Extubation

Algorithm is for patients who have only been intubated for a few hours

Inclusion

1. Resolution of clinical issue requiring intubation
2. Sat >95% on FiO2 40%, PEEP 5
3. RR <30, SBP >100, HR <130
4. Pt not known to be a difficult intubation

Preparation

1. Turn off sedatives
2. Leave opiods on at a low dose (e.g. fentanyl 50 mcg/hr)
3. Allow pt to regain full mental status
4. If pt shows signs of discomfort consider giving more pain medication
5. Pt should be able to understand respond to commands

Testing for Readiness

1. Ask pt to raise arm and leave in air for 15s
2. Ask pt to raise their head off the bed
3. Ask pt to cough (they should be able to generate a strong cough)
4. Place on pressure support 5; sit pt up to at least 45 degrees
5. Observe for 15-30
   1. If sat <90%, HR >140, SBP >200, severe anxiety or decreased LOC discontinue attempt

Procedure

1. Have nebulizer filled w/ NS attached to a mask
2. Sit pt up to at least 45 degrees
3. Suction ETT w/ bronchial suction catheter
4. Suction oropharynx w/ Yankeur suction
5. Deflate ETT cuff
6. Have pt cough; pull the tube during the cough
7. Suctio nthe oropharynx again
8. Encourage the pt to keep coughing up any secretions
9. Place nebulizer on pt at 4-6 L/min

After Extubation

1. Monitor closely for at least 60min
2. If pt develops resp distress, non-invasive ventilation will often be sufficient

Source

Weingart SD, Menaker J, et al. Trauma Patients Can Safely Be Extubated in the Emergency Department. J Emerg Med. 2009 Aug 22. [Epub ahead of print]