ICU Extubation Tips:
Let’s admit it. As intensivists, we will never be as good in airway management as our Anesthesia or Emergency Medicine colleagues are. They intubate many more pts than we do & some of them under very suboptimal conditions. So, we can never match their skills
Let’s admit it. As intensivists, we will never be as good in airway management as our Anesthesia or Emergency Medicine colleagues are. They intubate many more pts than we do & some of them under very suboptimal conditions. So, we can never match their skills
On the other hand, we are the ones tasked w extubating the "difficult" cases. Therefore, even if we cannot become the best "intubators", we do need to be excellent “extubators”. To this end, a few points (not emphasized in textbooks!) need to be kept in mind & used in practice:
1. Discontinuing ventilator support is not the same as weaning this support. The former is the abrupt termination of ventilation, also known as "pulling the breathing tube". The other is the gradual reduction in the level of vent support. Not every ventilated pt needs "weaning"!
2. More importantly, "weanability" (defined as tolerating the gradual ⬇️ in ventilatory support) does not equal "extubatability". If there is upper airway edema, difficulty in coughing up secretions, altered mental status etc, the pt may do fine w weaning but poorly w extubation
3. Assuming the pt needs to be "weaned", what is the "starting point" that has to be satisfied? We usually talk about "minimal vent settings (MVS)”, such as FiO2≤40% & PEEP ≤8 cmH2O. Problem is that if a pt is at 6 l/m O2 at home or has a BMI of 50, the MVS may be much higher!
On the flip side, adding 5 cm of PEEP can ⬇️ work of breathing by almost 40% in ventilated pts & can substantial ⬆️ cardiac output in pts w LV failure. If you've seen someone developing pulm edema right after extubation & elimination of positive intrathoracic pressures, you know!
4. The rapid shallow breathing index (frequency to tidal volume (f/Vt) ratio) can be used as a screening test. You don't have to be accurate but if f/Vt > 100, chances of successful weaning are good (test has high sensitivity but low specificity). I don't do the exact math...
5. I have no recipe for a breathing trial: PS of 5 versus 7 versus T-piece or 30 min versus 120 min etc etc. Use your judgement. A pt who is 100 yo recovering from CHF & ventilated x 10 d is probably different from a 40 yo intubated for V fib arrest. Of course, I may be wrong...
Every extubation attempt should ideally start well ahead of time...
6. Ensure that your frail patient gets a good night of sleep before weaning next morning. If I ever decide to ran a (half-)marathon, I will do my best to get a good amount of sleep the previous night...
6. Ensure that your frail patient gets a good night of sleep before weaning next morning. If I ever decide to ran a (half-)marathon, I will do my best to get a good amount of sleep the previous night...
7. Start diuresis as soon as possible. Starting PS trials w extra 20 lts of fluid on board does not sound as a great strategy...
8. Several "borderline" patients need thoracentesis/paracentesis/bronchoscopy before weaning trials. Again, use your judgement & ignore the literature
8. Several "borderline" patients need thoracentesis/paracentesis/bronchoscopy before weaning trials. Again, use your judgement & ignore the literature
Literature refers to populations of patients but we manage individuals. If you manage a patient with a massive pleural effusion (eg, with an inverted L hemi-diaphragm), draining this fluid may make all the difference
9. Optimize everything that you can think of & when I say everything, I mean it. If your patient has no bowel movement for a week & the abdomen is pushing the diaphragm upwards, just give an enema. It may help his breathing plus it is not fun dealing with this after extubation!
10. If the patient needs a second-look laparotomy or trans-esophageal echo the next morning, I don't understand the rush of extubating her the previous afternoon just to re-intubate the next day... 🤷♂️
11. Clarify goals of care before extubating someone. If patient/family are not in favor of reintubation->trach etc, then you have just one "shot". Otherwise, a sloppy, poorly devised extubation attempt may be forgiving. In addition, it is not nice calling the family at 03:00 am
trying to figure out if the gasping and unable to communicate patient should be placed back on the ventilator...
12. Check the previous intubation notes, if available. (Electronic health records can help a lot). Don't recklessly extubate someone just to discover 30 minutes later that half of the anesthesiologists in the operating room had tried to intubate her the previous day
13. If the upper airway anatomy is an issue, take a look yourself or at the minimum notify ENT/Anesthesia ahead of time
14. You can read a lot about the cuff-leak test. You don't have to use it in every patient but use common sense: if you are managing a short, female pt who is
14. You can read a lot about the cuff-leak test. You don't have to use it in every patient but use common sense: if you are managing a short, female pt who is
on the ventilator for 15 days & was emergently (and with difficulty) re-intubated 4 days ago after an unplanned self-extubation, it may be useful. In this case, use steroids early on...
