endotracheal extubation
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Indications
- mechanical ventilation
- see ventilation weaning criteria
- spontaneous breathing trial used to assess appropriateness
- see rapid shallow breathing index
Procedure
- suction pharynx
- suction endotracheal tube
- limit suction to 10 sec
- unneccessary if no secretions
- ventilate patient
- use breathing bag, 100% oxygen
- give several deep breaths
- remove tube
- deflate cuff
- withdraw tube after deep inspiration
- apply face mask delivering oxygen
- extubation to non-invasive positive pressure ventilation (NPPV)
- useful for patients with obstructive lung disease
- useful after abdominal surgery
- not necessary for patients with hypoxemic respiratory failure due to pneumonia[2]
- extubation to high-flow oxygen may be appropriate in selected patients[3]
- high-flow oxygen noninferior to NPPV for preventing reintubation in high-risk patients[4]
- editorialist not convinced
- NPPV + high-flow oxygen during breaks ftom NPPV[6]
Notes
- pre-extubation methylprednisolone 20 mg IV every 4 hours begining 12 hours prior to extubation (total of 4 doses) reduces laryngeal edema & re-intubation (number needed to treat = 25)[1]
- holding enteral feeding for several hours prior to extubation is standard practice in many intensive care units
- continuing enteral feeding until extubation results in slightly higher rates of early reintubation but also some favorable outcomes
- reintubation rates at 7 days similar
- incidence of aspiration & nosocomial pneumonia similarly low
- median time to extubation after a first successful spontaneous breathing trial shorter with continuous enteral feeding by 15 hours
- patients subsequently discharged sooner from the ICU[7]
- continuing enteral feeding until extubation results in slightly higher rates of early reintubation but also some favorable outcomes
More general terms
Additional terms
- mechanical ventilation (assisted ventilation)
- rapid shallow breathing index
- spontaneous breathing trial (SBT)
- ventilation weaning
References
- ↑ Jump up to: 1.0 1.1 Francois B, Bellissant E, Gissot V, Desachy A, Normand S, Boulain T, Brenet O, Preux PM, Vignon P; Association des Reanimateurs du Centre-Ouest (ARCO). 12-h pretreatment with methylprednisolone versus placebo for prevention of postextubation laryngeal oedema: a randomised double-blind trial. Lancet. 2007 Mar 31;369(9567):1083-9. PMID: https://www.ncbi.nlm.nih.gov/pubmed/17398307
- ↑ Jump up to: 2.0 2.1 Medical Knowledge Self Assessment Program (MKSAP) 16, 17, 18. American College of Physicians, Philadelphia 2012, 2015, 2018.
- ↑ Jump up to: 3.0 3.1 Jaber S et al. Effect of noninvasive ventilation on tracheal reintubation among patients with hypoxemic respiratory failure following abdominal surgery: A randomized clinical trial. JAMA 2016 Mar 15; PMID: https://www.ncbi.nlm.nih.gov/pubmed/26975890
Hernandez G et al. Effect of postextubation high-flow nasal cannula vs conventional oxygen therapy on reintubation in low-risk patients: A randomized clinical trial. JAMA 2016 Mar 15; [e-pub]. PMID: https://www.ncbi.nlm.nih.gov/pubmed/26975498
Spoletini G et al. High-flow nasal oxygen or noninvasive ventilation for postextubation hypoxemia: Flow vs pressure? JAMA 2016 Mar 15 PMID: https://www.ncbi.nlm.nih.gov/pubmed/26976699 - ↑ Jump up to: 4.0 4.1 Kritek P No Clear Right Choice for Postextubation Support. NEJM Journal Watch. Nov 15, 2016 Massachusetts Medical Society (subscription needed) http://www.jwatch.org
Hernandez G, Vaquero C, Colinas L et al Effect of Postextubation High-Flow Nasal Cannula vs Noninvasive Ventilation on Reintubation and Postextubation Respiratory Failure in High-Risk Patients: A Randomized Clinical Trial. JAMA. 2016 Oct 18;316(15):1565-1574. PMID: https://www.ncbi.nlm.nih.gov/pubmed/27706464 - ↑ Schmidt GA, Girard TD, Kress JP et al Liberation From Mechanical Ventilation in Critically Ill Adults: Executive Summary of an Official American College of Chest Physicians/American Thoracic Society Clinical Practice Guideline. Chest. 2017 Jan;151(1):160-165. PMID: https://www.ncbi.nlm.nih.gov/pubmed/27818329
- ↑ Jump up to: 6.0 6.1 Thille AW, Muller G, Gacouin A et al. Effect of postextubation high-flow nasal oxygen with noninvasive ventilation vs high-flow nasal oxygen alone on reintubation among patients at high risk of extubation failure: A randomized clinical trial. JAMA 2019 Oct 2; 322:1465. PMID: https://www.ncbi.nlm.nih.gov/pubmed/31577036 https://jamanetwork.com/journals/jama/article-abstract/2752582
Telias I, Ferguson ND. Added benefit of noninvasive ventilation to high-flow nasal oxygen to prevent reintubation in higher-risk patients. JAMA 2019 Oct 2; 322:1455. PMID: https://www.ncbi.nlm.nih.gov/pubmed/31577031 https://jamanetwork.com/journals/jama/article-abstract/2752579 - ↑ Jump up to: 7.0 7.1 Landais M et al. Continued enteral nutrition until extubation compared with fasting before extubation in patients in the intensive care unit: An open-label, cluster- randomised, parallel-group, non-inferiority trial. Lancet Respir Med 2023 Apr; 11:319. PMID: https://www.ncbi.nlm.nih.gov/pubmed/36693402 https://www.thelancet.com/journals/lanres/article/PIIS2213-2600(22)00413-1/fulltext