure for extubation. The procedure is designed to minimize the potential complications resulting from removal of the tube. INDICATIONS FOR INTUBATION ome of the reasons for intubation are: relief of airway obstruction, protection of the airway, suctioning of secretions, and to provide mechanical ventilation. The indication for extubation is simple: when the reason for intubation is no longer present. The first step in assessing a patient for extubation is to determine why the patient was intubated in the first place. This tells the practitioner what parameters need to be evaluated to predict a successful extubation. In some patients it is easy to determine if the cause for intubation has been resolved. In others, the opposite is true. For example, if the patient was intubated for respiratory failure from oversedation, its very easy to tell when the problem is resolved. If the reason for intubation was for upper airway obstruction, it is very difficult to evaluate if the problem has resolved. If there was edema or inflammation obstructing the upper airway, the tube masks its resolution while it remains in place. One clinical way to assess whether tracheal edema is significant enough to cause post-extubation complications is to deflate the cuff and auscultate for a leak. If air passes around the endotracheal tube, chances are the edema that may exist is not significant enough to cause a problem. If your patient has signs of significant upper airway obstruction, another idea is to suggest an Ear-Nose and Throat (ENT) consult from the primary physician. Sometimes, unfortunately, removing the tube is the only sure way to tell that the problem has been solved. Needless to say, if the edema is still present, the patient could be in serious trouble. Upper airway obstruction is an indication for intubation that presents particular problems when extubating. It is not unusual for the airway to become edematous upon removal of the tube. This occurs in most patients from simple mechanical irritation of the airway caused by the artificial airway. For this reason, patients with upper airway obstruction should be carefully monitored upon extubation. Glottic edema may take 2 hours to become apparent, but also can increase for up to 24 hours post-extubation. The patient should be observed closely for respiratory distress during this period. Most patients are not significantly affected by edema. However, those who were intubated for upper airway obstruction are very high risk for post extubation problems.

Another useful bedside test for post extubation airway patency is the cuff-leak test. The patient is disconnected from the ventilator and allowed to breathe spontaneously through the artificial airway. Then the cuff is deflated and the airway lumen occluded. The presence of a significant leak around the tube during spontaneous ventilation indicates adequate airway patency. Patients who have undergone surgical procedures, which cause head and neck edema, should be carefully assessed as well. These patients may benefit from the administration of intravenous (IV) corticosteriods prior to extubation. The artificial airway may have been placed to prevent aspiration. This is usually someone with inadequate glottic or tracheal reflexes. A patient needs adequate reflexes to close the glottis during swallowing or emesis to prevent aspiration. Good tracheal reflexes are necessary to cough out particles that get past the larynx. The patient may be overly sedated, comatose, or have neurological problems that interfere with these reflexes. Generally, reflexes are obtunded from the pharynx downward. If the patient has an adequate swallowing or gag reflex, there is a good possibility laryngeal and tracheal reflexes are adequate. If there is no swallowing response, it is unlikely the patient can protect their airway. If secretion removal was the reason for intubation, when the patient is able to clear them effectively without suctioning he/she can be safely extubated. The patient must be capable of a strong cough and secretions should be minimal in amount and viscosity. Specific guidelines will be provided later on how to evaluate the effectiveness of the cough mechanism. If the patient has been weaned from mechanical ventilation and has none of the above problems, they may be extubated. If the reason for intubation was to provide positive pressure ventilation and if the patient now maintains his or her own blood gases, the tube should be removed. Unfortunately another indication for extubation is when after discussion with the family, the physician and family agree that further medical care is considered futile whether or not they can maintain patency of their own airway. Noninvasive ventilation, CPAP and sometimes high FIO2 are required by some patients to maintain acceptable gas exchange after extubation or as an alternative to invasive ventilation and oxygenation. If these procedures are unsuccessful, then reintubation may be required. COMPLICATIONS OF EXTUBATION here are many potential complications of extubation. Most of these are not actually complications of extubation. Rather, they are complications of intubation and of artificial airways. However, they become evident upon extubation. The main categories of complications and hazards include hypoxemia, hypercapnia and death. Sore throat and hoarseness occur in most patients intubated. They generally resolve in 2-3 days. Laryngeal irritation occurs in approximately 45% of patients. Ulceration of the lips, mouth, or pharynx is possible, particularly if the intubation was traumatic. Trauma to the hypoglossal nerve may occur, resulting in a numb tongue for 1-2 weeks after extubation.

