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EARLY EXTUBATION IN THE CARDIAC SURGERY PATIENT
SANDRA BELLES, RN, CCRN NOVEMBER, 2015
ADVANTAGES ▪ Early mobilization▪ Decreased length of stay : ICU and Hospital▪ Reduced complications : DVT,PE, Neurologic compromise in the elderly▪ Reduced Mortality▪ Better Long-term outcomes▪ Early Extubation has been shown to hasten return of ciliary function, improve
respiratory dynamics and coughing thereby decreasing atelectasis, and VAP incidence
▪ Improved patient and family satisfaction
ADVANTAGES
▪ Mechanical ventilation itself can impair venous return ( lowering preload) and decrease Cardiac Output, requiring interventions and thus potentially prolonging ICU stay
▪ Tachycardia and hypertension are other responses to Mechanical Ventilation which necessitate treatment. If narcotic sedation is utilized as the treatment, it will increase intubation time and length of stay
▪ Based on STS CABG Data the morbidity rate associated with prolonged intubation ( defined as >24 hours) is 5.96%, and was an independent predictor for readmission to the ICU
GOAL
▪ Extubate within 6 hours of ICU admission The History:▪ Routine overnight Mechanical Ventilation following cardiac
surgery was adopted in the 1960’s, and continued until the 1990’s
▪ Weaning was not even attempted until the morning after surgery
▪ The development of low-dose opioids, better anesthesia techniques, as well as the need for cost containment resulted in the development of “Fast Tracking”.
▪ The implementation of early weaning protocols and reversible sedation has led to safe, ”early” extubation
GOAL
▪ Why < 6 hours? The debate regarding optimal Extubation time is still ongoing…recent studies are exploring Extubation in the OR.▪ However, the low point of ventricular function occurs
about 4hours after cardiopulmonary bypass. The first few post op hours are characterized by periods of hemodynamic instability, temperature dysregulation, increased blood loss, metabolic and electrolyte imbalance, and awakening from anesthesia.
▪ The instabilities can be most safely treated in an intubated patient
INITIAL VENTILATOR SETTINGS
▪ Tidal volume 8-10 cc/kg▪ FiO2 100%▪ Mode : IMV with Respiratory
Rate 10/min▪ PEEP 5 cmH20▪ PSV 10▪ ATC 80%
▪ Intermittent Mandatory Ventilation (IMV) refers to any mode of mechanical ventilation where a regular series of breaths are scheduled, but the ventilator senses patient effort and reschedules mandatory breaths based on the calculated need of the patient. IMV is frequently paired with additional strategies to improve weaning from ventilator support or to improve cardiovascular stability in patients who may need full life support.
▪ Positive end-expiratory pressure (PEEP) is the pressure in the lungs (alveolar pressure) above atmospheric pressure (the pressure outside of the body) that exists at the end of expiration. A small amount of applied PEEP (4 to 5 cmH2O) is used in most mechanically ventilated patients to mitigate end-expiratory alveolar collapse. A higher level of applied PEEP (>5 cmH20) is sometimes used to improve hypoxemia
Settings goal is to optimize gas exchange, decrease the work of breathing, and minimize complications of positive-pressure ventilation.
VENTILATOR SETTINGS
▪ PRESSURE SUPPORT is a spontaneous mode of ventilation also named Pressure Support Ventilation (PSV). The patient initiates every breath and the ventilator delivers support with the preset pressure value. With support from the ventilator, the patient also regulates their own respiratory rate and their tidal volume.
▪ In Pressure Support, the set inspiratory pressure support level is kept constant and there is a decelerating flow. The patient triggers all breaths. If there is a change in the mechanical properties of the lung/thorax and patient effort, the delivered tidal volume will be affected.
▪ Pressure support improves oxygenation,ventilation and decreases work of breathing. PSV 5cm will help overcome the resistance of the ETT
VENTILATOR SETTINGS
▪ The presence of an endotracheal tube augments respiratory load in spontaneously breathing patients who are receiving mechanical ventilation.
