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endotracheal extubation

Indications: - mechanical ventilation - see ventilation weaning criteria - spontaneous breathing trial used to assess appropriateness - see rapid shallow breathing index Procedure: 1) suction pharynx 2) suction endotracheal tube a) limit suction to 10 sec b) unneccessary if no secretions 3) ventilate patient a) use breathing bag, 100% oxygen b) give several deep breaths 4) remove tube a) deflate cuff b) withdraw tube after deep inspiration c) apply face mask delivering oxygen 5) extubation to non-invasive positive pressure ventilation (NPPV) - useful for patients with obstructive lung disease - useful after abdominal surgery - not necessary for patients with hypoxemic respiratory failure due to pneumonia [2] - extubation to high-flow oxygen may be appropriate in selected patients [3] - high-flow oxygen noninferior to NPPV for preventing reintubation in high-risk patients [4] - editorialist not convinced - NPPV + high-flow oxygen during breaks ftom NPPV [6] Notes: - pre-extubation methylprednisolone 20 mg IV every 4 hours begining 12 hours prior to extubation (total of 4 doses) reduces laryngeal edema & re-intubation (number needed to treat = 25) [1] - holding enteral feeding for several hours prior to extubation is standard practice in many intensive care units - continuing enteral feeding until extubation results in slightly higher rates of early reintubation but also some favorable outcomes - reintubation rates at 7 days similar - incidence of aspiration & nosocomial pneumonia similarly low - median time to extubation after a first successful spontaneous breathing trial shorter with continuous enteral feeding by 15 hours - patients subsequently discharged sooner from the ICU [7]

Related

mechanical ventilation (assisted ventilation) rapid shallow breathing index spontaneous breathing trial (SBT) ventilation weaning

General

clinical procedure

References

  1. Francois B, Bellissant E, Gissot V, Desachy A, Normand S, Boulain T, Brenet O, Preux PM, Vignon P; Association des Reanimateurs du Centre-Ouest (ARCO). 12-h pretreatment with methylprednisolone versus placebo for prevention of postextubation laryngeal oedema: a randomised double-blind trial. Lancet. 2007 Mar 31;369(9567):1083-9. PMID: 17398307
  2. Medical Knowledge Self Assessment Program (MKSAP) 16, 17, 18. American College of Physicians, Philadelphia 2012, 2015, 2018.
  3. Jaber S et al. Effect of noninvasive ventilation on tracheal reintubation among patients with hypoxemic respiratory failure following abdominal surgery: A randomized clinical trial. JAMA 2016 Mar 15; PMID: 26975890 - Hernandez G et al. Effect of postextubation high-flow nasal cannula vs conventional oxygen therapy on reintubation in low-risk patients: A randomized clinical trial. JAMA 2016 Mar 15; [e-pub]. PMID: 26975498 - Spoletini G et al. High-flow nasal oxygen or noninvasive ventilation for postextubation hypoxemia: Flow vs pressure? JAMA 2016 Mar 15 PMID: 26976699
  4. Kritek P No Clear Right Choice for Postextubation Support. NEJM Journal Watch. Nov 15, 2016 Massachusetts Medical Society (subscription needed) http://www.jwatch.org - Hernandez G, Vaquero C, Colinas L et al Effect of Postextubation High-Flow Nasal Cannula vs Noninvasive Ventilation on Reintubation and Postextubation Respiratory Failure in High-Risk Patients: A Randomized Clinical Trial. JAMA. 2016 Oct 18;316(15):1565-1574. PMID: 27706464
  5. Schmidt GA, Girard TD, Kress JP et al Liberation From Mechanical Ventilation in Critically Ill Adults: Executive Summary of an Official American College of Chest Physicians/American Thoracic Society Clinical Practice Guideline. Chest. 2017 Jan;151(1):160-165. PMID: 27818329
  6. Thille AW, Muller G, Gacouin A et al. Effect of postextubation high-flow nasal oxygen with noninvasive ventilation vs high-flow nasal oxygen alone on reintubation among patients at high risk of extubation failure: A randomized clinical trial. JAMA 2019 Oct 2; 322:1465. PMID: 31577036 https://jamanetwork.com/journals/jama/article-abstract/2752582 - Telias I, Ferguson ND. Added benefit of noninvasive ventilation to high-flow nasal oxygen to prevent reintubation in higher-risk patients. JAMA 2019 Oct 2; 322:1455. PMID: 31577031 https://jamanetwork.com/journals/jama/article-abstract/2752579
  7. Landais M et al. Continued enteral nutrition until extubation compared with fasting before extubation in patients in the intensive care unit: An open-label, cluster- randomised, parallel-group, non-inferiority trial. Lancet Respir Med 2023 Apr; 11:319. PMID: 36693402 https://www.thelancet.com/journals/lanres/article/PIIS2213-2600(22)00413-1/fulltext