EXTUBATION AND DECANULATION Flashcards
Extubation
The process of removing an artificial tracheal airway
Decannulation
The process of removing a tracheostomy tube.
Done on patient who are not being mechanically ventilated
QUESTIONS PRIOR TO WEANING
- If the patient getting better?
- Is initial reason for providing ventilatory support resolved or improved?
- Is patient clinically stable?
- Is there any impending condition that might require airway support?
- Is patient able to protect airway
- Manage oral secretions so there is not an excessive amount of oral or tracheal secretions
- Is patient requiring minimal suctioning
- Adequate cough and gag reflex
CLINICALLY STABLE
CNS Assessment and Psychological Factors
- Adequate CNS function needed to maintain stable ventilatory drive, adequate cough, and ability to manage oral secretions
- LOC, anxiety, depression, and dyspnea will all have an impact on weaning success
- GCS should be greater than 9
- How can you tell is someone is anxious versus is they are not ready for weaning
- Talk about switching patient without them knowing
- The wake up and breath protocol is aim to tackle ICU psychosis
- Precedex is a good medication to give patient if they are anxious or experiencing alcohol withdrawl
CLINICALLY STABLE
Airway Evaluation
- Patient ability to maintain a patent airway
- Inability to maintain patent airway is a contraindication for extubation but patients can be successfully removed from PPV (may require a tracheostomy)
- Some patients that can maintain patent airway but are only able to maintain spontaneous breathing for limited time are good candidates for non-invasive PPV
- Risk of aspiration
- Assess gag reflux
CLINICALLY STABLE
Oxygenation
- FiO2, PO2, Lactic Acidosis
- Lactic acidosis is an indication of anaerobic metabolism
- It is not necessarily wrong to extubate someone to is a little acidotic
- FiO2 <.5 with adequate PaO2
- Ideally want FiO2 >0.3
- If on the cusp?
- Extubate to BIPAP
- Lactic acidosis is an indication of anaerobic metabolism
- P/F Ratio
- >300
CLINICALLY STABLE
Ventilation and Acid Base Balance
pH, PCO2, VT, f spon, RSBI (<105)
CLINICALLY STABLE
Respiratory Muscle Strength
MIP or NIF (at least -20cmH2O)
CLINICALLY STABLE
WOB
thoracic cage movement , accessory muscle use, irregular ventilatory pattern during spontaneous breathing
Are there any signs of paradoxical breathing
CLINICALLY STABLE
Renal Function
Electrolytes, urine output
Why would urine output matter? – Pulmonary Edema
Criteria for Weaning
- No immediate need for mechanical ventilation
- Adequate oxygenation and ventilation with spontaneous ventilation
- Low FiO2 requirements that can be achieved by nasal prongs or mask
- Minimal risk for upper airway obstruction/able to protect airway
- LOC, manage oral secretions, Intact cough reflex, Positive cuff leak test
- Stable vital signs
- Stable hemodynamic parameters
- Not on any inotropes
- Optimum nutritional status and functioning GI tract
INDICATIONS FOR EXTUBATION
Decision to extubate is based on previously mentioned indexes but no one indicator is 100% specific for predicting successful extubation.
- No immediate need for mechanical ventilation or intubation
- Adequate oxygenation and ventilation achieved with spontaneous ventilation
- Adequate weaning parameters
- Minimal risk for upper airway obstruction
- Positive cuff leak test
- Adequate airway protection and minimal risk for aspiration
- LOC
- Super important do not try to extubate until patient is completely awake
- Able to manage/swallow oral secretions
- Discontinue tube feeds for 4- 6 hours before extubation
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CUFF LEAK TEST
- Assess the patient to ensure that they can breathe spontaneously off the ventilator
- Suction the mouth and upper airway
- Deflate the cuff
- Briefly occlude the ETT
- If the patient is unable to breathe around the occluded ETT with the cuff deflated, laryngeal edema should be suspected
The above is the Gold Standard for the Cuff Leak Test and should be used when you know the patient has swelling in the airway
We can also just drop the cuff and look for changes in tidal volume
EXTUBATION PROCEDURE
- Verify with physician and scan chart to look for indications that the patient may not be ready
- Measure spontaneous parameteres and blood gases. If possible attach an ECG
- Gather Equitment
- Introduce yourself and explain the procedure
- Position the patient and suction both mouth and pharynx
- When suctioning squeeze the resuscitation bag while deflating the cuff to force the seretion into the mouth from above the cuff so tey can be suctioned. Repeat until air is clear.
- Oxygenate with 100% oxygen using flow inflating manual ventilator
- Deflate cuff under positive pressure and withdraw tube
- Have patient cough several times and speak (say there name) to assess horseness and clear airway
- Administer cool aerosol. A large volume nebulizer will help sore throats
- Evaluate patient. Auscultate the patient in order to help determine when the lung volume is .Measure f, HR, and BP frequently for about 30 min
- Monitor patient while encouraging coughing and deep breathing
- Clean up area
- Monitor the patient for changes over the next hour. It may be desirable to obtain an ABG assessment at this time to be sure the patient is stable
- Chart
SPONTANEOUS BREATHING TRIAL
After a 30-120 minute spontaneous breathing trial (SBT), patients that can be successfully extubated should have
- Resolution of their disease state or condition
- Hemodynamic stability
- Adequate oxygenation
- Low FiO2 and PEEP
- Adequate ventilatory status
- PaCO2, Normal pH
What Position Should The Patient Be In For Extubation
Position the patient in semi or high Folwer position
