Extubation

1. EXTUBATION
Dr Farhan Shaikh
Consultant pediatric Intensisvist
Rainbow Children’s Hospital

2. Extubation is described as the discontinuation
of an artificial airway.

3. •The child should be capable of maintaining a
patent airway and generating adequate
spontaneous ventilation.
•Should have good central inspiratory drive,
• adequate cough strength to clear secretions,
and laryngeal function,
•Adequate nutritional status, and
•clearance of sedative and neuromuscular
blocking effects

4. Patients may need re-intubation immediately or
after some interval due to
•inappropriately timed extubation,
•progression of underlying disease,
•development of a new disorder.
Sometimes, in marginal patients extubation can be
done with the expectation that the need for re-
intubation is likely.

5. Assessment of
Extubation
Readiness

6. Successful completion of 30–120 minute spontaneous
breathing trial (SBT) demonstrating adequate respiratory
pattern and gas exchange, hemodynamic stability, and
subjective comfort
(Farias et al., 2001; Esteban et al., 1997; Esteban et al., 1999; Vallverdu et al., 1998; Ely et
al., 1999)

7. 1-Temporarily stop the enteral feeds
2- Reduce the FiO2 to 0.5%
3- Reduce the PEEP to 5cmH2O

8. Evaluate the SpO2 by pulse Oxymetry:
•If the SpO2 is below 95% and the FiO2 is less
than 0.5 then increase to 0.5
•If the SpO2 is above 95% change to the PSV
mode as per the size of ETT….
•3 to 3.5 mm: 10cmH2O3 to 3.5 mm: 10cmH2O
•4 to 4.5 mm: 8 cmH2O4 to 4.5 mm: 8 cmH2O
•5 mm or larger : 6 cm H2O5 mm or larger : 6 cm H2O
c. Monitor the SpO2,effective Vt and
respiratory rate

9. Assessment:
The patient is potentially ready for extubation if
3.The SpO2 is over 95%
4.The effective Vt is over 5ml/kg
5.The respiratory rate is within the goal range
for age..
AGE GOAL RANGE
Under 6 months 20 to 60 breathes/min
6 months to 2 years 15 to 45 breaths/min
2 to 5 years 15 to 40 breaths/min
Over 5 years 10 to 35 breaths/min

10. Precautions
•Extubation should take place during a period
of the day when adequate physician, nursing
and therapist staffs are readily available.
•Monitoring and continuous evaluation of the
patient is necessary
•Presence of skilled personnel who can
reintubate the patient is necessary.

11. –Appropriate level of consciousness
(Redmond et al., 1996; Harel et al., 1997; Coplin et al., 2000)
–Adequate airway protective reflexes
(Harel et al., 1997; Coplin et al., 2000)
–Easily managed secretions
(Epstein, 2002; Epstein, 2001; Harel et al., 1997; Coplin et al., 2000)
–Evidence of stable nonrespiratory functions
(Rothaar & Epstein, 2003; Sapijaszko et al., 1996; Smith & Shneerson, 1995; Scheinhorn et al., 1995)
–Electrolyte values within normal range
(Cerra, 1987; Aubier et al., "Effect of hypophosphatemia," 1985; Aubier et al., "Effects of
hypocalcemia," 1985)

12. •Malnutrition decreases respiratory muscle
function and ventilatory drive.
(Pingleton & Harmon, 1987; Lewis et al., 1986; Doekel et al., 1976; Larca &Greenbaum, 1982; Bassili &
Deitel, 1981
•Patient must have no intake of food or liquid
by mouth for a period of time prior to airway
manipulation.
(Lyons et al., 2002; ; American Academy of Pediatrics [AAP], 1992)

13. •Prior to extubation, all of the equipment
necessary for re-intubation should be
available at the bedside in case of acute
decompensation.
•Racemic or Levo epinephrine should be
available for aerosolization in case of acute
airway edema after extubation.

14. EQUIPMENT AND
MATERIALS
•Intubation Equipment (these items are
contained in the bedside intubation boxes):
•Laryngoscope and blades (appropriate size for
patient)
•Proper size endotracheal tubes (include a
smaller endotracheal tube than previously in
place due to the possibility of
laryngeal/tracheal edema)
•Tape or tube fixation device

15. •Stylet
•Scissors,Sterile gloves
•Suction, Suction catheters
•Oxygen to be administered post extubation
via mask/nebulizer system

16. Procedure
•Hyper oxygenate the patient with 100% O2
prior to extubation.
•Suction the endotracheal tube adequately
with pre and post hyper-oxygenation and then
suction the pharynx above the endotracheal
tube cuff.

