Presentation on theme: "J. Prince Neelankavil, M.D."— Presentation transcript:
1 J. Prince Neelankavil, M.D. Extubation CriteriaJ. Prince Neelankavil, M.D.
2 Case71 y.o. male s/p laparascopic surgery presents to the PACU intubated. Pt. remained intubated secondary to residual neuromuscular blockadeH/O HTN, DMWhen should we extubate?
3 General PrinciplesWhy was the patient intubated in the first place? Inadequate oxygenation/ventilation/airway protection.Patient should have adequate respiratory drive, respiratory muscle strength, cough reflex to clear secretions, laryngeal function and clearance of sedative and neuromuscular blocking medications.
4 Adequate Gas Exchange?Adequate arterial partial pressure of oxygen: [PaO2/FIO2] ratio >Appropriate pH (pH >7.25) and arterial partial pressure of carbon dioxide during spontaneous ventilation
5 Pass a Breathing Trial?30–120 minute spontaneous breathing trial with low level of CPAP (e.g. 5 cm H2O) or low level of pressure support (e.g. 5-7 cm H2O)Show gas exchange (ABG), hemodynamic stability, and subjective comfort
7 Able to Protect Airway? Appropriate level of consciousness Adequate airway protective reflexes (cough, swallow, vocal cord movement)Adequate managed secretions
8 All Systems Go? Hemodynamic Stability (+/- 20%) Nutritional status allowing for respiratory muscle strength
9 Risk Factors for Failed Extubation ICU patientAge > 70 or < 24 monthsHemoglobin <10 mg/dLLonger duration of mechanical ventilationMedical or surgical airway conditionFrequent pulmonary toiletLoss of airway protective reflexes
10 What do you need to extubate? Oxygen sourceSuctionOral/Nasal airwaysFace masksEndotracheal tubesLMAPulse oxCardiac MonitorsCO2 detectorsAmbu bags
11 What did we do before we extubated our patient? Ensured proper equipment needed for reintubationMonitoring BP, HR, Sat, RRUsed a twitch monitor to demonstrate no fade on TOF/sustained tetanyTurned off the propofol sedation
12 What did we do before we extubated our patient? We did not quantitatively evaluate his tidal volume, thoracic compliance, pH, NIF, breathing trial, etc…We qualitatively evaluated several things Stable hemodynamics2. Able to protect airway3. Able to exchange gases
13 Stable Hemodynamics His preoperative BP and HR were 134/77 and 68 Prior to extubation his BP and HR were 126/72 and 61
14 Able to protect airwayPatient was gagging on the ETT and would gag when we suctioned himPatient was coughing
15 Able to exchange gasesPatient was spontaneously breathing for 30 minutesGood ventilatory effortMaintained oxygen saturation
16 Case Our patient was extubated and had an uneventful PACU stay. Another satisfied customer
17 ReferencesAmerican Association for Respiratory Care (AARC). Removal of the endotracheal tube revision & update. Respir Care 2007 Jan;52(1):81-93Nir Hoftman, M.D.’s PACU extubation criteria