AARC Clinical Practice GuidelineRemoval of the Endotracheal Tube- Jan 2007 Revision and update

Rattana pensrichon , MD แพทย์�ประจำ�บ้ �นป�ท�� 2 หน�วย์

เวชบ้�บ้�ดว�กฤต21 มิ�ถุ น�ย์น 2550

AARC Clinical Practice GuidelineRemoval of the Endotracheal Tube-2007 Revision and update

This guideline focus on the predictors that aid the decision to extubation

The procedure refered to as extubation

The immidiate post extubation interventions that may avoid potential reintubation

The risk of prolonged tranlaryngeal intubation include

Sinusitis Vocal cord injury Laryngeal injury Subglosstic stenosis in neonates and children Tracheal injury Hemoptysis Aspiration Pulmonary infection Endotracheal tube occlusion Accidental extubation

Complication post extubation

Upper airway obstruction from laryngospasm

Laryngeal edema Supraglottic obstruction Pulmonary edemaPulmonary aspiration syndrome Impaired respiratory gas exchange

Indication of extubation

improvement of the underlying condition

pulmonary function and/or gas exchange capacity

Patient should be capable of maintaining a patent airway generating adequate spontaneous ventilation

(central inspiratory drive ,respiratory muscle strength to clear secretion ,laryngeal function ,nutritional status ,clearance of sedative and neuromuscular drug effects)

Contraindications of extubation

No absolute contraindications

May require one or more of the following Noninvasive ventilationCPAP High inspired oxygen fraction Reintubation

Hazards

Hypoxemia after extubationUpper airway obstruction Post obstructive pulmonary edema Bronchospasm Lung atelectasisPulmonary aspiration Hypoventilation

Hazards

Hypercarbia after extubation Upper airway obstruction resulting from

edema of trachea ,vocal cords ,or larynx Respiratory muscle weaknessExcessive work of breathing Bronchospasm

Assessment of extubation readiness

Extubation readiness criteria Exp.maintain adequate arterial partial pressure

( PaO2/FiO2 > 150-200)

Low level of PEEP (< 5 to 8 cmH2O)

The capacity to maintain appropiate PH(PH >= 7.25) and PCO2 during spontaneous ventilation

Assessment of extubation readiness

Acceptable respiratory rate decrease inversely with age

Adequate respiratory muscle strength Maximum negative inspiratory pressure >-20

cmH2O Vital capacity > 10 ml/kg, in neonate > 150

ml/m2 Modified CROP

index(compliance,resistance,oxygenation,ventilating pressure) above a threshold of >=0.1-0.15 ml .mmHg/breath/min/kg

Assessment of extubation readiness

Thoracic compliance > 25 ml/cmH2o Work of breathing < 0.8 J/L Vd/Vt <= 0.5( in children) Maximum voluntary ventilation > twice resting

minute ventilation In neonates,total respiratory compliance <=

0.9 ml/cmH2O associated with extubation failure

Assessment of extubation readiness

Rapid shallow breathing index RR/Vt < 105 breath/min

Resolution of the need for airway protection

Appropiate level of conciousness Adequate airway protective reflexes – white card test –( grade 0-2 ) Early managed secretions

Assessment of extubation readiness

Presence of upper airway obstruction or laryngeal edema Air leak test

Age dependent predictor of post extubation stridor

Air leak > 20 cmH2O Predictive post extubation stridor in chlidren >= 7 years of age (sens 83%,spec 80%)

Air leak test – predictive of postextubation stridor or extubation failure for children of upper airway pathology : traumatic patients,crop

Assessment of extubation readiness

Evidene of stable ,adequate hemodynamic function

Evidence of stable nonrespiratory functions

Electrlytes values within normal range Evidence of appropiate nutrition

Risk factor for extubation failure

Admit in ICU Age > 70 years or < 24 months Higher severity of illness upon weaning HgB < 10 mg/dl Use of continuous IV sedation Longer duration of mechanical ventilation Presence of syndromic or chronic medical condition ,known

medical or surgical airway condition ,congenital condition associated with cervical instability ( Klippel-feil or trisomy 21 )

In pidiatric cardiothoracic surgery population Age < 6 months Prematurity Congestive heart failure Pulmonary hypertension

Prophylaxis medication

Consider use lidocaine to prevent cough and/or laryngospasm in patient at risk

Steriod may be helpful to prevent reintubation rates in high risk neonates but not in children

Steroid may help reduced the incidence of postextubation stridor in children but not in neonates or adult

Steriod for patients with croup correlates with reduced rates of reintubation

Caffeine citrate reduced the risk of apnea for infants but not reduced risk of extubation failure

Methylxanthine treatment stimulate breathing and reduced the rate of apnea for neonates with poor respiratory drive

Assessment of outcome

Assess by PE, auscultation, invasive and noninvasive measurements of gas exchange and chest radiography

Quality of the procedure assessed by monitoring extubation complications and the need for reintubation

Postextubation support

Noninvasive Respiratory Support NIPPV or nasal CPAP

Binasal prong CPAP or single nasal or nasopharyngeal CPAP

In patients with COPD ,CPAP 5 cmH2O and pressure support ventilation of 15 cmH2O improve gas exchange ,decreased intrapulmonary shunt fraction and reduced work of breathing

Postextubation Medical Therapy and diagnostic therapy

Aerosalized levo-epinephrine is as effective as aerosolized racemic epinephrine in treatment of postextubation laryngeal edema in children

Heliox may alleviate the symptom of partial airway obstruction and resultant stridor ,improve patient comfort

Fiberoptic bronchoscopy may provide direct airway inspection and therapeutic interventions

Resources

Equipment Personal

Mornitoring

Appropiately trained personnal to detect cardiopulmonary impairment

Frequent respiratory evaluation include: vital sign ,neurologic status ,patency of airway ,auscultatory findings ,hemodynamic status

Equipment Pulse oximeter Two channel cardiac monitor Capnography

Frequency

Any recommendation for tracheostomy placement in the mechanically ventilated patient Etiology of respiratory insult Expected or known duration of mechanical

ventilation Balance of risks and perceived benefits of

continued mechanical ventilation via tracheostomy as opposed to a tranlaryngeally placed EET