Extubation presentation

1. RPN J.A van Wyk Extubation

2. Intubated patient

3. Extubation refers to removal of the endotracheal tube (ETT). It is the final step in liberating a patient from mechanical ventilation . At the end of the weaning process, it may be apparent that a patient no longer requires mechanical ventilation to maintain sufficient ventilation and oxygenation. However, extubation should not be ordered until it has been determined that the patient is able to protect the airway and the airway is patent. Extubation

4. Airway protection is the ability to guard against aspiration during spontaneous breathing. It requires sufficient cough strength and an adequate level of consciousness, each of which should be assessed prior to extubation . The amount of secretions should also be considered prior to extubation because airway protection is significantly more difficult when secretions are increased. Airway protection

5. 1. Hemodynamically stable No dysrhythmias Minimal inotrope requirements Optimal fluid balance 2. Adequate ventilation & oxygenation FIO2 < 0.5 Vital capacity of >10ml/kg. Tidal volume > 5ml/kg Respiratory rate < 25 BPM Criteria for extubation

6. Arterial Blood Gas PCO2 < 6kPa. PO2 > 8kPa on FIO2 of 40% & PEEP5. PH with a normal range (7.35 – 7.45) Other : Sedating agents must be stopped for > 24hrs. Causative condition resolved/under control. Paralysing agents stopped > 24hrs. Normal metabolic status. Electrolytes balance must be normal. Patient must be neurologically intact. Awake, well motivated, follows verbal commands & intact gag/ cough reflex. Take into consideration aspiration risk and airway edema . Criteria for extubation

7. Local haemorrhage at tracheostomy site. Air embolism Infection Tracheal necrosis Tracheal stenosis Tracheoesophageal fistula Failure of tracheostomy tube Obstruction of tracheostomy Accidental extubation Tube displacement Pneumothorax Swallowing dysfunction Complications associated with et & tracheostomy tubes

8. Suctioning equipment Personal protective equipment Sterile suction catheter Self – inflating manual resuscitating bag – valve device connected to 100% O2 source. O2 source and tubing. Scissors Supplemental oxygen 10ml syringe A rigid pharyngeal suction tip ( yankauer ) Sterile dressing for stoma ET intubation supplies Emergency trolley Equipment

9. equipment

10. E nsure the availability and functioning of your oxygen therapy, suction equipment, emergency equipment. Ensure the privacy of the patient. Explain the procedure to the patient. Assess the patients readiness for extubation : Cardiovascular status: BP, HR, Rhythm Respiratory status : RR, SpO2 Neurological status: LOC Stop feeds Make sure mechanical restraints are off Preparation and assessment

11. Wash hands put on sterile gloves Hyper oxygenate the patient and suction the patient via ET / tracheostomy tube Position the patient in high fowlers position Cut & remove tracheostomy tapes/ plaster of ET tube Deflate the cuff with 10 ml syringe and instruct the patient to breath Introduce suction catheter into tube Ask patient to cough Withdraw the tube and suction simultaneously Ask patient to cough again ( to determine laryngeal paralysis) IMPLEMENTATION

12. Remove secretions from oropharynx, mouth and nose and give a mouthwash. Commence O2 therapy via face mask, keep ventilator close for NIV CPAP Encourage patient to breath deeply and do PEEP bottle exercise Assessment of the patients respiratory and cardiac status. Connect pulse oximeter Discard used supplies, remove personal protective equipment and perform hand hygiene Implementation cont.

13. implementation

14. Assess air entry and respiratory status Auscultate the chest for breathing sounds and for the presence of secretions Do vital observations Remain with the patient to determine respiratory stability Obtain arterial blood gas within the next hour evaluation

15. Tidy up after the procedure Wash hands!!!!! Record all actions taken and chart vital signs on observation chart. Record keeping

16. ??? questions

17. Thank you! The end