10- Extubation-updated-1444 (2).pdf

Respiratory Care Therapeutics Course (RT 264) 144 Extubation 1444 Extubation Introduction - 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 pr...

Respiratory Care Therapeutics Course (RT 264) 144 Extubation 1444 Extubation Introduction - 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 institute infection control policy (appropriate precautions for airborne, droplet and contact precautions). Extubation - Definitions :- Extubation /Decannulation Extubation: The process of removing an artificial tracheal airway (oral or nasal endotracheal airway) Decannulation: Process of removing tracheostomy tube Assess patient readiness for extubation or decannulation Patients should be considered for extubation when they have met established extubation readiness criteria; examples of these criteria include : Original problem is no longer present Quantity & thickness of secretions ↓↓ Upper airway patency Presence of intact gag reflex Ability to clear airway secretions Extubation Assess patient readiness for extubation or decannulation (cont.,) - Adequate respiratory muscle strength( Maximum negative inspiratory pressure greater than −30 cm H2O, although current clinical practice may accept greater than −20 cm H2O) - Vital capacity greater than 10 ml/kg ideal body weight - Tidal Volume > 5 mL/kg - In adults, spontaneous exhaled minute ventilation less than 10 L/min - The capacity to maintain appropriate pH (pH ≥ 7.25) and arterial partial pressure of CO2 during spontaneous ventilation. - In adults, respiratory rate less than 30 breaths/min during spontaneous breathing - Thoracic compliance greater than 25 ml/cm H2O - Work of breathing less than 0.8 J/L 4 Extubation Assess patient readiness for extubation or decannulation (cont.,) Pass a Spontaneous Breathing Trial (SBT):- SBT (spontaneous breathing trial) 30–120 minute with low level of CPAP (or PEEP) (e.g. 5 cm H2O) or low level of pressure support (e.g. 5-7 cm H2O) Show improved gas exchange (ABG); PaO2 ≥ 60 mm Hg FiO2 ≤ 0.40 on PEEP ≤ 5 cm H2O Hemodynamic stability RSBI (rapid shallow breathing index): RR/Vt < 105 Subjective comfort Extubation Step 7: Assess/reassess patient (cont.,):- - 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 within 48 hours after extubation (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. Extubation Hazards and Complications of extubation -Hypoxemia after extubation may result from but is not limited to : Failure to deliver adequate FiO2 through the natural upper airway Acute upper airway obstruction secondary to laryngospasm Development of post-obstruction pulmonary edema Bronchospasm Development of atelectasis, or lung collapse Pulmonary aspiration Hypercapnia after extubation may be caused by but is not limited to : Upper airway obstruction resulting from edema of the trachea, vocal cords, or larynx Hypoventilation and Respiratory muscle weakness Extubation Predicting difficult extubation.. Cuff-leak test VT expired = VT inspired VT expired < - A positive cuff-leak test (absence of VT inspired leak or leak less than 15%) should alert the clinician of a high risk of upper airway obstruction. - It is done by measuring difference between the exhaled tidal volume when Oedema the cuff is inflated and when deflated. Leak with - Tracheal intubation > 48 h deflated cuff leak ≥15 % OK leak < 15 % increased risk of stridor and/or reintubation LEAK = 0 Extubation Risk Factors for Extubation failure Extubation failure means: the need for reintubation within 48 h after extubation. This may occur in; ICU patient Age > 70 or < 24 months Longer duration of mechanical ventilation Medical or surgical airway condition Frequent pulmonary toilet Loss of airway protective reflexes Extubation Causes of Extubation Failure Several attempts for difficult intubation.( Increased risk if number of attempts > 3 ) Traumatic intubation. Large diameter, overinflation, malposition of endotracheal tube. Prolonged surgery( more than 4hrs). Cervicomaxillofacial surgery. Prolonged trendelenberg position Radiotherapy and neck dissection. Extubation Decannulation Removal of tracheostomy tube Weaning process: Fenestrated tubes Double cannulated tube that has opening in posterior wall of outer cannula above cuff Progressively smaller tubes Tracheostomy buttons 16