Extubation Criteria

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Extubation Criteria

• J. Prince Neelankavil, M.D.

2
Case

• 71 y.o. male s/p laparascopic surgery presents to
  the PACU intubated. Pt. remained intubated
  secondary to residual neuromuscular blockade
• H/O HTN, DM
• When should we extubate?

3
General Principles

• Why 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.

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Adequate Gas Exchange?

• Adequate arterial partial pressure of oxygen
  PaO2/FIO2 ratio gt 150-200
• Appropriate pH (pH gt7.25) and arterial partial
  pressure of carbon dioxide during spontaneous
  ventilation

5
Pass a Breathing Trial?

• 30120 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

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Pass These Numbers?

• RR lt 35
• Vital capacity gt than 10 mL/kg
• NIF gt -20
• Tidal Volume gt 5mL/kg
• Minute ventilation lt 10L/min
• Thoracic compliance gt 25 mL/cm H2O

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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

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Risk Factors for Failed Extubation

• ICU patient
• Age gt 70 or lt 24 months
• Hemoglobin lt10 mg/dL
• Longer duration of mechanical ventilation
• Medical or surgical airway condition
• Frequent pulmonary toilet
• Loss of airway protective reflexes

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What do you need to extubate?

• Oxygen source
• Suction
• Oral/Nasal airways
• Face masks
• Endotracheal tubes
• LMA
• Pulse ox
• Cardiac Monitors
• CO2 detectors
• Ambu bags

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What did we do before we extubated our patient?

• Ensured proper equipment needed for reintubation
• Monitoring BP, HR, Sat, RR
• Used a twitch monitor to demonstrate no fade on
  TOF/sustained tetany
• Turned off the propofol sedation

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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 1.
  Stable hemodynamics
• 2. Able to protect airway
• 3. Able to exchange gases

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Stable Hemodynamics

• His preoperative BP and HR were 134/77 and 68
• Prior to extubation his BP and HR were 126/72 and
  61

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Able to protect airway

• Patient was gagging on the ETT and would gag when
  we suctioned him
• Patient was coughing

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Able to exchange gases

• Patient was spontaneously breathing for 30
  minutes
• Good ventilatory effort
• Maintained oxygen saturation

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Case

• Our patient was extubated and had an uneventful
  PACU stay.
• Another satisfied customer

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References

• American Association for Respiratory Care (AARC).
  Removal of the endotracheal tube--2007 revision
  update. Respir Care 2007 Jan52(1)81-93
• Nir Hoftman, M.D.s PACU extubation criteria