17. Remove tape or Tube Fixation System (TFS)
which secures the endotracheal tube.
Deflate the cuff or cut the pilot balloon.
Ask the patient to take a deep breath and to cough,
apply vacuum, and at the peak of inspiratory effort,
rapidly remove the tube.
Administer humidified oxygen therapy.
Continue to evaluate the patient post extubation
for signs of respiratory compromise.

18. POST PROCEDURE
Continuously assess the patient
• Patient’s comfort and ease of breathing.
• adequate gas exchange by an arterial blood gas
analysis at appropriate intervals usually 30 min to
60mins) following extubation. Mechanical ventilation by Susan P
Pilbeam et al 4
th
edn ch.22
•Incentive spirometry, cough and deep breathing
exercises and patient mobilization, to be performed
in conjunction with the nursing staff.

19. Possible post
extubation
problems
•Hoarseness, sore throat, and cough
•Subglottic edema causing stridor
•Risk of aspiration
•Increased WOB from
secretions,
airway obstruction,
postextubation laryngospasm.
Ely EW etal :Effects on the duration of mechanical ventilation of identifying patients capable of breathing
spontaneously.N Engl J Med 335:1864,1996

20. •Post extubation stridor
•Extubation failure

21. Post Extubation
Stridor
•Minor
–Audible high pitched inspiratory wheeze with
respiratory distress
•Major
–Severe respiratory distress needing tracheal
reintubation secondary to upper airway obstruction

22. •Prolonged intubation can lead to edema,
inflammation, and ulceration
–Level of cords and cuff site

23. •Incidence
–2-22% of patients intubated > 24 hrs
•Increases mortality and prolonged ICU stay
•Typically occurs shortly after extubation
•Also occurs after 36hrs of extubation
•Reintubation rate is 1-10%

24. •It resolves in 24 hours
•It is more common in patients with frequent
coughing episodes and in patients who move
more frequently while intubated.
•More prevalent in children 1–4 years of age,
•Also in association with any type of surgery
in the head/neck area.
Kemper, et al. Crit Care Med, 1991; 19:352.)

25. How to predict post
extubation stridor?
Air leak test
•Clinician deflates the cuff of ETT, places the
stethoscope directly over larynx and gives a manual
breath, the rush of gas around the ET should be
heard
•If this air leak sound is heard with peak pressures
of less than 20cmH2O, the child is unlikely to have
the stridor post extubation
Mechanical ventilation by Susan P Pilbeam et al 4
th
edn ch.22

26. •In present generation of ventilators, a leak is
displayed on the screen of ventilator, if more
than 20%, then chance of post extubation stridor
are less
•Using corticosteroids to prevent stridor after
extubation has not proven effective for neonates
or children.
•However, given the consistent trends towards
benefit, this intervention does merit further
study, particularly for high risk children or
neonates.
Khemani RG, Randolph A, Markovitz B. Corticosteroids for the prevention and treatment of post-extubation stridor in neonates, children
and adults. Cochrane Database of Systematic Reviews 2009, Issue 3.

27. •In adults, multiple doses of corticosteroids
begun 12-24 hours prior to extubation do
appear beneficial for patients with a high
likelihood of post extubation stridor.
Khemani RG, Randolph A, Markovitz B. Corticosteroids for the prevention and treatment of post-extubation
stridor in neonates, children and adults. Cochrane Database of Systematic Reviews 2009, Issue 3.

28. •In one study dexamethasone was given as
0.2mg/kg/dose, 6 to 12 hours before
extubation and every 6 hours afterwards for a
total of six doses with beneficial results.
•Such a protocol with some modifications can
be followed if there is risk of post extubation
stridor (absent leak at the time of extubation,
prolonged ventilation beyond 5 to 7 days,
difficult or traumatic intubation etc)
Mechanical ventilation by Susan P Pilbeam et al 4
th
edn ch.22

29. Treatment of Stridor
•Steroids (Dex 0.2mg/kg/dose q8-12 hrs)
•Nebulized epinephrine
–0.5ml of 2.25% racemic epinephrine OR 1% l-
epinephrine
–Aerosilized levo-epinephrine is as effective as racemic
epinephrine in the Mx of post extubation laryngeal
edema in children (Nutman et al., 1994)
–Try NPPV until the effect of steroids starts (Susan
Pilbeam et al:Mechanical Ventilation.Physiological and Clinical applications.4
th
Edn
–Heliox (Kemper et al., 1990; Kemper et al., 1991)
•Consider reintubation

30. Fiberoptic
bronchoscopy
For patients with post-extubation complications such as stridor
or obstruction, may provide
•direct airway inspection and therapeutic interventions
(secretion clearance, instillation of drugs, removal of aspirated
foreign objects)
(Liebler & Markin, 2000; Walker & Forte, 1993).

