Extubation, Airway Emergencies & Patient Positioning

Objectives - Identify when and how to extubate or decannulate a patient, troubleshoot artificial airway emergencies, and identify patient positioning techniques used to improve oxygenation and ventilation.

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Extubation

Definition and Indications

Extubation is the removal of an endotracheal tube.

Extubation is indicated when:

• The condition that required airway protection or mechanical ventilation is no longer present
• The patient can maintain a patent airway
• The patient has adequate spontaneous ventilation

The patient should have adequate:

• Central inspiratory drive
• Respiratory muscle strength
• Cough strength to clear secretions
• Laryngeal function
• Nutritional status
• Clearance of sedative and neuromuscular blocking effects

Hazards

Extubation hazards include:

• Hypoxemia and hypercapnia
• Upper airway obstruction from laryngospasm
• Laryngeal edema
• Vocal cord damage

Extubation Criteria

Extubation readiness should include:

• ABGs showing adequate ventilation and oxygenation
• Verification that the underlying disease process has been reversed
• Alert and oriented status
• Bedside ventilatory parameters within the source criteria

Maximum inspiratory pressure evaluates inspiratory muscle strength. Maximum expiratory pressure evaluates expiratory muscle strength. A pressure measuring device is used for MIP and MEP. A Wright spirometer can measure tidal volume, minute ventilation, and vital capacity.

Example Logic

For an ideal body weight of 80 kg:

• Minimum tidal volume is 400 mL
• Minimum vital capacity is 1200 mL
• A measured MIP of -25 cm H2O, minute ventilation of 9 L/min, and awake/alert status support readiness

For an ideal body weight of 50 kg:

• A measured MIP of -50 cm H2O
• Tidal volume of 350 mL
• Vital capacity of 850 mL
• Minute ventilation of 8 L/min
• Awake and alert status

These values are compared with the normal values needed for that specific patient.

Extubation Procedure

Step 1: Assemble needed equipment, explain the procedure, and position the patient.

Equipment:

• Endotracheal suctioning equipment
• Yankauer
• 10-mL or 12-mL syringe
• Oxygen and aerosol therapy equipment
• Usually high-flow aerosol device
• Face tent or mask
• Manual resuscitator and mask
• Racemic epinephrine nebulizer if there are concerns about post-extubation edema
• Bronchodilator
• Intubation equipment
• Incentive spirometer

Explain the procedure at a level the patient understands. Place the patient in semi-Fowler's or Fowler's position.

Step 2: Suction the ETT and pharynx above the cuff.

• Helps prevent aspiration after cuff deflation
• Suction above and below the cuff
• Suction inline while placing the patient on 100% oxygen
• Suction orally

Step 3: Oxygenate the patient well after suctioning.

Extubation is stressful and may cause hypoxemia and unwanted cardiovascular effects. Administer 100% oxygen for 5 minutes.

Step 4: Optional cuff leak step according to hospital policy.

• Attach a 10-mL or 12-mL syringe to the pilot tubing
• Listen for an audible leak around the tube
• Listen for stridor
• If no audible leak is present, reinflate the cuff and discuss with the physician

Step 5: Remove the tube.

• Remove tape or holder
• Have the patient take a large deep breath in
• Deflate the balloon
• Remove the tube at maximal inhalation to prevent vocal cord damage
• Have the patient cough after maximal inhalation
• Suction secretions

Step 6: Apply appropriate oxygen and humidity therapy.

Apply cool mist oxygen immediately after extubation using the same FiO2 that was on the ventilator before extubation.

Step 7: Assess and reassess.

