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
*
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
What Equitment Do You Need For Extubation
- Resuscitation bag
- Intubation tray
- 20 cc syringe for cuff deflation
- Suction
- 5 mL dose of normal saline or 5 mL syringe for irrigation with normal saline during suctioning
- Oxygen/Aerosol Equipment
- Oxygen source
- Oxygen mask
- Gloves, goggles or face shield
What Are Signs of Oxygenation and/or Ventilation Failure
↓ SpO2, ↑ FiO2
↑ WOB
↑ Accessory muscle use
↑ Dyspnea
↓ LOC
An extubation is considered successful if patient is able to remain extubated for 24 hours.
If patient deteriorates or requires reintubation before 24 hours has elapsed, patient has failed extubation.
COMPLICATIONS DURING AND IMMEDIATELY AFTER EXTUBATION
AIRWAY OBSTRUCTION
- Due to laryngeal edema causing stridor
- Smoke inhalation
- Epiglottitis
- Angioedema (dermal, subcutaneous or submucosal edema of the face or larynx)
- Compression of airway due to:
- Tumor
- Abscess
- Trauma
- Post- op head, neck or oral surgeries
- Only about 1% of extubated ICU patients experience stridor.
- Only about 1% of those require re-intubation
COMPLICATIONS DURING AND IMMEDIATELY AFTER EXTUBATION
STRIDOR
- Post extubation stridor viewed with concern
- Cool aerosol with supplemental O2
- Tx with nebulized 1:1000 epinephrine (5 mL)
- Tx with Heliox mixtures by NRBM
- Children at greater risk for developing post- extubation edema
COMPLICATIONS DURING AND IMMEDIATELY AFTER EXTUBATION
COUGH
About 25% of ICU patients following prolonged intubation develop cough
COMPLICATIONS DURING AND IMMEDIATELY AFTER EXTUBATION
HOARSENESS
Up to 70% of extubated ICU patients
Oral intubation and large tube size risk
Failure to resolve after 2 weeks indicates serious complication (vocal cord paralysis etc. ?)
COMPLICATIONS DURING AND IMMEDIATELY AFTER EXTUBATION
SORE THROAT
15% of short term intubations and 40% of long term intubations have sore throat
COMPLICATIONS DURING AND IMMEDIATELY AFTER EXTUBATION
Aspiration
Sensory deficit and incompetent laryngeal reflexes post extubation (can last for several hours even with short term intubation) risk of aspiration
Especially in patients with impaired cough
COMPLICATIONS DURING AND IMMEDIATELY AFTER EXTUBATION
Vocal Cord Paralysis
Permanent bilateral vocal cord paralysis very rare
Unilateral transient cord paralysis more commonly seen
COMPLICATIONS DURING AND IMMEDIATELY AFTER EXTUBATION
Odynphagia
Painful swallowing or talking
If severe may indicate glottic infection or ulceration (very rare)
Reasons to get a Trach
Help reduce deadspace
Oral care is easier
More comfortable
Allows us to wean more effectively When we are weaning from a trach we can remove them from a vent for periods in the day and put them on high flow oxygen
We can also exchange tubes and make them smaller and then cap the trachs.
Before Decannulation What Want To Make Sure A Patient Can Do What
Before decannulation, the patient is usually made to breathe through their own airways first.
This is accomplished in a variety of ways
Progressively smaller tubes
Tracheal buttons
Fenstrated Trach (Not commonly used)
Weaning Trachs In The Hospital
8 LPC→ #6CFS→ corked(24-72 hrs)→ decannulation
If you are trying to wean a person and you put the cap on and someone has to take the cap off in order to suction then it is considered a fail on the test
READY FOR DECANNULATION?
Corked for 24 hrs
Able to manage oral secretions
Pulmonary secretions not copious*
But if they are about to manage their secretions then you can still decannulate them
Able to cough effectively and clear pulmonary secretions
EQUIPMENT FOR DECANNULATION
Gloves and goggles
Suction equipment
Resuscitation bag
Oxygen-Remember don’t cap a pt when there is the cuff up
Tracheostomy care kit (basin and brushes)
Scissors
Occlusive Dressing
2 large opsite clear adhesive patches
Trach Care Kit
Tracheostomy care kit (basin and brushes)
Spare inner cannula
Hydrogen peroxide/sterile water
Cotton-tipped applicators
Precut gauze or 4 × 4 gauze pad
New tracheostomy tube ties/Velcro strap
Additional equipment for changing tracheostomy tube
New tracheostomy tube and component parts
Water-soluble lubricant
Syringe
Deannulation Proedure
- Assemble and prepare equipment
- Explain the procedure to the patient
- Assess the patient
- Prepare the patient
- Remove the tube
- Inspect and clean the stoma
- Dress the stoma
- Occlusive dressing
- Reassess the patient
- Chart the procedure and assessment
Policy-Tracheostomy Adult Patient: Decannulation and Stoma Care
Equitment
Personal protective equipment (PPE)
Dressing tray
Normal Saline
Suction supplies
Syringe, 10 mL, (if cuff is present)
Scissors and / or suture removal kit
Stoma Care Dressing (Open or Closed Care Dressing)
Policy-Tracheostomy Adult Patient: Decannulation and Stoma Care
Open Dressing Equitemnt
Breathable Tape
Non-Adherent dressing or sterile gauze, 10 cm x 10 cm
*From Prac Can Use a thick jelly like substance which they use on wounds and burns. Open stoma tends to only be for patient who have had a trachea surgery
Policy-Tracheostomy Adult Patient: Decannulation and Stoma Care
Closed Dressing Equitemnt
Skin closure tapes
Non-Adherent dressing or sterile gauze, 5 cm x 5 cm
Waterproof, occlusive dressing; preferred to be transparent
Breathable tape
Policy-Tracheostomy Adult Patient: Decannulation and Stoma Care
What is the Preferred Patient Position
Optimize patient position for procedure; the preferred position is supine with the head slightly extended.
Policy-Tracheostomy Adult Patient: Decannulation and Stoma Care
How to Remove It
Instruct the patient to inhale slowly and deeply and remove tracheostomy tube, following the curve of the tube.
After you remove it clean the stoma is needed
Policy-Tracheostomy Adult Patient: Decannulation and Stoma Care
How To Do An Open Stoma Dressing
Cover the stoma with non-adhering dressing or gauze.
Cover non-adhering dressing or gauze with breathable tape on 3 sides leaving the bottom open.
Redress stoma if the dressing becomes visibly soiled but not if a leak is present. Note: An open dressing is expected to have an air leak.
Policy-Tracheostomy Adult Patient: Decannulation and Stoma Care
How To Do An Closed Stoma Dressing
Apply skin closure tapes as required to hold the stoma closed.
Cover stoma with non-adherent dressing or gauze.
Cover area with an occlusive dressing.
