the difficult extubation

Post-ExtubationPost-Extubation Emergencies Emergencies

OH SH..!OH SH..!

Discontinuing Mechanical Discontinuing Mechanical VentilationVentilation

Resolution of the process that caused the Resolution of the process that caused the intubation.intubation.

Spontaneous breathing ability with Spontaneous breathing ability with adequate ABG’s and Hemodynamicsadequate ABG’s and Hemodynamics

Extubation CriteriaExtubation Criteria

Ability to CoughAbility to CoughMIFMIF

VC /PEFVC /PEF

Cognitive Cognitive

SecretionsSecretionsCan there be too many?Can there be too many?

““Salam et al, “Neurologic status, cough, secretions and extubation outcomes” Salam et al, “Neurologic status, cough, secretions and extubation outcomes”

Intensive Care Medicine (2004) 30:1334-1339Intensive Care Medicine (2004) 30:1334-1339””

Extubation CriteriaExtubation Criteria

Hardware IssuesHardware IssuesNG/OG tubesNG/OG tubes

Wired jawWired jaw

Cervical fixation devicesCervical fixation devices

The Top FiveThe Top Five

LaryngospasmLaryngospasm

Laryngeal StridorLaryngeal Stridor

Acute HypoxemiaAcute Hypoxemia

Acute Respiratory FailureAcute Respiratory Failure

Neurologic pathologyNeurologic pathology


Definition: The vocal folds spontaneously Definition: The vocal folds spontaneously closing and staying closed.closing and staying closed.

Presents as NO air movement and patient Presents as NO air movement and patient in a panic (conscience or not)in a panic (conscience or not)


Causes:Causes:HysteriaHysteria

Mechanical Mechanical

ChemicalChemical

Can you predict it?Can you predict it?Extubating with Positive pressureExtubating with Positive pressure


How do you treat it?How do you treat it?WaitWait

SedationSedation

Laryngeal StridorLaryngeal StridorDefinition: High pitched inspiratory noise that occurs Definition: High pitched inspiratory noise that occurs when vocal folds are swollen and close together allowing when vocal folds are swollen and close together allowing little air to pass through.little air to pass through.

Can you predict it?Can you predict it?Cuff leak testCuff leak test

– Volume leakVolume leak““Kriner et al, The Endotracheal Tube Cuff-Leak Test as a Predictor for Postextubation Kriner et al, The Endotracheal Tube Cuff-Leak Test as a Predictor for Postextubation

Stridor, Respiratory Care 2005 Dec;50(12)1632-1638Stridor, Respiratory Care 2005 Dec;50(12)1632-1638

– ETT occlusionETT occlusion

Risk populationsRisk populationsMen vs. WomenMen vs. WomenObesityObesity

“ “Erginel S. et al “High body mass index and long duration of intubation increase post-Erginel S. et al “High body mass index and long duration of intubation increase post-extubation stridor in patients with mechanical ventilation” J Exp Med. 2005 extubation stridor in patients with mechanical ventilation” J Exp Med. 2005 Oct;207(2)125-32.Oct;207(2)125-32.


Is it stridor or obstruction?Is it stridor or obstruction?Jaw Thrust/Sniff positionJaw Thrust/Sniff position

Secretion clearanceSecretion clearance

How do you treat the obstruction?How do you treat the obstruction?Nasal/oral airwaysNasal/oral airways

Mask CPAPMask CPAP


How can you treat?How can you treat?Racemic epinephrine/ bronchodilatorsRacemic epinephrine/ bronchodilators

.5cc/2ccNS.5cc/2ccNS

HelioxHeliox80/20 mixture80/20 mixture

Max. FiO2 .35Max. FiO2 .35

SedationSedation


Definition: Sudden decrease of oxygen in Definition: Sudden decrease of oxygen in the blood.the blood.

Can you predict it?Can you predict it?


Secretions/Mucous plugSecretions/Mucous plugCough or need for NTS quicklyCough or need for NTS quickly

Pulmonary edemaPulmonary edemaNegative pressure pulmonary edemaNegative pressure pulmonary edema

Support with oxygenSupport with oxygen

Cardiac Cardiac Mask CPAPMask CPAP

Vomiting/AspirationVomiting/AspirationPosition pt on sidePosition pt on side

Need for oral and NT suction quicklyNeed for oral and NT suction quickly

Support oxygenationSupport oxygenation

Acute Ventilatory FailureAcute Ventilatory Failure

Definition: An inability for the patient to Definition: An inability for the patient to ventilate to maintain a normal pH (7.35-ventilate to maintain a normal pH (7.35-7.45)7.45)

Presents itself by:Presents itself by:Increased RRIncreased RR

Increased WOBIncreased WOB

Decreased SaO2Decreased SaO2

Acute Ventilatory FailureAcute Ventilatory Failure

Can you predict it?Can you predict it?

How do you treat?How do you treat?NPPVNPPV

– COPD vs. Non-COPDCOPD vs. Non-COPDEsteban et al. Esteban et al. ““Noninvasive Positive-Pressure Ventilation for Respiratory Failure Noninvasive Positive-Pressure Ventilation for Respiratory Failure

after Extubation” N Engl J Med 2004;350:2452-60after Extubation” N Engl J Med 2004;350:2452-60

Ferrer et al. “Early Noninvasive Ventilation Averts Extubation Failure in Patients at Risk” Ferrer et al. “Early Noninvasive Ventilation Averts Extubation Failure in Patients at Risk”

AM J Respir Crit Care Med 2006;173:164-170AM J Respir Crit Care Med 2006;173:164-170

Sedation withdrawalSedation withdrawal

Re-intubateRe-intubate

Neurologic PathologyNeurologic Pathology

ALSALS

Traumatic Brain InjuryTraumatic Brain Injury

MS, Guillian Barre, TetraplegiaMS, Guillian Barre, Tetraplegia

Critical Illness neuromyopathyCritical Illness neuromyopathy

Post-Extubation EmergenciesPost-Extubation Emergencies

The inability to reliably predictThe inability to reliably predict

The Top FiveThe Top Five

How to treatHow to treat

BE PREPAREDBE PREPARED

Do not treat extubations as routineDo not treat extubations as routine

Assess, Assess, Assess Assess, Assess, Assess

Have Difficult Intubation Supply easily Have Difficult Intubation Supply easily available in unitavailable in unit

Don’t PanicDon’t Panic

the difficult extubation

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