In this podcast, I discuss extubating patients in the ED. Specifically, I deal with patients who have only been intubated for a few hours in distinction to extubation of the patient who has been lingering in your ED for 2-3 days. The best patients for this short-term extubation are those intox folks with a low GCS and signs of trauma, overdoses, or endoscopy cases.
My approach is outlined in this article; click on the link for the full text:
Weingart SD, Menaker J, et al. Trauma Patients Can Safely Be Extubated in the Emergency Department. J Emerg Med. 2009 Aug 22. [Epub ahead of print]
Here are the steps from the article:
Photo by EddieB55
The following are from a recently published article on ED Extubation [from [Critical Care volume 27, Article number: 414 (2023)]
Parameters during SBT
Each patient underwent a 30-min SBT using a T-piece or pressure support ventilation. The trial was suspended in cases of intolerance to the test. Failure was defined as the presence of at least one of the following criteria: partial pressure of arterial oxygen (PaO2) ≤ 60 mmHg or the arterial blood oxygen saturation (SpO2) ≤ 90% with the fraction of inspired oxygen (FiO2) ≥ 0.50, PaCO2 > 50 mmHg or an increase of > 8 mmHg from baseline, pH < 7.32 or a decrease of > 0.7 units, respiratory rate ≥ 35/min or an increase of ≥ 50% from baseline, heart rate ≥ 140 bpm or an increase of ≥ 20% from baseline, systolic arterial pressure > 180 mmHg or an increase of ≥ 20% or systolic arterial pressure < 90 mmHg. Additional criteria included the development of de novo cardiac arrhythmias, an abrupt change in mental status, and the presence of two or more signs of respiratory distress, such as tachycardia, bradycardia, increased breathing effort, use of accessory muscles, abdominal paradox, facial signs of distress, diaphoresis, cyanosis, and marked dyspnea [7, 13, 18]. from [Critical Care volume 27, Article number: 414 (2023)]
Cuff Leak
The cuff leak test was performed to determine the difference in expiratory tidal volume with the cuff inflated and deflated. During testing, the patient was on the ventilator set to support control mode at a tidal volume of 10–12 mL/kg. The patients were not administered any sedative medications during the test, only analgesic medications. One inspiratory tidal volume and six subsequent expiratory tidal volume values were recorded after oropharyngeal suctioning and endotracheal tube cuff deflation. Cuff leak was measured as the difference between the preset inspiratory tidal volume and the average of the lowest three of six subsequent expiratory tidal volume values. A larger leak value has been shown to predict SE, and a favorable test result was defined as a difference greater than 120 mL [19, 20].
RSBI
The RSBI index was calculated as the ratio of tidal volume to respiratory frequency (f/VT) and assessed immediately after the cuff leak test during the transition to spontaneous mode. A value lower than 105 breaths/min/L was considered a favorable test result [17, 21].
Cough
To objectively evaluate cough, the ventilatory parameters were set to spontaneous mode with zero assistance. Normal 0.9% saline (2 mL) was instilled through the closed suction at the end of inspiration, and the maximum expiratory flow was measured during the resulting involuntary cough. Cough-induced peak expiratory flow was categorized as follows: 0 = no cough, 1 = audible movement of air through the orotracheal tube but no audible cough, 2 = strong cough with mobilization of secretions within the orotracheal tube, and 3 = strong cough with mobilization of secretions out of the orotracheal tube [22].
Diaphragmatic Ultrasound
A diaphragmatic ultrasound was performed to measure the diaphragmatic excursion, duration of the diaphragmatic cycle, diaphragmatic thickening index, and diaphragmatic contraction rate [23,24,25]. The measurements were performed in the supine position using a subcostal or intercostal approach in the midclavicular or anterior axillary lines. The laterality chosen to perform the measurement was dependent on the ultrasound assessor’s technical ease and clinical decision. Eight ultrasound assessors (medical doctors who had completed a residency or fellowship in critical care medicine and had relevant training and experience) conducted the ultrasound examinations in the ICUs. To acquire competency in diaphragmatic ultrasound, each assessor received two months of chest ultrasound training during a radiology rotation, followed by 8 h of theoretical and practical diaphragmatic ultrasound training for the study measurements. The assessors were then evaluated by an intensive care medicine physician with extensive experience in diaphragmatic ultrasound (FVV) to confirm their competency in the measurement of diaphragmatic variables. This team of assessors previously participated in a similar study two years before this study [16]. After their initial training, the assessors acquired additional expertise in the two years prior to the current study by performing approximately 25 diaphragmatic ultrasounds for ventilator weaning assessments each month in each ICU, totaling approximately 2,400 diaphragmatic ultrasounds per ICU in the two-year period. Each of the assessors performed at least 50 diaphragmatic ultrasounds before participating in the current study. Furthermore, they underwent regular retraining in diaphragmatic variable measurements every six months throughout the study, surpassing previous studies’ requirements and learning curves [15, 23, 26,27,28,29].
Diaphragmatic ultrasound values were obtained from three consecutive tidal breaths, and the average values were used in the analysis. Diaphragmatic thickness was measured during quiet spontaneous breathing and during maximal inspiratory and expiratory efforts. An index of diaphragmatic thickening, the thickening fraction (TF), was calculated using the M mode and the following equation: TF = (thickness at end-inspiration − thickness at end-expiration)/thickness at end-expiration. In the M mode, the diaphragmatic excursion (displacement, cm), diaphragmatic contraction velocity (DCV) (slope, cm/s), inspiratory time (Tinsp, s), and duration of the cycle (Ttot, s) were measured as described elsewhere [25, 30, 31].
Update
- George Douros has written another excellent guideline for ED extubation.
- Sara Gray has also done a swell job discussing Sara Gray-ED Extubation
- Newest study from UMich (West J Emerg Med. 2020 May; 21(3): 532–537. )
- Excellent Tips for Extubation
- Review Paper PMID: 31262421
More on Extubation from the EMCrit Crew
- PulmCrit Wee – The meaning of nocturnal extubation is 42
- High-flow nasal cannula to prevent post-extubation respiratory failure
Additional New Information
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Liberation from the ventilator(Opens in a new browser tab)
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Professor
Nassau University Medical Center
No conflicts of interest (coi).
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Would a bailey’s maneuver of placing an lma…like the air-q or i-gel while the patient is intubated be advisable in some conditions? Like a difficult intubation patient..only difficult after experiencing the intubation first hand? Had a case this past weekend when GI asked for elective intubation to protect the airway for removal of a food impaction by meat in the esophagus. Lacking experience in intubation then extubating the patient in the ED we called anesthesia… the case was taken to the OR with intubation and extubation handled by anesthesia. We had no problems with intubation. Anesthesia wanted to do it… Read more »
If you think about an LMA and where it sits, I think you’ll see it will not work for Upper Endoscopy. ED Extubation can and should be done. https://emcrit.org/podcasts/extubation/
excellent, scott.