Periglottic sensation is abnormal for 4-8 hours after extubation in all patients intubated longer than 8 hours. This increases the risk of aspiration. Patients with central neurological injury with an already depressed cough or gag reflex are at the greatest risk. In 28% of patients intubated longer than 6 days, there is impaired closure of the glottis for the first 24 hours postextubation. This not only increases the risk of aspiration but also interferes with the ability to generate high intrathoracic pressures for coughing. Sinusitis, vocal cord injury, laryngeal injury, laryngeal stenosis, tracheal injury, hemoptysis and pulmonary infections are some other complications associated with prolonged intubation. The most significant immediate life-threatening complication of extubation in the adult patient is laryngospasm. It usually resolves within 30 seconds, but it may be necessary to assist ventilation during this time or provide an elevated FIO2 to prevent hypoxemia - another potential complication of extubation. If the problem persists, it may be necessary to administer a muscle relaxant. The patient with laryngospasm may have the symptom of stridor. However, persistent stridor is more likely related to the development of sub-glottic, supraglottic obstruction or glottic edema. Glottic edema is common and potentially very serious, particularly in infants. (A one mm narrowing of the airway from edema decreases lumen size by 65% in a newborn). As mentioned previously, glottic edema increase for up to 24 hours post extubation. Therefore, the appearance of stridor immediately upon extubation is a serious cause for alarm. If it persists longer than 1-2 minutes, aerosolized racemic epinephrine should be administered to cause vasoconstriction of the vessels. This reduces edema present and helps prevent further edema. Aerosolized steroids also may be administered to reduce inflammation that is present. Children run the highest risk of problems due to stridor and glottic edema because of their smaller airways. Postextubation stridor ranges from 4% in children having elective surgical procedures to 47% in pediatric trauma and burn victims. Helium-oxygen gas mixtures have been used to decrease airway resistance during the acute crisis to prevent reintubation. (Heliox mixtures are less dense then nitrogen-oxygen mixtures so airway resistance is less). The intubation procedure or if the cuff is not completely deflated upon extubation can result in vocal cord damage. It also may be the result of an oversized tube being inserted or left in place too long. The practitioner must be very careful when inserting the tube and make sure the cuff is completely deflated upon removal of the tube. The artificial airway must not be so large that it touches the vocal cords while in place. Vocal cord paralysis is uncommon but very serious. Males are seven times more likely to develop vocal cord paralysis. In the past, it was recommended that endotracheal tubes be removed or a tracheostomy performed within 3-7 days to minimize laryngeal damage. This has been extended considerably with tubes currently in use to 3 weeks or more. However, the longer the tube remains in place, the more likely there will be laryngeal damage. There is conflicting evidence regarding the value of tracheostomy in prevention of laryngeal damage. Some studies have demonstrated an increase in laryngeal damage in tracheotomized patients. Tracheostomy allows bacteria easier access to the trachea. Normal mucociliary clearance mechanisms then carry the bacteria towards the

larynx. This may explain the damage seen in these patients. In addition, being a surgical procedure, tracheostomy has many complications. Tracheostomy tube removal comes with its own set of complications: Difficult tube removal from a tight stoma Granuloma or scar at the stoma Unhealed, open stoma
Both endotracheal tubes and tracheostomy tubes with cuffs, although made to be high volume, low pressure, increase the patients risk for specific cuff-related complications: Granuloma Tracheomalacia Tracheal stenosis Tracheal web formation Tracheaoesophageal fistula Arterial fistula
Oropharyngeal secretions or stomach contents may be aspirated upon removal of the tube resulting in pulmonary aspiration syndrome. The former is caused by accumulation of secretions above the cuff. If these are not removed via suctioning, they enter the lungs when the cuff is deflated. (Intubated patients continuously aspirate minute amounts of oral secretions.) Aspiration of stomach contents is a result of pulling the tube out triggering a reflexive emesis. If adequate laryngeal and tracheal reflexes are present, aspiration is prevented. In addition, careful attention should be paid to removing all secretions above the cuff before extubation. In the majority of patients, it is wise to discontinue all feedings for 4-6 hours prior to extubation. This minimizes the risk of aspiration of stomach contents. Infants and children should have residuals aspirated prior to extubation. Extubation should be performed at peak-inspiration because this is when the cough is most effective. As mentioned, the most common complication is hoarseness or sore throat. Persistent sore throat indicates a more serious complication, such as, vocal cord trauma. A sore throat is usually relieved by administration of a cool aerosol via mask. The cool aerosol also causes vasoconstriction and may further reduce edema. Extubation may also result in pulmonary edema and/or impaired gas exchange such as hypoxemia and/or hypercapnia.