▪ During spontaneous respiration, greater force (ie, greater negative pressure) is required to move the same volume of air through a narrow endotracheal tube than through a wide endotracheal tube . In addition, breathing through the endotracheal tube itself requires greater force than does breathing through the natural trachea. “Breathing through a straw”
▪ ATC is applied to the endotracheal tube to decrease a patient’s respiratory work caused by the resistance of the endotracheal tube
▪ Automatic Tube Compensation (ATC) compensates for resistance associated with an endotracheal tube via closed-loop control of continuously calculated tracheal pressure. When ATC is used, several variables are entered into the ventilator system, including the internal diameter of the endotracheal tube, the type of tube, the percentage of support, and additional general settings(eg, trigger sensitivity). Information on the type of the tube (endotracheal or tracheostomy) is required to determine the length of the tube.
VENTILATOR PROTOCOL
▪
Treat Electrolyte Imbalances Can decrease muscle contractility, and
add to acidosis Administer Potassium, Magnesium and Calcium Chloride, as per policy
Correct Acid Base ImbalancesIf pH </= 7.35 AND NaHC03 is </= 21. Administer NaHC03 50mEq IV over 2
minutes
Do Not treat low NaHC03 levels in a non-acidotic and still hypothermic
patient
Stabilize the patient and achieve acceptable ABG'sChanges in Tidal Volume, Respiratory rate in response to ABG's and wean Fi02 to
50%pH 7.35 - 7.45 Pc02 35-45 Pa02 80-100
Sp02 >90%
VENTILATOR PROTOCOL
▪
Assess patients tolerance to Mechanical Ventilation Repeat ABG's >15 minutes after any change or
intervention Monitor respiratory status ,Sp02& VS, LOC
RewarmHypothermia causes SVR, Afterload, MV02, and may
precipitate shivering (Rx with Demerol)
Warm to at least 35.5°C with warm air blankets and heated ventilator tubing , then
allow to passively warm
Hemodynamic ManagementVolume status, HR/Rhythm, BP,CO/CI, SVR, Bleeding Fluids, Pharmacologic support, Pacing, correction of
coagulopathies
Assessing Tolerance to Mechanical Ventilation
Look At the Patient ! Grimacing with every ventilation given? Is the VT too high for the patient?
Ventilator alarming High Airway Pressure? Is the PIP high ?
▪ Peak inspiratory pressure (PIP) is the highest level of pressure applied to the lungs during inhalation. In mechanical
ventilation the number reflects a positive pressure in centimeters of water pressure (cmH2O). In normal breathing, it may
sometimes be referred to as the maximal inspiratory pressure (MIPO), which is a negative value. Peak Inspiratory Pressure
increases with any airway resistance. Things that may increase PIP could be increased secretions, bronchospasm, biting
down on the ETT, lying on ventilator tubing and decreased lung compliance.
PIP should never be chronically higher than 40(cmH2O) unless the patient has ARDS.
Assessing Tolerance to Mechanical Ventilation
▪ Is the patient restless, agitated, hypertensive, tachypneic, tachycardiac and/or fighting the Ventilator ?
▪ Are the paralytics fully reversed ?
If explanations, emotional support and re-orientation don’t help ….
Sedation may be in order, but NOT with opioids or benzodiazepines !
▪ Both decrease the respiratory drive respiratory depression and apnea
▪ Decrease BP and SVR Hemodynamic instability
▪ Over sedation slower to awaken, less spontaneous respirations, longer intubation time
Improving Tolerance to Mechanical Ventilation
Dexmedetomidine (dex-me-de-TOE-mi-deen) or Precedex
▪ Is a relatively selective Alpha2-adrenergic agonist with sedative and analgesic properties. It acts in the locus ceruleus to inhibit sympathetic stimulation
▪ Provides hemodynamic stability, does not affect the respiratory drive, and produces only mild cognitive impairment. Patients are “calmer” and less likely to attempt to self-extubate.