31. Extubation
failure
•Failure: inability to sustain effective gas
exchange without mechanical support within
48 hours of extubation
•Incidence of extubation failure varies between
6 and 47%.

32. •A low rate (5%) is s/o too conservative
approach at extubation & will lead to the risks
associated with prolonged intubation
•A high percentage of extubation failure (over
30%) might indicate that clinicians are too
aggressive with extubation criteria; presents
the risks associated with re-intubation.
•An extubation failure rate of 10% to 19%
seems to be clinically acceptable.
Susan Pilbeam et al:Mechanical Ventilation.Physiological and Clinical applications.Ch20.4
th
Edn

33. Effects of extubation
failure on patient
•Increases length of stay and ventilation
•Increases mortality and morbidity
•Causes eight fold increase in risk of VAP
Extubation failure in intensive care unit: Predictors and management Atul kulkarni etal. Indian J Crit Care
Med 2008;12:1-9
•Children requiring re-intubation within 48 hrs
had significantly increased mortality than
patients successfully extubated (20% vs. 2%,
p< 0.001)
Estebari, AJRCCM, 2001.

34. Causes for Extubation Failure
Excessive resp effort 42%
Poor resp effort 24%
Inadequate gas exchange 18%
Cardiovasc insufficiency 10%
Neurologic 6%

35. •metabolic acidosis
•Hypophosphatemia or phosphate deficiency,
may contribute to muscle weakness
and failure to wean. Values below normal (1.2
mmol/L) may impair respiratory muscle function.
•Hypokalemia
•Hypo-magnesemia
•Severe hypothyroidism may have impaired
respiratory muscle function
Pierson DJ: Nonrespiratory aspects of weaning from mechanical ventilation,Respir Care 40:263,1995

36. Avoiding Extubation failure
General measures:
•treatment of remediable causes of muscle
weakness
•Avoid high carbohydrate diet
•manage excessive secretions and
•daily assessment for readiness to extubate,
until predictors become more favorable

37. Specific measures:
•Treatment of anemia
•Treatment of Heart failure
•Treatment of dyselectrolytemia (mainly K, Mg
and Phosphate)
•NIV

38. NIV
•It may be beneficial after
extubation if child still
needs some ventilatory
support
•In neonates and premature
infants, continuous
positive airway pressure
(CPAP) is effective at
preventing re-intubation
(De Paoli et al., 2002)

39. NIV
•Found to be useful in older
children with chronic lung
disease who have a strong
cough reflex, and are
hemodynamically stable with
minimal secretions.
•Not found to be very useful in
adults in post extubation failure
except in those with COPDs,
but can be tried.
Susan Pilbeam et al:Mechanical
Ventilation.Physiological and Clinical applications.4
th

Edn Ch22

40. Tracheostomy
•Trachesotomy is an option in children
requiring long term ventilatory support and
failing extubation e.g. neuromuscular
disorders, upper airway problems (e.g.
subglottic stenosis etc)

41. Summary
•Failed extubation, or the need to reinsert an
artificial airway following extubation, is not
necessarily an indication of failed medical
practice.
•An extubation failure rate of 10% to 19% is
clinically acceptable. (Too low rates mean too
conservative approach and too high rates
mean too aggressive approach)

42. •Consider use of steroids before extubation in
children at risk of post extubation stridor
(absent leak at time of extubation,prolonged
ventilation,difficult intubation or airway,etc)
•Extubate the child in day time in presence of
important equipment and manpower so that post
extubation problems can be managed well

43. Quality
standards for
Extubation
•Monitor and document all post extubation
stridors, aspirations and failed extubations in
the unit
•Monitor the factors causing these problems
Periodic auditing of all above parameters
should be the part of quality control of the
ICU
American Association for Respiratory Care (AARC). Removal of the endotracheal tube--2007 revision & update. Respir
Care 2007 Jan;52(1):81-93.

44. THANK YOU