EVALUATION PARAMETERS With the objective parameters of weaning and extubation, the following are of primary consideration in extubation: Stable cardiopulmonary status The reason(s) for the tube being placed in the first place should be corrected Acceptable ABG Results Minimal tracheal secretions and the patients ability to cough them out
he negative inspiratory force (NIF) and maximum inspiratory pressure (MIP) are the same measurement. They are indicators of inspiratory muscle strength. They are useful to predict the effectiveness of the cough. The patient must be able to inhale an adequate inspiratory volume to build up intrathoracic pressure. Large volumes are necessary to expel secretions. The patient must generate a significant negative pressure to inhale a large volume. A normal NIF is more than -100 cm H2O. A NIF of -30 cm H2O is considered adequate for extubation in most patients. A NIF of -30 cm H2O may not be adequate in patients receiving muscle relaxants or others having nonfunctional airway protection muscles. A NIF of -30 cm H2O is associated with adequate minute ventilation but not with adequate airway protection muscles. Airway protection is assured at NIFs of -33 to -43 cm H2O, so one should use this range on some patients. A significant advantage to the NIF over other tests of pulmonary function is that no patient cooperation is necessary. Valid results can be obtained on uncooperative or disoriented patients. The forced vital capacity (FVC) may even be more valuable than the NIF as a predictor of cough effectiveness. Not only are high volumes necessary for a strong cough, high flows are just as necessary. The FVC gives both flow and volume information. An FVC of 10 cc/kg (ideal body weight) is needed to expel secretions from the trachea. The FVC requires an alert, cooperative patient to be valid. This is a disadvantage to the test. If the patient has chronic lung disease, a slow vital capacity (SVC) may yield better results than an FVC. Forced expiratory maneuvers cause early airway collapse in these patients. An SVC gives the practitioner an indicator of inspiratory volume but no information on flow capabilities. The peak expiratory flow rate (PEFR) has been proposed as a more accurate predictor of expiratory force for coughing. Increasing PEFR is associated with increasing cough effectiveness. In the absence of a peak flow, the forced expiratory volume in one second (FEV1) may be used. The PEFR or the FEV1 should be maximized before extubation. In adults, a minute volume of less than 10 lpm and a respiratory rate (RR) of less than 35 per minute are considered appropriate for extubation. Numbers greater than these generally indicate some degree of acute distress. (However, restrictive disease patients may have a normal RR

greater than 35). The patients tidal volume (VT) should be greater than or equal to 5 ml/kg (ideal body weight). Patients with poor ejection fraction, measured during echocardiography, may have higher respiratory rates to compensate for the inadequate cardiac output. Stable arterial blood gases (ABGs) are necessary before extubation. Normal ABG numbers vary between individuals. The patients age and FIO2 need to be considered, along with the presence of chronic lung disease in predicting a normal ABG. A generic PaO2 range is 80-100 mm Hg, % saturation is 94-97%, pH is 7.35 - 7.45, and PaCO2 is 35-45 mm Hg. Maintenance of adequate PaO2 with a PEEP less than or equal to 10cmH2O and a FIO2 less than or equal to .40 are suggested guidelines. Patients over 60 years old, or those with chronic lung disease may have a lower PaO2. PaCO2 and pH are probably more relevant in evaluating these patients for extubation. PaCO2 should be stable and pH between 7.35 - 7.45. PaCO2 may be elevated in patients with chronic obstructive lung disease, but as long as pH is normal extubation is reasonable. The FIO2 should be less than 60% (preferably less than 40%) before extubation. Generally, high FIO2 is associated with acute lung disease so extubation is unwise. However, this one parameter should not prevent extubation if other parameters are positive. Patient secretions should be minimal in both amount and viscosity. The level of consciousness should be maximized. The ideal situation is an alert, cooperative patient. The work of breathing should be minimal. This is evaluated by compliance studies and observation of the accessory muscles of breathing. These are the muscles of the upper chest and neck. If there is an increase in the work of breathing, they are in use. If the accessory muscles are hypertrophied, it indicates a chronic condition of labored breathing (COPD). The soft tissues of the chest (intercostal spaces, supraclavicular and suprasternal notches) also should be observed as an indicator of work of breathing. Retraction of the soft tissues on inspiration indicates an increase in the work of breathing. This may be related to acute or chronic respiratory distress. A simple indicator of work of breathing is the RR. If neurological status is normal, the lower the respiratory rate (RR), the less work of breathing. Work of breathing index of less than 0.8J/L, oxygen cost of breathing of less than 15% total, and a dead space to tidal volume ratio of less than 0.6 are other parameters that may be used by the clinician to assess the patients abilities for