• Auscultate over the larynx for stridor
• Recognize that stridor is a common post-extubation complication
• Consider laryngospasm or tracheal edema
• Auscultate lung fields
• Wheezing suggests bronchospasm
• Rhonchi suggests secretions
• Monitor vital signs, SpO2, and respiratory rate
• Observe for distress and dyspnea
• Instruct the patient on incentive spirometry
• Do not leave until the patient is stable

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Airway Emergencies

Overview

Airway emergency topics include:

• Tube obstruction
• Cuff leaks
• Unplanned extubation
• Repositioning endotracheal tubes

Tube Obstruction

Causes:

• Tube kinked or against tracheal wall
• Herniated cuff
• Complete or partial obstruction from mucus or blood

Troubleshooting:

• If kinked or against the tracheal wall, adjust the patient's head
• Verify previous placement, such as 22 cm at the teeth
• Reposition the tube by advancing or withdrawing if needed
• If the cuff is herniated, deflate the cuff
• For partial or complete obstruction, attempt suctioning
• Instill normal saline if necessary
• Reintubate with an airway exchange catheter if it passes the obstruction
• If complete obstruction remains, extubate and reintubate or obtain an emergency surgical airway

Cuff Leaks

Potential sources:

• Pilot balloon
• Pilot tube
• Cuff

Clinical signs:

• Decreased peak pressures
• Decreased delivered tidal volumes
• Sounds heard over the trachea
• Patient can talk

Troubleshooting:

• Determine where the leak is originating
• Notify the physician
• Decide whether to extubate and reintubate or manage the leak until extubation
• If the patient must remain intubated and the leak is significant, reintubate using an exchange catheter

Unplanned Extubation

Causes include:

• Sedation holidays
• Spontaneous breathing trial
• Inadequate restraints
• Transport
• Bathing
• Improper use of securing devices, circuit placement, or suction catheter placement
• Patient factors such as beards, diaphoresis, alcohol use, or drug abuse

Hazards and complications:

• Laryngospasm
• Laryngeal edema
• Aspiration pneumonia
• Bronchospasm
• Vocal cord damage
• Respiratory failure
• Death
• Longer ICU stay

Repositioning Endotracheal Tubes

Need to reposition may be identified during ventilator checks by:

• Watching for equal chest movement
• Listening for equal breath sounds
• Checking tube position
• Reviewing chest x-ray

Procedure:

• Elevate head of bed to 45 degrees when possible
• Note current placement at teeth or gums
• Hyperoxygenate the patient
• Suction the trachea and oropharynx
• Loosen tape or securing device
• Deflate cuff enough to cause a slight leak
• Advance or retract to the appropriate depth
• Reinflate cuff and check cuff pressure
• Secure the airway
• Chart new placement and depth
• Recommend x-ray for definitive confirmation

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Patient Positioning

Purpose

Frequent changes in body position and posture are normal in healthy people, even during sleep. Mobilization during illness and after surgery helps prevent:

• Bed sores
• Musculoskeletal wasting
• Atelectasis
• Pneumonia
• Thromboembolism

The primary purpose is to promote lung expansion, improve oxygenation, and prevent secretion retention.

Positioning may be performed by the patient, caregiver, or special bed.

Contraindications

Relative contraindications:

• Marked agitation
• Increased ICP
• Hypotension
• Worsening dyspnea
• Hypoxia
• Cardiac arrhythmia

Absolute contraindication:

• Unstable spinal cord injury

Common Positions

Pulmonary Disease-Specific Positioning

ARDS

Prone positioning is shown to improve oxygenation in acute respiratory distress syndrome.

The suspected mechanisms include:

• Improved V/Q
• Recruitment of collapsed alveoli
• Increased FRC
• Increased cardiac output

Disadvantages:

• Hemodynamic instability
• Decrease in gas exchange
• Need for specialized nursing care
• Special equipment such as beds

Obstructive Airway Disease

Upright Fowler's position decreases resistance.

Leaning forward in tripod position is used by severe COPD patients trying to relieve dyspnea.

Unilateral Lung Injury

Use lateral decubitus with the good lung down to improve oxygenation in spontaneously breathing or mechanically ventilated patients.

High-Yield Review