15. Managing sedation can be tricky: pt should be awake enough to take over from the vent but also needs to be comfortable enough to tolerate the irritation/pain from the breathing tube. Ideally, sedation has been strategically interrupted the previous days. The day of extubation
switching to dexmedetomidine may keep the patient calm and comfortable without suppressing his breathing. Keep in mind that a supportive family at the bedside may be more helpful than all the sedatives expertly combined...
16. If there is concern that the patient may not be able to take her pills (eg, the 10 pills for her heart failure) post-extubation due to dysphagia/mental status etc, switch the oro-gastric to naso-gastric tube before extubation
17. Place the patient in a comfortable, sitting up position way before extubation & certainly afterwards. You need to have as many alveoli open...
18. Treat fever/pain/nausea etc before extubating
18. Treat fever/pain/nausea etc before extubating
19. Know your patient & ideally "study" him for a while before extubating. Is he post-CABG who came 2 hours ago & just gave 500 cc of blood from the chest tube? I don’t care if we will not hit the “extubation target” of x hours (is it 4?) or if the surgeon wants him extubated
as soon as possible. I will take my time to do my homework first and convince myself that the patient is relatively stable to be extubated
20. If staffing permits, prepare to move the pt out of bed on a chair as soon as possible. If your post-CABG pt has to be in a chair within 6 h post-extubation because "the surgeon asked for it", I would argue that your COPD pt who spent a week on the vent deserves the same!
So: know your resources well before deciding to extubate. If I manage two crashing patients in an understaffed ICU with one respiratory therapist covering 2 more floors, I will not extubate someone who is “borderline” in the middle of the night. Nor will I extubate someone
at 6:00 pm if there is no intensivist at night... This is the reality!
If you made it here, thanks for reading!
If you made it here, thanks for reading!
Typo:
The rapid shallow breathing index (f/Vt) is "good" when it is LOW, I just use <100 because it's easy to remember...
The rapid shallow breathing index (f/Vt) is "good" when it is LOW, I just use <100 because it's easy to remember...
Let's add a few more points:
21. Make the pt member of the extubation team. It's all about her, anyway! Let her know what the plan is. Give her a time frame; say something like: "It's 10:00 am. If you are still looking good at 11 am, we will pull the breathing tube. Otherwise,
21. Make the pt member of the extubation team. It's all about her, anyway! Let her know what the plan is. Give her a time frame; say something like: "It's 10:00 am. If you are still looking good at 11 am, we will pull the breathing tube. Otherwise,
we will let you rest and try again tomorrow". Also, explain to her that the transition/weaning phase may be uncomfortable but pulling the tube herself will only make things worse. Finally, give her a plan for how things will look like post-extubation. Say something like:
"We may need to put you on CPAP, like the one you use at home. And you will have to stay in the ICU at least until tomorrow". Even when they don't hear what they want, patients appreciate knowing what the goal and the plan are!
22. Respect the rest of the ICU team. If the patient's nurse and respiratory therapist did not have lunch yet, it does not hurt to "give them a break". You are not getting a trophy for extubating the patient 15 min earlier! Extubation - like intubation - is a team sport!
23. You don't have to stop the tube feeds many hours before extubation to reduce the risk of aspiration. But, you also won't make anybody a favor by restarting them right away. Ice chips and mouth care may be all that patient needs but explain to her and do it early.
24. I extubate more and more pts directly to non-invasive ventilation even if they don't fall under the well-known categories (age>65?, heart failure etc). Yes, HFNC can be an option but I still consider NIV the standard of care. Please ask the resp therapist to bring the vent
for NIV in pt's room before extubation and explain to the pt what the plan will be. "We will put you on CPAP for 2 hours right away; if you do well, we will give you a break for an hour and then..."
25. Please turn off this damned tv in patient's room unless the patient is addicted to it. Make sure she has another good night of sleep. You will be surprised how many restless, "CPAP-intolerant" pts sleep great on CPAP if you explain why you do it, position them well, try a
better fitting mask and minimize interruptions. Yup, you don't have to check vitals at 3:00 and you don't have to stick her for blood at 4:00. Give her a break!
Thanks again for following along!
Thanks again for following along!
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