extubation. The cardiovascular status obviously varies between individuals. Ideally, one would like to see no arrhythmias or heart medications being administered. This is impossible in some patients. Like ABGs, evaluating the stability of the cardiovascular system instead of specific numbers is recommended. If stable, the patient may be extubated. The VD/VT ratio and the maximum voluntary ventilation (MVV) also are used for evaluation. The VD/VT ratio gives information on the amount of wasted ventilation. Normally, the ratio is 33%. For extubation, it should be less than 60%. The MVV has been criticized because it is an effort-dependent test. However, it can be useful as a mini pulmonary stress test. If used, a patient should be able to double their resting minute volume with an MVV. The MVV gives information on the amount of pulmonary reserve. One simple guideline for MMV is that it should be greater than twice the patients resting minute ventilation. Another stress test is to
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have the patient breathe unassisted through the tube for one hour prior to extubation. If the patient has the pulmonary reserve to breathe through the tube for an hour they may be extubated. One must remember that airway resistance is inversely related to the radius of the airway to the fourth power. Just having an artificial airway in place means the patient has a considerable increase in the work of breathing. This may affect the performance on some of the above tests. Removal of the tube may, in fact, improve some of the numbers tremendously. Therefore, many patients are unable to meet the above criteria in all categories but can still safely be extubated. Each case needs to be evaluated on an individual basis. The pros and cons of extubation need to be weighed carefully on each patient. Many patients, particularly the COPD patient, will be unable to meet some of the above criteria even in the best of health. Obviously, they should not remain intubated if they have returned to their normal baseline health. COMMON EXTUBATION CRITERIA NIF more than -30 cm H2O FVC greater than or equal to 10 cc/kg PEFR (higher the better) Minute volume less than 10 lpm (adults) RR less than 35 bpm (adults) PaO2 (stable) PaCO2 (stable) pH 7.35 - 7.45 Minimal secretions Alert, cooperative Minimal work of breathing Stable cardiovascular status
The extubation criteria above are presented as guidelines only. Many patients have bad values in one category but meet other criteria. The practitioner must then use their experience and knowledge of the individual patient to decide when to extubate. NOTE: Patients intubated for epiglottitis can be difficult to evaluate for extubation. Most of the above parameters are not helpful in their evaluation for extubation. Some physicians will use
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repeated laryngoscopy or neck x-rays to evaluate resolution of upper airway edema. Others recommend extubation when the patients general toxic appearance and fever are gone. One can also deflate the cuff and monitor the amount of air leak around the tube. As edema resolves, the leak increases. If the patient tolerates plugging the tube with the cuff deflated, extubation may be performed. Approximately 90% of patients intubated for epiglottitis are extubated within 24 hours. It may be wise to place an endotracheal tube changer in the tube before extubation. The patient may then be extubated and the changer left in place. Should reintubation be necessary, the changer can aid access to the trachea. The changer can be left in place for several hours post extubation. ACCIDENTAL EXTUBATION
he patient may be accidently extubated before a planned extubation, so this will be briefly discussed. There are approximately 15 million intubations per year in the United States. Approximately 10% of extubations in the ICU are accidental. They are the result of accidental removal during another procedure or removed by the patient. Risk factors for selfextubation are delirium, agitation, and restlessness. Many patients self-extubate simply because they feel intubation is uncomfortable and / or painful. Many experience intense feelings of gagging and breathlessness with a tube in place. Self-extubation is a simple survival tactic. Patients must be properly sedated and restrained to prevent self-extubation. They must be constantly oriented to time, place, and the importance of the tube. Obviously, the staff must properly secure the tube and ensure it will not be pulled out during patient movement or other procedures. Surprisingly, 35-40% of accidental extubations do not require reintubation. The patient is high-risk for reintubation if they have four or more of the following: 40% FIO2 7 lpm mechanical minute volume pH > 7.45 just before accidental extubation PaO2/FIO2 < 250 mm just before accidental extubation peak heart rate > 120 in 24 hours before accidental extubation coexisting disease (at least three of the following) COPD history heart failure history renal dysfunction
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liver dysfunction stroke, seizure, coma history current use of antibiotics electrolyte abnormality nonalert mental status reason for intubation was for acute respiratory failure reason for intubation was for airway protection To prevent accidental extubation: Secure the airway in place Maximize patient acceptance of the airway Control delirium and agitation Apply physical restraints
