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The difficult extubation

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The difficult extubation

  1. 1. Post-Extubation Emergencies
  2. 2. OH SH..!
  3. 3. Discontinuing Mechanical VentilationResolution of the process that caused theintubation.Spontaneous breathing ability withadequate ABG’s and Hemodynamics
  4. 4. Extubation CriteriaAbility to Cough MIF VC /PEF CognitiveSecretions Can there be too many? “Salam et al, “Neurologic status, cough, secretions and extubation outcomes” Intensive Care Medicine (2004) 30:1334-1339”
  5. 5. Extubation Criteria Hardware Issues NG/OG tubes Wired jaw Cervical fixation devices
  6. 6. The Top FiveLaryngospasmLaryngeal StridorAcute HypoxemiaAcute Respiratory FailureNeurologic pathology
  7. 7. LaryngospasmDefinition: The vocal folds spontaneouslyclosing and staying closed.Presents as NO air movement and patientin a panic (conscience or not)
  8. 8. LaryngospasmCauses: Hysteria Mechanical ChemicalCan you predict it? Extubating with Positive pressure
  9. 9. LaryngospasmHow do you treat it? Wait Sedation
  10. 10. Laryngeal StridorDefinition: High pitched inspiratory noise that occurswhen vocal folds are swollen and close together allowinglittle air to pass through.Can you predict it? Cuff leak test – Volume leak “Kriner et al, The Endotracheal Tube Cuff-Leak Test as a Predictor for Postextubation Stridor, Respiratory Care 2005 Dec;50(12)1632-1638 – ETT occlusion Risk populations Men vs. Women Obesity “Erginel S. et al “High body mass index and long duration of intubation increase post- extubation stridor in patients with mechanical ventilation” J Exp Med. 2005 Oct;207(2)125-32.
  11. 11. Laryngeal StridorIs it stridor or obstruction? Jaw Thrust/Sniff position Secretion clearanceHow do you treat the obstruction? Nasal/oral airways Mask CPAP
  12. 12. Laryngeal StridorIs it stridor or obstruction? Jaw Thrust/Sniff position Secretion clearanceHow do you treat the obstruction? Nasal/oral airways Mask CPAP
  13. 13. Laryngeal StridorHow can you treat? Racemic epinephrine/ bronchodilators .5cc/2ccNS Heliox 80/20 mixture Max. FiO2 .35 Sedation
  14. 14. Acute HypoxemiaDefinition: Sudden decrease of oxygen inthe blood.Can you predict it?
  15. 15. Acute HypoxemiaSecretions/Mucous plug Cough or need for NTS quicklyPulmonary edema Negative pressure pulmonary edema Support with oxygen Cardiac Mask CPAPVomiting/Aspiration Position pt on side Need for oral and NT suction quickly Support oxygenation
  16. 16. Acute Ventilatory FailureDefinition: An inability for the patient toventilate to maintain a normal pH(7.35-7.45)Presents itself by: Increased RR Increased WOB Decreased SaO2
  17. 17. Acute Ventilatory FailureCan you predict it?How do you treat? NPPV – COPD vs. Non-COPD Esteban et al. “Noninvasive Positive-Pressure Ventilation for Respiratory Failure after Extubation” N Engl J Med 2004;350:2452-60 Ferrer et al. “Early Noninvasive Ventilation Averts Extubation Failure in Patients at Risk” AM J Respir Crit Care Med 2006;173:164-170 Sedation withdrawal Re-intubate
  18. 18. Neurologic PathologyALSTraumatic Brain InjuryMS, Guillian Barre, TetraplegiaCritical Illness neuromyopathy
  19. 19. Post-Extubation Emergencies The inability to reliably predict The Top Five How to treat
  20. 20. BE PREPAREDDo not treat extubations as routineAssess, Assess, AssessHave Difficult Intubation Supply easilyavailable in unitDon’t Panic