AARC Clinical Practice Guideline

Removal of the Endotracheal Tube- Jan

2007 Revision and update

Rattana pensrichon , MD
แพทย์ ประจำบ้ านปี ที่ 2 หน่ วยเวชบำบัดวิกฤต
21 มิถุนายน 2550
AARC Clinical Practice Guideline
Removal of the Endotracheal Tube-2007 Revision and
update

 This guideline focus on the predictors

that aid the decision to extubation

 The procedure refered to as extubation

 The immidiate post extubation

interventions that may avoid potential
reintubation
The risk of prolonged tranlaryngeal
intubation include
 Sinusitis
 Vocal cord injury
 Laryngeal injury
 Subglosstic stenosis in neonates and children
 Tracheal injury
 Hemoptysis
 Aspiration
 Pulmonary infection
 Endotracheal tube occlusion
 Accidental extubation
Complication post extubation

 Upper airway obstruction from

laryngospasm
 Laryngeal edema
 Supraglottic obstruction
 Pulmonary edema
 Pulmonary aspiration syndrome
 Impaired respiratory gas exchange
Indication of extubation
 improvement of the underlying condition
pulmonary function and/or gas exchange
capacity
 Patient should be capable of
 maintaining a patent airway
 generating adequate spontaneous ventilation
(central inspiratory drive ,respiratory muscle
strength to clear secretion ,laryngeal function
,nutritional status ,clearance of sedative and
neuromuscular drug effects)
Contraindications of extubation

 No absolute contraindications

 May require one or more of the following

 Noninvasive ventilation
 CPAP
 High inspired oxygen fraction
 Reintubation
Hazards

 Hypoxemia after extubation

 Upper airway obstruction
 Post obstructive pulmonary edema

 Bronchospasm

 Lung atelectasis

 Pulmonary aspiration

 Hypoventilation
Hazards

 Hypercarbia after extubation

 Upper airway obstruction resulting from
edema of trachea ,vocal cords ,or larynx
 Respiratory muscle weakness

 Excessive work of breathing

 Bronchospasm
Assessment of extubation readiness

 Extubation readiness criteria Exp.

 maintain adequate arterial partial pressure
( PaO2/FiO2 > 150-200)
Low level of PEEP (< 5 to 8 cmH2O)

 The capacity to maintain appropiate PH(PH

>= 7.25) and PCO2 during spontaneous
ventilation
Assessment of extubation readiness

 Acceptable respiratory rate decrease inversely

with age
 Adequate respiratory muscle strength
 Maximum negative inspiratory pressure >-20
cmH2O
 Vital capacity > 10 ml/kg, in neonate > 150
ml/m2
 Modified CROP
index(compliance,resistance,oxygenation,venti
lating pressure) above a threshold of >=0.1-
0.15 ml .mmHg/breath/min/kg
Assessment of extubation readiness

 Thoracic compliance > 25 ml/cmH2o

 Work of breathing < 0.8 J/L
 Vd/Vt <= 0.5( in children)
 Maximum voluntary ventilation > twice resting
minute ventilation
 In neonates,total respiratory compliance <=
0.9 ml/cmH2O associated with extubation
failure
Assessment of extubation readiness

 Rapid shallow breathing index RR/Vt < 105

breath/min

 Resolution of the need for airway protection

 Appropiate level of conciousness
 Adequate airway protective reflexes
– white card test –( grade 0-2 )
 Early managed secretions
Assessment of extubation readiness

 Presence of upper airway obstruction or

laryngeal edema
 Air leak test
 Age dependent predictor of post extubation
stridor
 Air leak > 20 cmH2O Predictive post extubation
stridor in chlidren >= 7 years of age (sens
83%,spec 80%)
 Air leak test – predictive of postextubation stridor
or extubation failure for children of upper airway
pathology : traumatic patients,crop
Assessment of extubation readiness

 Evidene of stable ,adequate

hemodynamic function
 Evidence of stable nonrespiratory
functions
 Electrlytes values within normal range
 Evidence of appropiate nutrition
Risk factor for extubation failure
 Admit in ICU
 Age > 70 years or < 24 months
 Higher severity of illness upon weaning
 HgB < 10 mg/dl
 Use of continuous IV sedation
 Longer duration of mechanical ventilation
 Presence of syndromic or chronic medical condition ,known
medical or surgical airway condition ,congenital condition
associated with cervical instability ( Klippel-feil or trisomy 21 )

 In pidiatric cardiothoracic surgery population

 Age < 6 months
 Prematurity
 Congestive heart failure
 Pulmonary hypertension
Prophylaxis medication
 Consider use lidocaine to prevent cough and/or laryngospasm in
patient at risk

 Steriod may be helpful to prevent reintubation rates in high risk

neonates but not in children
 Steroid may help reduced the incidence of postextubation stridor
in children but not in neonates or adult
 Steriod for patients with croup correlates with reduced rates of
reintubation

 Caffeine citrate reduced the risk of apnea for infants but not
reduced risk of extubation failure

 Methylxanthine treatment stimulate breathing and reduced the

rate of apnea for neonates with poor respiratory drive
Assessment of outcome
 Assess by PE, auscultation, invasive and
noninvasive measurements of gas exchange
and chest radiography

 Quality of the procedure assessed by

monitoring extubation complications and the
need for reintubation
Postextubation support

 Noninvasive Respiratory Support

 NIPPV or nasal CPAP

 Binasal prong CPAP or single nasal or

nasopharyngeal CPAP

 In patients with COPD ,CPAP 5 cmH2O and

pressure support ventilation of 15 cmH2O improve
gas exchange ,decreased intrapulmonary shunt
fraction and reduced work of breathing
Postextubation Medical Therapy
and diagnostic therapy
 Aerosalized levo-epinephrine is as effective as
aerosolized racemic epinephrine in treatment of
postextubation laryngeal edema in children

 Heliox may alleviate the symptom of partial airway

obstruction and resultant stridor ,improve patient
comfort

 Fiberoptic bronchoscopy may provide direct airway

inspection and therapeutic interventions
Resources

 Equipment
 Personal
Mornitoring
 Appropiately trained personnal to detect
cardiopulmonary impairment
 Frequent respiratory evaluation include: vital
sign ,neurologic status ,patency of airway
,auscultatory findings ,hemodynamic status
 Equipment
 Pulse oximeter
 Two channel cardiac monitor
 Capnography
Frequency

 Any recommendation for tracheostomy

placement in the mechanically ventilated
patient
 Etiology of respiratory insult
 Expected or known duration of mechanical
ventilation
 Balance of risks and perceived benefits of
continued mechanical ventilation via tracheostomy
as opposed to a tranlaryngeally placed EET