LEAK TEST PROCEDURE Patients with possible airway burns, traumatic intubations and victims of allergic reactions may have edema of the trachea. Extubation of these patients without first verifying that swelling no longer exist is critical for save extubation of these patient. The cuff-leak test is intended to help predict the occurrence of glottic edema and/or stridor after extubation. The two methods that are frequently used are as follows: 1) Totally deflate the cuff, and then completely occlude the endotracheal tube. The presence of a leak around the tube during spontaneous breathing indicates that tracheal tissue is not encroaching on the endotracheal tube (a positive test) and therefore swelling is nonexistent or reduced. 2) The second method is similar, but the leak is assessed during positive pressure ventilation. A negative test (no leak) indicates a high potential for postextubation obstruction
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EXTUBATION PROCEDURE
he procedure for extubation varies from institution to institution. The following is presented as a general procedure for use in the absence of a specific procedure. It requires 2 people to perform. In the clinical situation it is more common for one person to perform extubation. This person (or another in the immediate area) should be proficient at intubation should reintubation be necessary. It is also recommended that the patient breathe unassisted through the tube for a brief period before extubation. Breathing unassisted through the tube gives an indication of pulmonary reserve. An adequate pulmonary reserve is necessary after extubation to overcome glottic edema, cough, expel secretions, and prevent atelectasis. The patient should be physiologically monitored, emergency equipment and personnel trained in airway management skills should be present. Personnel should follow the Center for Disease Control Standard Precautions and institute appropriate precautions for airborne, droplet and contact precautions. 1. Perform all indicated measurements and observations. After careful evaluation, if it is decided to extubate, the following equipment should be gathered and assembled: Oxygen source Suction set-up with sterile catheters and pharyngeal suction devices Oral and pharyngeal airways Resuscitation bag and mask Cool aerosol set-up with mask Scissors 10 cc syringe Hand-held nebulizer, MDI or IPPB set-up Racemic epinephrine and normal saline Reintubation supplies, (laryngoscope and blades, endotracheal tubes, batteries, stylettes) Equipment for establishing an emergency surgical airway (scalpel, lidocaine with epinephrine, appropriately sized endotracheal or tracheostomy tubes) Pulse oximeter Supplies for arterial puncture and blood gas analysis
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A physicians order is necessary for the cool aerosol, hand-held nebulizer, MDI, IPPB, and medications. Equipment and personnel for emergency reintubation should be available, should it be necessary. The patient is informed of the upcoming procedure and that coughing, hoarseness, sore throat, and dyspnea are not uncommon. Reassure the patient these will pass quickly and they will be closely monitored. 2. Suction the trachea and when no more secretions are obtained, suction the oropharynx to remove saliva. (person 1). Suctioning prior to extubation helps prevent aspiration of secretions after cuff deflation. 3. Hyperinflate the patient several times with the resuscitation bag and hyperoxygenate for two minutes. Extubation is a stressful procedure that can cause hypoxemia and unwanted cardiovascular side effects. Spontaneous hyperinflation may be adequate in some patients. One suggested guideline is that the FIO2 be increased 5 to 10 minutes prior to extubation. 4. The tape holding the endotracheal tube in place should be cut. If an endotracheal tube holder is being used; it should be removed (person 2). 5. Place a sterile suction catheter into the endotracheal tube (person 1). Some clinicians, if the patient is on continuous mechanical ventilation (CMV), give the patient a sigh breath while deflating the cuff. This forces the secretions from above the cuff into the oropharynx to be suctioned with a tonsil tip device. Deflate the cuff slowly with a syringe (person 2). Some practitioners then cut the valve off the pilot tube to ensure that any remaining air is easily displaced during removal Person 1 suctions any secretions that enter the trachea from cuff deflation. Two clinical variations arise at this time. Some clinicians leave the suction catheter in the endotracheal tube and suction as the tube is pulled out. Others feel this depletes oxygen and they remove the suction catheter prior to removing the tube.
6.
7. Ask the patient to take a deep breath and hold it. Timing is critical at this point. 8. Remove the tube in an anatomical configuration at peak-inspiration. Removal at peak-inspiration maximizes cough effectiveness as the tube is removed. Be prepared to suction the patients oropharynx with a tonsil-tip device. 9. Have the patient cough forcefully to expel secretions. This results in maximal abduction of the vocal cords, which helps prevent them from being damaged.