▪ Can be used for ICU sedation for up to 24 hours
▪ Administered by IV infusion : initially, 1mcg/kg/min as a loading dose over 10 minutes, followed by maintenance infusion of 0.2 – 0.7 mcg/kg/min
▪ Dosage should be individualized and titrated to the desired level of sedation, which is, easy arousability or tranquilly sedated
▪ Hypotension or bradycardia may occur with too fast administration or too high a dosage
▪ Rapidly distributed and terminal half-life of 2 hours
Weaning
As the patient awakens and begins to breathe spontaneously, weaning to Extubation may commence.▪ The patient must be awake and able to follow
commands appropriately ▪ They must also be Hemodynamically stable. ▪ The ABG's must be within acceptable parameters on
Fi02 50%▪ The patient must be able to tolerate the HOB being
elevated 30-40°▪ The patient must have a cough and a gag reflex
WEANING PROCEDURE
STEPSIf the clinical criteria is
met
Decrease the IMV rate by 2 breaths
Repeat ABG's in 15 minutes
Re-evaluate patient,criteria and
ABG's
Continue the process until the patient is on IMV rate
of 4
Obtain ABG's and Ventilatory Parameters
If all Clinical Criteria is met
Place the patient on CPAP 5,PSV 10 and
Fi02 50%
▪ If at any step, the clinical criteria is NOT met, the patient should be placed on the previous setting for 1 hour, then re-evaluated.
▪ It is important to remember the patients' Pre-op Room Air ABG's, Pulmonary Function Tests and History .
▪ Elevate HOB, Turn up the room lights, Stir Up
VENTILATOR SETTINGS
▪ Continuous positive airway pressure (CPAP) is a form of positive airway pressure ventilator, which applies mild air pressure on a continuous basis to keep the airways continuously open in a patient who is able to breathe spontaneously on his or her own. CPAP stents the lungs' alveoli open and thus recruits more of the lung's surface area for ventilation.
▪ CPAP applies continuous positive airway pressure throughout the breathing cycle. Thus, the ventilator itself does not cycle during CPAP, no additional pressure above the level of CPAP is provided, and patients must initiate all of their breaths.
VENTILATORY PARAMETERS
▪ Tidal volume ( VT) is the amount of air inhaled and exhaled normally at rest.
▪ Minute ventilation (Ve) is the volume
of air that can be inhaled (inhaled minute volume) and exhaled during one minute. Blood carbon dioxide (PaCO2) levels generally vary inversely with minute volume. For example, a person with increased minute volume (e.g. due to hyperventilation) should demonstrate a lower blood carbon dioxide level.
▪ Respiratory Rate or Frequency: the number of breaths per minute
▪ Normal...500-700cc (5 - 7 cc/kg)
▪ Normal …. 6 – 10 Liters/min
▪ Normal ……12-20/min
VENTILATORY PARAMETERS
▪ Vital capacity (VC): the volume of air breathed out after the deepest inhalation. It is equal to the sum of inspiratory reserve volume, tidal volume, and expiratory reserve volume.
▪ Forced vital capacity (FVC): Forced vital capacity (FVC) is the volume of air that can forcibly be blown out after full inspiration, measured in liters. FVC is the most basic maneuver in spirometry tests.
▪ A normal adult has a vital capacity between 3 and 5 liters. A human's vital capacity depends on age, sex, height, mass, and ethnicity. Normal ….>10cc/kg
▪ Normal... 65-75 liters
VENTILATORY PARAMETERS
▪ NIF (MIP) Maximal inspiratory pressure (MIP), also known as negative inspiratory force (NIF), is the maximum pressure that can be generated against an occluded airway beginning at functional residual capacity (FRC). Maximum inspiratory pressure is an important and noninvasive index of diaphragm strength.
