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Post-Extubation Emergencies. OH SH..! Discontinuing Mechanical Ventilation Resolution of the process that caused the intubation. Spontaneous breathing.

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Presentation on theme: "Post-Extubation Emergencies. OH SH..! Discontinuing Mechanical Ventilation Resolution of the process that caused the intubation. Spontaneous breathing."— Presentation transcript:

1 Post-Extubation Emergencies

2 OH SH..!

3 Discontinuing Mechanical Ventilation Resolution of the process that caused the intubation. Spontaneous breathing ability with adequate ABG’s and Hemodynamics

4 Extubation Criteria Ability to Cough MIF VC /PEF CognitiveSecretions Can there be too many? “ Salam et al, “Neurologic status, cough, secretions and extubation outcomes” Intensive Care Medicine (2004) 30: ”

5 Extubation Criteria Hardware Issues NG/OG tubes Wired jaw Cervical fixation devices

6 The Top Five Laryngospasm Laryngeal Stridor Acute Hypoxemia Acute Respiratory Failure Neurologic pathology

7 Laryngospasm Definition: The vocal folds spontaneously closing and staying closed. Presents as NO air movement and patient in a panic (conscience or not)

8 Laryngospasm Causes:HysteriaMechanicalChemical Can you predict it? Extubating with Positive pressure

9 Laryngospasm How do you treat it? WaitSedation

10 Laryngeal Stridor Definition: High pitched inspiratory noise that occurs when vocal folds are swollen and close together allowing little air to pass through. Can you predict it? Cuff leak test – Volume leak “ Kriner et al, The Endotracheal Tube Cuff-Leak Test as a Predictor for Postextubation Stridor, Respiratory Care 2005 Dec;50(12) –ETT occlusion Risk populations Men vs. Women Obesity “ Erginel S. et al “High body mass index and long duration of intubation increase post- extubation stridor in patients with mechanical ventilation” J Exp Med Oct;207(2) “ Erginel S. et al “High body mass index and long duration of intubation increase post- extubation stridor in patients with mechanical ventilation” J Exp Med Oct;207(2)

11 Laryngeal Stridor Is it stridor or obstruction? Jaw Thrust/Sniff position Secretion clearance How do you treat the obstruction? Nasal/oral airways Mask CPAP

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14 Laryngeal Stridor Is it stridor or obstruction? Jaw Thrust/Sniff position Secretion clearance How do you treat the obstruction? Nasal/oral airways Mask CPAP

15 Laryngeal Stridor How can you treat? Racemic epinephrine/ bronchodilators.5cc/2ccNSHeliox 80/20 mixture Max. FiO2.35 Sedation

16 Acute Hypoxemia Definition: Sudden decrease of oxygen in the blood. Can you predict it?

17 Acute Hypoxemia Secretions/Mucous plug Cough or need for NTS quickly Pulmonary edema Pulmonary edema Negative pressure pulmonary edema Support with oxygen Cardiac Mask CPAP Vomiting/Aspiration Position pt on side Need for oral and NT suction quickly Support oxygenation

18 Acute Ventilatory Failure Definition: An inability for the patient to ventilate to maintain a normal pH ( ) Presents itself by: Increased RR Increased WOB Decreased SaO2

19 Acute Ventilatory Failure Can you predict it? How do you treat? NPPV –COPD vs. Non-COPD Esteban et al. “ Noninvasive Positive-Pressure Ventilation for Respiratory Failure after Extubation” N Engl J Med 2004;350: after Extubation” N Engl J Med 2004;350: Ferrer et al. “Early Noninvasive Ventilation Averts Extubation Failure in Patients at Risk” AM J Respir Crit Care Med 2006;173: Sedation withdrawal Re-intubate

20 Neurologic Pathology ALS Traumatic Brain Injury MS, Guillian Barre, Tetraplegia Critical Illness neuromyopathy

21 Post-Extubation Emergencies The inability to reliably predict The Top Five How to treat

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23 BE PREPARED Do not treat extubations as routine Assess, Assess, Assess Have Difficult Intubation Supply easily available in unit Don’t Panic

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