10. If stridor is present or there is difficulty breathing, begin the nebulizer, MDI or IPPB treatment with racemic epinephrine. This reduces glottic edema and the swelling caused by the tube and its removal. Aerosolized steroids may be necessary to further reduce inflammation and swelling. It is recommended to use a high flow rate to create turbulence within the upper airway. This causes most of the medication to be deposited in the upper
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airway, where it will do the most good. This is contrary to most breathing treatments where the practitioner uses a low flow rate to maximize deposition within the lungs. One wants the medication to rain out in the upper airway post extubation. 11. Place the patient on a cool aerosol at an appropriate FIO2. If intubation was not prolonged, a nasal cannula or other oxygen device (appropriate for required FIO2) may be used. 12. Place a sterile dressing over the stoma if they were trached. 13. Assess/Reassess the patient. The clinician should monitor and evaluate the patient every 30 minutes for several hours. Encourage deep breathing and coughing. Auscultate for upper airway noise as well as breath sounds. An ABG should be performed in 30-60 minutes to assess PaO2 and PaCO2. Oxygenation should be monitored via oximetry in the meantime. Next assess the patients respiratory rate, heart rate, color, and blood pressure. Mild hypertension and tachycardia immediately after extubation are common and resolve spontaneously in most cases. Also, watch for nosebleeding following nasotracheal extubation. Encourage the patient to cough, with assistance as needed. Because laryngeal edema may worsen with time and stridor may develop, be sure that racemic epinephrine is available. Sample and analyze ABG values as needed. The most common problems that occur after extubation are hoarseness, sore throat, and cough. These are benign and will improve with time. A rare, but serious, complication associated with extubation is laryngospasm. Post extubation laryngospasm is usually a transient event, lasting a matter of seconds. Should this occur, oxygenation can be maintained with a high FIO2 and the application of positive pressure. If laryngospasm persists, a neuromuscular blocking agent may have to be given, which will necessitate manual ventilation or reintubation. Since the vocal cords have had limited function during the intubation period, they may not fully close as needed, once the airway has been removed. To avoid aspiration, oral feedings, especially liquids, should be withheld for 24 hours after extubation. Patients may aspirate liquids even with an intact gag reflex. Extubation failure, defined as reinsertion of the airway, due to airway problems often occurs within eight hours of extubation. Aspiration and edema are the most common problems. If the patient was also mechanically ventilated, reintubation may be required for work of breathing issues unrelated to the airway.
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CLINICAL PRACTICE EXERCISE The following practice exercise is discussed at the end of the course. The discussion is based upon the text material. Individual experience and institutional standards may suggest equally correct responses to the questions. 1. The patient is a 42 year old, male, 78 kg patient. He was admitted following a blunt injury to the head. He was intubated following massive aspiration and respiratory arrest. Mental status has improved considerably. The patient now follows commands and appears oriented. He has been weaned from mechanical ventilation and is now receiving 24% humidified oxygen via oral endotracheal tube. You have been asked to evaluate the patient for extubation. What data will you gather for your evaluation and why? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 2. Based upon the above history and the following, evaluate the patient for extubation: NIF -32 cm H2O, FVC 1100 cc, minute volume 9.8 liters, RR 24, small amount of thin, clear secretions suctioned over last 4 hours. Suctioning of trachea produces a strong cough. Suctioning of the oropharynx produces gagging. ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ 3. You receive the order to extubate the patient. What should you tell the patient in preparation for extubation? ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________
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SUMMARY
xtubation is the removal of an artificial airway from the patient. It should be done as soon as the need for the airway has been resolved. Some of the reasons for an artificial airway are: to relieve upper airway obstruction, to provide protection of the airway, for removal of excessive secretions, and to provide mechanical ventilation. Should the problem be resolved, extubation is indicated. Some of the complications of extubation include: laryngospasm, stridor, aspiration, glottic edema, vocal cord damage, hoarseness, and sore throat. These may be minimized by: removing all secretions above the cuff before deflation, deflating the cuff and removing the tube at peak-inspiration, initially selecting the proper size tube, providing post-extubation aerosolized racemic epinephrine and corticosteroids, and by placing the patient on a cool aerosol after extubation. Some parameters used to evaluate the patient for extubation are: NIF, FVC, RR, minute volume, and peak flow rates. An NIF of -30 cm H2O, FVC of 10 ml/kg, RR less than 35, minute volume less than 10 lpm are considered adequate. Peak flow rates should be maximized prior to extubation. PRACTICE EXERCISE DISCUSSION 1. NIF will give information on inspiratory muscle strength. FVC and PF indicate ability to cough effectively. RR and minute volume indicate his work of breathing. Based upon patient being weaned from ventilator and only receiving 24% O2, ABGs are probably not necessary at this time. A review of the neurological progress notes is warranted considering his aspiration problem. The patient must have adequate glottic reflexes to protect his airway. Lastly, an evaluation of sputum being suctioned is necessary. 2. The NIF, minute volume, and RR meet extubation criteria. FVC exceeds extubation criteria at approximately 14 cc/kg. Secretions do not preclude extubation. The reason for intubating this patient appears to be reversed. He was intubated because he was unable to protect his airway due to neurological trauma. The patient is now alert and appears to have the return of his normal reflexes. Breathing appears adequate and unlabored based upon RR, minute volume, and low FIO2. Recommend extubating this patient. 3. Explain to him that you will be removing the tube and that hoarseness, sore throat, and coughing are common. He may feel a little short of breath temporarily but he will be closely monitored. He should be reassured to relieve any anxiety he may feel.