▪ Rapid shallow breathing index The rapid shallow breathing index (RSBI) is a tool that is used in the weaning of Mechanical ventilation. The RSBI is defined as the ratio of respiratory frequency to tidal volume (f/VT). People on a ventilator who cannot tolerate independent breathing tend to breathe rapidly (high frequency) and shallowly (low tidal volume), and will therefore have a high RSBI.
▪ Normal : > - 25 cmH20
▪ An RSBI score of less than
50, indicating a relatively low respiratory rate compared to tidal volume is generally considered as an indication of weaning readiness.
ASSESSING READINESS TO EXTUBATE
▪ Awake, following commands appropriately....... Assess the need for Narcan/Romazicon ?▪ Able to lift head off pillow x 5 seconds ( an indicator of muscle strength)▪ Stable hemodynamics ( without high dose pressors), Temperature > 35°C , Stable Rhythm ▪ ABG’s within clinical criteria on 50% Fi02 , Sp02 >90%▪ Ventilatory parameters within acceptable ranges: VT>3cc/kg, VC >10cc/kg, NIF >-21, RSBI <50, RR >8/<30▪ Adequate respiratory effort ( No Apnea ventilation on CPAP ! ). Intact cough and gag reflex▪ Coagulopathies corrected and Chest Tube output < 100 cc x past 2 hours▪ Nursing Judgment and Gut feelings...How does the patient look ? Physiologic parameters
are not perfect predictors of successful Extubation. Treat patients, not numbers.
Extubation and Post Extubation CareExtubate, as per Hospital Policy▪ Place on Venti Mask @ 50% Fi02▪ Assess for laryngeal edema and a
patent airway▪ Repeat ABG's in 15 minutes▪ Continue to monitor respiratory
status, hemodynamics, mental status,
▪ If patient stable with acceptable ABG's and/or Sp02>/= 90% -- they maybe changed to Nasal Cannula @ 4-6 L/min within 2 hours of extubation
• Continue to Titrate the Fi02 to maintain Sp02 >/= 90%
• Begin Incentive Spirometry, Flutter Valve, Coughing and Deep Breathing Q1 hr
• HHN treatments with EZPap• OOB to chair...ASAP !• Oral Care
Post Extubation Care
▪ Observe for laryngospasm for as along as 1 hour, and stridor for as long as 24 hours, post – extubation
▪ Frequently evaluate the patient in terms of work of breathing, respiratory rate, use of accessory muscles, breath sounds and Sp02
▪ Support for marginal respiratory status Post-Extubation: Hi Flow 02 BiPap
Challenging Patients To Extubate
▪ Patients on mechanical circulatory support▪ Patients with poor LV function▪ Patients with severe lung disease▪ Patients with neurological dysfunction or post-op
delirium▪ Patients with unstable hemodynamics on high
pharmacologic support▪ Alcoholics
Thank –You !
♡
References▪ Wilkes-Barre General Hospital, Cardiothoracic ICU, Respiratory Support For Open Heart
Surgery and Acute Clinical Situation Protocols▪ Wilkes-Barre General Hospital, Respiratory Services, Bedside Ventilation Studies▪ STS Measure #164.CABG:Prolonged Intubation. Rationale and Clinical Recommendation
Statement▪ AATS / STS CT Critical Care Symposium ,April 27, 2014 Toronto, Ontario . Nevin M. Katz,
M.D. Johns Hopkins University.” Protocols Early Extubation After Cardiothoracic Surgery.”▪ Hardin,Sonya.Kaplow,Roberta. Cardiac Surgery Essentials for Critical Care Nursing, Jones
& Bartlett Learning, Oct 25, 2010▪ Ulrich Guller, Kevin J Anstrom, William L Holman, Richard M Allman, Monique Sansom,
Eric D Peterson. Outcomes of early extubation after bypass surgery in the elderly. Annals Of Thoracic Surgery March 2004 p781–788
▪ MAQUET, "Modes of ventilation in SERVO-i, invasive and non-invasive", 2008 MAQUET Critical Care AB, Order No 66 14 692, 66 61 131
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