I have spent a ton of time on how to intubate COVID19 patients. I think we need to give some time on to the other end of things: COVID extubations:
One of my favorite upstairs intensivists is Sahar Ahmad.
Sahar Ahmad. M.D. Assistant Professor of Medicine Director of Ultrasound Education Associate Program Director, Pulmonary and Critical Care Medicine Fellowship Division of Pulmonary, Critical Care and Sleep Medicine Stony Brook University Hospital
To intubate or not to intubate?
This question has rapidly risen to the forefront of management decisions. Prior to the era in which SARS CoVi- 2 dominated as the etiology for acute hypoxemic respiratory failure, this was largely an undebated thought sequence: Very hypoxic? Intubate.
My recent experience of caring for COVID patients in hypoxemic respiratory failure has rapidly convinced me to re- think this paradigm: Perhaps the answer is actually to not intubate. Perhaps the moderate degree hypoxemia (on the order of SaO2 80-95% range on 100% Non-Rebreather or High-Flow support, or both together) leaves the patient at fewer risks than does an inevitable 5-15 days on mechanical ventilation.
Once on mechanical ventilation many do improve their oxygen requirements. Many of these patients become trapped into a loop where their oxygenation requirements and respiratory system mechanics are compatible with liberation from mechanical ventilation, however due to a combination of “still depressed mental status, but coughing excessively” they are returned to full sedation and full vent support. Mechanical ventilation seems to beget mechanical ventilation–even when the reason for mechanical ventilation has improved, the reason to keep intubated is for intolerance of the mechanical ventilation itself (i.e. coughing and agitation).
To extubate or not extubate?
Repeatedly, the intensivist across these fields of medicine finds herself faced with this dilemma: deciding between re-sedating an already sedation-driven encephalopathy condition; or extubating without the usual fair mental status that we search for in the decision making scheme for extubation.
Neither is an appealing option. I personally have chosen the latter in my last 11 COVID19 respiratory failure patient extubations. In my limited, but poignant experience, only 1 case was reintubated within 24 hrs. Two of the remaining 10, at day 5 post extubation, were sent out of ICU only to be reintubated while under another service within 2 hours of leaving the ICU. These reintubations were for unclear reasons given their respiratory stability over the course of 5 post-extubation days, and perhaps there was an intolerance to the degree of encephalopathy they showed. The remaining 8 regained, albeit inordinately slowly, a mental status over the course of 1-5 days post extubation. Organ failure (liver/ kidney) related delays to sedation clearance were not an explanation in any of these “slow to awaken” patients. Hyperactive delirium and sever agitation developed in 4 cases.
None of these clinical courses represent ideal options for care that is optimally safe for patients and provider. But I stand behind any option that somehow gets most of our patients off mechanical ventilation sooner rather than later or prevents mechanical ventilation altogether.
We need to change our usual paradigms of decision making for mechanical ventilation. This not only includes decision-making of when to intubate–an ongoing discussion–but in this essay I turn our attention now to rethink the usual paradigms pertaining to when to extubate. It is my opinion based on my (again- limited but poignant) experience, that we must strive to re-write parameters for:
- The allowance of patients to continue without the initiation of mechanical ventilation;
- The allowance of what is considered acceptable mental status parameters to pursue extubation perhaps earlier than our past paradigms allowed for;
- What is considered acceptable respiratory and mental status to keep from pursuing re-intubation.
The sedation requirements, degree of agitation and intolerance on mechanical ventilation by all age groups and all tidal volume strategies, the degree and time course of encephalopathy during sedation holiday as well as multi organ failure which sometimes appears to be driven by mechanical ventilation in this condition are committing many to remain intubated. Mechanical ventilation seems to beget mechanical ventilation, even when lung function itself improves.
Sahar Ahmad MD
How to Safely Extubate
Extubation is an aerosol-generating procedure with a high risk of coughing. You need full PPE. If it is logistically feasible, a negative pressure room is preferred.
Many have noted airway swelling is higher in COVID intubations, consider a leak test (I know we are in the evidence-scant land) prior to extubation
Mask over ETT
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