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SUGGESTED READINGS AND REFERENCES 1. AARC Clinical Practice Guideline; Bland Aerosol Administration - 2003 Revision & Update, Respiratory Care 2003; 48(5): 529-533. 2. AARC Clinical Practice Guideline; Delivery of Aerosols to the Upper Airway, Respiratory Care 1994; 39(8): 803-807. 3. AARC Clinical Practice Guideline; Management of Airway Emergencies, Respiratory Care 1995; 40(7); 749-760. 4. AARC Clinical Practice Guideline; Removal of the Endotracheal Tube, Respiratory Care 1999;44(1):85-90. 5. Barnes, T., CORE TEXTBOOK OF RESPIRATORY CARE PRACTICE, 1994. Mosby-Year Book, Inc., St. Louis. 6. Burton, G., Hodgkin, J., Ward, J., RESPIRATORY CARE, A GUIDE TO CLINICAL PRACTICE, 4th ed., 1997. Lippincott-Raven, Philadelphia. 7. Chipley P. et al, PROLONGED USE OF AN ETT CHANGER IN A PEDIATRIC PATIENT, Chest, Mar. 1994, Vol. 105, #3, pp 961-963 8. Colice G., Stukel T., Dain B., LARYNGEAL COMPLICATIONS OF PROLONGED INTUBATION, Chest, Oct. 1989, Vol. 36, #4, pp 877-883 9. Rippe J., Irwin R., Alpert J., Fink M., INTENSIVE CARE MEDICINE, 2nd edition, 1991, Little Brown and Co., pp 14, 15, 697, 1354 10. Scanlan C, Spearman C, Sheldon L., EGANS FUNDAMENTALS OF RC, 6th edition, 1995, Mosby Year-Book Inc., pp 575-578 11. Sessler C, Glass C, Grap M., TECHNIQUES FOR PREVENTING & MANAGING UNPLANNED EXTUBATIONS, Journal of Critical Illness, June 1994, Vol. 9, #6, pp 609-619 12. Sharar S., WEANING AND EXTUBATION ARE NOT THE SAME THING, Respiratory Care, Mar. 1995, Vol. 40, #3, pp 239-243 13. Sills, J., RESPIRATORY CARE REGISTRY GUIDE, THE COMPLETE REVIEW RESOURCE FOR THE REGISTRY EXAMS, 1995. Mosby-Year Book, Inc., St.Louis. 14. Marik P., THE CUFF-LEAK TEST AS A PREDICTOR OF POSTEXTUBATION STRIDOR, Respiratory Care, June 96, Vol. 41, #6, pp 509-511 15. Marini J., WEANING TECHNIQUES AND PROTOCOLS, Respiratory Care, Mar. 95, Vol.
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40, #3, pp 223-237 16. Whelan J, Simpson S, Levy H., UNPLANNED EXTUBATION, Chest, June 94, Vol. 105, #6, pp 1808-1812
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POST TEST DIRECTIONS: IF COURSE WAS MAILED TO YOU, CIRCLE THE MOST CORRECT ANSWERS ON THE ANSWER SHEET PROVIDED AND RETURN TO: RCECS, 16781 VAN BUREN BLVD, SUITE B, RIVERSIDE, CA 92504-5798 OR FAX TO: (951) 789-8861. IF YOU ELECTED ONLINE DELIVERY, COMPLETE THE TEST ONLINE PLEASE DO NOT MAIL OR FAX BACK.
1. When should extubation be considered? a. b. c. d. When the patient requests it When you feel it is appropriate When the need for an airway is no longer present When the patient is ready to be weaned from mechanical ventilation
2. What is recommended to reduce the possibility of post-extubation glottic edema? a. b. c. d. Aerosolized epinephrine and NS Aerosolized arformoterol and NS Aerosolized corticosteroids, racemic epinephrine, and NS Aerosolized corticosteroids, Mucomyst, and NS
3. To prevent accidental extubation: a. b. c. d. e. secure the airway in place. control delirium and agitation. apply appropriate physical restraints. all the above. a & c.
4. Which of the following may be required post extubation? I. Application of CPAP II. Reintubation III. Increased FIO2 delivery IV. Noninvasive ventilation a. b. c. d. I I, II, IV II, III All of the above
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5. The most immediate life-threatening complication of extubation in the adult patient is: a. b. c. d. Sore throat and hoarseness Laryngospasm Hypoglossal nerve trauma Aspiration of stomach contents
6. Which of the following is necessary prior to extubation? I. II. III. IV. Deflate cuff Aerosolize racemic epinephrine Suction trachea and oropharynx Cut trach ties or tape holding tube a. b. c. d. I, II, III I, III, IV II. III I, II, IV
7. Which of the following make a patient high-risk for reintubation following an accidental extubation? I. > 40% FIO2 II. > 7 lpm mechanical minute volume III. pH > 7.45 just before accidental extubation IV. PaO2/FIO2 < 250 mm Hg just before accidental extubation a. b. c. d. e. II, III I, II, III, IV II, III, IV I, IV II only
8. How can the possibility of aspiration be minimized when extubating? a. b. c. d. e. Remove all secretions above cuff Deflate cuff before suctioning the oropharynx Extubate at peak-inspiration for maximum cough effectiveness a&c a&b
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9. Aspiration of oropharyngeal secretions or stomach contents during extubation results in: a. b. c. d. Pulmonary aspiration syndrome Pulmonary edema ARDS Tension pneumothorax
10. When should an oral endotracheal tube be withdrawn? a. b. c. d. At end-expiration At mid-expiration At peak-inspiration At the beginning of inspiration
11. Both endotracheal and tracheostomy tube cuffs may cause: I. II. III. IV. Tracheal stenosis Tracheomalacia Tracheoesophageal fistula Arterial fistula a. b. c. d. I, II, III II, III, IV I & II only All of the above
12. What value is the FVC in evaluating for extubation? a. b. c. d. It has little value Indicates ability to cough out secretions Indicates patient cooperation Indicates amount of wasted ventilation
13. If the objective parameters of weaning and extubation are met, the following are also of primary consideration in extubation: I. II. III. IV. Acceptable arterial blood gas results Patients ability to clear secretions Stable cardiopulmonary status Clear chest X-ray a. b. c. d. I, III, IV II, III, IV I, II, III All of the above
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14. Tracheostomy tubes have complications that differ from endotracheal tubes. These complications are: I. II. III IV. Tracheal web formation Granuloma or scar at the stoma Unhealed, open stoma Difficulty removing tube from a tight stoma a. b. c. d. I, II, III II, III, IV None of the above All of the above
15. Equipment for establishing an emergency surgical airway should be available during extubation. a. true
b. false
KM: Test Version G
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ANSWER SHEET NAME____________________________________ STATE LIC #_______________________ ADDRESS_________________________________ AARC# (if applic.)___________________ DIRECTIONS: (REFER TO THE TEXT IF NECESSARY PASSING SCORE FOR CE CREDIT IS 70%). IF COURSE WAS MAILED TO YOU, CIRCLE THE MOST CORRECT ANSWERS AND RETURN TO: RCECS, 16781 VAN BUREN BLVD, SUITE B, RIVERSIDE, CA 92504-5798 OR FAX TO: (951) 789-8861. IF YOU ELECTED ONLINE DELIVERY, COMPLETE THE TEST ONLINE PLEASE DO NOT MAIL OR FAX BACK. 1. 2. 3. 4. 5. 6. 7. 8. 9. a b c d a b c d a b c d e a b c d a b c d a b c d a b c d e a b c d e a b c d
10. a b c d 11. a b c d 12. a b c d 13. a b c d 14. a b c d 15. a b
KM: Test Version G
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EVALUATION FORM NAME:____________________________________________ DATE:______________ AARC # (if applic.)________________________ STATE LICENSE #:______________ RC Educational Consulting Services, Inc. wishes to provide our clients with the highest quality CE materials possible. Your honest feedback helps us to continually improve our courses and meet CE regulations in many states. Please complete this form and return/submit it with your answer sheet. Thank you. YES NO Were the objectives of the course met? Was the material clear and understandable? Was the material well-organized? Was the material relevant to your job? Did you learn something new? Was the material interesting? Were the illustrations, if any, helpful? Would you recommend this course to a friend? What was the most valuable portion of the material? ________________________________________________________________________ What was the least valuable portion of the material? ________________________________________________________________________ Suggestions for future courses: ______________________________________________ Comments: ______________________________________________________________ ________________________________________________________________________ What is your specialty area?______________________________ Credentials?________ How did you hear about RCECS?____________________________________________
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Extubation Guidelines

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EXTUBATION: GUIDELINES AND PROCEDURE

Kevin T. Martin BVE, RRT, RCP